Freud

Streaming, Path of Exile & The Repetition Compulsion

June 11, 2019 by langloimsw Leave a Comment

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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Filed Under: Gamer Therapy Tagged With: addiction, adolescents, behavior change, education, Freud, game theory, gamers, games, gaming, path of exile, psychoanalysis, psychodynamic, psychology, psychotherapy, repetition compulsion, stress, technology, therapy, twitch, video games, Web 2.0

Taking Leaps: Fortnite, HIPAA & Psychotherapy

May 31, 2018 by langloimsw Leave a Comment

“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:

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.

Find this post interesting? I can speak in person too: Click here for Public Speaking info & Press Kit. And, for only $4.99 you can buy my book. 🙂

Filed Under: Gamer Therapy Tagged With: adolescents, avatar, children, digital literacy, Fortnite, Freud, gamers, games, gaming, HIPAA, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, technology, therapy, video games

The Relationship Between Emerging Technology & Psychodynamic Theory

May 23, 2014 by langloimsw Leave a Comment

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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Filed Under: Gamer Therapy Tagged With: activism, building your business, digital literacy, education, emerging technology, Freud, game theory, gamers, games, gaming, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, social media, technology, therapy, video gmaes, Web 2.0

No Matter How You Feel, You Still Failed

January 14, 2014 by langloimsw 4 Comments

Psychotherapists are often people who prefer to deal with feelings in their workings with people. Feelings are important, and being empathically attuned to how patients are feeling is equally important. We are taught to explore the patient’s feelings, imagine ourselves into their lived experience, and validate that experience.

This is often where we become disconnected from other professionals we collaborate with, such as educators. Be it Pre-K or graduate school, educators are charged with working with students to learn and grow as a whole person. It’s not that they aren’t concerned with feelings, they just can’t get hung up on them to the exclusion of everything else.

To be fair, psychotherapy has a long history of taking a broader view on the individual as well. A famous psychoanalyst, Winnicott, once responded to a patient of his who was expressing feelings of hopelessness by saying something to the effect of “sometimes when I am sitting with you I feel hopeless too, but I’m not going to let that get in the way of continuing to work with you.”

But often in the past decade or two, feelings have held sway over everything. Students don’t complete their assignments because they felt overwhelmed and still expect to pass the course. Adults feel emotionally exhausted and miss work or are late to it. Children feel angry at the injustice of chores and don’t do them but still want their allowance.

A criticism I often hear toward video games is that they encourage people to believe that they can always just reset, do over and have another shot. But implicit in this criticism is the fact of something I feel video games actually do better than many of us sometimes: They acknowledge the reality of failure.

When we play video games, we are failing 80% of the time. Failing in the sense of Merriam Webster’s definitions including:

to not succeed : to end without success
to not do (something that you should do or are expected to do)
to fall short <failed in his duty>
to be or become absent or inadequate
to be unsuccessful

In video games the reality of this is driven home to us by a screenshot:

You can feel any way you’d like about it, angry, sad, annoyed, blase, frustrated with a touch of determination. But no matter how you feel you still failed.

In life outside games, many of us have a hard time accepting the reality principle when it comes to failing at something. We think we can talk, think, or feel our way out of failing to meet expectations. My own predilection is that of a thinker, which is probably why I became a psychodynamic psychotherapist and educator. I often waste a lot of time trying to think (or argue) myself into a new reality, which just boils down to not accepting the reality principle. I notice the same with patients, colleagues and students, who miss deadlines, avoid work, come late to class and then try their best to think or feel their way out of it.

The first class each semester I tell my students, who are studying to be social workers and psychotherapists, that the most frequent complaint I get as an instructor is “I feel put on the spot by him.” I assure them that this is a valid feeling and actually reflects the reality that I will put each and every one of them on the spot. I will ask them tough questions, I will point out that they are coming late to class, I will disagree with ideas that seem erroneous to me. Because if they think it is ok to be late or avoid thinking through a problem or confrontation in class, how in the world will they ever be a decent psychotherapist or social worker? If the single mother you are working with wants to know how to apply for WIC, and you say you feel put on the spot by her question, that is a valid feeling AND you are useless to her. If your therapist was 15 minutes late every week I hope you’d fire him. And when you are conducting a family session and someone discloses abuse it is unprofessional to say “I’m feeling overwhelmed and sad right now, can you ask somebody else to go next?”

These sort of disconnects doesn’t happen overnight. It comes from years of being enabled by well-intentioned parents and yes, mental health providers who focus on feelings to the exclusion of cognition and behavior, and worse, try to ensure that their children grow to adulthood feeling a constant sense of success. When I hear self psychology-oriented folks talk it is almost always about mirroring and idealizing, and never about optimal frustration. And I suspect that this is because we have become so focused on feelings and success that we are preventing people from experiencing optimal frustration at all.

The novelist John Hersey has said “Learning starts with failure; the first failure is the beginning of education.” We commence to learn because reality has shown us that we lack knowledge or understanding. That’s the good news. We’ve woken up! In this light I regard video games as one of the most consistent learning tools available to us. When that fail happens and that screen goes up you can try to persuade it to cut you some slack, flatter or bully it, weep pleadingly for it to change to a win, but no matter how you feel, you still failed. And because that reality is so starkly there, and because the XBox or PS3/4 doesn’t get engaged in your drama, that feeling will eventually dissipate and you will either try again, or give up.

Because that is in a lot of ways the conflict we’re trying to avoid isn’t it? We want to avoid looking reality square in the face and taking responsibility for what comes next. We want to keep the feelings flowing, the drama going, and we are willing to take entire groups of people and systems with us. If we are lucky they put their feet down, but more often then not they want to avoid conflict too, and the problem just continues.

So here’s a confession: I have failed at things. I have ended a task without success. I have not done things I was expected to do. I have fallen short, been inadequate and been unsuccessful at stuff. And nobody took away my birthday. I’m still around doing other things, often iterations of the previous failures, quite successfully.

If you are a parent or educator please take a lesson from video games. Start saying “Game Over” to those in your care sometimes. If they can try again great. If they want to read up on some strategy guides or videos to learn how to do it better, awesome. But please stop capitulating to their desire to escape reality on the illusory lifeboats of emotional expression, rationalization or verbal arguments. As Mrs. Smeal says in “Benny and Joon,” “when a boat runs ashore, the sea has spoken.” Reality testing is probably the most important ego function you can help someone develop, please don’t avoid opportunities to do so.

Nobody likes to experience failure, I know it feels awful. But to move through it to new realizations can be very liberating, and in time become more easily bearable. And I truly believe that success without past failures feels pretty hollow. When I play through a video game from start to finish without a fail I don’t feel like a winner. I feel cheated.

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Filed Under: Gamer Therapy Tagged With: addiction, adolescents, behavior change, buddhism, building your business, children, digital literacy, education, ego psychology, failure, Freud, gamers, games, gaming, Kohut, mindfulness, minecraft, optimal frustration, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, reality testing, ROI, self psychology, social justice, social work, stress, technology, therapy, video games

Reality Testing & The 7 Billion Rule

December 20, 2013 by langloimsw 3 Comments

In this video, I discuss the ego function of reality testing, how it affects us, and ways to cope with distortions in it. This is also another example of how I use technology, in particular YouTube as a transitional object for patients, allowing them to continue to remember our work together without compromising any of their personal health information.

This will be the last post for 2013, have a good end of the year and I’ll see you sometime in late January!

Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: adolescents, behavior change, children, cognitive distortions, distortions, education, ego, ego psychology, Freud, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, reality testing, social media, stress, technology, therapy, Web 2.0

Dopey About Dopamine: Video Games, Drugs, & Addiction

August 25, 2013 by langloimsw 4 Comments

Last week I was speaking to a colleague whose partner is a gamer. She was telling me about their visit to his mother. During the visit my colleague was speaking to his mother about how much he still enjoys playing video games. His mother expressed how concerned she had been about his playing when he was young. “It could have been worse though,” she’d said, “at least he wasn’t into drugs.”

This comparison is reminiscent of the homophobic one where the tolerant person says, “I don’t mind if you’re gay, as long as you don’t come home with a goat.” The “distinction” made actually implies that the two things are comparable. But in fact they are not.

Our culture uses the word addiction pretty frequently and casually. And gamers and opponents of gaming alike use it in reference to playing video games. Frequently we hear the comments “gaming is like a drug,” or “video games are addictive,” or “I’m addicted to Halo 3.” What muddies the waters further are the dozens of articles that talk about “proof” that video games are addictive, that they cause real changes in the brain, changes just like drugs.

We live in a positivistic age, where something is “real” if it can be shown to be biological in nature. I could argue that biology is only one way of looking at the world, but for a change I thought I’d encourage us to take a look at the idea of gaming as addictive from the point of view of biology, specifically dopamine levels in the brain.

Dopamine levels are associated with the reward center of the brain, and the heightened sense of pleasure that characterizes rewarding experiences. When we experience something pleasurable, our dopamine levels increase. It’s nature’s way of reinforcing behaviors that are often necessary for survival.

One of the frequent pieces of evidence to support video game addiction is studies like this one by Koepp et al, which was done in 1998. It monitored changes in dopamine levels from subjects who were playing a video game. The study noted that dopamine levels increased during game play “at least twofold.” Since then literature reviews and articles with an anti-gaming bias frequently and rightly state that video games can cause dopamine levels to “double” or significantly increase.

They’re absolutely right, video games have been shown to increase dopamine levels by 100% (aka doubling.)

Just like studies have shown that food and sex increase dopamine levels:

This graph shows that eating food often doubles the level of dopamine in the brain, ranging from a spike of 50% to a spike of 100% an hour after eating. Sex is even more noticeable, in that it increases dopamine levels in the brain by 200%.

So, yes, playing video games increases dopamine levels in your brain, just like eating and having sex do, albeit less. But just because something changes your dopamine levels doesn’t mean it is addictive. In fact, we’d be in big trouble if we never had increases in our dopamine levels. Why eat or reproduce when it is just as pleasurable to lie on the rock and bask in the sun?

But here’s the other thing that gets lost in the spin. Not all dopamine level increases are created equal. Let’s take a look at another chart, from the Meth Inside-Out Public Media Service Kit:

This is a case where a picture is worth a thousand words. When we read that something “doubles” it certainly sounds intense, or severe. But an increase of 100% seems rather paltry compare to 350% (cocaine) or 1200% (Meth)!

One last chart for you, again from the NIDA. This one shows the dopamine increases (the pink line) in amphetamine, cocaine, nicotine and morphine:

Of all of these, the drug morphine comes closest to a relatively “low” increase of 100%.

So my point here is twofold:

1. Lots of things, not all or most of them drugs, increase the levels of dopamine.

2. Drugs have a much more marked, sudden, and intense increase in dopamine level increase compared to video games.

Does this mean that people can’t have problem usage of video games? No. But what it does mean, in my opinion, is that we have to stop treating behaviors as if they were controlled substances. Playing video games, watching television, eating, and having sex are behaviors that can all be problematic in certain times and certain contexts. But they are not the same as ingesting drugs, they don’t cause the same level of chemical change in the brain.

And we need to acknowledge that there is a confusion of tongues where the word addiction is involved. Using it in a clinical sense is different than in a lay sense– saying “I’m hooked on meth” is not the same as saying “I’m hooked on phonics.” Therapists and gamers alike need to be more mindful of what they are saying and meaning when they say they are addicted to video games. Do they mean it is a psychological illness, a medical phenomenon? Do they mean they can’t get enough of them, or that they like them a whole lot? Do they mean it is a problem in their life, or are they parroting what someone else has said to them?

I don’t want to oversimplify addiction by reducing it to dopamine level increase. Even in the above discussion I have oversimplified these pieces of “data.” There are several factors, such as time after drug, that we didn’t compare. And there are several other changes in brain chemistry that contribute to rewarding behavior and where it goes awry. I just want to show an example of how research can be cited and misused to distort things. The study we started out with simply found that we can measure changes in brain chemistry which occur when we do certain activities. It was not designed or intended to be proof that video games are dangerous or addictive.

Saying that something changes your brain chemistry shouldn’t become the new morality. Lots of things change your brain chemistry. But as Loretta Laroche says, “a wet towel on the bed is not the same as a mugging.” We need to keep it complicated and not throw words around like “addiction” and “drug” because we want people to take us seriously or agree with us. That isn’t scientific inquiry. That’s hysteria.

Filed Under: Gamer Therapy Tagged With: addiction, adolescents, behavior change, call of duty, children, dark souls, dopamine, education, Freud, game theory, games, gaming, mindfulness, minecraft, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, social justice, social media, technology, therapy, video games, Web 2.0, World of Warcraft

Breaking Eggs and Holding Your Fire: Some Thoughts on Skills Acquisition

August 14, 2013 by langloimsw Leave a Comment

Not too long ago, I was learning how to fire a sniper rifle in Call of Duty. It wasn’t going very well. I kept firing (which you do by holding down the right-hand trigger) and missing. Or I would use the scope, which you do by holding down the left-hand trigger; and then try to find my target so slowly that I’d get shot long before seeing it. To make thing more complicated, my patient Gordon** was trying to teach me the difference between “hardscoping” which meant to press and hold down the left trigger, and “quickscoping” which was more like a quick tap and release of the scope.

The key to success, I was told, was to locate the target, quickscope it for a second to take aim, and then fire. The source of my failure was that I’d see the target and not bother to scope at all, and just fire. At first I didn’t even know I was doing that. I thought the scope was going up, and it was, but it was going up a split second after I was firing and not before. After several fumbled attempts Gordon said, “you have to not fire and learn to push the scope first instead.” I suddenly realized that he was teaching me about impulse control.

Because many parents and therapists are reluctant to play video games, in particular first-person-shooters, they only tend to see them from outside the experience. What they learn from seeing that way is that FPS are full of violence, mayhem, blood and noise. Is it any wonder then that they grow concerned about aggression and the graphic nature of the game? It’s all that is really available to them unless there is a strong plot line and they stick around for that.

But as someone who has been playing video games for years I can tell you things are different from within the experience. And one of the most counterintuitive things I can tell you from my experience is this: First Person Shooters can help you learn impulse control. It takes a lot more impulse control to not fire at a target the second you see it. It takes a lot more impulse control to wait and scope. And because all of these microdecisions and actions take place within the player’s mind and the game experience, outside observers see violence and aggression alone and overlook the small acts of impulse control the player has to exert over and over again.

Any therapist who has worked with adolescents, people with ADHD, personality disorders and a host of other patient types understands the importance of learning impulse control. That act of mindfulness, that ability to create a moment’s space between the situation and the patient’s reaction to it is necessary to help people do everything from their homework to suicide prevention. In addition, there is always a body-based aspect to impulse control, however brief or small, and so to create that space is to forge a new and wider relationship between mind and body.

