Dungeons & Dragons can help teens in therapy 

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Teenagers with social adjustment issues can learn to better understand and relate to others through the fantasy role-playing game Dungeons and Dragons. Here to explain how this works is Dr. Robin Dean. She's a doctor of psychology and an assistant professor of psychiatry and behavioral sciences at Upstate. Welcome to "The Informed Patient," Dr. Dean.

[00:00:34] Robin Dean, PsyD: Thank you for having me. I'm excited to talk.

[00:00:38] Host Amber Smith: You heard about using fantasy games in therapy for young people at a psychotherapy conference, is that right?

[00:00:45] Robin Dean, PsyD: Yes. I am a member of the American Group Psychotherapy Association, and they hold a conference every year that's focused on group psychotherapy options for children, adults, private practice, kind of across the spectrum.

[00:01:03] Host Amber Smith: Well, can you describe what fantasy games are in general?

[00:01:08] Robin Dean, PsyD: So usually we talk about, in this area, tabletop role play games, which is folks sitting around a table working together to create a story. And so in most of these situations there is a leader most often known as the Dungeon Master who creates the fantasy world and who establishes the main objective for the group and characters that they interact with along the way, and then with the other players -- each one taking on a persona or personas in the game -- they create a story of folks working together, maybe sometimes even in opposition, toward this main objective.

[00:02:04] Host Amber Smith: So it's not on a TV screen or a computer screen, it's not on telephones or cell phones. It's played in person, sitting around looking at each other.

[00:02:14] Robin Dean, PsyD: It can be. With COVID, a lot of things moved online, and so there are definitely virtual games. And when you want to connect with folks that are farther away, that can also be done virtually. But for the most part, it's played in your mind and your imagination. And so however it is that you want to connect with others and build that story together, you can use multiple platforms.

[00:02:44] Host Amber Smith: So what can you tell us about Dungeons and Dragons, for someone who's never played that game? What's important to know before you get started?

[00:02:51] Robin Dean, PsyD: Dungeons and Dragons is really just one example of these tabletop games. Different games have slightly different rules, but in the end it really kind of boils down to a group of folks working together toward that, I guess, mission or adventure.

Some specific things that may come into play that could be of interest... so there are different types of characters, warlocks or rangers, gnomes. And, different characters have different skill sets. And so for example, as the DM (Dungeon Master) currently, I've created a non-player character, somebody that's joined the game in order to facilitate, who is a forrest gnome. And in his back story that I've given him in my head, he was a guy of the world. And gnomes are small and kind of don't really get considered a lot in the human world, or amongst the bigger monsters. And so he's moved out to the forest to just kind of live a simpler life.

And so when our players come to interact with him, he's a tinkerer, and he's really into, like, gnome culture and heritage, and he is helping to put on a basically a gnome culture fest. And they're helping with this party. And so, him as a character, he would be really good at things that require some level of intelligence because he's a builder, and he's creative. And so, he's more likely to have skills in those things.

In addition to the skills that come inherent with the character's race and class, there's also a level of chance. And so, although he might be really good at building stuff, when we get to a point where he says he wants to build something, there are the dice which add a little bit of chance. And so rolling the dice,then adds in, like, possibly an epic fail. So maybe he says, "well, I want to build a crane in order to help the team reach high places as we're decorating." And you roll the dice, and he just gets a really bad roll. And so he builds it, sets it up, and everything just crumbles.

Because in life, even if you do have skills and are generally more successful in stuff, sometimes the roll of the dice or the luck of the draw means that things don't go well for you. And so it's also interesting to kind of think about, like, that aspect. And so in playing the game you create a character that has a back story, that has a history, that has a way of interaction, that has skills and abilities. And then there's also this idea of chance, and the things that you can control and not control with what other characters do, or just the roll of the dice.

[00:06:08] Host Amber Smith: Is there any dressing up or props that come about with this?

[00:06:13] Robin Dean, PsyD: There can be. It's not necessary, because as I said, the game is played in your imagination. But a lot of times people do like to dress up in order to get into the persona of their character.

I keep a dragon puppet in my office. And every once in a while when I need a little inspiration, he and I will walk through the building, in order to really get into the dragon feel. It helps with the mood of the game.

[00:06:43] Host Amber Smith: Now, before we get into this anymore, I wanted to ask you how teens are traditionally treated for social adjustment issues, because traditionally it wasn't by playing Dungeons and Dragons. What has it been before?

[00:06:58] Robin Dean, PsyD: Usually treatment within the child and adolescent clinic is focused on individual interventions. So what that may look like, typically, is talking to your therapist about some struggle you had with the world outside, and processing through how you feel about that, and getting support or techniques on ways in which to do that better going forward.

And so your therapist may say, "OK, so you're in an argument with your friend. Why don't you try looking at their perspective, and what would their perspective look like?" And so from their perspective, what could they be looking for from you? And so now what can you do now might be to try to explain your feelings to them and apologize for the parts that you've played, and this is what you can do going forward.

[00:08:03] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with doctor of psychology Robin Dean about using Dungeons and Dragons to help teens in therapy at Upstate.

[00:08:15] Robin Dean, PsyD: Now, what made you interested in trying D and D with teens at Upstate? The short answer is that it sounded fun. I am not much of a gamer. And I think that's partially because it's not the way I was told or that you're supposed to behave. Gaming is a thing for geeks and nerds. And so growing up I never really got into it, although I think I was always kind of interested. And so when, as an adult, I found out that there is the possibility of doing good therapy and also getting into something that for the longest time I was told, oh, maybe you shouldn't do that because then you're a bit of an outcast or kicked aside.

