An Open Letter to Parents, Teachers & Administrators Now That School Is Officially Closed
Streaming, Path of Exile & The Repetition Compulsion
As many of you know I have begun streaming. My goal in doing this is to both have some fun, and reach a wider audience when talking about psychodynamic concepts. This is my latest attempt, in which I talk about the Repetition Compulsion in terms of farming for a unique sword in the game Path of Exile. Keep in mind that the conversation about the repetition compulsion during the stream if for a general audience, and should not be substituted for seeking out medical advice or a mental health professional. My hope is that you’ll share it with the gamers in your life, therapy practice, class, etc. And of course if you sign up to follow my Twitch channel I’d be delighted!
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Can’t We All Just Game Along?
I had a powerful reminder about the prosocial nature of video games this week, and it was nowhere near a console screen. I was on my way home and ran into a Dunkin’ Donuts, in a town I’d never been to before and was unfamiliar with. I ended up waiting in a rather lengthy line and was a bit grumpy. I happened to be wearing a T-Shirt which said this:
I hadn’t worn it for ages, and had forgotten in fact I was wearing it until the cashier called out to me, “I love your shirt.” Cue the endorphins.
“Thank you,” I said, and smiled (which thanks to state bound learning probably cued my body to produce even more endorphins.) Waiting in the line seemed much more pleasant by this point. I ordered my coffee and sandwich and while waiting for them received another compliment from a customer walking by.
The third person to compliment me was a man in his 40s, scruffy and in jeans and t-shirt. “I love that game,” he said. “I haven’t played it in a while though.”
By now I was in a mood that allowed me to initiate conversations, so I asked “What are you playing nowadays.”
He proceeded to tell me that his 14 year-old daughter had gotten him into Fortnite. She had enjoyed it initially for the crafting, he said, because she really enjoyed Minecraft; but now that they were playing together she was enjoying the combat as well. His face lit up as he recounted how much fun they were having together. I told him about a study that had been done by Brigham Young that indicated increased levels of protective factors against depression. He smiled at that, and we both went on our way.
We spend so much time debating the neurological impact of playing video games that we often lose sight of another dimension; that of talking about playing video games. Talking about arts and culture is a powerful social adhesive. It identifies commonalities, allows for compliments and increased levels of engagement with others, allows us to recall exciting moments and share them. All of these activities in turn facilitate attachment, and increase a sense of well-being on the neurological level. That was the best line I’ve waited in a ages!
We need to find a way to get that message to Salty Sally the Social Worker and Morose Martin the Mental Health Counselor, whose eyes grow dull at the mention of gaming when their patients bring it up. “How much time are you playing Candy Crush?” they say, in uninviting tones, and eye such T-shirts as a clear sign of video game addiction. The next patient, who comes in with a T-Shirt of Monet’s “Water Lilies,” will get a compliment on it and no such screening for an Impressionist Art Addiction. In fact, the WHO didn’t include Art Disorder this go round at all, unless you include the art form of the video game.
In this current political climate, where we are so polarized, I wonder how many bridges (Minecraft or other) might be built if we paused to ask strangers in line if they play any games? I imagine Republicans, Democrats and Independents alike play something.
If Teams Valor, Instinct, and Mystic can all get along together raiding in Pokemon Go, perhaps we can too..
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Taking Leaps: Fortnite, HIPAA & Psychotherapy
“You keep dying,” Sam* said. The annoyance in the 9 year old’s voice was palpable. I looked at my avatar lying face down on the screen. Another of the 100 players in the game, appearing as a brunette woman in sweats sporting a ponytail, was doing a victory dance with her rifle over me. Sam was nowhere to be seen on the screen, but I knew he was hiding somewhere in the game, and seething.
“You’re disappointed in me,” I said calmly. A moment of quiet.
“Yeah.”
“You were hoping I’d be better at this, as good as you or maybe better, and it’s frustrating.”
“Yeah… Can we try again?”
And so we tried again and again, and while we did I talked with Sam about the other adults who were disappointments to him, who kept leaving or letting him down. And I guessed that we were also talking about his frustration and disappointment in himself. And at the end of our appointment I promised I would practice Fortnite, the game we had been playing. We had turned on our webcams again so we could see each other to finish the session, so I could see that he brightened at this idea.
