1994 - Use of D&D as a therapy for suicidal schizoid

by Omar published 2019/02/18 02:06:00 GMT-7, last modified 2022-11-12T09:27:33-07:00
Blackmon, Wayne D. (1994, Fall). Dungeons and Dragons: the use of a fantasy game in the psychotherapeutic treatment of a young adult. Journal of Psychotherapy, 48:4, 624-632.

Wayne D. Blackmon (1994). Dungeons and Dragons: The Use of a Fantasy Game in the Psychotherapeutic Treatment of a Young Adult. American Journal of Psychotherapy, 48 (4), 624-632. Reprinted, with permission of the Association for the Advancement of Psychotherapy, athttp://www.rpgstudies.net/blackmon/dungeons_and_dragons/.


Dungeons and Dragons: The Use of a Fantasy Game in the Psychotherapeutic Treatment of a Young Adult

Wayne D. Blackmon, M.D.

4501 Connecticut Ave. N.W., Suite 104, Washington, DC 20008, USA

A case is presented of extended character analysis of a person with a schizoid personality. Because of the difficulty in establishing a therapeutic alliance, the therapy was a form of modified play therapy using a game to enhance ego development. A theoretical discussion explores the reasons of this deviation from standard therapy works and its indications for other cases.

This article demonstrates how a young man with an obsessional, schizoid personality was treated by utilizing a fantasy game, Dungeons and Dragons, as a vehicle for releasing his unconscious fantasies. It aims to show how the game may serve to free fears and feelings for useful consciousness with enhanced ego development so as to improve the patient’s ability to interact with others and feel comfortable with himself.

Case Report

Fred, a 19-year-old, single white college student, had cut both of his wrists in a methodical suicide attempt and had gone into the shower in an effort to prevent the wounds from coagulating. He claimed that he had been depressed for several years, actually since grade school and that he had always been a “loner.” Friendships he did develop were usually short-term and superficial. College, he reported, had been particularly lonely for him and he had done little outside of school work. Yet he could not describe any unusual events or possible precipitants. However he reported that school work, which had been an area of success for him, had lately been going badly.

Fred gave no indication of sleep or appetite disturbance, spontaneous crying spells, depressive dreams, constipation, weight loss or other signs of endogenous depression. He denied any hallucinations or delusions.


Fred grew up in a small town. His father is in the legal profession, “likes his work,” and is very formal and not close at all. The mother is a housewife but is “otherwise a pretty good mother.” He is the second of three brothers. The oldest brother is three years older than Fred and has an undefined physical condition, “a problem with the vessels on one side of his brain” (probably Sturge-Weber syndrome) and is retarded. He stays home, “mooching” off the parents. Fred never got along with his older brother, and he was constantly angry with him because of the extra attention he got from the parents. “They always took my brother’s side in any conflict.” He stated he always got along with his younger brother. Fred was sent to boarding school and was relieved to be away.

He described, with many examples, a history of slights by family and schoolmates and how awful it felt to be known as the brother of a retarded boy. Fred denied any form of homosexual ideation.

The mental status exam showed depressed mood and affect but was otherwise unremarkable. Except for his self-inflicted wounds, his physical exam was entirely within normal limits.

Treatment Course

Fred was seen by me in the hospital and later in twice-weekly, 45-minute outpatient sessions in addition to group therapy with different psychiatrists. He was diagnosed as having apparently free-floating depression, and was given desipramine, 150 mg per night.

At first, Fred tended to keep distance from me. He was only involved in treatment superficially but appeared to need assistance in defining life goals for himself. He used intellectualization and other obsessive defenses, but there was also an element of emotional impulsivity.

Fred felt uncomfortable in dealing with male therapists because of the strong angry feelings that were, he said, much like those he had toward his father who had “let him down” in the past.

Fred took a leave of absence from school and worked to support himself. In the first year, much of the therapeutic work was to maintain an alliance, as he had no friends and no social contacts since the suicide attempt. Two attempts of living with roommates ended in his being cheated out of rent twice. My therapeutic function at this time was primarily to allow him to share his experiences.

