Streaming, Path of Exile & The Repetition Compulsion

As many of you know I have begun streaming. My goal in doing this is to both have some fun, and reach a wider audience when talking about psychodynamic concepts. This is my latest attempt, in which I talk about the Repetition Compulsion in terms of farming for a unique sword in the game Path of Exile. Keep in mind that the conversation about the repetition compulsion during the stream if for a general audience, and should not be substituted for seeking out medical advice or a mental health professional. My hope is that you’ll share it with the gamers in your life, therapy practice, class, etc. And of course if you sign up to follow my Twitch channel I’d be delighted!

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Tetris Beats Nazis: Video Games & Worry

This week I have two stories about video games, one that causes worry and one that effects it.

The first, worrisome, one concerns white nationalism, video games and propaganda. For as long as we have had Nazis, Aryanism, or White Nationalism, we have had its propaganda. Art is one of the most powerful medium that propaganda gets disseminated: Paintings by Erler and Feuerbach; film by Leni Riefenstahl; and music curated by Axis Sally were all examples of how the art form was used to convey Nazism. It should surprise no one that 21st century art mediums such as video games have their own share of deplorables.

One example, which I won’t link to, from the early 21st century was “Ethnic Cleansing” which came out in 2002. Since then there have been games like “Muslim Massacre” and “Zog’s Nightmare.” The games primarily target, Jews, Blacks, and Latinos, and are often on or linked to Nazi sites. Meanwhile, young people may find themselves being solicited online, where low-to-no moderation servers and bulletin boards like Discord and 4Chan provide a safe place to foster white supremacy.

Today, NPR came out with a story worth your attention, on the rise of recruitment efforts by white hate groups in online gaming environments. Now please don’t blame Fortnite. Most video games, even the violent ones, do not blatantly pedal nazi propaganda. The few that do are pretty explicit about it. What we need to worry about is how disillusioned and disenfranchised young men are vulnerable to being recruited by domestic terror groups, and of course they will be doing recruitment where youth are, including video games. My recommendation? When hate crimes or white supremacy comes up in your family discussions please ask your kids if they ever here things online that sound like hate speech or stereotypes. Assure them that you are more interested in hearing about what they may be experiencing than pulling the plug on Call of Duty, and that this is just one thing that people need to keep an eye on in online communities.

If anything shows up in their chat, consider taking screenshots and sending it to Discord or the chat platform you are using to let them know about the hate speech or recruitment. Both things are violation of TOS, and if your child doesn’t send it and someone else does they be banned themselves. Above all, keep an eye on gameplay, the content and the chat happening while it is happening. You don’t have to be Big Brother all the time, but let family members know that occasionally the games and chat need to be without headphones so you get a sense of who their “friends” are, just like you would if the friends were visiting your home in body.

Now that I have you worried about something new, go play some Tetris. That’s right, a recent study published in Emotion, a psychology journal, found that Tetris helped distract people from worrying by helping them achieve flow experiences. I have discussed before how distraction gets a bad rap and is actually evolutionarily adaptive. Here is some more research to support that theory!

So, now that I’ve made you worry, go play a little Tetris. You can do that here. Then, tomorrow, go vote.

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Taking Leaps: Fortnite, HIPAA & Psychotherapy

“You keep dying,” Sam* said. The annoyance in the 9 year old’s voice was palpable. I looked at my avatar lying face down on the screen. Another of the 100 players in the game, appearing as a brunette woman in sweats sporting a ponytail, was doing a victory dance with her rifle over me. Sam was nowhere to be seen on the screen, but I knew he was hiding somewhere in the game, and seething.

“You’re disappointed in me,” I said calmly. A moment of quiet.

“Yeah.”

“You were hoping I’d be better at this, as good as you or maybe better, and it’s frustrating.”

“Yeah… Can we try again?”

And so we tried again and again, and while we did I talked with Sam about the other adults who were disappointments to him, who kept leaving or letting him down. And I guessed that we were also talking about his frustration and disappointment in himself. And at the end of our appointment I promised I would practice Fortnite, the game we had been playing. We had turned on our webcams again so we could see each other to finish the session, so I could see that he brightened at this idea.

“Nice to see you again,” I said. He smiled faintly.

“You too.” His screen went dark.

As I reflect on the work I do with patients, meeting them where they are at, I am struck by the same issues, opportunities, and conversations that can happen in an online play therapy session. I only wish more of my colleagues would try it. What gets in the way? For some it is a dismissal of emerging technologies which masquerades a fear of trying something new. For others it is a worry about running afoul of HIPAA and being sued. If you are one of those people who wonders about how to integrate video games online into your therapy practice, read on.

