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Table of Contents
Overview....................................................................................................................................................3
Applicable Therapeutic Recreation Interventions......................................................................................4
Intervention #1 - Tabletop RPG Modification - Choose Your Own Adventure for Severe TBI-related
impairments...........................................................................................................................................5
Example CYOA Process...................................................................................................................5
Needs addressed by intervention......................................................................................................6
Common Settings.............................................................................................................................7
Equipment Needed............................................................................................................................7
Program Adaptations........................................................................................................................7
Examples of intervention..................................................................................................................7
Program Name.............................................................................................................................8
Location.......................................................................................................................................8
Description of clients served........................................................................................................8
Qualifications of program facilitator...........................................................................................8
How I found this program............................................................................................................8
Intervention #2 - Computer-based RPG Use and Modifications for Client With TBI..........................9
Needs addressed by intervention......................................................................................................9
Example CRPG Process.................................................................................................................10
Common Settings...........................................................................................................................10
Equipment Needed..........................................................................................................................10
Program Adaptations......................................................................................................................10
Examples of intervention................................................................................................................10
Program Name...........................................................................................................................11
Location.....................................................................................................................................11
Description of clients served......................................................................................................11
Qualifications of program facilitator..........................................................................................11
How I found this program..........................................................................................................11
References................................................................................................................................................11
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Overview
After consultation with the family and care-takers, it is determined that prior to injury, one of
the client's favorite activities included various forms of role-playing games (RPGs). The client mostly
preferred tabletop, but had dabbled with both computer-based and live-action forms. As the client
slowly regains various levels of functioning, modified versions of RPGs can be presented in which the
client may participate to stimulate neurological recovery.
While other therapies are assumed to be undertaken, this document will focus on the use of
therapeutic recreational techniques in treating the client, specifically using variants of role-playing
games, with various modifications as warranted to fit specific client needs, throughout different stages
of impairment and recovery.
One of the major obstacles in writing this section is that role-playing games appear to have not
yet been considered by any health professionals as a potential therapeutic intervention, let alone
specifically the recreation therapy industry in the USA. I have had multiple dialogues in person and via
websites, with various RT professionals, many with decades of experience, and in speaking with them,
they never even considered, or ever heard of anyone considering, using any version of role-playing
games for therapeutic intervention. The closest I have been able to find included drama therapy, and
standard game therapy, but nothing in the full form of “role-playing game therapy”. There are a few
possibilities outside of the United States, and there are a number of educational programs using RPG's,
so this document is purely hypothetical in the proposed interventions for TBI clients, but is based on
closely similar approaches, but using the structure of RPG forms. Hopefully some recreation therapists
will attempt these in the future and report on the results and modifications necessary for maximal
efficacy.
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Not counting purely experimental research projects, after researching and searching worldwide
now for several years, there appears to only be one actual ongoing RPG-related therapy program that I
have found to date, and this is in Israel through the Romach group (http://www.lance.co.il/).
Unfortunately the site is completely in Hebrew. There are however any number of educational
programs using role-playing games for instructional purposes, including a Danish public high school
(Østerskov Efterskole - http://osterskov.dk/?page_id=213) with an entire curriculum taught using live-
action role-playing (LARP). Because using RPG as a therapeutic intervention is not (yet) established,
every effort was made in this document to extrapolate likely scenario matching the use of related
activities, expected implementations, outcomes, using hypothetical suggestions based on the
information be gleaned from the aforementioned areas.
Applicable Therapeutic Recreation Interventions
When the client is actually in the coma and at the Rancho Los Amigos Cognitive Level I, RT is
not able to implement anything in the way of an interactive intervention. However, once the client is
out of the coma, even at just Rancho Los Amigos Cognitive Levels II & III, the RT can begin to
implement various modifications of role-playing games as a recreation therapy intervention.
Initially the client is too disoriented and has such significant cognitive and memory impairment
that using the “Choose Your Own Adventure” CYOA form of RPG is probably contraindicated, but
after just a few days, when the functioning is closer to b11428.2, and within a week around b11428.1.