“Nice to see you again,” I said. He smiled faintly.
“You too.” His screen went dark.
As I reflect on the work I do with patients, meeting them where they are at, I am struck by the same issues, opportunities, and conversations that can happen in an online play therapy session. I only wish more of my colleagues would try it. What gets in the way? For some it is a dismissal of emerging technologies which masquerades a fear of trying something new. For others it is a worry about running afoul of HIPAA and being sued. If you are one of those people who wonders about how to integrate video games online into your therapy practice, read on.
* * * * *
Quick, without Googling it; what does the “P” in HIPAA stand for?
If you are a psychotherapist or other health provider, you probably guessed “privacy.” At least that’s often the consensus when I ask this question at my talks. It would be understandable if this was your guess. You’d be wrong.
The correct answer is “portability,” the basic premise that individuals have the right to healthcare treatment that moves with them as they go through the vicissitudes of life and work. That is also where technology comes in– electronic health records, telemedicine, etc., are ways that technology increases portability by collapsing time and space so that the patient and the healthcare professional can get to work.
In therapy, that work traditional has happened in an office setting. And in the case of children and youth especially, that meant play therapy which was bounded by the space and time of a physical office. From Uno to Sandtrays to the infamous “Talking Feeling Doing Game,” we have often assumed that play therapy needs to be the games of our own childhoods. But 21st century play can, and I maintain should, include 21st century play. That’s where video games come in.
In the days of the Atari 2600, there was no worry about patient privacy, because the system was hooked up directly to a television that didn’t even need to be connected to cable. But nowadays with SmartTVs, PCs and PS4s, video games are often played online with many other people and seamlessly connected to voice chat. This can be a concern for the psychotherapist who is unfamiliar with newer technology, especially with games like Fortnite, which boast Battle Royales having as many as 100 players at a time in the same game instance.
Videoconferencing programs and online therapy using video/audio chat have been around long enough to have specifications that adapt to HIPAA’s privacy requirements, largely because there is market force behind developing products that can be sold to the healthcare industry. Video games and their platforms, on the other hand, do not have a similar demand to give them an incentive to supply. Games like World of Warcraft, Platforms like STEAM, and streaming services like Twitch were designed for gamers, not therapists, and it is unlikely they will go through the technical and legal procedures to become HIPAA compliant anytime soon.
Some therapists have begun developing their own video games, which, like most therapy games are dismally boring. They are thinly veiled therapy interventions that are disguised as play, but lack any of the true qualities of play. True, they are more likely private; but they are also boring, and easily recognizable as “not playful” by patients. Mainstream games have broader appeal, critical user mass, and better graphics and gameplay in many cases, and are more immediately relevant to the patient’s life. But they are definitely not HIPAA-compliant. So what to do?
* * * * *
My solution, which I’m sharing as an example that has not been reviewed by policy experts, lawyers or the like, has two parts:
- 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.
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Whether you love Freud or hate him, most experts agree that he was one of the fathers of modern psychiatry. He was also an early adopter. He based his hydraulic model of the drives on steam technology of his era. His concept of the “mental apparatus” was likewise integrated from the advances in mechanics and his formulation of ego defenses such as projection occurred simultaneously with the Lumiere brothers’ creation and screenings of motion pictures. Regulatory concerns aside, therapists can be early adopters. Doing so would probably help our patients no end, and definitely cut down on my waitlist.
* “Sam” is based on several patients whose identifying information has been disguised to protect patient privacy.
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Mindfulness, Minecraft & The I Ching
Video Games can be a form of mindfulness meditation, both playing and watching them. The Grokcraft Staff take you on a meditative creative session as we begin to build our I Ching Sculpture Park. Watch, listen, and enjoy..
For more info on joining the Grokcraft project, go to http://grokcraft.com . We are launching Grokcraft with an introductory subscription of $9.99 a month, & subscribers who join now will be locked in at that rate for as long as they are subscribed. If any of this appeals to you, please check out our new site at http://grokcraft.com & please spread the word to anyone you think might find this resource useful!
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Evocation and Mindfulness: Or, How to Think Better
Like other art forms, video games can be both a mirror and a candle held up to our culture, at times reflecting it and at times revealing things about it. Normally I direct my posts primarily at people: therapists, gamers, educators, parents. But today I want to include the company that produces World of Warcraft as well. We have a crisis regarding thinking, and although I don’t think WoW created it at all, it has reflected it in a recent game mechanic change.