 *  *  *  *  *

Quick, without Googling it; what does the “P” in HIPAA stand for?

If you are a psychotherapist or other health provider, you probably guessed “privacy.” At least that’s often the consensus when I ask this question at my talks. It would be understandable if this was your guess. You’d be wrong.

The correct answer is “portability,” the basic premise that individuals have the right to healthcare treatment that moves with them as they go through the vicissitudes of life and work. That is also where technology comes in– electronic health records, telemedicine, etc., are ways that technology increases portability by collapsing time and space so that the patient and the healthcare professional can get to work.

In therapy, that work traditional has happened in an office setting. And in the case of children and youth especially, that meant play therapy which was bounded by the space and time of a physical office. From Uno to Sandtrays to the infamous “Talking Feeling Doing Game,” we have often assumed that play therapy needs to be the games of our own childhoods. But 21st century play can, and I maintain should, include 21st century play. That’s where video games come in.

In the days of the Atari 2600, there was no worry about patient privacy, because the system was hooked up directly to a television that didn’t even need to be connected to cable. But nowadays with SmartTVs, PCs and PS4s, video games are often played online with many other people and seamlessly connected to voice chat. This can be a concern for the psychotherapist who is unfamiliar with newer technology, especially with games like Fortnite, which boast Battle Royales having as many as 100 players at a time in the same game instance.

Videoconferencing programs and online therapy using video/audio chat have been around long enough to have specifications that adapt to HIPAA’s privacy requirements, largely because there is market force behind developing products that can be sold to the healthcare industry. Video games and their platforms, on the other hand, do not have a similar demand to give them an incentive to supply. Games like World of Warcraft, Platforms like STEAM, and streaming services like Twitch were designed for gamers, not therapists, and it is unlikely they will go through the technical and legal procedures to become HIPAA compliant anytime soon.

Some therapists have begun developing their own video games, which, like most therapy games are dismally boring. They are thinly veiled therapy interventions that are disguised as play, but lack any of the true qualities of play. True, they are more likely private; but they are also boring, and easily recognizable as “not playful” by patients. Mainstream games have broader appeal, critical user mass, and better graphics and gameplay in many cases, and are more immediately relevant to the patient’s life. But they are definitely not HIPAA-compliant. So what to do?

 *  *  *  *  *

My solution, which I’m sharing as an example that has not been reviewed by policy experts, lawyers or the like, has two parts:

  1. Due Diligence– Research the existing privacy settings and technologies to maximize benefit and minimize risk to patient privacy. So for example, I structure the “talk” part of therapy to happen over HIPAA-compliant software like Zoom or GoToMeeting. We start on that platform with video camera on, until we begin playing. Then we, turn off the camera to save on bandwidth and talk over this software, not the game. Previously, I will have sent the patient or their parent a snapshot of the settings of the game we are using with the voicechat disabled if possible. We also want to lower or turn off the game sound so we can hear each other. So in the case of Fortnite, the settings would look like this:

 

2. Limited HIPAA Waiver- This is the part most therapists overlook as even being a possibility. You can ask patients to sign a release waiving in a limited capacity their HIPAA rights in order to use noncompliant technology. It is entirely voluntary and I’ve yet to have a patient decline. I use a informed consent form that I developed that looks like this:

 

These are examples of how to engage with online technologies in a clinical way that is thoughtful yet forward-moving.

 *  *  *  *  *

Whether you love Freud or hate him, most experts agree that he was one of the fathers of modern psychiatry. He was also an early adopter. He based his hydraulic model of the drives on steam technology of his era. His concept of the “mental apparatus” was likewise integrated from the advances in mechanics and his formulation of ego defenses such as projection occurred simultaneously with the Lumiere brothers’ creation and screenings of motion pictures. Regulatory concerns aside, therapists can be early adopters. Doing so would probably help our patients no end, and definitely cut down on my waitlist.

* “Sam” is based on several patients whose identifying information has been disguised to protect patient privacy.

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Better Living Through Minecraft

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Last month I had the opportunity to talk at SXSW 2015 about how the video game Minecraft has a lot to teach us about mindfulness.  Video games often get a bad rap with mental health folks, but I try to change that thinking by pointing out that playing video games can actually be a form of concentration meditation, albeit one that does not jibe with many people’s traditional concepts of such (focus on your breathing, focus on the candle, focus on..erm, Mario?)  If you want to hear more, the Audio is here:

https://soundcloud.com/michael-langlois-6/better-living-through-minecraft-audio-version

If you want to see the visuals from the Prezi, feel free to do so here:

If you enjoy it, please feel free to share, and if you want me to come talk to you and your colleagues drop me a note.

