Role-Playing Games (RPG) as Intervention Modalities
to Achieve Therapeutic & Educational Goals
for Individuals and Groups
from the Therapeutic Recreation Perspective.
Paper for Living Games Pre-Conference, Texas State University, Austin, TX.
by W.A. Hawkes-Robinson
April 1st, 2016
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This paper includes background information and a few example program plan overviews from
the Therapeutic Recreation / Recreation Therapy (TR) perspective, utilizing both regular & adapted
versions of all 4 role-playing game formats: tabletop (TRPG), live-action (LARP), solo adventure
Choose Your Own Adventure books (CYOA), & computer-based (CRPG). Standard & non-adapted
uses of RPGs for various populations are covered, & specifically adapted forms to better achieve
targeted goals, or the adaptation needs of specific disabilities. The full-length (120 minutes)
presentation on which this paper is based, & other details here: http://rpgr.org/tsu-paper-collection.
I am registered with the Washington Department of Health & Human Services as a Recreation
Therapist since 2014 & currently an undergraduate student at Eastern Washington University (EWU)
working on an interdisciplinary degree in Recreation Therapy, Music Therapy, Neuroscience &
Research Psychology. Involved with RPGs since ~1978. Details: http://rpgr.org/staff/hawke-robinson.
Regarding program plans that are more cooperative in nature, Stumbo & Peterson's Therapeutic
Recreation Program Design Principles & Procedures (2009) states that it is “overwhelmingly
important” to provide programs that emphasize the Avedon Intragroup interaction pattern, especially
with such an overabundance of TR solo & competitive programs & lack of truly cooperative activities
(192). Important for many, especially children (Statsky 2006).
Professor Dattilo's book (2011), maps very well between TR & RPGs. Especially the chapters
on “Adventure Therapy” (15) for all RPG formats, “Expressive Arts as Therapeutic Media” (153) for
LARP, & “Therapeutic Use of Play” (515) for TRPG.
Most early research on RPGs was triggered by the popular media, individuals, & various
organizations such as Patricia Pulling of B.A.D.D. (1988 & 1989), and others (Dear 1985, Pratte 1986,
Greenberg 2005, Robertson 2012) claiming the “dangers” of RPGs (Cardwell 1994), however research
found either neutral or opposite-indicating results (Leeds 1995). Using online lists (Kim 2008) and
EWU library database searches in 2008 I found only about 60 studies on psychological relationships
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between RPGs & gamers, though observing increasing momentum in recent years. Examples include:
more rapidly develop foreign language skills (Phillips 1994), novelty & stimulus in classroom settings
for ADHD (Dendy 2011), developing stronger skills in reading, mathematics, creative thinking,
cooperative play, problem-solving, & social skills. (DeRenard & Kline 1990), improved child behavior
& attitudes (Bay-Hinitz 1994), & catharsis (Hughes 1988). Also development of many other skills as
well as potentially significant therapeutic benefits (Kestrel 2005), a suicide rate of TRPG players 1/8th
that of non-gamers (Blackmon 1994), use of RPG in the self-treatment of clinical depression (John
Hughes 1988), lower levels of meaninglessness & alienation (Derenard & Kline 1990, Hawkes-
Robinson 2011), & a study by Abyeta, Suzanne & Forest, James (1991, December) indicating that
gamers are lower in criminal tendencies than rest of population, however, psychoticism, which was
higher in the non-gamers, did predict criminality.
CYOA format pros: Accessible to a wide population, flexible time commitment, well structured,
reusable, very inexpensive, & easiest learning curve for TRS & other care-providers without prior RPG
Cons: Not social (unless modified/adapted to be read aloud by others, though through guided
post-activity “processing” can be used to work on social skills), rigidly structured, doesn't allow
flexibility outside of the if/then design, doesn't really allow for “character development”, requires
matching language abilities & cultural cohort considerations between the client & book, & requires
reading skills unless someone to read for them (non-English literate, younger, or reading impaired
TRPG format pros: Inherently social activity, cooperative game-play. Research further
reinforces that fantasy RPG players have higher empathy scores than non-gamers (Rivers et al. 2016)
(Yee 1999). Accessible to wide range of populations, & generally inexpensive initial investment with
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long-term re-usability of equipment. Creativity & unlimited flexibility choices. Easy to find players in
small cities or larger, & easy to find locations to play. Triggers many other interests in peripheral
subjects such as history, literature, cartography, painting, sculpting, metallurgy, physics, etc. &
motivations for ancillary activities like miniature painting, terrain building, map drawing, etc.
