Role-play Games (RPGs) for Mental Health (Why Not?): Roll for Initiative

Abstract

COVID-19 has impacted the mental health of the general public negatively, associated with preventative measures, restricting life activities. These restrictions, such as the stay-at-home strategy, have resulted in heightened stress, depression, loneliness, substance abuse and domestic violence, violating people’s occupational and personal lives. During the pandemic, the demands for roleplay games (RPGs) have increased: for example, the sales of “Dungeons & Dragons” tripled, underscoring the potential mental health benefits of such games. However, research into the mental health benefits of such games remains under-developed, needing more scientific attention. Accordingly, this commentary paper reviews the existing literature, and suggests areas for application and research about RPGs and mental health including psychotherapy, career guidance, education, and people with disabilities. Insights offered can help practitioners and researchers in RPGs and mental health conduct empirical research and develop alternative approaches for mental health in stressful times.

Full text

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International Journal of Mental Health and Addiction (2023) 21:3901–3909
https://doi.org/10.1007/s11469-022-00832-y
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COMMENTARY
Role‑play Games (RPGs) forMental Health (Why Not?): Roll
forInitiative
IanS.Baker1 · IanJ.Turner2· YasuhiroKotera3
Accepted: 25 April 2022 / Published online: 11 May 2022
© The Author(s) 2022
Abstract
COVID-19 has impacted the mental health of the general public negatively, associated
with preventative measures, restricting life activities. These restrictions, such as the stay-
at-home strategy, resulted in heightened stress, depression, loneliness, substance abuse,
and domestic violence, violating people’s occupational and personal lives. During the pan-
demic, the demands for role-play games (RPGs) have increased: for example, the sales of
“Dungeons & Dragons” tripled, underscoring the potential mental health benefits of such
games. However, research into the mental health benefits of such games remains under-
developed, needing more scientific attention. Accordingly, this commentary paper reviews
the existing literature, and suggests areas for application and research about RPGs and
mental health including psychotherapy, career guidance, education, and people with dis-
abilities. Insights offered can help practitioners and researchers in RPGs and mental health
conduct empirical research and develop alternative approaches for mental health in stress-
ful times.
Keywords Dungeons & Dragons· D&D· Mental health· Applications· COVID-19
Mental Health Diculties During COVID‑19
The COVID-19 pandemic has brought negative impacts on our mental health due to
drastic lifestyle changes (e.g. social distancing, quarantine, lockdown). Derivative
impacts such as unstable employment and access to health services as well as the fear
of being infected with the virus have raised stress levels (Bhandari etal., 2021). The
rates of anxiety and depression areincreasing more rapidly than ever before, with a rise of 20%
in stress levels since the beginning of the pandemic (Rajkumar, 2020; Vindegaard & Benros,
2020). Levels of domestic abuse and substance use have also increased (Abramson,
2021; Evans etal., 2020). Research has identified many risk factors for mental health
* Ian S. Baker
i.s.baker@derby.ac.uk
1 School ofPsychology, University ofDerby, Kedleston Road, DerbyDE211GB, UK
2 Provost, Learning & Teaching: Student Performance, University ofDerby, Kedleston Road,
DerbyDE211GB, UK
3 University ofNottingham, NottinghamNG72RD, UK
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difficulties in COVID-19, including poor sleep quality (Liu etal., 2020), being female
(Liu et al., 2020), working in healthcare (Kotera etal., 2021), those with a pre-COVID
medical diagnosis (Barber etal., 2020), and being a migrant (Bhandari etal., 2021). The
diversity of these factors implies that COVID-19 has impacted our mental health on a
broad level: many of us have been mentally impacted by COVID-19.