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The Internet & Real Relationships


Today I was slicing some lemons for shish kabobs and so not surprisingly I began to think about social media, attachment and what constitutes an authentic relationship.

Authenticity was a key term when I was becoming a therapist in the mid nineties, and society in general.  Today, most people I have spoken to in the mental health profession would say our happiness in part depends on having authentic relationships with others.  Setting aside for a moment that we often talk about “authenticity” as if there is one monolithic thing that “everyone knows” it is, this belief in the connection between authentic relationships and happiness often gives psychotherapists, social workers and educators their moral imperative to discourage use of technology.  That’s where the lemons come in.

Ten years ago, I met my friend Jackie Dotson on the bulletin boards of Psychology Today.  These bulletin boards were designed for clinicians to have an online forum where they could discuss a range of issues, make referrals, and share ideas.  They were also a place where early-adopting clinicians stumbled and experimented, behaved badly, gossiped and misspoke, as we tried to make sense of emerging technologies.  I remember heated online conversations about whether the forums were private and “safe,” where people were startled to consider that anyone could cut and paste your confidential posts anywhere on the web.  People were emboldened or perhaps I should say “emoboldened” by the relative anonymity on the forum to say things that could be breathtaking in both their vulnerability and/or sadism.  It was the Wild West of mental health on the web.

My interactions with Jackie were few and far between when she and I were both active there.  It wasn’t until I moved on from the forums to spending more time on Facebook that I think we really began socializing more.  Perhaps it was because FB allowed for a flow of text and images, more seamless interaction, and chat.  Whatever the reason, over the past few years my life has intersected with Jackie more and more.  We have several mutual acquaintances from the PT forums, and a mutual friend with whom I went to college with.  I’m glad I friended her.

From 3,000 miles away, Jackie has crept into my online and emotional life with the secret code of affinity that could only be shared via social media.  We share a love of bone marrow as evidenced by our food pics, and she has forced me to rethink my stance in social media workshops I do where I used to announce to my audience, “Nobody wants to see your food.”  Our dark wit and banter is present more days than not in my FB feeds, I’ve even taken more of an interest in my local sports teams so I can insult hers.  In return she pretends to be a bigot on LGBT issues to bait me.  Although I’ve never told her explicitly, she has reassured me when I worried about how my picture looks online, and comforted me when my city suffered a terrorist attack.

And then last year she started sending me lemons.  Real lemons.

Jackie lives in CA, and has at least one prolific lemon tree.  Last year she offered to mail a box of them to anyone of her friends on Facebook for the price of shipping.  I jumped at the chance.  They arrived within days and were enjoyed by my family immensely.  So immensely, that when Jackie began posting pictures of budding trees this year, I grew quite impatient for them.  They arrived two weeks ago, and for the past two Sundays I have used them for cooking.  As I write this, there are chicken kabobs marinating in lemon and thyme for tonight.

Jackie and I have never sat down together for a heart to heart or face to face conversation, but we carry our connection to each other throughout our day with our smartphones.  In the decade that we have been in each others’ orbits, I suspect we have each known deep sadnesses that we haven’t spoken of to each other.  Yet I am convinced that if I ever chose to reach out to her that way it would be okay and vice verse.  Not all intimacy needs to be acted on.

That said, for two Sundays, as I have chopped and squeezed fresh lemons, I have thought of Jackie and smiled.  I have imagined her and our conversations as I move through my kitchen, while my brain alters levels of different neurochemicals and changes my affective state in ways that are real and comforting to me.

The stubborn adherence to imagining that technological use inherently diminishes our authenticity has been eroding the mental health field’s relationship with the people we work with for decades now.  Friends and colleagues of mine in the tech industry are consistently amazed that I still need to educate and advocate with my peers about this.  Our profession continues to act as if relationship mediated by emerging technologies is one step removed from other relationships, less authentic because we use our bodies in different ways to achieve connection with each other.  I wonder if our dogs feel that we are less authentic because we have replaced smelling butts with eye contact and uttering sounds all the time?

I jest, in part because I doubt our companion animals feels as fearful of becoming irrelevant as many of my colleagues do.  I think this fear is only justified to the extent that we are dogmatic about what constitute authenticity for everyone.  Pierre Teilhard de Chardin once said:

Love is the only force which can make things one without destroying them. … Some day, after mastering the winds, the waves, the tides and gravity, we shall harness.. the energies of love, and then, for the second time in the history of the world, man will have discovered fire.