All of this was going on as we were playing Xbox. Over and over again, I was developing, practicing impulse control from behind that virtual sniper rifle. Again and again I was trying to recalibrate my bodily reflexes and sensations to a new mental model. Don’t fire. When my kill score began to rise, it wasn’t because my aim had gotten better, it was because my impulse control had.

Meanwhile, for the past two weeks I have been practicing making omeletes.

In particular, I have been learning how to make an omelette roulée of the kind Julia Childs makes below (you can skip to 3:30 if you want to go right to the pan.)

This type of omelette requires the ability to quickly (in 20-30 seconds) tilt and jerk the pan towards you multiple times, and then tilting the pan even more to flip it. Doing this over the highest heat the movement needs to be quick and reflexive or you end up tossing a scrambled eggy mess onto the burner. I can’t tell you how tense that moment is when the butter is ready and you know that once you pour in the egg mixture there is no going back. To jerk the pan sharply towards you at a tilt seems so counterintuitive, and this is an act of dexterity, meaning that your body is very involved.

In a way an omelette roulée requires impulse control just like Call of Duty in order to learn how to not push the pan but pull it toward you first. But just as importantly, making this omelette requires the ability to take risks. It can be scary to make a mess, what happens if the eggs fly into the gas flame?!

Let me tell you, because I now know what happens: You turn off the flame, wait a minute and wipe off the messy burner. And then you try again.

Adolescents, all people really, need to master both of these skills of impulse control and risk-taking. To do so means widening the space in your mind between situation and action, but not let that space become a gaping chasm impossible to cross. Learning impulse control also happens within experience, not in a special pocket universe somewhere apart from it. Learning risk-taking requires the same. And at their core they are bodily experiences, which may be what Freud meant when he said that the ego was first and foremost a body ego.

When I worked in special education settings, I was often called on to restrain children in crisis. Afterwards we would usually do a postvention: “What was happening?” “How could you do things differently next time?” We were looking at their experience from the outside, constructing a little pocket universe with words, as if we understood what had been going on in the experience, in the body and psyche of the child. I doubt these post-mortems taught impulse control.

I wonder what might have happened if we had risked throwing some eggs on the fire and encouraged the kids to play first person shooters or other video games. If my theory is right, then we would have been cooking.

**Not his real name. Name, age, gender and other identifying information have been altered to preserve confidentiality.

Mike is on vacation until September, which means that he has started talking in the third person at the end of blog posts. It also means that the next new post will be next month. He’ll repost an old fave or book excerpt to tide you over in the meantime.

Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: adolescents, avatar, behavior change, call of duty, children, digital literacy, education, Freud, game theory, gamers, games, gaming, mindfulness, omelette, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, social media, technology, therapy, video games

“Can I Kill You Again Today?”: The Psychoanalysis of Player Modes

July 28, 2013 by langloimsw 2 Comments

In 1947, Virginia Axline published the first edition of what was to become a seminal work in the field it was named for, Play Therapy. In her book she championed the concept of non-directive play, the form of play therapy where the therapist takes in some ways a very Rogerian approach of reflecting rather than directing the play either overtly or subtly.

This is easier said than done, as I learned when I started using it as an intern. I recall watching a youngster play and describe a family in a horrible car accident. My first comment was, “are they all right?” covertly signalling to the child that I was anxious in the presence of such violence and the possibility of death. The child reassured me that the family was okay, and I am convinced that I had essentially ruined that session’s treatment. Fortunately I was lucky to have an amazing supervisor, Linda Storey (great name for a therapist too!) who helped me to learn how to truly be non-directive. Over the next year and since I have greeted tornadoes, murder, floods, monster attacks, plane crashes, burning buildings and other disasters with “what happens next?”

Non-directive play therapy is still at it’s heart a two-part invention between the therapist and the patient. However, unlike some other forms of treatment, it requires the therapist to be able to tolerate a lot of violence and anxiety. Trying to direct children away from their aggressive fantasies and desires is often rooted in the therapist’s own anxiety about them. Let’s face it, for many of us death and destruction are scary things. It isn’t just a rookie mistake to ask the child to make the story turn out “okay,” and yet I think it has never been more urgent for therapists to be able to tolerate violent fantasy and encourage it to unfold in the play.

21st Century Play

Virginia Axline never had to contend with Call of Duty Special Ops, Modern Warfare or Battlefield 3. What was different about 20th Century play therapy was that the games in the consulting room usually resembled the ones from the child’s everyday life at home or school. The therapists therefore knew how to play them, and didn’t necessarily need to learn them as they went. But now we are in the 21st century, where the therapy office often has games from our childhoods rather than those of our patients, and they are very different.

If you are a therapist and never intend to learn to play video games and play them with your patients, you should probably stop reading here; the post won’t be useful to you and I’ll probably annoy you. But if you don’t plan on using video games with your young patients I hope you’ll consider stopping doing play therapy with children as well. Certainly stop calling yourself a non-directive play therapist, because you’ve already directed the child’s play away from their familiar games and away from this century. I actually hope, though, that you will lean into the places that scare you and try to meet your patients where they are at in their play, and for 97% of boys and 94% of girls that means video games.

Video games like Call of Duty and Minecraft are both very useful in both diagnosis and treatment of patients, as I hope to demonstrate by focusing just on one aspect here, that of player modes. Most video games have a range of player modes, and what the patient chooses can say a lot about their attachment styles, selfobject needs, and object relations.

Solo Play is OK

Like other forms of play, sometimes patients want to play alone, and have me bear witness to their exploits. They may do so out of initial mistrust, or a yearning for mirroring. Solo play is looked down on by some therapists, who often think kids using “the computer” are austitic and/or “stuck” in parallel play. I’d refer you to Winnicott, who taught us that it is a developmental achievement to be alone in the presence of another. (I’d also refer you to my colleague and therapist Brian R. King who has a lot to say about a strengths-based approach to people on the autistic spectrum, on which he includes himself.)

The Many Reasons to Collaborate.

Some patients want to play with me on the same team in first person shooter games. The reasons for this can vary. Some patients want to protect me from their aggression because they are afraid I’ll be scared of it like parents, teachers and other adults may have been. Other patients want to be on the same team because they want to have a merger with an idealized parent imago to feel more powerful and able to take on the game. Still other patients, seen in their daily lives as oppositional or violent, want to play on the same team so they can revive me and have me experience them as nurturing and a force for good in the world.

Some patients want to have their competition framed by overall collaboration, meaning that they want to get the most or final “kills” but remain on the same team. Some patients secretly yearn to play on a different team, and may need to “accidentally” change the settings to put us on opposing teams and passively want the game to continue.

Let’s Bring On A World of Hurt.

On the other hand, there are a lot of reasons patients want to compete. They may want to see if I can stand their aggression and/or desire to win without being annihilated. They may want to express their sadism by tormenting me for my lack of skill, or alternately project their yearnings for recognition by praising me when I kill them. They may want to see how I manage my frustration when playing, and interpret that frustration as investment in the game and therefore my relationship with them. They may be watching very carefully to see how I act when I win or lose. Do I gloat when I win? Do I make excuses when I lose? How might these behaviors be understood by children and adolescents who often feel like they are chronically losing and behind their peers in the game of education?

More questions arise: Does the patient ask me what mode I want to play or simply decide on one? Do they modulate their anxiety by playing a combat mode but expressing the desire to stay away from the zombie mode? By allowing them to do that am I helping them to learn that sometimes life is about choosing the lesser of two anxieties rather than avoiding anxiety altogether?