Despite the large and broad impact of mental health difficulties, appraisal for effec-
tive treatment remains to be refined. Indeed, reduced rates of mental health difficulties
have been found in some countries; however, these changes can be explained by exter-
nal events. For instance, in the UK, the level of anxiety has dropped from 62% in March
2020 to 42% in February 2021 among the general population, and from 67% in June
2020 to 58% in February 2021 among people with a pre-existing mental health diagno-
sis (Mental Health Foundation, 2021). These improvements can be understood as being
a result of the administration of the vaccine, initiated in December 2020 (British Broad-
casting Corporation, 2020) earlier than most countries, but this left the root cause of the
COVID-19 mental health difficulties untreated. Unsurprisingly, the rate of people who
feel that they are coping with stress associated with the pandemic has reduced from 73%
in April 2020 to 64% in February 2021 (Mental Health Foundation, 2021). Significant
post-COVID-19 mental health challenges are expected (Mayne, 2020), with the poten-
tial for us to experience a worldwide outbreak of mental health problems alongside or
following COVID-19 (Pies, 2020). These findings illustrate the need for developing an
effective and practical mental health strategy. On an individual level, one emergent cop-
ing strategy during the pandemic was the increased use of role-playing games (RPGs).
Increasing Demand forRole‑playing Games (RPGs) During
thePandemic
Role-playing games emerged from wargames which, in turn, originated in ancient strategy
games, particularly chess. Role-playing games are unlike wargames in that they are co-
operative in nature and the operational level is on the individual rather than groups, units,
battalions, etc., and the interactions can be complex, going beyond combat. A typical role-
playing game involves a “Dungeon Master” (DM, or “Games Master”) who describes what
the other players can see and experience, outlines the nature of the imaginary world, and
controls the non-player characters (NPCs) that the players interact with. The DM also out-
lines the missions, tasks, problems, and challenges the players face, but the decisions they
make can be relatively open-ended, resulting in a complex and multi-layered experience.
The players each control one (occasionally more) character that has set characteristics and
abilities that are determined by a numerical value, and this is supplemented by equipment
that may help their abilities. These characteristics and abilities are typically constructed
via set formats, and when a player wishes their character to perform an action (e.g. climb
a wall, swing a sword, cast a spell, persuade someone), they have to roll a die and add or
subtract values based upon how good their character is at that task; typically a higher roll
will indicate success, and the DM will describe the consequences of the success or failure
of the die roll. This creates a rich, narrative-based interaction between DM and players that
is akin to modern storytelling; the players are not playing “against” the DM, but rather all
participants are joined together in a shared story experience. This can be face-to-face or
online, and there are dedicated online systems (e.g. D&D Beyond, Roll20) for playing such
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games. Much of the experience relies upon the imaginations of the participants, but this
can be augmented with the use of miniatures that represent the players and the NPCs, and
two-dimensional maps (with or without three-dimensional terrain) to help make the experi-
ence more immersive. In the online environment, this has been extended to players being
only able to see the parts of their environment that their characters themselves can see,
resulting in surprises for the uncautious (or unlucky) player.
Due to the plethora of games available today, the setting of a particular role-playing
game can be varied, from fantasy to science-fiction, from history to horror. The first role-
playing game (known as “Generation 1”) available commercially was Dungeons & Drag-
ons (or D&D/DnD), designed by Gary Gygax and Dave Areson and published in 1974.
Although its popularity has ebbed and flowed over the years, it has also experienced its
controversies, for example, in the 1980s it formed part of the “Satanic Panic” in the USA
which claimed that “this imaginary game could induce players to believe its fantasy was
real, they believed that players mistakenly thought the fantasy of the game was imaginary,
when it actually indoctrinated them into real-world witchcraft and demonology.” (Peter-
son, 2021; p. 181) which led to devils and demons being removed from its 2nd Edition
(Grundhauser, 2016). There have also been issues with stereotypes around the portal of
race with supplements such as Oriental Adventures in 1985 and the Tomb of Annihilation
in 2017 being criticised for how Black culture is presented and amalgamated (D’Anastasio,
2017); Garcia (2017) has explored how players’ identities and experiences are influenced
by the deceptions of constructs like race and gender in D&D. However, recent research
into whether people view orcs as racist has indicated that playing D&D was not associated
with higher levels of ethnocentrism or racism, and priming people questions regarding if
certain material is racist may prime them to see racism in such material (Ferguson, 2022).