I do not think it is the role of the therapist to be the arbiter of truth in what makes intimacy or authentic relationships.  Our role is to help our patients explore their capacity and harness their energies for love in ways that may go beyond the imagination our own experience affords us.  It is not for us to give them fire as gods would, but to help them make themselves whole without destroying them.

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The Lava Expert

lava cave

“Sometimes it is the people no one imagines anything of who do the things that no one can imagine.”  –The Imitation Game

Shortly before I fell into the lava I began a conversation with an eleven year old girl, we’ll call her Sal.  This was a while back, on a Minecraft server I play on from time to time.  My name when I play Minecraft has the word “therapist” in it, and Sal had noticed this.

“Hey, are you really a therapist?” Sal asked via our server text chat.

“Yes I am.”  I typed back.  I had been mining obsidian and using a river to cool the lava so I could chip away at it with my diamond pickaxe.  In the time it took to type my reply, I managed to fall into the river and get washed into the lava.  I watched myself go up in flames, and with me most of my loot.  There is always a chance though, when one falls into lava this way, that some of one’s loot can be thrown clear.  So upon respawning I quickly made my way back to the scene of my demise as we continued our conversation.

“Oops, burned up,” Sal said, as the server had announced just that when I fell in the lava.  “Are you the kind of therapist that talks to kids about their problems?”

“Kids and adults both, yes.”

“My mother wants me to see a therapist,” Sal said.

“Why?” asked another one of the kids on the server.

“She says I have problems with friends,” Sal said.  By this point I had returned to the lava pool.  There was no loot that had survived.

“Sal,” I said.  “Everyone needs help with their problems from time to time.  That’s why there are 7 billion people on the planet, to help each other out.”

For some reason that made quite an impact with the other players.  “Wow, you must be an expert!!” one typed.  I’m not sure how he’d come to that conclusion.

“I’m certainly not an expert on lava,” I replied, and fortunately the conversation went back to the business of mining after some sympathetic emoticons.

I have no problem talking with kids about therapy, or being a psychotherapist.  If I did, I certainly wouldn’t have the word in my userid.  And it wasn’t even that I was “off duty.”  I’ve had many conversations in chats over the years and heard a range of problems.  In part I was a little protective of Sal’s right to privacy, although experience has again shown me that kids are often less hung up on therapy than adults, and in many ways are often more trusting of psychotherapy than adults are.  Mostly the reason I wanted us all to get back to playing was that I had caught myself sounding “educational.”

*  *  *  *  *

In play if there is any such thing as an expert it is certainly not the therapist, or adults in general.  Virginia Axline, knew this.  In her book Play Therapy she writes, “Non-directive therapy is based upon the assumption that the individual has within himself…  the ability to solve his own problems satisfactorily.”  (Axline, 1947)  My trainees are often as surprised to find that I am friend to both psychodynamic and solution-focused theories as I am to find that they have been taught the two have irreconcilable differences.

As I see it, my job is often to be a unique experience in the lives of patients.  “It is a unique experience,” Axline writes, “for a child to find adult suggestions, mandates, rebukes, restraints, criticisms, disapprovals, support, intrusions gone.” (Axline, 1947)  And by the time people come to us as adolescents or adults, those suggestions, mandates, rebukes, restraints, criticisms, disapprovals, etc. have become internalized.  By adulthood, many of us feel as if we lack expertise in anything, except perhaps screwing our lives up.

Education has increasingly played a hand in this.  We do not teach so that our students learn to think independently and feel resourcefully.  Instead we teach them to think like someone else.  Critical thinking and exploration become supplanted by the sense that education has to give us something tangible in a materialistic sense:  A good grade; a profitable job; published ideas or maybe if we really drink the Koolaid admiration from other academics.

One thing that is so enjoyable about Minecraft for many is its’ open sandbox environment.  There is an endgame you can play if you want, but there are also myriad variations of play you can do instead.  Sal and millions of other children and adults can range freely through such open and creative spaces without “experts.”  Education certainly can happen there, but often in a lightly curated if not autodidactive way.  People have created versions of Westeros, Middle-Earth, Panem or their own creations.  There are PvP versions where conflict and combat, stealth and griefing hold sway; fantasy realms where people can role-play.  It is a topsy-turvy world where children can have the most wisdom, and we adult experts can trip and fall into lava.

*  *  *  *  *

In a world obsessed with measuring outcomes, psychotherapy can have a rough time of it.  If Sal ever goes to therapy, she will have to be labeled as ill somehow if her mother wants insurance to help pay for it.  Notes will have to be written, treatment plans planned, goals and objectives filed away so bean-counters can determine that Sal should get 14 beans-worth of help.  It’s hard for me to get too angry at the bean-counters though, over the past 25 years I’ve met a few of them and they don’t seem too happy either.