This means the client might be able to engage in “let's pretend” imaginary scenarios and differentiate
from the real and imagined situations. Though the client has memory issues, and may not remember
much from 30 seconds to a few minutes ago, the exercises could still be useful for stimulating neuro-
plasticity and recovery. The client may need repetition and occasional reminders, but is now potentially
ready to begin the CYOA form of RPG TR treatment.
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Though the client had previously enjoyed and participated in RPGs, he/she did not do so
constantly, so it is not believed to be an “overlearned leisure skill”(Porter, p 144), so that it may still be
a reasonable activity for monitoring and assessment of overall recovery.
Intervention #1 - Tabletop RPG Modification - Choose Your Own Adventure
for Severe TBI-related impairments
Once the client is out of the coma, and rated at just Rancho Los Amigos Cognitive Levels II &
III (able to open eyes in response to stimuli such as a spoken request or physical touch) (Burlingame,
2002), the RT can begin to implement various modifications of role-playing games as a recreation
therapy intervention. At this stage, the RT could begin to implement the most rudimentary of RPGs, the
Choose Your Own Adventure (CYOA) form. As long as the client can make a binary/Boolean
responses indicating yes or no, whether verbally, by number of eye blinks, hand squeeze, or other
method, the client potentially qualifies for participation in this therapeutic intervention.
Example CYOA Process
After establishing that the client meets sufficient cognitive functioning, and determining that
client has a sufficient means of response and interaction with the recreation therapist, the RT asks the
client, “Would you like to play a simple version of a role-playing game?”. “Squeeze/blink once for yes,
two for no.” Client indicates yes...
“This adventure is set in Chicago during the 'Roaring '20's'. It is a mystery-style adventure.”
Of course any genre/setting will work.
“You will have three characters you can choose from. I will first list the three options, then I
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will ask you which one you prefer as I go through the list a second time. You will then indicate 'yes'
when I mention the character you want.”
“You may choose to play: 1. A Police Detective, 2. A Private Eye, 3. An Investigative Reporter.”
“Would you like me to repeat that list again?” (yes/no)
“Have you decided which option to pick from those 3 choices?” (yes/no)
When the client indicates “yes” to being ready to choose, the RT states, “I will now repeat those
three choices. Squeeze once for yes when you hear the option you want.”
Client squeezed yes for “Private Eye”.
“You selected 'private eye', is that correct?”. (yes/no).
The RT continues, “You have chosen Private Eye, is that correct?” Client confirms with single
squeeze/blink.
The RT continues, “The story unfolds as follows. An old man has come to your office. A family
heirloom has been stolen from his house. The police have no leads, but he says everyone knows that
you, as the ace private detective that you are, can use alternate channels to find things the police can't
or won't....”
If the client is continuing to be responsive to this form of modified RPG, and if it is deemed
appropriate, as the client's functional level continues to improve, the client's family, friends, and
caretakers may be able to engage the client in continuing the “adventure” when the RT is not around.
Needs addressed by intervention
This intervention addresses a number of the diagnosis A&P codes, some of which include:
•d163 Thinking
•d310 Communication with - receiving – spoken messages.
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•d1750 Solving simple problems
•d177 Making decisions
•d9200 Play
Common Settings
Any environment that is relatively quiet and distraction free, allowing the client to focus on
listening to the storyteller's voice.
Equipment Needed
No special equipment required. TR might need a Choose Your Own Adventure Book, or else a
prepared adventure outline or script.
Program Adaptations
Using hand-squeeze or eye-blink with Boolean-only (yes/no) questions for the client to answer
(one squeeze/blink for yes, two squeezes/blinks for no). As client progresses, may be able to use simple
multiple choice questions instead of only Boolean choices.
Examples of intervention
After spending hours searching, I was unable to find any existing programs using this exact
form of intervention. This intervention meets the requirements for activities addressing the functional
impairments listed, but so far I am unable to find any research information or current programs that
have tried this approach.
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The closest match I could find was an article about the Lincoln University (Snow, 2009)
program requested by the Missouri National Guard using a “choose your own adventure” style
interactive computer video (Hemmerly-Brown, 2010) for military personal suffering from suicide due
to complications from PTSD and TBI. I was not able to find a second program that was even remotely
relevant.
Program Name
The Home Front interactive video.