Cons: Generally not at all physically active, can be difficult to find players/groups in small
towns with some locations having ongoing societal stigma & outright hostility, especially in more rural
communities. Many facilities are not wheelchair friendly, are noisy, dirty, too hot, cold, or otherwise
uncomfortable. Without an experienced & skilled GM/TRS running the game, if participants are
lacking in social skills (such as ASD/PDD clients), games can rapidly break down & lead to group
dissolution. Steepest learning curve for a care provider lacking prior TRPG experience, which can take
weeks, months, or years to develop, but this can be addressed through collaboration with TR & non-
TR-trained GMs, similar to the Romach program in Israel.
CRPG format: Critical consideration is real-time vs. turn-based. Clients with significant
physical &/or cognitive impairments will be much better served with turn-based CRPGs that wait
indefinitely for user input, compared to real-time CRPGs that rely on coordination, reflexes, & fast
cognitive processing speeds. Aggregate of research indicating “healthy” screen time is around 1-2
hours per day, happier kids (Gosden 2014), increased pre-frontal cortex gray matter and improved
memory & navigation abilities (Kelman 2015), and neuro-plasticity benefits (McGonigal 2011).
Caveats related to social & empathetic skills, with exceptions illustrated in NPR's Science
Friday “How Games Move Us” (2016), games that specifically work on evoking emotion, compassion,
Pros: Many styles & genres, now more culturally accepted. Some useful for social skills & trial-
by-error learning, example: Life is Strange. Online versions can join with existing friends & family &
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provide a means for making new friends online, especially helpful for those that are severely physically
restricted, allowing connection with the world when would otherwise be socially isolated, & for those
with social phobias they can slowly increase social connections behind the safety of the screen. Easy to
find others to game with online. Many adaptive interfaces available for disabilities. The more
physically interactive interfaces such as the Wii, can provide physical activity. Training curve for care
providers is low.
Cons: Majority not physically active, higher levels of obesity. Most offline versions do not help
with social skill development, can be detrimental to empathy, etc., though exceptions with examples of
That Dragon, Cancer, or Life is Strange. Online communities can be poor social experiences. Potential
issues regarding violent games, interface & traits (Jung, Park, & Lee 2015). More limited choices &
creativity than TRPG or LARP. Poor communication skills. Companies build in much “grinding” &
“hooking” reinforcing “addictive-like” behavior patterns by design. Expensive upfront & recurring
costs & obsolescence.
LARP format: TR professionals have extensive training in managing groups & the many
dynamics that occur in group challenges under pressure, so this is another area where as-yet untapped
potentially strong synergistic relationship could be developed between this professional community &
the LARP community!
Pros: Variable physicality, flexibility for wide range of populations, encourages variants of team
work, strongly encourages creativity & problem-solving, verbal & other communication skills, social
skills, neural mapping with objects & world, many ancillary interests like painting, music, costume
design & manufacture, etc.
Cons: Often more competitive in nature, the more combat-centered LARPs require athletic
prowess rather than character abilities beyond the player's normal limitations which can exclude many
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with significant physical or cognitive disabilities. Some can be somewhat expensive either in time or
materials for equipment/costumes. Often difficult to find LARP groups nearby. Location
accommodations can be challenging &/or limited by weather if outdoors, & many are not
ADA/wheelchair friendly. There is significant ongoing social stigma & downright hostility in many
locations (more than all the other formats of RPG). Learning curve for care providers without prior
RPG experience is steep compared to computer-based or solo RPGs, though with some entry-level &
rules-light LARP systems, but less steep than typical TRPG.
My general observations of ASD/PDD populations when participating in well-run TRPG &
LARP generally leads to reduction of stereotyped behaviors such as fixation, distraction, hand-flapping,
isolation, lack of response/interaction to/with others, & improvements in social interaction, cooperative
play, communication, affect, self-confidence, while competitive game “losses” reduce their confidence.
The key is structure, balance, & guidance. Little-to-no modifications necessary to either LARP or
TRPG for this population to benefit. CRPG & CYOA need more supervision to limit hyper-focus.
Example: TRPG for ASD, Civic Resources. 1940s Noir Setting, “Case of the Missing Surgeon”.
Participants working together, access & use civic resources such as police, fire department, doctor's
office, hospital, theater, community center, etc. Details: http://rpgr.org/first-prototype-rpg
Example: TRPG & LARP for ASD Youth & Adults. Transit System. Participants build
confidence & competence toward improved autonomy through use of the public transit system. Begins
by using TRPG for phase I, then LARP actually using the buses for the final phase II. Details:
Example: ASD / PDD Toddlers, Adapted LARP. Implemented trial with ASD toddlers & their
neurologically normal peer group. Immediate reduction in stereotyped behaviors during the activities
using LARP-basis compared to the simultaneous non-LARP activities. Higher success rates at
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completing all tasks cooperatively. All but one participant completed all tasks successfully, & all
maintained attention & focus for full duration of 15 minute session rotations, compared to average of
only 5 minutes for non-LARP. Details: http://rpgresearch.com/blog/creating-larp-program-for-autism-
Example: TRPG & LARP for Deaf & Hard of Hearing. Social activity for Deaf participants to
reduce isolation & encourage interaction with TRPG & LARP using American Sign Language (ASL).
Example: TRPG or LARP, At-risk & Troubled Youth, Substance Abuse Recovery & Transition
Plan. Using regular TRPG & LARP, provide other forms of diversionary activities than substance
use/abuse, or associated destructive, violent, theft & high risk activities. If higher stimulus requirement,
then participation in combat-based LARP, as outlet for such energy. Transition plan includes local
gaming groups at hobby store, separate from drug culture peer group that would otherwise
automatically return to as only recreational activity. Pilot program discussions & development with TR
staff at Navos Mental Health in Seattle, WA.
MMORPG to TRPG for Social Phobias. 1 year informal research project, 12 new groups, 2
participants in 2 separate groups struggling with severe social phobias. Started with MMORPG, but
wanted to try a more social connection, but in a safe setting, so each joined a group. Reported
significantly decreasing anxiety levels in groups over time.
Example: All 4 Formats of RPG for Brain Injury Recovery Program. Based on amalgamation of
actual cases from multiple facilities. Detailed video presentation (24:22) & supporting documents here:
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Recovery Stage 1, CYOA Modality. Assessment: Diffuse brain injury, & localized concussive &
piercing injuries to specific parts of the brain & spinal cord. Coming out of induced coma, Rancho Los
Amigo Stage II, with minimal interactive capacity. Stamina limited to around 15-30 minutes between
extended hours of rest.
Planning: After consultation, client's favorite activities included CRPG. RPG modality can be
considered even if the client has never played RPGs, if interested in any books, television, or movies.
Implementation of adapted interactive CYOA: RTS (Recreation Therapy Specialist) asks the
client, “Would you like to play a simple version of a role-playing game?”. “Squeeze/blink once for yes,
two for no.”
Evaluation: Measurable improvements in the following areas: basic cognition, social
interaction, simple to moderate problem solving, speech comprehension, encourages brain plasticity
Recovery Stage 2 – CRPG Modality. Assessment: Regained full visual function, only able to
answer with simple monosyllabic words, very labile, significant aphasia, limited motor function of
right arm, hand, & fingers, with full sensory response. Stamina 30 minutes.
Planning: Recommend using mouse, Wii-mote, or adaptive interface to participate in an offline,
turn-based, CRPG. Should aide in neuroplasticity-related improvements in general cognition, problem
solving, audio &/or visual language comprehension, gross motor functions, limited fine motor
Implementation & adaptations: Client able to move & click both buttons on mouse, can see the
computer screen clearly, & has enough cognitive functioning to interact in the game at a much higher
level than before.
Recovery Stage 3, TRPG Modality. Assessment: Temporary impairment from spinal injury
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around T1-T4, has regained limited use of entire upper body, can engage in light speech using very
simple sentences, still some aphasia, can't move legs, stamina about 1 hour, using wheelchair.
Planning: Client now able to participate with minimal modification in TRPG. Some assistance
is necessary from other participants to be patient & assist as needed when client has trouble
communicating correct word or intention verbally. Able to pick up & roll, manipulate, read, & calculate
dice rolls & simpler character variable calculations, though may have some trouble with verbally
expressing the result. Comprehend letters, rulebooks, dialog, & mildly complex scenario puzzles. Can
handle & write on paper with pencil, engage in adventure dialog between GM & other players.
Implementation & Adaptations: Only minor modifications are necessary for client to participate
in this form of RPG. The tabletop interaction with other players & the Game Master (GM) will need to
operate at a slower pace than “normal”, but client will be able to participate in the complete TRPG
Evaluation: Measurable improvements in reading comprehension, social skills, joint &
individual complex problem solving, speech, listening & comprehension, basic math, fine motor skills.
Recovery Stage 4 – LARP Modality. Assessment: Permanent L3 injury. Some ability to walk
with assistance (braces), speech mostly recovered with occasional aphasia, some continued loss of
some past memories but able to create & maintain most new memories. Some ataxic & spastic gross
motor movement, but prognosis is positive if continue to engage in regular physical activities. Client is
strongly averse to “regular” workout regimen or physical therapy, but curious about LARP with
wheelchair or with braces. Planning: Will need to be a LARP program & group that allows for client's
disabilities. Implementation: Client initially participates in controlled clinical setting with other
“LARPers”. Over time client may be able to participate in LARP activities outside of clinical setting.
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