Hollander (2021) argues that D&D can yield a personal-political edification providing an
informal “moral training” but notes it can also reinforce harmful associations that exist
towards others.
Even with controversies, it remains popular. As of 2014, it is now in its fifth edition, and
it has seen a tremendous growth in recent years, with Wizards of the Coast (a division of
Hasbro which owns the game) estimating over 50 million people had played the game, and
their revenue increased 24% in 2020 to over $816 million. Part of this surge in growth has
been as a reaction to the COVID-19 pandemic, with Fandom (the owners of D&D Beyond,
an online platform where D&D can be played) reporting their number of subscribers dou-
bling between 2019 and 2020, and individuals reporting that playing D&D has supported
their mental health during the pandemic (Skipwith, 2021). Although there are a multitude
of RPGs available (including highly related ones, such as Pathfinder) and the conclusions
drawn here could apply to most of them, due to its historical status in the community and
increased popularity during the pandemic, D&D is the main focus of this piece.
Impact ofRole‑playing Games onMental Health
D&D has a long history with mental health. In its early years, it was incorrectly linked by
the mainstream media to teenage delinquency and immorality, without any demonstrable
causal relationship. Not long after the game’s development, the alleged role of D&D in the
disappearance of James Dallas Egbert III and the suicide of Irving Bink Pulling II, along-
side religious condemnation of D&D based on its purported links to satanism and other
controversies mentioned previously, created a stigma associated with D&D that persists
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at times today (Kelly, 2019; Sidhu & Carter, 2020; Polkinghorne etal., 2021). This link
between D&D and psychopathology, caused by the persistence of these stereotypes, has
been investigated by several scholars (Ben-Ezra et al., 2018; Lis et al., 2015). However,
their findings suggest that engagement with D&D is not associated with a sign of psycho-
pathology. They furthermore show that familiarity with D&D leads to a lower likelihood
of that belief. In fact, regular D&D players demonstrated no difference on the scores in the
Beck Depression and Eysenck Personality Inventories compared with a control group, who
did not play the game (Carter & Lester, 1998). Additional research examining the impacts,
both positive and negative, of D&D is needed.
Role‑play Games intheClinical Setting
Role-play in clinical practice is reported to be associated with higher levels of reflection,
empathy, insights about the client, and peer learning (Rønning & Bjørkly, 2019). By simu-
lating a real situation, participants are more able to appreciate people in the context, lead-
ing to better understanding (Caltabiano etal., 2018). RPGs are sometimes used as thera-
peutic tools in psychodrama and drama therapy; psychodrama therapy involves patients
under supervision dramatising a number of scenes such as specific happenings from the
past, often with help from a group, enabling them to reflect on and explore alternative ways
of dealing with them (Kedem-Tahar & Felix-Kellermann 1996). Drama therapy has more
of an emphasis on spontaneity and creativity and employs playful approaches. More spe-
cifically, it is a systematic and controlled approach that uses dramatic action to explore
emotional issues (Kedem-Tahar & Felix-Kellermann 1996).