Location
Online: http://www.armyg1.army.mil/hr/suicide/videos/HomeFront_New/the-home-front/index.html
Description of clients served
For at-risk military personnel to attempt to reduce the levels of depression and suicide from personnel
recovering from PTSD , TBI, and other causes.
Qualifications of program facilitator
Basic computer and online skills. Typical therapeutic background.
How I found this program
Lengthy search for any kind of “choose your own adventure” and “Traumatic brain injury” through
many books and online resources.
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Intervention #2 - Computer-based RPG Use and Modifications for Client
With TBI
Client is now at Rancho Rating IV+. Though client's cognitive functioning is now higher, the
client's ability to communicate is still significantly limited. Based on client's current functioning, it is
recommended to have the client try using a mouse (or Wii-mote) to participate in a computer-based
RPG that is turn-based rather than real-time. The client is able to move and click both buttons on a
mouse, can see the computer screen clearly, and has enough cognitive functioning to interact in the
game at a much higher level than before.
As client slowly regains various levels of functioning, modified versions of RPG will be
presented in which the client may participate.
Client will initially use a mouse with large buttons to interact with computer. This requires the
functioning of at least one arm, hand, and finger, as well as usable visual capacity. The compute-based
RPG should initially be turn-based, using the mouse and then using Wii-mote later as grasping
improves.
Client with click on various options, direct the digital character to take certain actions, and solve
various levels of simple to complex problems.
Needs addressed by intervention
In addition to addressing some of the previous codes in intervention #1, this also addresses:
•d1751 Solving moderately complex problems
•d440 general fine hand use
•d4401 grasping development.
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Example CRPG Process
Client's functional arm (and hand/finger(s)) are placed upon the mouse (or later Wii-mote as
grasping capacity develops). The client navigates on screen prompts to develop character, and than
guides the character through the many challenging scenarios in the game.
Common Settings
In this scenario, ICU or long-term care facility, but potentially usable anywhere that has a
computer.
Equipment Needed
A computer with screen, mouse, and installed software. Optional Internet connection.
Program Adaptations
Different means of interaction with the computer through different interfaces.
Examples of intervention
There are a number of programs using computer games as interventions for many needs,
including TBI recovery, though I was not able to find specific mentioning of computer-based RPGs
specifically, it is not a difficult stretch to extrapolate the benefits. The closest I found was an online
game created by Jane McGonigal (2010) that experienced post-TBI depression and created the game to
help herself recover. I had heard some of the NPR interview about this, and was able to track that down
(Flato, 2011).
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Program Name
Jane the Concussion Slayer by Jane McGonagal & Co.
Location
Online: https://www.superbetter.com/about
Description of clients served
Clients that enjoy computer games that will benefit from stimulus to help recovery from illness
or injury, including traumatic brain injury. The program was created when the creator experienced a
TBI, and was struggling to recover, creating games she found helped her, and other's, recovery process.
Qualifications of program facilitator
Some computer skills, recreation or other similar therapy background.
How I found this program
Web searches for any computer-based games aiding recovery of TBI patients.
References
Burlingame, J. & Blaschko, T.M. (2002). Assessment tools for recreational therapy and related fields
(3rd edition). Ravensdale, WA: Idyll Arbor.
Flato, Ira. (2011, February 18). Talk of the Nation: Could gaming be good for you?. National Public
Radio. Retrieved March 11th, 2013, from http://www.npr.org/2011/02/18/133870801/could-
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gaming-be-good-for-you
Hemmerly-Brown, A. (2010). Army creates new scenario-based suicide-prevention video. Retrieved
March 11th, 2013, from
http://myarmybenefits.us.army.mil/Home/News_Front/Army_creates_new_scenario-
based_suicide-prevention_video.html
McGonigal, J. (2010). Achievements: Unlocked. Retrieved March 11th, 2013, from
http://janemcgonigal.com/2010/12/23/achievements-unlocked/
Porter, H.R., & Burlingame, J. (2010). Recreational therapy handbook of practice: ICF-based
diagnosis and treatment. Enumclaw, WA: Idyll Arbor.
Snow, T. (2009). Soldiers at risk: Mo. Guard responds to threat. Retrieved March 11th, 2013, from
http://www.connectmidmissouri.com/news/news_story.aspx?id=287534
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