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.


  1. Hi Mike,

    Your posts are truly inspiring 🙂

    Making therapy work appear as a game to a client is indeed a creative way of further motivating the client to overcome their obstacle(s)/symptom(s). Have you already tried applying this technique with any of your clients? And if so, do adults respond as enthusiastically as teens?

    Also, are you envisioning the application of play with technology and games to the cognitive behavioral modality or to any type of therapy?

    Thanks for writing such enlightening posts!

    • I have applied these techniques, with a range of ages, and in general my experience over the past several years is that adults respond MORE enthusiastically.

      You are right that CBT lends very well to many games, and I’ve mentioned the Epic Win as an example of that. But more psychodynamic therapies can make use of sand play, online gaming or sessions in Second Life, and more. And the narrative therapy approach of Michael White et al would lend to creating epic solutions to the presenting problems. Clearly though we all need to think more deeply than broadly to make the most effective interventions in Tx, and explore the meanings and boundary concerns that might arise in virtual worlds.

  2. I completely agree that gaming and magic circle are viable and beneficial.

    My interpretation of analysis / session work with psychotherapists is that there is a layer of addiction to behavior that permeates. For me, this has been the most difficult and persevering obstacle. Gaming and magic circle may be a good technique, but when up against the omnipotent power of addiction, well – it would have to be a really great game.

    Good article, thanks. Bree

  3. Very thought provoking post, Mike (as always!).

    I am totally on board with the idea of therapy as play–it actually explains to me some things I have never truly appreciated about how my work as a therapist transformed me over the years.

    As I read the end of your post I had an exciting question that popped into my head (and I will bet it’s been in your head for a while based on what you wrote): How can we create games for therapists to help them overcome their resistance to technology? What would those games look like?

    Okay..that’s two questions, not one. 😉

    Any thoughts that you might have in response to them?

    • Hi Nancy, thanks for the questions! I have thought a little about it. 😉 There are a few ways, for example, you could have a game that helps clinicians diagnose using the DSM-IV. The game begins with a random video of a simulated clinical interview, and awards experience points for the most accurate diagnoses. Or a game where learning the diagnostic criteria for different conditions allows you to progress through “mood,” “anxiety,” “childhood,” and other trees, gaining a badge for each one, and a “Master of Diagnoses” completing them all.

      Or to encourage therapists to use twitter for sharing their research, each tweet you send with a link to an article earns you a point, and when you earn a set number of points you win a $25 gift certificate to Amazon.

      Or a widget that plugs into your email, progress notes or billing software that will pop up a game of scrabble every half hour to help you take a break and have more stamina when you’re through to go back to the work. And of course these scrabble widgets could link to facebook or some social media so that you can play with friends who are online at the time.

      Other ideas? I’m sure folks can come up with even more fun ones..

  4. As an art therapist, the notion of therapy as a game fits beautifully. The “magic circle” is something that art therapists strive for. We call it “holding the space”, meaning we intentionally manifest a physical and psychological space in which clients can take risks. When they are in this space, they can experiment with new ways of being, and experience new bx patterns while at the same time feeling safe and supported. I like to think of it as a game, a simulated world, where risks that are perceived as too dangerous in the real world can be safely tackled. One of my primary goals as an art therapist is to provide my clients with a place where they can learn to tolerate mistakes/errors/failures — learning resilience and creative problem solving. These skills translate to improved competence when they deal with challenges outside the therapy room.

  5. I too am interested in the idea of therapy as play, and have done some reading into the idea of liminality; a threshold type space and time which is in between. As a practitioner with a background in theatre, I first came across the idea of liminality via anthropology and Victor Turner, although Richard Schechner takes it up to apply it to theatre. It seems to have resonance with the Magic Circle idea too. More food for thought…


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