During the early part of the second year Fred made his first social contact outside of therapy by joining a group of “fringe people like myself” in a game of Dungeons and Dragons. At first, I was reluctant to encourage his bringing me material from his game sessions as it appeared to be resistance; however, it did allow him some social contact, and the eagerness with which he told me about the game indicated to me the importance of his sharing this material. I began to encourage him to bring summaries of episodes into therapy and to ask about motivation and feelings of characters. Therapy was now confined to his displaced material, and emotional content began to emerge. He returned to school during this period.

After six months of this approach, Fred was able to verbalize feelings toward me and began to abandon the need to speak through the displaced medium of Dungeons and Dragons.

He said his parents made him feel rejected and punished through implied loss of love and attention. They criticized him for being angry at, or envious of, his deformed brother. This left Fred with the belief that there was “something wrong with me for having these feelings.”

He stated that he had been able to experience the full range of feelings from hate to love in therapy, first displaced, then toward me, and that my tolerant, encouraging attitude allowed him to develop the sense that these emotions are permissible. This helped him to gain mastery of these feelings. It further led him to state that it gave him a sense of being “OK,” and that much of his feeling of self-worth began with my first acceptance of his Dungeons and Dragons fantasies.

What is Dungeons and Dragons?

Dungeons and Dragons is an imagination game. Worlds are created and the participants play characters in this imaginary world. Each player’s character is created according to a set of rules that govern abilities and classes of characters.Through complicated series of dice rolls, a character is dealt strength, intelligence, wisdom, dexterity, constitution, and charisma. The types of characters are clerics, dwarves, elves, fighters, halflings, magic users or thieves. Each of these has a characteristic range of the above abilities. All characters choose “alignments” of Lawful (good), Chaotic (or evil) or Neutral, which will further dictate behavior in situations: a complete personality or alter ego is thus delineated. These characters then work their way as a party (group of players) through the imaginary world, casting spells, undergoing adventures, fighting monsters, and non-player characters and seeking treasure. The outcome of each encounter is dictated by rolls of odd-shaped dice that take into account a character’s profile through a formula. All of this is overseen by a Dungeon Master or a character who acts as a referee.1

Two points stand out. The worlds, or dungeons, are very much primary-process creations. There is no sense of time or reality. Thus, walls may be alive and grab a passing character. Sexes may change, dead may be resurrected and so forth. In juxtaposition to the suspension of the rules of the real world are the complicated rules by which the game is governed. Every encounter is governed by rules. The game is characterized by rules. The introductory book of rules is 64 pages long and there are many additional books of rules beyond this! In order to become proficient, a player must study the rules at great length, as the game has no fixed end point. A single game may last for years. As the group of players masters a dungeon, it can go to lower (more difficult) levels to begin again.

Fred eventually joined several games and developed complete characters in each, with mores, personalities, hopes, fears, and emotions. As he described his ongoing adventures in therapy, it became possible to use each projectively and relate the characters’ thoughts, feelings and motives.

In one game, an encounter lasted for several months. Fred had taken a character who had a “lawful-evil” personality. His party had stopped in a village. He had gotten his character hired to work for the richest man in the village, a character controlled by the dungeon master. He related his progress to me as his character killed the sons of the rich man, conspired to marry his daughter, and ultimately seize the treasures of this man.

As he recounted this material in the therapy we focused on two questions: the motives and feelings of the character as he schemed and acted, and wether Fred had ever had such feelings, and in what situations. Gradually, he was able to relate that he had felt his brother had always gotten the family “treasures” of love and attention and that he had wanted to murder him much of the time. Further he revealed how such feelings were always difficult to express, but that he could see himself experiencing these feelings toward his brother again and again in many situations.

Another illustrative situation involved an episode when, in his group therapy, he had been confronted unrelentingly by the other members of the group about his lack of a girlfriend to which his only response was an angry, “Back off!” In individual therapy shortly thereafter, he revealed that the intervening Dungeons and Dragons encounter had involved his party’s striking out into an uncharted portion of a valley which they created as they went along. In this valley the party encountered five farms (the number of other group members in his therapy group). Because of an insult in the party, under Fred’s direction, they proceeded to slaughter the farmers’ families and livestock and burn down the farms. This incident involved his working through murderous rage at the therapy group in a safe, displaced way. He could talk about this incident directly only months later at which time he revealed a prior inability to find an outlet for such feelings. Similarly, grandiose and magical desires were revealed in his experience as a dungeon master; feelings of loss and separation over death of one of his characters and many similar examples.

The feelings this patient expressed in therapy were all threatening to him initially. The game provided a vehicle for the safe emergence of feeling within the context of organizing rules. As he first expressed them in a displaced way and got used to them in fantasy, he could feel safe with his feelings and begin to direct them more directly to another person. Slowly this man has been able to emerge from his isolation. He has developed self-esteem, made friends, lost his virginity, and has been able to date fairly regularly. He continued in therapy with me in more traditional ways, off and on, over a period of ten years after his suicide attempt. He is now a more openly emotional person who does not need to displace his feelings. Fred terminated therapy appropriately when his career required a move and was married about nine months later.


Freud described dreams as the “road to the unconscious” and pointed to the value of discussing dreams and a patient’s associations to his dreams in conducting therapy.2 As the century progressed, the principles were expanded by various authors to both waking fantasy and to play in children for their projective value and revelation of primary process. Thus Freud discussed the relationship between fantasy and dreams3 (p. 178) but also described how play could be used as a repetition-compulsion to re-experience events that overwhelm the ego and thus to master them.4 This observation was modified and expanded by Erikson5 to demonstrate that play could be used to gain mastery. Waelder6 saw play and fantasy as: “Instinctual gratification and assimilation of disagreeable experiences” (p. 222), in other words, mastery. Freud also suggested that fantasy provided immediate wish-fulfillment.2 Thus there is much to suggest in these observations that there is a relationship among play, dreams and waking fantasy. This relationship has been shown to be closer than analytic writers may have realized. Thus Cartwright7 demonstrated that the need for Rapid-Eye-Movement (REM) dreams could be decreased by waking, drug-induced hallucinations. Cartwright and Monroe8 showed that REM deprivation could be fended off by encouraging waking fantasy. In a study of WREM dreams, Pivik and Foulkes9 demonstrated that: “waking story telling ability correlated with NREM dreamlike fantasy” (p. 148).Klinger10 describes them as functionally interchangeable: “REM sleep suppression is reduced by permitting the substitution of waking dream description and related fantasy-like ideation for the dream loss” (p. 83).

The therapeutic use of fantasy is well known. It has formed the core of some therapies such as Guided Affective Imagery where fantasies are suggested to relaxed patients11-13 while Klinger10 suggests that: “Fantasy is incapable of reducing drives as such, but [...] can prevent or reduce the build-up of anger and can diminish anticipatory anxiety about unavoidable pain better than activities that [...] cure off anger and anxiety” (p. 315). Wolpe14 describes the use of fantasy as a means of “systemic desensitization.”

Dungeons and Dragons is a form of group-related, organized, controlled waking fantasy. It has all the elements of free fantasy and encourages free fantasy as there is no board or movable pieces to provide inhibitions to imagination. Players are encouraged to become their characters in the course of the game, which is to say, to become their own fantasies. Juxtaposed to this active encouragement of the merge of the player’ fantasies is the ever present structure of the rules that provide a vehicle for how one is to fantasize. This further offers reassurance that when needed, there are rules to provide structure for the wanderings of one’s imagination. For the patient, the game served as an organized vehicle to become familiar with his own unconscious. The use of this material in therapy, the questioning of motives and emotions allowed these underlying unconscious thoughts to come to awareness and be worked through.