Multiplayer and Uninvited Guests

In terms of settings, there is some direction on my part, which is part of maintaining the therapeutic frame. I make it a requirement that we play either locally or in a private game. And of course this sometimes go wrong, with a random player joining us.

What to do then? What if we are on an extremely high level and just terminating the game will do more harm than good? In that case I make sure we are on mute and the our conversation can’t be heard by the added player, and then things get even more interesting in the therapeutic conversation: Does the patient have any feelings about the new player’s arrival? What do they imagine the usertag “NavySeal69” means anyway? Do we help them when they are down or try to ignore them? How do we feel if they are ignoring us? Do we team up against them?

Minecraft and the Repetition Compulsion.

I could probably write a whole post or paper on this, but for know let’s talk about creative mode and griefing. In Minecraft you and other players can build things alone or together. Other players can also “grief” you, meaning cause you grief by destroying your structures and setting you back after a lot of hard work. What does it mean when a patient griefs my building, apologizing and promising not to grief it if I rebuild, then griefs it over and over again? What may be being reenacted here? Are there adults in the patient’s life who tear her/him down again and again? When does one give up on any hope for honesty or compassion from the other? What sort of object are they inviting me to become to them; angry, patient, gullible, limit-setting, mistrustful?

I have used the term child or adolescent here, but exploring the gameplay of adults when they describe it to me is often useful as well. I often encourage my adult students or gamer readers to do a little self-analysis on their play-style? What does your preferred mode of moving through video games say about you? What questions does it invite you to explore?

The goal here is not to give you an explicit case presentation or analysis of one hypothetical patient or game. Rather, it is to provide you with a Whitman’s Sampler of practice and theory nuggets to give you a taste of the richness you are missing if you don’t play video games with your patients, especially if you are a psychodynamic therapist. There is a lot that “happens next” if you engage with your patients in 21st century play that has themes you may find familiar: How do I live in a world that can be hostile to me? Why should I trust you to be any different? Will my badness destroy or repulse you? Will you hurt me if I am vulnerable? These and dozens of other fascinating and relevant themes emerge in a way that never did for me when I forced kids to endure 45 minutes of the Talking, Feeling, Doing Game. And what’s more you don’t have to remember to take the “What Do You Think About a Girl Who Sometimes Plays with or Rubs Her Vagina When She’s Alone?” card out of the deck.

I’m not THAT non-directive. 🙂

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Filed Under: Gamer Therapy Tagged With: adolescents, axline, battlefield, behavior change, call of duty, children, digital literacy, FPS, Freud, gamers, games, gaming, mindfulness, minecraft, object relations, play, private practice, psychoanalysis, psychology, psychotherapy, rogers, self psychology, shooters, social media, special ops, technology, therapy, video games

Epic Supervision Fail

April 2, 2013 by langloimsw 7 Comments

This past week social work colleagues Ericka Kimball and JaeRan Kim had an article published in Social Work entitled: “Virtual Boundaries: Ethical Considerations for Use of Social Media in Social Work.” It’s a good article, and more importantly it’s a nice start. The article discusses if, when and how to use social media ethically. The authors don’t purport to have a solution to every potential problem that social media poses clinicians, but they have some good suggestions.

I have mixed feelings about the constant yoking of “technology” to “ethics” in our profession. (In general, not specifically the article above.) It always seems to imply that social media and ethical problems go hand-in-hand. No other ethics issue, even patient abuse by psychotherapists, gets as much play in our current professional development course offerings, and the irony is that there is evidence to support the much higher prevalence of the latter than the former. It seems the only way the majority of psychotherapists can get curious about social media is if somebody scares them with the idea of ethical or legal violations.

Is there an ethical dimension to integrating technology into psychotherapy? Absolutely. It’s just not the only dimension. And the problem with always focusing on ethics is it often encourages fear-mongering and contempt prior to investigation. Part of the problem is that most of the people talking about ethics and technology in clinical practice have little to no experience with the technology side of things. And as a result, they can’t engage us with ideas and brainstorming, but instead often adopt the fall-back of “you need to be careful.”

The result is that many clinicians get understandably scared: You told me something is dangerous, and that the only solution is to be careful. So seasoned clinicians often adopt what I call the “just say no” attitude. Firewalls go up. Patients can’t be emailed. Agencies adopt no-Facebook policies, and in general evoke an air of monasticism. I have even heard cases where clinicians are told they need to renounce having personal social media. Though Shalt Not Tweet.

Into this “just say no” milieu come our trainees. Many of them are digital natives, and have been wired for technology in a way we digital immigrants may never be. In many cases they are more digitally literate than we are. They come into their supervision sessions with questions about cell phones in the office, suicide posts on Facebook, and being followed by patients on Twitter.

And they get “just say no.”

So let’s get real a sec here.

The Pew Internet Research Group states that roughly two-thirds of North Americans are on Facebook. It, along with other social media, has become a primary source of communication and shaper of culture for our society. This means that a majority of our trainees and their patients are probably using it. We can’t just say no. We can’t just say, “be careful out there.” Our trainees look to us for supervision, and understanding social media and technology is part of 21st century clinical work.

I can’t tell you how many times I have heard horror stories in my classes about how supervisors fail their students this way. And I get emails detailing, for example, how a young clinician tried to bring up the positive impact of social media to a supervisor: “I thought her head was going to implode.”

Psychotherapy has a past history of using innovations in technologies to enhance our work, and our theoretical models. Freud used the newer technologies of hydraulics to explain drive theory. Similarly, advances in thermodynamic technology helped pave the way for family systems theory. By now, many of the principles and parallels of those technologies have become so commonplace in our lives and understanding that we don’t even connect them with being familiar with technology.

Historically technology creates a period of suspicion and confusion before integration into culture. A favorite example of mine is this:

Prior to the Gutenberg printing press, books were a much rarer technology. In the 8th Century, approximately 12,000 books were published in all of Western Europe; by the 18th century that number had risen to 1 billion. As this technology became cheaper and more easily accessible, literacy rose. But this was also a time when things got overwhelming. When you had a handful of books read by a handful of people, the knowledge in them was much easier to locate. But when the number of books and readers increased, there was an overwhelming amount of information to remember and locate. The book index was the technology we came up with to solve that problem, but we needed to experience the technology as problematic before a solution was necessary.

Today we take indices, books and literacy largely for granted. We know how they work, we aren’t afraid of them. If anyone wanted to hold a workshop on the “Ethical Considerations of Printing” they’d be hard-pressed (heh) to get anyone to attend.

So now we find ourselves faced with a new technology, one as revolutionary in many ways as the printing press. Only this time we are the generations that need to get used to it and confused by it. And it’s risky and scary, because we don’t fully understand its implications yet. But just as we wouldn’t have wanted our ancestors to forbid us to read and write, we need to let our trainees learn how to use the newer technology of social media in our lives and work. And to do that, we need to learn it too.

This takes time, and it takes someone with expertise to teach you. So before you hire a consultant, keynote speaker, or workshop presenter to talk about social media or technology in general, ask yourself, and them, these questions:

1. What do you plan to teach me beyond ethics about technology?

2.What strategies can you help me and my agency deploy besides be careful or “Just say no.”

3.What if any experience do you have with technology? Do you use social media? Professionally? Personally?

