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.
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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?
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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..
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