It has been suggested that D&D, with its narrative structures about overcoming adver-
sity and exploring alternative identities, mirrors aspects of mental health recovery (Kerr
etal., 2020). The use of D&D in a clinical setting is reported as early as 1994 where Black-
mon describes the treatment of Fred (19) who suffered from an obsessional, schizoid per-
sonality. In the therapy sessions, Blackmon (1994) gradually allows Fred to describe his
D&D experiences as he realises it is almost a form of self-therapy and Fred’s character
has provided an outlet for working through his emotions in a safe way. Blackmon specifi-
cally notes that D and D rule systems shape the fantasy construct of the game, the structure
is not there to constrict but to reduce anxiety and enable. Kallam (1984) observed that a
group of “mildly handicapped” adolescents who played D&D twice a week, for 9 weeks,
gradually developed higher self-efficacy and capacity for creative and complex situations
when playing D&D compared to a control group. There are other published studies that
touch on the effectiveness of psychodrama and drama therapy adaptations of role-playing,
though not in all cases focusing specifically on D&D (Enfield, 2007; Rosselet & Stauffer,
2013; Zayas & Lewis, 1986; Hughes, 1988). Much of this work is based on localised case
studies which makes it difficult to extract the essential aspects into clinical recommenda-
tions which could be tested on a larger scale. It does indicate that RPGs could provide a
structured “safe space” (Dare etal., 2021) for the exploration of psychopathologies.
Henrich and Worthington (2021) conducted a rapid evidence assessment of the thera-
peutic utility of D&D, and they found a tentative link between D&D and psychological
benefits such as creativity (Chung, 2013) and empathy (Rivers etal., 2016). This is sup-
ported by the broader literature on RPG, where evidence exists for a wider range of skills
positively impacted by RPG. For example, Abbott etal. (2022) have shown that D&D in
a small therapeutic setting can help increase confidence, the ability to confront situations,
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and cope with unexpected events. Furthermore, the author demonstrates that these skills
were transferred to the real world.
Polkinghorne etal. (2021) agree RPGs offer great potential in the context of narrative
therapy for building resilience and improving the resilience of participants. However, they
argue that not enough consideration has been given to the game’s environments and rules
themselves, with focus localised upon commercial games like D&D. The collaborative
nature of D&D and its scaffolded storytelling experience offers great therapeutic poten-
tial but they argue the game itself is part of that therapeutic experience. The D&D game
world is often used without significant adaptation to the client: there is a lack of explora-
tion of its specific contribution to the therapeutic experience. In a similar theme of tailor-
ing the D&D experience appropriately and the potential benefits of the experience itself,
Mendoza (2020) argues that D&D is not for novices and that the games itself contains very
little guidance on active role-play (5th Edition) and the games’ rules focus heavily on the
“hack-and-slash” mechanisms for gaining in-game experience points to improve your char-
acter. They believe the therapeutic benefits come from D&D familiarity, scaffolding, and
structured rules that specifically reduce anxiety of choice paralysis. Therefore, appropriate
introduction to such games is essential, ideally by experienced and compassionate players.
Role‑play Games intheNon‑clinical Setting
The use of role-play games (rather than therapeutic role-play) in a clinical setting could be
a valuable tool for clinicians. However, their potential benefits in non-clinical settings show
broader promise of assisting people in a COVID-19 world and beyond. Previous studies
have been limited in number and focussed on small samples with qualitative approaches,
but researchers have studied the benefits of D&D play on mental health and wellbeing in
non-clinical settings.
Adams (2013) analysed the Facebook chat log of a nine-person D&D group over a
3-year period using Bormann’s (1972) theme analysis. The four themes that emerged were
(1) democratic ideologies, (2) friendship maintenance (3) extraordinary experiences, and
(4) good versus evil. The findings provide a description of group members’ real-world
needs being met through symbolic in-game interactions evidenced by communicative
markers.
In a similar study, Sargent (2014) undertook a qualitative analysis of six D&D players,
using uniform narrative analysis from structured interviews. Although specific measures
of players’ mental health were not recorded, Sargent did find that playing D&D decreased
players’ social anxiety and allowed them to interact with their own emotional content in
an experience that “meant something” and often was only (perceived) to be possible in
a fictional world. Five of the players reported how trauma during childhood was in part
successfully navigated through playing D&D; likewise, the players describe how gaming
experiences helped them cope with internal conflicts and stress. The sense of community
and belonging was important to the players; they felt that experimentation through their
characters led to improved real-world social skills and the development of new relation-
ships. These relationships in turn were reported by the players as helping them cope with
stressful situations.
In a qualitative study that focussed more specifically on how D&D relates to mental
health, Causo and Quinlan (2021) utilised narrative enquiry to understand the experi-
ences of thirteen players who were recovering from mental health difficulties. Narrative
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enquiry of the interview transcript was undertaken inductively and deductively, and sev-
eral themes were identified that linked D&D to their well-being. These were (a) experi-
encing through characters, (b) skill building, (c) finding space from mental health symp-
toms, (d) safely engaging with mental health difficulties, and (e) building relationships.
The authors report that all five stages of the Psychological Recovery Model (Andresen
etal., 2003) were observed and that all players engaged with D&D in a manner reflec-
tive of their mental health recovery process.
In a theoretical exploration of how RPGs can benefit individuals, Hall (2015) argues
that players benefit from an increased emphasis on role-play as an important aspect of
psychosocial growth. The author suggests D&D characters are well-formed, semi-inde-
pendent personae of their players, who have potential to be equal in influence to an indi-
vidual’s other expressions of personality. Hall argues that players’ D&D characters, like
all aspects of personality, exist at the junction of mythical, psychological, and socio-
logical forces and therefore potentially an important tool for strong mental health. More
recently, and particularly in response to the COVID-19 pandemic, there have been sev-
eral anecdotal accounts in the media of the benefits of playing D&D in supporting the
mental health of children (Krieger, 2021) and adults (Hughes, 2021), addressing social
anxiety in “post-lockdown angst” (Hazel, 2021) and helping autistic individuals con-
structively interact with others (Leach, 2021). These qualitative studies and anecdotal
reports all provide evidence that playing RPGs such as D&D can aid in friendship and
relationship maintenance, mitigation of social anxiety, improved social skills, reducing
stress, alleviation from mental health challenges, and providing connection with oth-
ers. This alone provides strong support for the need for more systemic and wide-scale
research into the benefits of playing RPGs in a COVID and post-COVID world.
Suggestion forApplications andResearch
We have several recommendations for the exploration of how RPGs can be researched
and used to support mental health:
• Building upon the qualitative research above, further research could be conducted
examining the experiences of players during the pandemic and how it had supported
them.
• There is a dearth of research looking at larger samples of players, their experiences
of and attitudes towards RPGs, and how they have been affected by the pandemic. In
addition, how these relate to other personality characteristics such as anxiety, extra-
version, relationship formation and maintenance, and others.
• Qualitative approaches could also be used to examine how neurodiverse individuals
may be able to experience and interact with others using role-play games as a struc-
tured medium of expression.
• Mixed method approaches could examine the types of characters players create and
how they use them as a method of exploring aspects of one’s self as a form of posi-
tive expression, such as gender identities or the use of archetypes.
• The use of RPGs could be used as an intervention-based approach for the improve-
ment of mental health, such as reducing levels of depression, stress, anxiety, or lone-
liness.
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• In terms of pedagogic research, RPGs could be examined as a game-based learning
method for the teaching of probability theory, basic statistics, and exploring ethical
dilemmas.
• Due to some of the controversies surrounding the playing of RPGs, when tailoring the
experience of playing it (e.g. Polkinghorne etal.’s (2021) suggestion) in the research
and applications outlined above, an inclusive environment should be engendered to sup-
port the mental health and/or learning of players.
Considering the ever-increasing demands of RPGs associated with the pandemic, their
effects on mental health need to be empirically evaluated, as mental health is a cause of
concern for many countries today. Insights from this article can help practitioners and
researchers in RPGs and mental health conduct empirical research, and develop non-clini-
cal approaches to improve people’s mental health in stressful times. The title of this piece
includes the phrase “roll for initiative”, which in D&D is where each player rolls a die to
determine the order in which they act in combat, with a high roll going first; it is time for
us to roll high and systematically explore how RPGs can help support mental health.
Declarations
Conflict of Interest The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly
from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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