Education fares little better, with things like the Common Core which tells us what should be taught; standardized testing which masquerades as achievement; and trigger warnings which are supposed to warn students of upsetting content as if they somehow were entitled to get through the mind-altering experience of learning without ever being upset.

It takes bravery to stand up to this.  To let the individual chart their own course, make their own mistakes, draw on their own core.  For the therapist and educator it takes bravery to get out of the way, to radically reflect the developing self.  I do believe that each one of us needs help throughout our lives; but that help needs to be asked for lest we run the risk of telling others what to do and implying they aren’t up to the task of living their own lives.

*  *  *  *  *

Many therapists, social workers, and teachers I have met chose to become members of those professions at least in part as an expression of admiration for their own therapists, social workers and teachers.  They had no interest in falling into the lava ever again, so they started focusing on helping other people out.  It’s a thankless job if you are going to go through it secretly hoping to be thanked.  I’m not sure I’ve ever had someone I work with refer to me as an “expert” unless they were being facetious about some blunder I’d just made.  And I’ve made many.  As an apotheosis, being a psychotherapist or academic is rather anticlimactic, not because the work is devoid of meaning or value, but rather because if we truly place such people on a divine pedestal it needs a steady stream of troubled people to hold it steady.

Perhaps an alternative for therapists, social workers, educators and our ilk is to think of ourselves as “lava experts.”  We have some acquaintance with falling into pits, being consumed by intense feelings, losing all our, erm, loot.  These are human experiences.  This is not a secret to anyone, and I doubt most people would put their trust in someone who knows nothing of failure, obsession, overwhelm or grief.

What’s more is we’ve fallen into lava, often the same pit again and again!  We know something of the repetition compulsion.  We have let our yearning for whatever we think we need lead us to risky or self-defeating behaviors.  We can talk to people about their problems, because we are people who have problems ourselves.  We’ve been burned.  Minecraft miners know mining deep is risky:  We know what we’re doing even up to that moment our bones ignite.

Rather than being an expert on a pedestal, accept that you will tumble into fire, again and again, looking outside of yourself for what is precious.  Straight A’s, that book you published, six or seven figures–There’s a little Gollum in all of us.  It’s what makes us forget mindfulness, build empires, win arguments or wars.  No one was ever oppressed by play, only the lack of imagination that comes from the absence of it.

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Using Gaming & Gamification in Clinical Practice

What does “gamification” mean, and what is its relevance to mental health practice?  In this video of a conversation I had at University at Buffalo with Charles Syms, I take a stab at answering those questions.  This is just a start, and hopefully by the end of the video you can begin to see how applying principles of game design could be therapeutic for people dealing with issues ranging from trauma to executive functioning challenges to substance abuse and beyond.

 

 

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Gamer-Affirmative Practice: Today’s Play Therapy

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The importance of play is universal, and in many ways the nature of play is timeless.  That said, there is a lot to learn about video games as 21st-century play, especially if you are a play therapist.  Adding 21st-century forms of play to your repertoire can be daunting.  With so many naysayers in the mental health profession, avoidance of learning the new takes the form of contempt prior to investigation.  With video games being low-hanging fruit for political arguments ranging from gun control to teen bullying, many social workers, psychologists and counselors give in to the media hype and spend far more time demonizing or ignoring this form of play than they do understanding it.

Recently my colleagues at the University at Buffalo made it a point to take a gamer-affirmative stance and offer a beginning piece of continuing education on integrating video games as play therapy in the form of a podcast.  In it my friend, colleague, and yes, fellow video game player Anthony Guzman and I have a beginning conversation about just that.  Have a listen:

inSocialWork® Episode 144 – Michael Langlois: Gamer-Affirmative Practice: Today’s Play Therapy

 

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Bringing Emerging Technology into the Clinical Process: Implications for Engagement and Treatment

If you have ever wondered how to begin attending to, listening for, and asking questions about a patient’s use of technology, this video might give you some ideas.  In it my colleague Lesa Fichte, LMSW, University at Buffalo School of Social Work, and I, discuss the role of technology, people’s relationship with technology, and how to integrate it into the treatment process by listening, inquiring, and learning.

 

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The Relationship Between Emerging Technology & Psychodynamic Theory

Often when I present, people are surprised that I teach on both emerging technologies such as social media and video games, and classic psychodynamic theories.  Although it may initially seem counterintuitive, especially to classically trained psychotherapists and social workers, I see a strong connection between the two.  Here is the first in a series of posts featuring work I am doing with the University at Buffalo, in which Charles Syms and I discuss the relationship between the two.

 

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