“Hypothetical Therapeutic Recreation Program Plan for Clients with

Traumatic Brain Injury Using Role-Playing Games as Therapy”

Essay (short version)

INTERVENTIONS

March 11^th, 2013

The RPG Research Project

http://www.rpgresearch.com

by W.A. Hawkes-Robinson (c) 2013

Revised for Creative Commons License Release: March 31^st, 2013

Hypothetical Therapeutic Recreation Program for Clients with Traumatic Brain Injury Using Role-Playing Games as Therapy Essay (Short Version)

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Overview

After consultation with the family and care-takers, it is determined that prior to injury, one of the client's favorite activities included various forms of role-playing games (RPGs). The client mostly preferred tabletop, but had dabbled with both computer-based and live-action forms. As the client slowly regains various levels of functioning, modified versions of RPGs can be presented in which the client may participate to stimulate neurological recovery.

While other therapies are assumed to be undertaken in parallel, this document will focus on the use of therapeutic recreational techniques in treating the client, specifically using variants of role-playing games, with various modifications as warranted to fit specific client needs, throughout different stages of impairment and recovery.

One of the major obstacles in writing this section is that role-playing games appear to have not yet been considered by many health professionals as a potential therapeutic intervention, let alone specifically the recreation therapy industry in the USA. I have had multiple dialogues in person and via websites, with various RT professionals, many with decades of experience, and in speaking with them, they never even considered, or ever heard of anyone considering, using any version of role-playing games for therapeutic intervention. The closest I have been able to find included drama therapy, and standard game therapy, but nothing in the full form of “role-playing game therapy”. There are a few possibilities outside of the United States, and there are a number of educational programs using RPG's, so this document is purely hypothetical in the proposed interventions for TBI clients, but is based on closely similar approaches, but using the structure of RPG forms. Hopefully some recreation therapists will attempt these in the future and report on the results and modifications necessary for maximal efficacy.

Not counting purely experimental research projects, after researching and searching worldwide now for several years, there appears to only be one actual ongoing RPG-related therapy program that I have found to date, and this is in Israel through the Romach group (http://www.lance.co.il/). (Update: Their program ended in the Spring of 2015, due to the store closing where they provided sessions.) Unfortunately the site is completely in Hebrew, though I have had some dialog with them in English through email.

There are however any number of educational programs using role-playing games for instructional purposes, including the Danish public high school (Østerskov Efterskole - http://rpgr.org/blog/osterskov-efterskole-danish-public-high-school-teaching-all-subjects-using-larp) with an entire curriculum taught using live-action role-playing (LARP). Because using RPG as a therapeutic intervention is not (yet) established for TBI, every effort was made in this document to extrapolate likely scenarios matching the use of related activities, expected implementations, and outcomes, using hypothetical suggestions based on the information to be gleaned from the aforementioned areas.

Applicable Therapeutic Recreation Interventions

When the client is actually in the coma and at the Rancho Los Amigos Cognitive Level I, RT is not able to implement anything in the way of an interactive intervention. However, once the client is out of the coma, even at just Rancho Los Amigos Cognitive Levels II & III, the RT can begin to implement various modifications of role-playing games as a recreation therapy intervention.

Initially the client is too disoriented and has such significant cognitive and memory impairment that using the “Choose Your Own Adventure” CYOA form of RPG is probably contraindicated, but after just a few days, when the functioning is closer to b11428.2, and within a week around b11428.1. At this stage the client may be able to engage in “let's pretend” imaginary scenarios and differentiate from the real and imagined situations. Though the client has memory issues, and may not remember every detail from 30 seconds to a few minutes ago, the exercises could still be useful for stimulating 
“neuro-plasticity” related recovery. The client may need repetition and occasional reminders, but is now potentially ready to begin the CYOA form of RPG TR treatment.

Though the client had previously enjoyed and participated in RPGs, he/she did not do so constantly, so it is not believed to be an “over-learned leisure skill”(Porter, p 144), so that it may still be a reasonable activity for monitoring and assessment of overall recovery.

Intervention #1 - Tabletop RPG Modification - Choose Your Own Adventure for Severe TBI-related impairments

Once the client is out of the coma, and rated at just Rancho Los Amigos Cognitive Levels II & III (able to open eyes in response to stimuli such as a spoken request or physical touch) (Burlingame, 2002), the RT can begin to implement various modifications of role-playing games as a recreation therapy intervention. At this stage, the RT could begin to implement the most rudimentary of RPGs, the Choose Your Own Adventure (CYOA) form. As long as the client can make a binary/Boolean responses indicating yes or no, whether verbally, by number of eye blinks, hand squeeze, or other method, the client potentially qualifies for participation in this therapeutic intervention.

Example CYOA Process

After establishing that the client meets sufficient cognitive functioning, and determining that client has a sufficient means of response and interaction with the recreation therapist, the RT asks the client, “Would you like to play a simple version of a role-playing game?”. “Squeeze/blink once for yes, two for no.” Client indicates yes...

“This adventure is set in Chicago during the 'Roaring '20's'. It is a mystery-style adventure.”

Of course any genre/setting will work.

“You will have three characters you can choose from. I will first list the three options, then I will ask you which one you prefer as I go through the list a second time. You will then indicate 'yes' when I mention the character you want.”

“You may choose to play: 1. A Police Detective, 2. A Private Eye, 3. An Investigative Reporter.”

“Would you like me to repeat that list again?” (yes/no)

“Have you decided which option to pick from those 3 choices?” (yes/no)

When the client indicates “yes” to being ready to choose, the RT states, “I will now repeat those three choices. Squeeze once for yes when you hear the option you want.”

Client squeezed yes for “Private Eye”.

“You selected 'private eye', is that correct?”. (yes/no).

The RT continues, “You have chosen Private Eye, is that correct?” Client confirms with single squeeze/blink.

The RT continues, “The story unfolds as follows. An old man has come to your office. A family heirloom has been stolen from his house. The police have no leads, but he says everyone knows that you, as the ace private detective that you are, can use alternate channels to find things the police can't or won't....”

If the client is continuing to be responsive to this form of modified RPG, and if it is deemed appropriate, as the client's functional level continues to improve, the client's family, friends, and caretakers may be able to engage the client in continuing the “adventure” when the RT is not around.

Needs addressed by intervention

This intervention addresses a number of the diagnosis A&P codes, some of which include:

• d163 Thinking

• d310 Communication with - receiving – spoken messages.

• d1750 Solving simple problems

• d177 Making decisions

• d9200 Play

Common Settings

Any environment that is relatively quiet and distraction free, allowing the client to focus on listening to the storyteller's voice.

Equipment Needed

No special equipment required. TR might need a Choose Your Own Adventure Book, or else a prepared adventure outline or script.

Program Adaptations

Using hand-squeeze or eye-blink with Boolean-only (yes/no) questions for the client to answer (one squeeze/blink for yes, two squeezes/blinks for no). As client progresses, may be able to use simple multiple choice questions instead of only Boolean choices.

Examples of intervention

After spending hours searching, I was unable to find any existing programs using this exact form of intervention. This intervention meets the requirements for activities addressing the functional impairments listed, but so far I am unable to find any research information or current programs that have tried this approach.

The closest match I could find was an article about the Lincoln University (Snow, 2009) program requested by the Missouri National Guard using a “choose your own adventure” style interactive computer video (Hemmerly-Brown, 2010) for military personal suffering from suicide due to complications from PTSD and TBI. I was not able to find a second program that was even remotely relevant.

Program Name

The Home Front interactive video.

Location

Online: http://www.armyg1.army.mil/hr/suicide/videos/HomeFront_New/the-home-front/index.html

Description of clients served

For at-risk military personnel to attempt to reduce the levels of depression and suicide from personnel recovering from PTSD , TBI, and other causes.

Qualifications of program facilitator

Basic computer and online skills. Typical therapeutic background.

How I found this program

Lengthy search for any kind of “choose your own adventure” and “Traumatic brain injury” through many books and online resources.

Intervention #2 - Computer-based RPG Use and Modifications for Client With TBI

Client is now at Rancho Rating IV+. Though client's cognitive functioning is now higher, the client's ability to communicate is still significantly limited. Based on client's current functioning, it is recommended to have the client try using a mouse (or Wii-mote) to participate in a computer-based RPG that is turn-based rather than real-time. The client is able to move and click both buttons on a mouse, can see the computer screen clearly, and has enough cognitive functioning to interact in the game at a much higher level than before.

As client slowly regains various levels of functioning, modified versions of RPG will be presented in which the client may participate.

Client will initially use a mouse with large buttons to interact with computer. This requires the functioning of at least one arm, hand, and finger, as well as usable visual capacity. The compute-based RPG should initially be turn-based, using the mouse and then using Wii-mote later as grasping improves.

Client with click on various options, direct the digital character to take certain actions, and solve various levels of simple to complex problems.

Needs addressed by intervention

In addition to addressing some of the previous codes in intervention #1, this also addresses:

• d1751 Solving moderately complex problems

• d440 general fine hand use

• d4401 grasping development.

Example CRPG Process

Client's functional arm (and hand/finger(s)) are placed upon the mouse (or later Wii-mote as grasping capacity develops). The client navigates on screen prompts to develop character, and than guides the character through the many challenging scenarios in the game.

Common Settings

In this scenario, ICU or long-term care facility, but potentially usable anywhere that has a computer.

Equipment Needed

A computer with screen, mouse, and installed software. Optional Internet connection.

Program Adaptations

Different means of interaction with the computer through different interfaces.

Examples of intervention

There are a number of programs using computer games as interventions for many needs, including TBI recovery, though I was not able to find specific mentioning of computer-based RPGs specifically, it is not a difficult stretch to extrapolate the benefits. The closest I found was an online game created by Jane McGonigal (2010) that experienced post-TBI depression and created the game to help herself recover. I had heard some of the NPR interview about this, and was able to track that down (Flato, 2011).

Program Name

Jane the Concussion Slayer by Jane McGonagal & Co.

Location

Online: https://www.superbetter.com/about

Description of clients served

Clients that enjoy computer games that will benefit from stimulus to help recovery from illness or injury, including traumatic brain injury. The program was created when the creator experienced a TBI, and was struggling to recover, creating games she found helped her, and other's, recovery process.

Qualifications of program facilitator

Some computer skills, recreation or other similar therapy background.

How I found this program

Web searches for any computer-based games aiding recovery of TBI patients.

References

Burlingame, J. & Blaschko, T.M. (2002). Assessment tools for recreational therapy and related fields (3^rd edition). Ravensdale, WA: Idyll Arbor.

Flato, Ira. (2011, February 18). Talk of the Nation: Could gaming be good for you?. National Public Radio. Retrieved March 11^th, 2013, from http://www.npr.org/2011/02/18/133870801/could- gaming-be-good-for-you

Hemmerly-Brown, A. (2010). Army creates new scenario-based suicide-prevention video. Retrieved March 11^th, 2013, from http://myarmybenefits.us.army.mil/Home/News_Front/Army_creates_new_scenario- based_suicide-prevention_video.html

McGonigal, J. (2010). Achievements: Unlocked. Retrieved March 11^th, 2013, from http://janemcgonigal.com/2010/12/23/achievements-unlocked/

Porter, H.R., & Burlingame, J. (2010). Recreational therapy handbook of practice: ICF-based diagnosis and treatment. Enumclaw, WA: Idyll Arbor.

Snow, T. (2009). Soldiers at risk: Mo. Guard responds to threat. Retrieved March 11^th, 2013, from http://www.connectmidmissouri.com/news/news_story.aspx?id=287534