In this way the game within therapy could be used to work through processes halted in childhood in the way Bettelheim15 suggests fairy tales do, by giving form and structure to day dreams and fantasies and, therefore, form to a person’s life. Beyond this, however, the use of game material in therapy served the therapeutic relationship. Bettelheim states that when parents do not allow a child an organized outlet for the “dark side of humanity” or convey the thought that such a side does not or should not exist, the child, experiencing natural thoughts and feelings, is left with the feeling of being a monster. Further, the fantasies of fairy tales teach children how to channel their emotions in a way that allows integration of personality by “meaningful and rewarding relations in the world around him.15 Certainly this patient took something from the peer relationships in the games. In his own words, however, almost as if speaking from Bettelheim, the encouragement to become familiar with the emotions of his characters allowed him to “become familiar” with his own emotions. Beyond that, my patient’s acceptance of these feelings allowed him to see himself as not a monster for having them. His parents had left him with the impression that it was wrong to be angry with his crippled brother. In the patient’s words: “This fact, more than anything that was actually said in the therapy is what I’ve gotten from the therapy.” Langs16 points out that there is always a “spiralling unconscious communicative interaction” between patient and therapist, and that this is where the work of therapy transpires and that the patient’s communications are “adaptational responses prompted by emotionally meaningful stimuli.” Certainly this is what has happened in this therapy. The relationship allowed permission for feelings of anger and love and all in between to emerge. The vehicle to reach these feelings quickly and safely was through the use of projections and displacements of the fantasies onto the Dungeons and Dragons game. This was the vehicle by which this patient could interact with me as his therapist in an emotional way. This made possible the later work of therapy that might not otherwise have been possible in an individual who was so schizoid. It allowed this patient to experience as safe the working through of transference later in the therapy. This is essentially what Kernberg17 speaks of in emphasizing the need for structure in therapy to proceed. Structure will “[...] [U]ndo the confusion caused by frequent ‘exchange’ of self- and object-representation projections by the patient.”

Perhaps the most important aspect of all can best be summed up by the words of Winnicott: “Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.18 In much this way, play and fantasy were used as vehicles to help foster an ego-building relationship for this patient. He could develop better selfobjects out of the safety he felt in a therapeutic relationship where his fantasies were tolerated, encouraged and guided. It seems, therefore, that we could help many people for whom traditional modes of therapy are unavailable because they lack the capacity to regress sufficiently in the company of the therapist to allow the work of therapy for structural, emotional change to proceed. By introducing fantasy and play, Dungeons and Dragons appears to have been the vehicle that allowed the patient described in this paper to enhance ego development.


A process whereby fantasy is used to overcome the inability of obsessives, schizoids, borderlines, adolescents, and alexithymics to work toward emotional change may have considerable merit. The high degree of structure engendered by the rules of Dungeons and Dragons seems to bypass some of the risks of fantasy-based therapies such as Guided Affective Imagery while allowing emotions to emerge within the therapy in a nonthreatening manner. At the same time, the therapist’s interest and attention may serve a function of mirroring approval as patients become familiar with their own, but displaced, psychic structure. The use of this game as an adjunct to therapy can allow patients an opportunity to explore their mental dungeons and slay their psychic dragons.


A schizoid young man made a methodical attempt at suicide. He revealed a paucity of object attachments leading to profound isolation. His early upbring led him to extreme isolation of affect and a fear of fragmentation.

His inner life was not safely reachable by conventional therapy. After he became involved in playing a fantasy game, Dungeons and Dragons, the therapy was modified to use the game material as displaced, waking fantasy. This fantasy was used as a safe guide to help the patient learn to acknowledge and express his inner self in a safe and guided way. The patient ultimately matured and developed healthier object relations and a better life.

The theoretical underpinnings of this process are explored, both in dynamic terms and in terms of the biologic correlation and equivalence of dreams and waking fantasy. The utility of this game as a vehicle for treatment of selected individuals is discussed.


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