Just asking potential consultants those 3 questions could save you or your professional organization a lot of money down the line, as well as make the difference between helping you embrace innovation or stagnation.

Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: activism, building your business, digital literacy, education, facebook, Freud, gaming, gutenberg, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, social justice, social media, technology, therapy, Web 2.0

Minecraft & The Uncanny, Part 2

August 27, 2012 by langloimsw 1 Comment

This is the second of a two part series on Minecraft. Up until now you could only read it if you bought my book, but I am posting it here to give you a sense of what the book is like. You can buy it here. More importantly, I’m hoping you will find the topic interesting enough to vote for my presentation proposal on Minecraft & Mindfulness for SXSW this year. You can do that here.

In Minecraft, nothing is present-at-hand, at least initially, until you realize that the ground you are running on or the mountain you are climbing aren’t just that, they are materials. You can dig up stone to make a furnace, then bake bricks out of clay, build a house and so on. The world gradually becomes ready-to-hand.

There is no avoiding the sense of throwness when you begin playing Minecraft. It comes with very few directions, although there is plenty of info on the web to be had. The downloadable beta allows you to play single and multi-player, with the single being a good way to practice the basic mechanics. The multiplayer version opens up a whole new vista.

The multiplayer game is hosted on individual servers all over the world, some of which you can log into for free, others for a small fee. Once logged in, the virtual world is a huge massively multiplayer sandbox, which can be a very social experience. The cooperative building in some of these worlds is incredible. My first journey to a server in France threw me into a world which included a vast underground city beneath a dome of molten lava. Players are allowed to explore the world, and at a certain distance from their neighbors mine, farm and build. Like Second Life, you can port to various places on the server, and encounter anything ranging from a Waterslide Park to a model of Hyrule, all built out of the game materials by the players.

Once in the multiplayer world, the social element of the game can become compelling. People on chat are offering to sell gold ingots, suits of armor they crafted, or tracts of land they have developed, for both in-game and out of game monies. You can have as much or as little to do with that as you like, and you can teleport to far-off corners of the map if you want to build and play in undeveloped lands.

In its simple mechanics, Minecraft allows us to glimpse the uncanny experience that I would suggest all video games have. Video games are a unique art form in that they are both interactive and aesthetic by nature. In fact they are far more stimulating and less anergic than watching television, and stimulate more regions of the brain.

Video games allow us to experience our throwness in a new world, and the animistic state of being inherent in the uncanny. We are never completely at home in the world of the game, although the game may become more familiar over time (or not, in the case of the indie game Limbo.) We are always just visiting, strangers in a strange land. But within the game world, mana and magic are also real, and our thoughts and strategies can quickly and permanently change the world.

Psychotherapy is in many ways, another sandbox game. There really is no way to win in it. The office becomes a setting for a potential space that can be shaped and altered by the patient and something new created. Psychotherapy is also an uncanny space, one that resembles the world outside the office and yet does not. It is a place for “everything that ought to have remained … secret and hidden but has come to light.” Within that space, the patient experiences hauntings by ghostly relationships from the past, encounters the internal monsters of the drives, and explores the wishes behind their secret injurious powers. Unexplored and avoided, these have calcified into symptoms, and the anxious, exciting, process of therapy helps the patient break down that calcification for a more flexible psyche.

Any child or gamer knows that play is a serious and dangerous business. There is always the risk of annihilation, and no place worth going to doesn’t have its hazards. But there are great treasures to be found in the game. Further, the emotional and intellectual changes encountered within the game can then be taken out of it into the daily life of the gamer. This is one of the reasons that video games are so compelling. Why else would people spend hours making houses out of pixel bricks?

Both psychotherapy and video games create very real thought and feeling states in people, and that is part of their curative power. In this book I hope I have shown that they can restore a sense of purpose and achievement that our patients have lost. I have discussed how they can help people stay connected with others over great distances in times of duress, help us feel the sense of achievement necessary to learn and change behaviors, and explore aspects of their personalities that may be less easily seen or developed in their daily lives. I have also explored how we can use the experience and metaphors from video games with patients to help them understand ego defenses, communication patterns and strategies that impact their relationships, and apply game mechanics to their lives to change them. I have tried to discuss the stigmatization of gamers and technology in terms of diversity, in particular social class. Finally, I hope I have shown how therapists can apply the principles from video games and gamification to impact both their clinical work and business skills.

All of this pales in comparison to doing the actual work, and by this I mean two things. The first and most obvious one is the practice of psychotherapy. Theory is a necessary but insufficient precursor to clinical practice and healing. The second piece of actual work will be for the therapist to begin playing some video games. Reading is not the same as doing, and it is only by entering the uncanny and enriching world of the video game that therapists can hope to truly understand them. Never has play been more important in our work, and never has understanding video games been more urgent in healing the world. To do so we need to rethink our attitudes and reconsider our biases towards gaming and technology.

It’s time to reset.

Gamer Therapist is on vacation, so we’ll see you in two weeks! In the meantime, please vote for our minecraft panel at SXSW!

Like this post? There’s more where that came from, for only $2.99 you can buy my book. I can rant in person too, check out the Press Kit for Public Speaking info. Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: education, Freud, game theory, gamers, gaming, heidegger, mindfulness, minecraft, psychoanalysis, psychodynamic, psychology, psychotherapy, sxsw, technology, therapy, uncanny, video games, Web 2.0

Minecraft & The Uncanny, Part 1

August 15, 2012 by langloimsw Leave a Comment

This is the first of a two part series on Minecraft. Up until now you could only read it if you bought my book, but I am posting it here to give you a sense of what the book is like. You can buy it here. More importantly, I’m hoping you will find the topic interesting enough to vote for my presentation proposal on Minecraft & Mindfulness for SXSW this year. You can do that here.

In 1919 Freud wrote and published an article on “The Uncanny.” In it he described the concept of the uncanny as a specific type of fear something both strange and familiar. It is worth noting that the article begins with an investigation into aesthetics, something that was not usually done in the medical literature of Freud’s time. But Freud realized that there was something particularly aesthetic about the uncanny. It is an anxiety that both draws on the aesthetic, and from a distance also acquires an aesthetic quality itself. In fact, it could be argued that a whole genre of fiction, such as Lovecraft, embodies the aesthetic of the uncanny.

In German, the uncanny is unheimlich, which translates literally to the “unhomely” or “unhomelike.” Here homely has a double meaning. First homely is the quality of domesticity, the warm hearth of the house, down comforters, a cheery cottage coziness, etc. Second, heimlich refers to concealment, contained within the house’s domestic sphere, hidden from the public eyes of outside society.

Seen in this light, the uncanny or unheimlich is both alien and a revelation or an exposure. Freud quotes Schelling as saying that ‘“Unheimlich” is the name for everything that ought to have remained … secret and hidden but has come to light..’” Is it any wonder that Freud took up exploration of this concept, with all of its allusions to the unconscious, anxiety, and societal repression?

Freud also talks about the element of repetition in the uncanny, such as arriving at certain places we’ve been to before, or noticing the number 62 appearing throughout the day in a variety of places. This element of repetition gives rise to the sense that there is a pattern that we may not be aware of, which in turn makes the world suddenly seem both stranger and more imbued with meaning.

Freud goes on to discuss something gamers will be very familiar with, mana, although he discusses it from outside the framework of fantasy as a form of magical thinking that attributes powers to the neurotic overvaluation of their thought processes and their impact on reality. But the game world is within the realm of fantasy. Within that world, what Freud refers to as “the Apparent death and the re-animation of the dead” are fairly commonplace. The game world returns us in many ways to the animistic state of being, characterized by “the prompt fulfilment of wishes, with secret injurious powers and with the return of the dead.”

The uncanny also figures largely in the philosophy of Martin Heidegger, and is connected to the idea of man’s “throwness” into the world. Human beings want to feel at home in the world, but when they encounter the uncanny they experience themselves as thrown into it and apart from it. For Heidegger the unheimlich eradicates our sense of Being-at-home-in-the-World, but as it does so it reveals something about the World to us.

For Heidegger the World is also revealed to us (and we are revealed as well) by that which is ready-to-hand, something that has a meaning that connects us to the world. An example is a hammer, which we experience as imbued with meaning and value and inextricably linked to human being. We don’t think about the hammer, in fact the only time we are really conscious of it is when it isn’t working. A similar example is your car, if you reflect on it you will probably notice that you only really pay attention to your car as a concept when it isn’t working.

As opposed to ready-to-hand, present-at-hand refers to an uninvested, detached way of looking at something, one that takes us out of any sort of meaningful relationship. Its meaning may be unclear and unconnected with human being at all. If I ask you what you’d like to do with that round green and red thing, you’ll be confused. But if you see it as an apple, things will become much clearer. It probably isn’t a coincidence, by the way, that most depictions of Adam and Eve in the Garden of Eden show the fruit as an apple. Before the Fall, everything is ready-to-hand and imbued with meaning. Afterwards, in our thrown state, things become less clear, and more uncanny. Paradise has been lost.

Ninety years after Freud wrote “The Uncanny,” Markus “Notch” Persson created the game Minecraft. Minecraft is a sandbox type of video game, meaning that the world generated can be permanently changed by the player. Creativity and survival is the goal, and there is no way to “win” the game. The premise of the game is that your character is thrown into a vast world designed with 8-bit graphics (think early Nintendo) with only your bare hands. The game has a day and night cycle, and at night zombies, skeletons, and other monsters come out and will attack you if you are exposed.

Everything in the game world can be destroyed and broken down into elements that can be crafted if you have the right ingredients. At first you have fewer options, because destroying a tree with your hands takes more time than if you had an axe. But slowly you gather materials so that you can build things that in turn allow you to build more things, so that you can hopefully build a shelter before night falls.

The landscape of the world is randomly generated by the game, and remains saved if you are killed. Dig a hole in the ground and it will be there when you return from the dead and to the game. The graphics are not realistic, with the blocky edges of 8-bit design, which underscores the uncanny element of the world. The world is vast, and looks like the real world, and also doesn’t. Minecraft is not trying to trick you into thinking it looks like real life, in fact that is one of the things that makes it so immersive.

Part 2, next week.

Filed Under: Gamer Therapy Tagged With: Freud, game theory, gamers, games, heidegger, mindfulness, minecraft, play, psychoanalysis, psychodynamic, psychology, psychotherapy, sxsw, technology, therapy, video games, Web 2.0

If Freud Had Played Video Games

December 12, 2011 by langloimsw 20 Comments

This post is dedicated to my supervisee, Alex Kamin, who inspired me to make the connections. I learn so much from my supervisees!

Last night I spent a great deal of time mining for diamonds. They are fairly rare, and can only be mined if you have an iron pickaxe (or a diamond one). This meant that I needed to mine iron ore first with a stone pickaxe, but I should start at the beginning.

Minecraft is a game which now rivals WoW in popularity. It has been around in beta for a while, but now has been released to the general public. The game takes place in what is known as a sandbox world. What that means is that the game world can be effected permanently by the player. Dig a hole and it stays dug, chop a tree down and it stays chopped, plant new ones and in time they grow. As opposed to having a beginning, middle and end, Minecraft can be played for as long as you like. You can play it in single-player mode or log on to a minecraft server and participate in a multiplayer world.

Starting with nothing but her or his bare hands, your character takes materials from the environment and fashions tools, houses, works of art out of these raw materials. That is the crafting part. Once you have fashioned the most basic pickaxe, out of wood, you start to do the mining part. Which brings me back to diamonds.

Diamonds are very rare blocks in Minecraft, and are mostly found at the bottom layer of the world. You have to tunnel through loads of dirt blocks, stone blocks, and gravel blocks. Sometimes you tunnel straight into lava and get burned up. Sometimes the ground beneath you turns out to be a giant chasm and you plummet. Sometimes there is water that floods your tunnel, or monsters if you are looking in one of the world’s many caves.

A lot of time is spent underground, but a big part of the game is to bring the materials back up to the surface. There you make your crafting table, house, and forge. Days and nights pass. At night the monsters from the caves come out and roam the surface, and you’d better be in your house with the doors shut!

This is a very brief synopsis of an amazing virtual world that is already being used in classrooms and by families to provide cooperative and fun learning. You can find one such example, The Massively Minecraft Network, here.

One group who could benefit from understanding and playing Minecraft is psychodynamic psychotherapists, especially psychoanalytically-oriented ones.

For decades, psychology textbooks have used the iceberg to explain Freud’s early topographical model of the mind. It’s the one I grew up as a therapist with, and you probably did too. One version is this one:

Photo found on Allpsych.com

The topographical model introduces the concepts of the conscious, the preconscious, and the unconscious. Freud was ultimately dissatisfied with this model, and moved on to his structural theoretical model of Id, Ego and Superego. I wonder if he would have done so if he’d been able to play Minecraft.

Two of the deficits of the topographical model as pictured by an iceberg are its static nature and its failure to locate where and how psychotherapy works. The second deficit derives from the first. Psychodynamic therapy is as the name suggests, a moving process. Now imagine playing the game I described above, and you have a dynamic model. There is the conscious surface that changes over time, is constantly changing and growing, where things are visible. There are the caverns and depths which are the unconscious. And there is the preconscious twilight and night, when the monsters and creatures from the unconscious slip up to the surface and terrify us.

In terms of describing psychodynamic therapy, Minecraft makes that easy too. I have often had a difficult time explaining to a patient what the unconscious is and why I think it is important. But any gamer who has played Minecraft will understand the process of therapy and their work in it in the metaphors of mining. During the week, our patients roam the surface of their psychosocial world. Then one, two, or three times a week, they come into therapy and begin tunneling. Week after week they mine dirt, stone, and occasionally strike a vein of insight. Like iron ore, insight is a necessary but insufficient requirement for change. Without smelting and crafting, iron ore can never become a tool we can use. Likewise, without reflecting on our behaviors and changing them we can never improve our ego functions.

You can explain ego functioning via Minecraft as well, by discussing those above tools. Tools in Minecraft include shovels, pickaxes, hatchets, swords, wool shears and hoes. A hoe is excellent to use in gardening, whereas a sword will not function in the game that way. You can chop down a tree with a pickaxe but it takes longer and wears down the pickaxe more quickly than if you were to use a hatchet. Different ego functions do different things, and the ego defenses are only one subset of the ego functions. Only one of the tools is explicitly made to be a weapon.

And if you lead with your ego defenses all the time you will be disappointed. Take sheep for example. If you kill a sheep with a sword you get one block of wool. But if you shear it with the iron shears you get three wools, and the sheep lives to grow more wool. By the way, if you craft a hoe you can grow wheat, which allows you to domesticate and breed sheep for even more wool. Just so our ego functions, which provide a holistic and dynamic system that allows us to mediate the world and our wishes.

When you start mining you have a wooden pickaxe. You mine stone so you can get a stone pickaxe. You mine iron ore with the stone one. Only iron pickaxes can mine diamonds.

Psychotherapy takes time and effort, lots of time and effort, if you are aiming for more than symptom reduction. Patients begin with the raw tools they started out with, and build on each developmental gain. Often our patients will feel very raw and discouraged, state that they despair of ever getting better, whatever better means to them. When that happens we can remind them that therapy is minecraft. It takes delving and work back on the surface in the real world outside the office. It takes time and patience. Sometimes they will feel consumed by feelings as hot as lava, or flooded by memories like water in a mineshaft. Sometimes it will feel like they’ve lost everything they’ve been carrying and have to start over. But with each set of tools they acquire they’ll find it easier to make their way in the world.

And sometimes they will find diamonds.

Like this post? There’s more where that came from, for only $2.99 you can buy my book. I can rant in person too, check out the Press Kit for Public Speaking info

Filed Under: Gamer Therapy Tagged With: ego psychology, Freud, gamers, gaming, minecraft, psychoanalysis, psychodynamic, psychology, psychotherapy, therapy, video games

Save and Continue

April 15, 2011 by langloimsw 6 Comments

Recently I was playing God of War III, and noticing something I take for granted much of the time, the savepoint. This is something that has become so integrated into video games that gamers hardly notice it after we discover what the particular “savepoint” looks like in the game we are playing. The saved game has been around for decades, and has become increasingly important as games have grown in length and complexity. I was reminded recently by Nancy Rappaport, a colleague and attending psychiatrist at Cambridge Health Alliance about how the concept of the saved game may not be taken for granted. I was trying to explain to Nancy during a workshop certain gaming concepts, and she was explaining that her point of reference in playing video games was Pac-Man, and in a general sense video games from an arcade setting that early on didn’t always have savepoints, where the player was asked if they wanted to “Save and Continue.”

This may be useful to remember when you are becoming frustrated with a gamer who is not as concerned with the quantitative time (bedtime, for example) as they are with the qualitative time of getting to the savepoint. But that actually isn’t what this post is going to be about. Instead I want to return to the concept of what makes an Epic Therapist here:

Epic Therapists remember the importance of saving and continuing.
To start with, therapy is in many ways a savepoint. At certain times in their lives or week our patients arrive at our office, pause, and take stock of things. In his 1914 paper “Remembering, Repeating and Working-Through” Freud alludes to this when he remarks that “In these processes it particularly often happens that something is ‘remembered’ which could never have been forgotten because it was never at any time noticed–was never conscious.” Like the savepoint in a game, the patient arrives at the place for the first time, understands how important it is to hold on to that progress, and remembers or saves it from repression. But part of what makes therapy therapy is the therapeutic frame, and at some point the session ends, and the patient goes back out into the rest of their life. They can’t just stay at the savepoint, they have to continue.

Readers have probably noticed by now that I draw frequent parallels to psychoanalytic theory and video games, and this is no exception. Our profession has a rich theoretical history that has grown from individual therapists learning from each other, disagreeing with each other, building on the prior work of each other and diverging from each other. Psychology as a field to flourish has had to frequently “save and continue” by writing these theories down in journals and now blogs, to take stock of what we have learned, but we’ve also had to move forward and continue to challenge pre-existing models. It can never be just save or just continue: To just save would stagnate our thinking and practice, and to just continue would mean we never consider thoughtfully the work we are doing.

In many ways, the problem with healthcare has been few if any savepoints, discouraging providers from taking time between patients to reflect before continuing on to the next patient. Interns in mental health agencies have many no-shows, and with no infrastructure to hold patients responsible to keep their appointments, these interns “continue” through the years where they should be receiving the most training with a fluctuating and diminishing number of patients to practice their craft under supervision.

Ask yourself this: If you were about to have open heart surgery and the doctor told you that he had only had the opportunity in medical school to practice the procedure 3 times because most of his patients cancelled or no-showed, would you feel confident in their ability? And yet we crank our interns through graduate programs based on the number of years rather than skills acquired, because the healthcare system is flawed and and patients are not held accountable for missing/cancelling appointments. This isn’t the interns’ fault, they are trying to get through to their knowledge and experience “savepoint,” but graduate schools and placements inadvertently become the parent shutting off the light because its “bedtime,” and we are producing generation after generation of clinicians who have had inconsistent or insufficient practice. This is continue without the save.

On the other hand, let’s take a look at the radical save mentality that permeates our profession. There are certain parts of the way many of my colleagues practice psychotherapy which have become extremely fixed, and I too fall prey to this at times. The 45-50 hour, a certain therapeutic stance, and my favorite, shunning technology. They bar their adolescent patient’s cellphones at the door rather than exploring who is texting them, refuse to consider Skype as an option let alone suggest it to their patients.

I frequently get referrals emails from several listservs, looking for therapists in Seattle, London, or Singapore. I enjoy practicing in-person therapy immensely, but does it ever occur to these colleagues to consider beginning to practice online as well? Why refer a patient to someone in Taiwan based on location when you could have one of your colleagues whom you know and respect take the patient on? On occasion I reply to these referral requests asking if the patient would be interested in Skype, but for the most part I’ve become reluctant to do that because I am pretty sure it doesn’t go anywhere. In terms of technology these psychotherapists are often in a lock-down save mode, and I foresee that they will resist change as the world continues without them.

My friend and colleague Susan Giurleo and I often find these things frustrating, and I realized today one reason why we may have this in common. We both went to Connecticut College in the late 80s early 90s, between the college presidency of Oakes Ames and Claire Gaudiani. In fact our graduating class became known as “the folks who knew Oakes.” And during this time our college had a motto that was drilled into all of us: Tradition and Innovation. Everywhere we looked, in all the college information and stationary were those words, tradition and innovation. Save and continue.

I have definitely tried to live that in my profession and my life of the mind. I’m a psychodynamically oriented therapist who uses Twitter and plays video games. I teach my students about Freud and Facebook. And I think that perhaps the affinity I find in the fin de siecle of the 19th century is how its denizens struggled to save and continue, to embrace the advances of technology then as we do now in the 21st century. In a recent article at boston.com Chris Brogan alluded to this when he said, ““The excitement for me about [social media] is, it’s gone from ‘Gee whiz!’ to ‘Now what?’ ”

Technology is here to stay and embedded in our lives, and today, like after the Industrial Revolution, we must learn the “now what?” To do this we can’t just rush forward and forget everything we ever knew, but we can’t stay stuck in a mindset from the pre-IBM world. Web 2.0 has arrived, and we need both tradition and innovation if we want to progress.

We must save and continue.

Filed Under: Gamer Therapy Tagged With: adolescents, building your business, chris brogan, Freud, gamers, god of war 3, psychoanalysis, psychology, psychotherapy, referrals, susan giurleo, therapy, video games, Web 2.0

The Gamification of Psychotherapy

February 19, 2011 by langloimsw 13 Comments

“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.

Filed Under: Gamer Therapy Tagged With: adolescents, Freud, game theory, gamers, gaming, ludology, play, psychoanalysis, psychodynamic, psychology, psychotherapy, video games, Web 2.0

New Lease on Second Life

October 19, 2010 by langloimsw 12 Comments

So let me introduce you to Sigmund Steampunk, my avatar on Second Life. I have already learned that there is more to Second Life and avatars than learning how to “walk” in the virtual world. One of the lessons came from my supervisor, whom I value and idealize immensely, and who has only begun to learn about avatars and SL through our work together. So the other day I emailed her and included the above photo of Sigmund, mentioning that since we’d been discussing it I thought she’d find it interesting to see what I was talking about. She did, and then she lightheartedly mentioned that Sigmund looked like a slightly anorexic version of Ellen DeGeneres…

Lesson #1 Avatar Cathexis

People who experience avatars from the “outside in” don’t always understand immediately how cathected the user can be to them. When I say cathexis, I am referring to the psychoanalytic concept of emotional and or libidinal investment in the object. In most MMORPGs and virtual worlds the user has some to a lot of input into how to design their avatar. The result? The more time one spends shaping one’s avatar, the more emotionally invested in it one can become. I was reminded of this when I read the less than flattering description of Sigmund: I was taken aback by the fact that the description actually had an emotional impact. Namely, ouch!

And when I noticed the ouch, I noticed that there was a stronger cathexis than I had bargained for. So when you are given the opportunity to meet one of your patient’s avatars, tread carefully. You don’t know how emotionally invested they are in their avatar. They may not know how emotionally invested they are in it. I know that we will have a rewarding supervision session next time, and I know that my supervisor will “get it.” But I will think twice before introducing her to my level 80 draeni mage from World of Warcraft. Sigmund has only been around for a few months, the mage has been around for 4 years! Another example of avatar cathexis is said mage. I recently wrote a two-part article for my local NASW paper on online gaming. My co-author asked me what licensure or work qualifications I wanted included in my byline. I wanted to include that I was an assistant faculty at Harvard Medical School and a level 80 draeni mage. She informed me that NASW wouldn’t consider the mage qualification professional enough. Again, ouch! Do you know how many hours it took to level that guy? We’ve been through thick and thin, and I consider him as source of pride on par as my Harvard appointment. Looking at that from the “outside in” you may think that is bizarre. But in terms of avatar cathexis it makes perfect sense.

Lesson #2 Avatar’s are fraught with meaning, conscious and unconscious meaning.

Now that I look at Sigmund, I can clearly see what my supervisor was describing. I could make excuses, in truth I wanted his hair to be more dirty blonde like mine but couldn’t figure out how to do that. But the reality is, I hadn’t been entirely conscious of my wish to be a few pounds thinner. But there is my wish fulfillment, standing there waving at us. Luckily I can tolerate seeing it. Some of our patients may have a harder time. Some may want to have more powerful bodies, others may want bodies assigned a different gender, still others want to give their avatar a chance at childlike innocence they never had, as the latest issue of TILT describes in “Alice in VirtualLand.”

So when exploring your patient’s avatar, tread carefully. But definitely explore it, the avatar is a gift to the treatment. It is wish fulfillment, idealized self, object relation, projection and IFS part all rolled up in one! If you are a psychodynamically oriented psychotherapist, you’ll be amazed at what comes up for your patient when you start to express interest in getting to know their avatars. And if you express disinterest, you have made a great empathic failure, and like all such empathic failures, you need to correct it ASAP.

In Second Life, there is a lot of joking about the bumping into things that first happens “inworld” when a user starts to try to move her or his avatar around. I see this as also a metaphor for integrating avatar therapy into your treatment repertoire. I have no intention of beginning to start having sessions with patients virtually in SL any time soon. But I can see that a day may be coming when that will be part of meeting them where they are at. I don’t want to be bumping around into walls or ego defenses, so I am practicing a little now, on my own time. Many of the people I supervise around technology want to jump right in, and I applaud their enthusiasm. I also caution them that we didn’t start meeting with patients before we had had at least some education in how to practice therapy, and that the same applies for learning to navigate Web 2.0.

What technology are you willing to play with and learn about before you are asked to by a patient? Where will you go this week?

Filed Under: Gamer Therapy Tagged With: avatar, cathexis, Freud, metal health, object relations, psychodynamic, psychotherapy

Secret Formula PB+5

September 22, 2010 by langloimsw 12 Comments

I have frequent consults with beginning or seasoned practitioners looking to get on Medicaid as private practitioners. Their logic on the surface makes a lot of sense coming from their agency backgrounds. A majority of their patients in agency are on Medicaid, and they may want to keep them as they transition to private practice. And many of us went into this work because we want to help a range of people, including the most impoverished or differently abled. These are laudable goals, and I want to assert that they are not incompatible with private practice. But I do think that Medicaid is, at least in terms of building one.

What happens when your patient misses their appointment? With Medicaid you cannot charge them for a missed appointment. And after they miss two or three, you may have the conversation about “are you really interested in treatment?” They say yes, miss again, and you fire them, or don’t call them back and feel guilty and frustrated; or they drop out of treatment feeling like they’ve failed yet again. And in Massachusetts, the newest vendor of Medicaid, Beacon Health Strategies, is trying to change the provider contract to say that you are not allowed to fire them for no-shows! Outrageous, but hey, you signed the contract, so until NASW or APA fights this statewide that is your agreement.

This is such a lose-lose! Private practitioners are not able to make a living, low-income patients are not able to get consistent treatment, and everyone feels like a failure, except the insurance company which pays nothing. But there is a way to build social justice and healthy treatment into your practice right at the beginning, I call it my Pro Bono + 5 session.

Imagine this, you decide that you want to start out in private practice, and while you are building it you want to be able to take referrals from your old agency, which usually has mostly Medicaid patients. So you call them and let them know that you have 2 immediate openings for your pro bono plus 5$ sessions.

Your what?

You explain that while you don’t take Medicaid, you are offering two sessions in your practice where you contract with the patient that as long as they are on Medicaid you will never charge them more or less than $5. You don’t participate in Medicaid, but you won’t bill Medicaid either. You’ll only ask them for a nominal $5 fee payable each week as part of your committment to building a socially just practice. When you meet the patient, you explain this to them, and explain your no-show policy. They keep their appointment, they pay the $5. They miss the appointment, they pay the $5. If they’re sick or unable to make the session, you’ll gladly offer them a phone session, because they’ll still be paying the $5. This is made clear the first appointment, with whatever your normal policy is. You see, you can’t do phone therapy on Medicaid, but on your PB+5 plan you can. For the patient, they are getting a great discount and affordable treatment. For the beginning private practitioner you are getting great clinical experience, including talking about the fee and your therapeutic contract, and feeling like you are doing some diverse work, which hopefully helps you feel more confident in being circumspect when filling the rest of your week. The referring agency gets to win in that they can refer someone immediately. Win-win.

This is not a new concept. Freud created the Vienna Ambulatorium to provide free psychoanalysis almost 90 years ago. We all know that Freud saw many upperclass patients, but he also allotted some time for low-cost or free treatment. You can do the same. And I suggest that you set a fixed number of sessions right at the start of your practice, which will help you later keep the number of full-pay or insurance appointments fixed as well. So what do you think?

Filed Under: Business Tagged With: Ambulatorium, Freud, low-cost therapy, managed care, marketing, private practice, pro bono, psychotherapy

Streaming, Path of Exile & The Repetition Compulsion

Taking Leaps: Fortnite, HIPAA & Psychotherapy

Minecraft & The Uncanny, Part 2

Minecraft & The Uncanny, Part 1

If Freud Had Played Video Games

Save and Continue

The Gamification of Psychotherapy

New Lease on Second Life

Secret Formula PB+5

Mouse Over My Pic For A Secret Message..

Epic Tweets

Ye Olde Vault

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Mouse Over My Pic For A Secret Message..

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