During the conference we played a little. And you could really see how this could be effective for clients. And, it was fun.

[00:09:22] Host Amber Smith: So how did you introduce the game? Did you already have a group of teens that you thought this would work with, or did you assemble them?

[00:09:32] Robin Dean, PsyD: Because it is a very new idea and an untraditional approach, I needed to get permission in order to run the game. And so we started with a little bit of research in terms of the effectiveness, and we needed to make sure that it would be paid for by insurance.

And then I got referrals from other therapists within the clinic for kids, specifically teenagers, that had some interpersonal difficulties who would benefit from being able to practice their skills in the moment with the support of a therapist.

[00:10:10] Host Amber Smith: How long does the game last?

[00:10:12] Robin Dean, PsyD: The game can last as long as you like. And so, in just playing D and D, you can do a one-shot game, which is, a random group of people get together, you have an objective that you want to accomplish, and you spend an hour or two accomplishing that objective.

[00:10:30] Robin Dean, PsyD: Or, the game can last for years. Depending on the complexity of the story or what happens after you accomplish one objective, you can always add on another. So the storyline that we are playing currently is the youth have all been recruited into a government organization, and the goal of the government is to help the various factions within the community to live better in harmony and peace and to have the resources that they need and order to thrive.

And so we've been doing this particular game for three campaigns. Each of our campaigns last about eight weeks, and so 20 something weeks approximately -- and still going strong. We managed, oh, there's been a shift where in the current campaign, the previous government administration has been ousted, and now there's a new government administration that does things differently.

[00:11:38] Host Amber Smith: How many teens are in this group?

[00:11:41] Robin Dean, PsyD: There are currently seven in the group.

[00:11:43] Host Amber Smith: And is it male and female?

[00:11:47] Robin Dean, PsyD: Male, female, and other. So we have some kids who identify as non-binary. I don't think we currently have any folks who identify as trans.

[00:11:59] Host Amber Smith: Now, what were you hoping to see through the use of D and D? Because I imagine the teens enjoy it or they wouldn't stick with it, and maybe they've sort of bonded. Is that what you were looking for?

[00:12:12] Robin Dean, PsyD: Really what we're looking for, mostly, is that they see the value of therapy, and that they have a space to practice skills that they wouldn't be able to do otherwise.

Probably the best example of, like, real progress is ... We had a kid who the very first day came in, put his head down and couldn't introduce himself because he was experiencing so much anxiety. The only times where he did speak on that first day were about his character. And so he could say one or two things about the character.

And so now, a few months later, he is probably one of the most active and engaged folks. And periodically we have someone come in that'll observe, and in the last session where there was an observer, he outwardly introduced himself and greeted the person, which is coming a long way from where he started in terms of the level of anxiety. And he is able to talk about some of that and what's been helpful. And part of that is feeling comfortable in the environment that it's OK for him to be him.

[00:13:39] Host Amber Smith: So you are able to track progress among the individuals?

[00:13:43] Robin Dean, PsyD: Yes. So some of it is subjective, things that we see in the environment. We also use a social skills assessment inventory to track progress a little bit more objectively. Every eight weeks or so we take a break, and during that break we reassess in order to have the children and their parents complete a rating scale so that we can keep track of things like the kids' level of engagement or cooperation or assertiveness and how they're progressing as the group has continued.

[00:14:15] Host Amber Smith: Have you seen any negative effects from this game?

[00:14:20] Robin Dean, PsyD: One of the things that we did struggle with... when we first started to run the game, we were doing it in just the eight weeks. We would recruit a group of kids, we would run the eight week session, and then they would be discharged.

And I wanted to run a long-term group. And so we went from two months to four, in order to see what would a long-term group would look like. And, a couple things came up from that: 1., the group of kids that were in it all had been in the group before, and so there were dynamics that ended up getting a little muddled because you come in knowing some folks but not others, and you have this idea of what the group is supposed to be like because you've run it before, but each person has a different idea of what the group's supposed to be like. So there was some of those dynamics.

And because we didn't have a built-in way to really do more processing -- because we do spend a lot of time in game play and not so much kind of actually thinking about the feelings and talking about specific things that happened -- there wasn't enough opportunity to really delve into disagreements and really explore some of that, which is another reason why we run, now, eight weeks and take a break, because then we can check in with the individual group members about what's going on and how they're feeling and give natural points for people to transition out, or for new people to transition in.

[00:15:50] Host Amber Smith: What has the response been from your colleagues and from the staff in psychiatry and behavioral sciences?

[00:15:56] Robin Dean, PsyD: They love it. We have a wait list currently because all of the clinicians are like, "I've got a kid for you." And it tends to be the ones that are anxious or depressed. A lot of times we get children that are diagnosed with autism spectrum disorder, that have just this social awkwardness, and they really need a space where it's OK to be a little nerdy, a little geeky, and where they can practice those interpersonal techniques with extra support.

[00:16:27] Host Amber Smith: Do you think using Dungeons and Dragons would have an application with adults?

[00:16:33] Robin Dean, PsyD: Well, so when it was initially introduced in the AGPA conference, it was introduced by a practitioner that uses it with adults. So yes, absolutely.

[00:16:46] Host Amber Smith: Well, Dr. Dean, thank you so much for making time to tell us about this.

[00:16:49] Robin Dean, PsyD: Absolutely. It was a pleasure to be here. Hopefully, people are excited and interested, and maybe other people will start to think about integrating this as well.

[00:17:01] Host Amber Smith: My guest has been doctor of psychology, Robin Dean. She's an assistant professor of psychiatry and behavioral sciences at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.