The Gamification of Psychotherapy

“Ring Around The Rosy by W. Earle Robinson

In the 19th century Sigmund Freud revolutionized the fields of neurology and psychiatry.  Whether you agree or disagree with the particulars, psychoanalytic theory, and the psychodynamic theories that sprang from it changed the way we understand the human mind.  Freud pioneered our understanding of the psychosomatic illness, conflicts, drives and the unconscious, to name but a few of the ideas that still influence theory and practice of psychotherapy today.

The way Freud came to understand and then attempt to help us understand these ideas was by applying other theoretical models to our psychology.  The industrial revolution, with its steam-powered hydraulics and locomotives powered by internal pressure, heavily influenced his beginning work of trauma affect and drive theories.  His famous topographic model of the psyche, with its strata of conscious, preconscious and Unconscious, was inspired by the advances in geology and archaeology of his day.  In short, the technological advances of his time informed and shaped the way he thought about and worked with people.

Now we are in the 21st century, which is new enough that saying it still fills us with amazement.  The revolutions in technology continue, and I want to begin applying some of these technological advances to my theory and practice.  I have blogged a lot about games, and today I want to discuss the application of game theory in understanding the human psychology.

Gamification is the act of using the elements of game design and applying it to other parts of human existence.  We have seen gamification begin to be used in businesses like IBM and written about in the Harvard Business Review.  MacDonald’s has been using gamification with its’ Monopoly game for years.  The Army has been using viedo game technology to gamify our defenses.  Socially Serious Games like Against All Odds are being used to educate people about human rights and global conflict.  So can gamification be applied to psychotherapy?

I think so.

In her new (and excellent!) book Reality Is Broken, Jane MacGonigal reminds us of the concise yet brilliant description of what a game is according to Bernard Suits.  Suits states that “playing a game is the voluntary attempt to overcome unnecessary obstacles” in his book The Grasshopper.  An example of would be chess where we agree to use the playing pieces on the board, the unnecessary obstacle is that each type of piece can only move a certain prescribed way, and we attempt to overcome this in order to capture the king of our opponent.

One example of gamifying psychotherapy is if we posit something similar:  Psychotherapy is the voluntary attempt to overcome unnecessary obstacles.

Psychotherapy must be voluntary to be successful. If the patient refuses to engage in the process either by physically or mentally absenting himself, therapy will not happen.  Yet even people mandated to treatment can benefit from it if they agree subconsciously to engage with us.  Adolescents who are dragged to treatment will sit with us in stony silence week after week because they are not there voluntarily.  Sometimes we can get a part of them to come out and “play,” i.e. engage with us.  And if we don’t want to work with the patient for some reason, it makes treatment next to impossible.

Patients come to us because they are attempting to overcome something.  They don’t just drop in because they wanted to read the magazines in the waiting room.  Something in their life has caused them pain, sadness, anger, discomfort and they want that to stop.  They may have noticed a pattern of bad relationships, they may be having traumatic flashbacks, they may be encopretic.  But something in their life outside the therapy office has seemed insurmountable, and they want our help in overcoming it.

Which brings us to the unneccessary obstacle.  I would suggest that in many cases the symptom is the unnecessary obstacle.  Whatever the behavior might have been in the past it is no longer necessary now.  As a child, hiding their body or mind may have been necessary to keep themselves safe from an abusive parent or sibling.  As an adult, their tendency to dissociate in meetings and avoid success at work is an unnecessary obstacle.  As a teen a patient may try to control an out of control environment in order to feel a sense of self.  As an adult they may seek to control their bodies through disordered eating or self-injury for much the same reason.  The challenge here is that the patient continues to go through life unconscious of this and acting as if the obstacle was necessary.  In a sense they are playing out (albeit very seriously and sometimes fatally) something outside of the playground.

Huizinga referred to the “magic circle” of play, within which the game unfolds.  Therapy, with its 45-50 minute hour, office setting and professional boundaries, is such a magic circle.  If you don’t take the idea of play seriously, you will probably find this analogy offensive.  But in my opinion play is very serious.  In psychotherapy, patient and therapist become earnestly engaged in the immediacy of what happens.  People become ghosts of other people, monsters appear, and ancient kingdoms rise up from beneath the waves for a day.  I believe that most people who have been in treatment will be able to recall the immersive and powerful experiences they have had there, experiences which have felt tragic and heroic.  Hopefully the patient leaves the magic circle having changed, the unnecessary obstacle is overcome, and life gets better.

We live, as Freud did, at the threshold between two centuries.  We live, as Freud did, in a world story frequently punctuated by war.  I imagine that back then things felt as difficult, healing seemed as urgent as it does today.  People came to Freud then, and us now, to help them overcome unnecessary obstacles that were ruining their lives.  Freud benefited from applying the diverse technologies of hydraulics, geology and archaeology to understand the human condition; and I believe that we can benefit from applying ludology and game theory to the serious business of therapy.  Gamification will not be used to “lighten up” treatment but rather deepen it.  Patients who play video games may respond better to leveling up than treatment planning, power-ups as opposed to coping strategies.  Virtual worlds may serve as practice for real ones, just as therapy has served as practice for other relationships.

Freud was an Epic Therapist.  He researched and synthesized what was going on in the art and science of his day in order to do better treatment.  Today’s Epic Therapists will need to do the same, and that means having the courage to play with technology, games and ideas.  Our resistance to doing so is an unnecessary obstacle we need to overcome, and our success in achieving this will be an Epic Win for our patients and our profession.