I am referring to a change mages that happened recently, where the spell Evocation was replaced by Rune of Power. For people not familiar with the game, here’s a simple explanation. Mages cast spells, but spells require an energy called mana, which gets used up gradually as you cast spells. How much mana you start with depends on your character’s intellect, and once you have used up your mana, you can’t cast any more spells until it is replenished. To replenish it you can either wait and it will gradually return (not the greatest idea in combat,) or eat and drink (not possible while you are in combat.) Or you could in the older days cast Evocation, which meant you stood in place as the spell was going, gain 15% of your total mana instantly and another 45% of your total mana over 6 sec. Move or get attacked, and the spell broke.
This recently was replaced with Rune of Power, which places a rune on the ground, which lasts for 1 min. While standing within 5 yds of it, your mana regeneration is increased by 75% and your spell damage is increased by 15%. You have to keep remembering to replace it every minute, but that’s not the problem. It may even be an easier game mechanic, but that’s not the problem either. My problem with it is how it reflects our dysfunctional attitude about thinking, and specifically our tendency to think of thinking as separate from doing something.
We live in a culture where people frequently worry about things, and in fact have ruminations that are intrusive. Many people report feeling hijacked by their minds with worrying or intrusive thoughts. And yet at the same time, few of us seem to mark our time and set it aside specifically for thinking. We schedule appointments to do things, but thinking isn’t one of them. We treat thinking, which is intangible, as if it can occur in the same space as doing other activities that are more observable and tangible. And then we are surprised when our minds rebel and hijack our thinking with thoughts and feelings that come unbidden, when all along we have been failing to cultivate the practice of intentional, mindful thinking about things.
This is where I think Blizzard and Wow initially had it right with Evocation. It was acknowledging an important truth, that Thinking IS doing something, and when done intentionally it occupies time and has benefits. Sure you weren’t able to do other things while casting Evocation, but isn’t that the point? In the real world, when you want to think deeply and seriously about something, you really do need to be intentional about it, and make a space in your day to do it. Rune of power definitely embraces the multitasking model, which encourages you to set up a rune and then go about your other business while keeping half an eye on it to know when to refresh. Multitasking is not inherently a bad thing, but there are times and places that intentional thinking may be more appropriate and less anxiety-provoking.
Part of helping patients learn to manage worrying is often to help them set up a specific time for worrying about things. This “worry time” can be a placeholder in the day or week which the patient uses when an intrusive worry enters into their thinking: They can dismiss it by deciding to put that on the agenda for the scheduled worry time. This is a way of training your mind to be intentional about what you choose to think about and when. But implicit in this is the idea that training your mind to think about things intentionally is a learned skill.
You can apply this to many different aspects of your life and work. If you are growing your private practice, when was the last time you set aside an hour to think deeply about your business plan or clinical focus. I’m not talking about daydreaming here, I’m talking about sustained intentional thought. Clinically, do you set aside supervision time to think deeply about patients? As students do you take 15 minutes after each article to think specifically about the reading? As parents, when was the last time you said to your co-parent, let’s make a time to think together about how our child is doing in life at home and school. Classroom teachers, when was the last time you asked students to take 5 minutes and think quietly about the classroom topic?
Another challenge here is the confusion of tongues around the concept of thinking. Self-help gurus often exhort us to stop thinking about things and JUST DO IT. But I don’t think they are talking about intentional thinking, I think they are talking about reactive or intrusive thinking. Procrastination is reactive thinking, worrying can be intrusive thinking. Those are often roadblocks to success, but the form of thinking I have been referring to is perhaps better described as a form of concentration meditation. Concentration meditation has come to be seen by many of us as concentrating on an image, or a candle, or chanting, or a revered object, but that is not necessarily the case, and in fact it is limiting.
What if your idea is the revered object? What if your thought process about your work, child, patient, class is worthy of your undivided attention? What if you were to schedule a specific time to think about a certain project?
If you are one of those detractors who say, “I just don’t have time to think,” I don’t buy it. Thinking time is not a luxury item, although it may be a learned discipline to set aside a few minutes at a time to do it. So please take a second and schedule a time on your calendar to think about an idea that is important to you. Schedule a time to hold your random worries and thoughts and show up at that appointed time to seriously consider them. I suspect this will free up more mental space and time than you may imagine.
And please Blizzard, bring back Evocation. I miss it, and the important life lesson in mindfulness it has to teach us.
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Bio Breaks
If you’re a therapist looking to join a group of innovative colleagues for supervision, you may want to take advantage of this. 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!
Minecraft & The Uncanny, Part 1
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.
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Tower Defense & Executive Functioning
Some of the most important tasks the human brain performs are known as the executive functions. According to the National Center for Learning Disabilities, executive function is “a set of mental processes that helps connect past experience with present action. People use it to perform activities such as planning, organizing, strategizing, paying attention to and remembering details, and managing time and space.” As such, the executive functions are crucial to the learning process over the life cycle.
Like many phenomenon in mental health, executive functions were focused on initially in regards to populations that had some deficits in them. With the advent and prevalence of the diagnosis of ADHD, as well as the study of learning and learning disabilities, educators and therapists began to become familiar with a concept that had previously been of most interest to neuroscientists. We still tend to think of executive functioning from a pathology-based approach, only paying attention to how they work when they don’t work.
The truth is everyone has executive functions, which are a combination of nature and nurture, and can develop well into adulthood. They can also deteriorate for a variety of reasons, from traumatic brain injury to Alzheimer’s disease. And there is a body of research which suggests that mental and physical exercise can help maintain, if not improve our executive functions as we age. Not surprisingly, as the Baby Boomers age, interest and research grows in this area. At both ends of the life cycle, our focus on the executive functions are widening beyond pathology to the optimal environments for human learning. How might we get better at planning, attending, strategizing, and managing time and space?
My suggestion: Start playing more tower defense games.
Tower defense is a particular genre of video games, one which in general focuses on on preventing the progress of an enemy army across a map. This is done by the use of towers which have varying abilities, costs to build, and points earned from downing enemies. You don’t necessarily need to have towers in the game: Plants Vs. Zombies for example is an example of a tower defense game where the plants are the equivalent of towers, with special abilities used to defend against the march of those pesky undead across the lawn.
More recently I have been fascinated with one of the latest iterations of tower defense games on the iPad, Kingdom Rush. You start out with a variety of maps and coins for building. You can use one of 4 basic tower types. There are barracks which have soldiers who can fight and slow down the invaders. There are artillery towers which drop bobs for an area wide (AOE) damage. There are marksman towers which target individuals and fire arrows or guns. Finally, there are magician towers with wizards firing spells of various types.
Each invading monster has different strengths and vulnerabilities, which are discovered by trying out different towers and noting their effects. As the invading army is always moving forward in waves, the time element requires you to plan which towers to build first, where to place them, and what upgrades to focus on. To do this requires a tremendous amount of strategy, organization and time management. You also need to make decisions, including how long to delay gratification. The more powerful towers require you to save up many more coins to buy them. Upgrades that you can select from a talent tree add another layer of choice and complexity.
In short, to succeed in Kingdom Rush you need to have good executive functions. It isn’t enough to have good hand/eye coordination or reaction time. You need to be able to learn from your past experiences, and often switch strategies midway through the game. You need to recall which towers are best for different situations and monsters. There is a map to be managed in space and a marching army and builders to manage in time. You need to recognize both immediate feedback and notice trends. And there are multiple towers and units to keep track of.
The more I play Kingdom Rush, the more struck I am by how many if not all of my executive functions are required to succeed. I can see where using this game could be both a useful assessment tool and intervention for deficits in EF. It also has reminded me how necessary executive functions are in terms of managing money as well. The ability to recall prices, to budget and pace spending, and set up investments that accrue value over time–all these economic experiences are embodied in the game.
Speaking of economy, you can try this game for free if you have a computer in your office or classroom here. And you can buy it for a whopping $2.99 for your iPad. Check it out, and see if you agree that it might be a fun, feedback rich way to challenge your executive functions.
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Some Beginning Games for Therapists to Try
This Video Blog was inspired by friend Carolyn Stack, who asked that I recommend a iPhone game to ease her into the world of iPhone gaming. Here are a few of my favorites and why you might want to try them: