The therapeutic potential of larp has been discussed in a growing body of literature. Elektra Diakolambrianou (2021) presented a wide-ranging overview of this connection in general. For good reason she is (amongst others) focusing on drama therapy by Jacob Moreno. Despite the fact that larp and drama therapy share a kind of common history, the research on that connection has only unfolded in recent years (Burns 2014, Fatland 2016, Linnamäki 2019, Mendoza 2020).
In this article, larp will be discussed from the perspective of cognitive behavioral therapy (CBT), which is not a typical larp approach on the first glimpse. But due to the important standing of CBT in empirical research and public healthcare, this point of view appears to be worthwhile. In the second half of this article, a prototype of a CBT larp is presented, which is part of a research project by the author in cooperation with Tagrid Leménager (Central Institute of Mental Health Mannheim).
Why Cognitive Behavioral Therapy?
When you are establishing a new therapeutic method in the healthcare system, you have to prove the effectiveness of this method (Edejer et al. 2003). This requirement concerns somatic interventions as well as psychotherapeutic ones. CBT is one of the best examined psychotherapeutic approaches (Butler et al. 2006) and therefore an important part of healthcare all over the world. The question of effectiveness becomes crucial in healthcare systems in countries like Germany, where CBT is one of only four accepted therapy approaches that are paid by public insurance. It is important to note that the following considerations do not assume that CBT is the “best” method (which unfortunately is often portrayed as such), but only one of the most important methods from a health economics perspective. On the other hand, role-playing has always been a popular technique in CBT (Fliegel 2020). So it is easy to argue from a technical point of view that larp and CBT are “good companions.” Ultimately, however, I also deal with this method because I am a CBT therapist myself and an active larper.
So in the following, this article focuses on CBT aspects in larp. A general overview of relevant psychological processes and mechanisms in larp has already been presented very well elsewhere. The Event Series of the Transformative Play Initiative from the Department of Game Design at Uppsala University is particularly recommended (Uppsala Universitet, 2022).
Role-play in CBT in General
So what role-play techniques are present in CBT in everyday clinical work?
The basic goal of CBT is the training of helpful and desired behavior. These can be very different types of target behaviors. For example, a client with social anxiety may have the target behavior of being able to speak freely in front of a group or to speak to other people without feeling ashamed. A person with dog phobia will have the behavioral goal of walking past dogs without crossing the street; (the latter would be avoidance in CBT terms). A depressed person will likely aim to get up in the morning and engage in activities that bring them pleasure and motivation.
There are some basic techniques in CBT to train target behavior. Role-playing games are an important element because they are experience-oriented. In contrast to psychoanalysis, for example, which mainly takes place “on the couch,” in CBT, corrective experiences should be made directly in the therapy session. Of course, that is not entirely correct, because in psychoanalysis, too, the client is motivated to transfer their findings to “real life” and to practice the desired behavior there. In classical analysis, however, this practice is not a direct part of the therapy session, in contrast to CBT. CBT has the perspective that corrective experiences should always be made on a cognitive, affective, physiological, and behavioral/motor level, because these can be expected to result in maximum therapeutic success. Martin Cierjacks (2002) explains that larp is suitable as a psychological method precisely for this reason, namely the interlocking of these levels. He therefore has used larp as a method in organizational team training.
It seems useful to distinguish three types of CBT approaches relevant to a therapeutic larp. These are presented below, with a reference to where they play a role in therapeutic larp.
Role-play in Group Therapy
In group therapy, the role-play in CBT is mainly carried out according to the following pattern (Fliegel 2020): A client in the group describes a problem situation from their everyday life, e.g., “How can I say ‘no’ better, when my boss asks me to do extra tasks?” Then a suitable scene is worked out together. The client acts out the scene (with the other clients or the therapist as the interaction partner). Then there is feedback from the group on the client’s behavior. Alternative behavior is then discussed. The client then plays the same scene again and then there is feedback from the group again.
In CBT it has (so far) been customary to use specific treatment manuals for specific mental disorders. So-called skills training programs exist in the area of therapeutic role-play in the group setting. Well known programs are, for example, the Assertiveness Training Program (ATP) (Ullrich et al. 2002) or the Gruppentraining sozialer Kompetenzen (GSK) (group training of social skills) (Hinsch et al. 2015). The latter is very widespread in German speaking countries and is part of the standard repertoire of the CBT there. The GSK also provides a problem analysis and then suitable role-plays in the group as core components. The authors differentiate between three types of training situations for the therapeutic role-play:
- Enforcing one’s rights,
- Social competence in relationships, and
- Courting sympathy.
The GSK is particularly interesting to mention (and also serves as a reference for the CBT larp outlined below), because it is a well-evaluated standard method, is versatile, and reduces all social training situations to three topics, which is very helpful for the design of a CBT larp. In GSK — as in CBT in general — therapists and clients repeatedly assess how well the target behavior has already been achieved and what can still be improved after individual therapy sections (more on this below).
It is also important to mention that we are not the first to relate the concept of social skills – as understood in the GSK – to larp and we are not the first who see larp as a good training method for this. Myriel Balzer (2008) has published a book that is widely known in German-speaking countries and that focuses on this connection. Additionally, the larp-related thesis of Franz Aschenbrenner (2013) is explicitly based on the GSK. And there are already groups that realize similar concepts, e.g. ECW event (with their hero coaching approach for children and young people), but without it being intended as therapy (ECW Jugendbildung e.V., n.d.).
There is also a broad community of therapists who use tabletop roleplay, with a focus on social skills and related topics. The Geek Therapeutics initiative, for example, should be mentioned here, which offers material on the therapeutic use of role-playing games and even offers courses for certification as a geek therapist (Leyline Education 2020). Other groups that train social skills in the context of tabletop roleplay are Mastermind Adventures with their Quest! program (Mastermind Adventures LLC n.d.); the non-profit Game to Grow, which developed in cooperation the game Critical Core (Game to Grow n.d.); and The Bodhana Group (n.d.). These training programs and games have developed rapidly in recent years and reached a wide audience, but as said, they use the medium of tabletop role-playing games.
So far, however, there is no CBT larp concept with a focus on social skills complemented and quantitatively evaluated in a standardized way, as far as I know.
Role-play in a Psychotherapeutic One-on-One Session
The CBT role-play in the individual setting is very similar to that in the group setting (Fliegel 2020). A problem analysis should also be carried out first, then target behavior should be worked out, and then the client practices this target behavior in role-play with the therapist. The difference is that in the one-on-one setting, only the therapist gives feedback, although support through video recordings of the session is also possible. A therapeutic 1:1 setting is also possible in larp, for example if a therapist accompanies a client to a convention and acts as a permanent contact person. Other scenarios are conceivable here. A method for a small group is presented below, which is why the 1:1 setting is not further explored here.
Behavior Experiment and Exposure Training
Exposure exercises and behavioral experiments are the modern terms for the form of exercise commonly known as confrontation therapy (Kaczkurkin et al. 2015). The latter term is no longer used today in CBT, because it is not about mere confrontation (since that would mean that the client simply endures a fearful situation). Rather, exposure is about experiencing an active management of your fear. One mechanism behind exposure is habituation (I get used to the anxiety-provoking situation after a certain amount of time) (Mühling et al. 2011) and the statement: “I can cope with the situation if I don’t avoid it.”.
Very similar is the behavioral experiment: Before the therapist visits a fearful situation with the client, the client’s (fearful) concerns are collected and written down. Example: “If I give a presentation in front of a group, the audience will laugh at me.” A corresponding situation is then sought out and the client checks whether or not their fears are real. In this way, negative belief systems can be gradually changed. In CBT-oriented larp, the procedure is very similar. Together with the therapist, the client considers a target behavior. Then, a player-character is created that matches that target behavior. And then the client performs that behavior over time in their role. Due to the fact that a larp lasts several hours, a habituation effect as in the exposure exercise should occur at some point. And as in the behavioral experiment, the client is also instructed to check how others react to their behavior, whether their fears come true, or how the new target behavior feels in general.
Let’s take a fictitious client as an example of what this can look like in a larp therapy session: Lily is quite shy in real life. She finds it difficult to stand by her needs in private life and to demand her rights. She always puts the wishes of her partner, family members, and friends above her own wishes. And even in professional life, she can hardly say “no” to her boss, which is why she often does more work than her colleagues. A possible target behavior that Lily can train in (larp) therapy is “say no and stand up for my rights.” In preparation, Lily works out this target behavior with the therapist. Fears that Lily has are then also discussed. For example, Lily might think, “Other people will reject me if I say no to what they want,” or “I can’t assert my needs anyway.” These are negative assumptions. Together with the therapist and the larp therapy group, Lily then looks at which role-playing character goes well with this target behavior. In other words, “Which character already masters the target behavior very well that I want to practice?” In Lily’s case, that can be a shieldmaiden. So, with the help of the therapist and the group, Lily designs a shieldmaiden that she wants to play, who is very self-confident, always takes what she needs, and only goes into the wishes of others when it suits her. Let’s call this shieldmaiden Gudrun. Lily then plays Gudrun in the therapeutic larp and has in mind, “I say no if someone wants to take advantage of me and I stand up for my rights.” It is now her task to observe her fears:
- “Do others really reject me in my role as Gudrun?” and
- “How does it feel to behave this way and have a corrective experience?”
(Remember: Lily’s self-image was that she can’t assert her needs anyway). How all this can be organized in a therapeutic Larp is explained below in the description of the individual sessions.
In addition, role-playing in CBT can also be used more generally as a diagnostic tool to observe how clients react to difficult situations (Bellack et al. 1990). The problem analysis in the CBT larp described here, however, proceeds differently, as will be shown below.
Other Relevant CBT Terms
Conditioning and reinforcement: The concept of conditioning should be familiar to many people in its simplest form from Pavlov’s dog (Kohler 1962). Another form of conditioning that is more relevant to therapeutic larp is operant conditioning, most notably made famous by Burrhus F. Skinner (Staddon and Cerutti 2003). The basic concept is: By reinforcing desired behavior, it will be more likely to occur again in the future. In CBT larp, this trivial fact is very important: Clients should be given some kind of reward for acting out their target behavior if possible, be it through an appreciative remark from an NPC or even game-relevant effects. An example: If a shy client dares to repeatedly approach strange NPCs in their role and speak to them, they solve the plot very quickly and successfully. At best, they get recognition from NPCs and other players (social reinforcement) and e.g. gold or a powerful sword from the NPCs (material reinforcement). This motivates the client to approach other people openly in the future.
Goal Attainment Scaling: The so-called Goal Attainment Scaling (GAS) (Kiresuk et al. 2014) is a relatively simple way of presenting goal achievement in written/graphic form. A similar method is used in CBT larp. In psychology, a graded assessment is generally called Likert scale (Joshi et al. 2015), e.g., “How often do you think about your larp character and their behavior in everyday life on a scale from 0 (not at all) to 5 (always)?”
And now summarized again: What is CBT? And (how) does it differ from drama therapy?
Benefits of CBT
CBT has certain basic characteristics that probably most therapists and researchers could agree on:
- CBT is highly structured. This means that as a therapist I should always have a plan as to which goal I am pursuing in today’s session and with which methods. This distinguishes CBT from some other forms of therapy, such as psychoanalysis, where the basic rule is free association (Lothane 2018), which means that the client should basically say whatever comes to mind and the therapist may pick up on that and interpret it.
- In the CBT, we treat disorders specifically. Therefore, there are a large number of treatment manuals for all possible mental disorders. These specialist books have very specific instructions that are designed to guide you from the diagnosis process until the end of therapy in such a way that you can work through them from start to finish. CBT therapists are still learning to do psychotherapy this way in their training. Therefore, it is also our concern in the project described below to offer our standardized CBT larp for other therapists to use. However, one should point out two things:
- In clinical reality, hardly any therapist works through a treatment manual word for word from A to Z.
- There is a strong development in CBT towards a much more individualized psychotherapy, so-called process-based CBT (Hayes et al. 2017). Its advocates indicate that the classic treatment manual could be replaced more and more by the new approach.
- CBT is evidence-based and verifiable with empirical data. As described at the beginning, CBT is also so successful because it is “easily illustrated in figures.” For this reason, a CBT larp that can be evaluated empirically is also desirable, if it is to be paid for by health insurance companies in the future, for example. So much for the supply reality. Critics say that CBT is so successful in quantitative studies because:
- Many therapists who are also active in research are CBT therapists; and
- Many CBT concepts can be easily measured quantitatively (e.g. with the mentioned Likert scale), whereas in psychoanalysis or drama therapy, such measurements are not conceptually provided. One could say quantitative measurements do not necessarily correspond to the “spirit” of the therapy.
CBT vs. Drama Therapy
What is the difference between CBT and drama therapy? There really is no sensible dividing line for this. Some authors have gone so far as to say that role-playing in CBT was actually just adopted from drama therapy (Fliegel 2020). This is a typical accusation against CBT: it would incorporate foreign techniques and call them CBT. A former supervisor of mine used to say, “CBT is therefore an imperialist school of therapy.” Other authors suggest deliberately using mixtures of drama therapy and CBT (Hamamci 2006).
Ultimately, CBT and drama therapy are just different approaches to very similar problems. Both use different terms and have slightly different basic assumptions. Because of the three basic properties mentioned, we consider CBT to be a very helpful form of therapy that is easy to scientifically examine and that can be easily combined with other media such as larp. Because of these specific properties, we believe that a specific look at larp from the CBT perspective can be worthwhile.
How to Larp in CBT: A Prototype
In 2020, in cooperation with Tagrid Leménager from the Central Institute of Mental Health Mannheim, I started to develop a CBT larp and to make preparations for its empirical evaluation. During the preparation, we had contact in particular with German academics that use larp as an educational or psychological tool, including Katrin Geneuss, Martin Cierjacks, Myriel Balzer, and Franz Aschenbrenner.
As explained earlier, a hallmark of CBT is that it is highly structured. This has the advantage that a precise concept can be used in the same way by different therapists. In addition, if you have a guide in the form of a treatment manual, you can carry out several runs of the therapeutic larp and always improve small details. Another advantage of a standardized manual is that it is much easier to obtain data that is as comparable as possible for the evaluation because you can use the data to compare individual larp events and individual clients.
We would like to present the most important cornerstones of our CBT larp here. We would also like to motivate other health professionals to gain their own experience with it.
CBT Larp as Group Therapy in 6 Steps
The CBT larp is designed like group therapy with up to 6 clients. There should be 6 sessions, of which 5 sessions have the usual length of a group therapy session, i.e. about 90 minutes. One session is the larp intervention, which is designed for 5 hours. Only one therapist needs to be present in the preparatory and follow-up sessions. In the following text this person is referred to as the therapist. The other members of the therapist team are game masters and can be, but do not have to be psychotherapists, as described below.
In the first session, a problem analysis is carried out for each individual client. A recurring problem in everyday life is thus specified. These can be difficult social situations (“I always find it hard to say no when a friend asks for a favor”), but they can also be, for example, difficulties in giving oneself a daily structure, as occurs for example in attention deficit hyperactivity disorder. We already had both constellations of problems in test runs.
The problem analysis takes place in the group setting, using the example of a client. A standardized questionnaire that we developed for this purpose is used to support this (see Appendix I). Points are written on it such as “Problem analysis in keywords: What do I find difficult in everyday life? What do I want to change?” or “For the game section, I plan to try the following behavior…” The clients also get the worksheets to take home to continue as homework.
At the end of this session, a therapeutic role-play takes place for demonstration purposes, not in the larp setting, but in the way known from GSK or ATP.
In addition, clinical questionnaires are distributed to make any successes visible to each individual client, but also to enable scientific evaluation.
First there is a debriefing of the previous lesson and a discussion of the homework; if necessary, we provide assistance in formulating goals. Then the therapeutic rationale of CBT larp is explained and the basics of live action role-playing, because we assume that most clients have no experience with this. This is important to emphasize at this point: we want to use a method here that is not only aimed at role-players. (If the clients then become role-players, all the better).
There should also be a distinction made between larp and therapeutic larp (not just recreational fun, but with a therapeutic objective). The connection to the role-play from the previous sessions is explained: “Trying out and experiencing is elementary for the learning process!” Then there is a basic explanation of important game mechanics: explanation of in-game time and out-of-game time, setting a safe word, and the procedure for when a player wants to fold temporarily or is taken out by the therapist or a co-therapist. The group then discusses together where clients can build on their interests or previous knowledge, e.g., fantasy literature/series/films, video games, pen-and-paper role-playing games.
The next big point is the creation of the larp character. Together we reflect: How can I create a larp character that suits my development goals? For example, for social anxiety: creating a bold, daring character. The second section of the output worksheets is designed for this. The setting of the forthcoming larp is briefly explained.
We have found it helpful at this point to provide an illustrated list of archetypes loosely adapted from C.G. Jung (1990) and to state, for example, “If you want to practice reckless behavior, play the wild warrior.” Whitney “Strix” Beltrán (2012, 2013) has written some articles that are well worth reading, which also explain the connection between larp characters and archetypal theory. Clients can often more easily transfer their development goal to a specific character this way. For example, if I have set myself the goal of acting much more assertively in everyday life, then an archetypal “wild warrior” can help me to get an idea of how an offensive larp character can be. For example by asking myself: From which films, games or books do I know this archetype? I might think of King Leonidas from 300. And then I finally base my acting on this character. White et al. (2017) found in a study of young children that imagining oneself as an archetypal character (in the study it was Batman) was enough to change one’s behavior towards that character.
Clients take the worksheets home at the session’s end to continue writing their character.
The character arcs are discussed afterwards and possible difficulties are clarified. There should be a few minutes of rehearsal role-play with the characters, with the therapist presenting a small conflict scene that could occur in a larp setting. Our rehearsal situation: The therapist plays a guard in front of a gate and one of the clients is given the task of convincing the gate guard to let him through. Here it is already clear that a barbarian likely will choose a different path than a magician.
The most important rules are now repeated again and a (very short!) written set of rules is issued. The safe word is repeated and the course of the game is presented. Organizational points are clarified.
There is also a section on the trigger analysis on the worksheets: “I definitely don’t want to experience the following (e.g. triggers, phobias…)” This is now explained separately by the therapist. In our dealings with the topic so far, it has been shown that clients have good spontaneous access to what they indicate here. It is quite possible to “talk about a trauma without talking about the trauma,” which means that even in therapeutic larp, the therapist and other clients do not necessarily have to know why someone does not want to experience certain things. It is only important that the client can write this down here. It is at the discretion of the therapist to discuss the trigger analysis again with the client in a one-on-one session.
Most professionals who are using larp as a therapeutic tool say that the depiction of violence should be restricted in a therapeutic larp. We also assume that. “Dramaturgically sensible” combat with foam weapons is okay, but torture or sexual violence are to be ruled out as a matter of principle. But not so clear is the question among therapists of whether triggers should be consciously activated in therapeutic larps or not. Our position is that only those triggers that have been pre-determined as therapeutic targets, or at least have not been excluded, should be activated. In concrete terms, this usually means that triggers are an important part of the game when a client wants to overcome fears, e.g., when they say, “Whenever someone speaks harshly to me, I fall silent.” Here we have a kind of activation (harsh response) that can be usefully processed in the CBT larp. However, it seems inappropriate to us to activate a trigger in the sense of a post-traumatic stress disorder in the CBT larp, because this exceeds the capacity of the setting.
Since, despite a trigger analysis, it sometimes happens that triggers are accidentally activated in therapeutic larp. Here is a tip: The therapist/game master, who always accompanies the group, must be a trained psychotherapist with group experience, who also feels competent enough to deal with such situations professionally. In our concept, this will be the same therapist at the larp itself, who also did the preparation sessions with the clients.
In extreme cases, “acting professionally” means that the therapist has knowledge of how to deal with a dissociating patient if a trigger was accidentally activated. And in general, “professional behavior” can also affect the therapeutic relationship. In all off-game situations, we recommend maintaining the same distance from the client that we have in a normal therapeutic setting. This is a challenge because we are nevertheless “playing” a game with the client when we do therapeutic larp.
Session 4 is the actual larp intervention and, therefore, at around five hours, is significantly longer than the preparatory and follow-up sessions. Here are my impressions of a CBT larp that we carried out in Summer 2021 and that we will repeat in a similar form in the coming months and years. The venue is a rented piece of forest in Northern Germany.
Game Master/Therapist: There is a game master who accompanies the group at all times. This is also the therapist who led the sessions previously. In the following, however, the term therapist is used instead of game master. The therapist must have a qualification as a behavioral therapist as described and sufficient experience with groups. In addition, a little larp experience should be available in order to control in-game processes. The therapist always keeps in mind the clients’ goals, gos, and no-gos.
NPCs/Co-Therapists: All non-playable characters in a CBT larp are co-therapists. In the CBT larp we developed, three of these are required. A fourth co-therapist is helpful, but not absolutely necessary. In any case, these should be people with a therapeutic or educational background. They do not have to have any larp experience, but they must have been instructed in the CBT larp method. There is a written guide for co-therapists for this. Our experience so far is that this is also important in order to clarify the basic principles of CBT to the co-therapists, in particular the principle of exposure, which initially seems inappropriately “harsh” to people in other helping professions. At best, the co-therapists are already present in the group sessions beforehand. In our previous work, it was sufficient that the co-therapists received a brief overview with the names of the clients, their characters, their behavioral goals, and their no-gos, triggers, etc.
Initial setting: The initial situation for the clients is that they accidentally trigger a magical trap when they enter an unfamiliar forest. They can no longer leave the forest; it will gradually become contaminated and everything living in it will die on the same day. The CBT larp genre is classic medieval fantasy. Clients have no restrictions on their character choices here, as long as they are not unduly powerful.
Plot: After a few meters, the clients meet the therapist, who then accompanies them intimately the whole time. He plays Björn, a local villager. He enlightens the clients about the threat that has now been created and indicates that the clients should come along to his friend Svante, who knows a little more about the magic trap. From now on, the clients play at several stations and solve classic adventure quests. The common thread here is that the clients have to earn clues and artifacts from the inhabitants of the forest in order to get out of the forest alive. The rescue is a portal through which they have to step to get out of the closed forest.
Without going into too much detail, a concept that has already been described should be taken up, namely the three exercise situations from the GSK. The situations in which the co-therapists appear in our CBT larp correspond to at least two categories of the GSK. There is an elf queen whose sympathy the clients have to acquire (corresponding to GSK situation 3). Later, a situation with the same elf occurs in which the clients can defend themselves against being punished disproportionately for accidentally infecting the forest (GSK situation 1). It should be noted here that a client whose character has the goal of “more adjustment in the group” will behave completely differently than one who “always wants to stand by himself and his needs.”
One long quest involves clients seeking amulets that match their particular in-game behavioral goals. In our experience, these amulets have three advantages:
- Symbolization of the therapy content, so that what has been learned can be remembered for a long time;
- Positive reinforcement (as described, this increases the probability that the practiced behavior will be shown again); and
- Enabling the players to evaluate what has already been achieved.
In our CBT larp, the amulets had a similar function to goal attainment scaling (see above). At the moment when all clients have earned a suitable amulet, a magic test takes place (performed by the therapist). The amulets can only be put on if the respective client has already shown some of his/her target behavior in his/her role. If, according to the therapist’s assessment, this has not happened in the previous game, he explains that the client still has the chance to try out the target behavior for a while. The task of the therapist is now to support that particular client in implementing the target behavior.
At the end of the CBT larp, clients have the opportunity to exit the forest through the portal. We have found that it is perfectly appropriate not to let individual clients “win” too easily. Nevertheless, the group should finally master the last quest (escape from the forest). Therapists and co-therapists can help a little here.
Debriefing: Almost all authors who write about therapeutic larp are of the opinion that the debriefing actually makes a larp therapeutic (e.g. Diakolambrianou 2021) and it fundamentally contributes to emotional safety (Bowman 2014). We are also convinced that a good debriefing is essential for transfer to real life to support what we call bleed-out in the larp community (see also Montola 2010). The CBT larp therefore ends with a ritual in which the characters say goodbye to one another and a meta perspective is taken (de-roling process).
Then all clients meet again in a round with the therapist and the co-therapists. Everyone fills out an initial evaluation form, which also includes target achievement (in the form of Likert scales). Then, there is a round of debriefing in which all clients report how they experienced themselves in the game and whether they feel that they have practiced their target behavior. Then, there is feedback from the therapist, co-therapists, and the other clients. The amulets may be taken home as a symbol to remember the larp.
Some Thoughts on the Plot
In developing the CBT larp, we were of the opinion that a great deal of external pressure had to be exerted on the characters. This is especially true because, in most cases, the characters of the clients will exhibit very different attitudes, goals, and behaviors. In our opinion, a scenario is therefore necessary that builds up a certain pressure to cooperate. Based on previous test runs, it is our assessment that it is possible to design a therapeutic larp that can cover many different therapeutic goals through its plot and is not only suitable for one or two specific target areas, e.g., increasing empathy.
Which CBT techniques were included? In the described session 4, several of the techniques mentioned above can be found. Clients experience exposure to behavior that is foreign to them. They conduct behavioral experiments and can compare their fears with the actual reactions of those around them. Dysfunctional cognitions and basic assumptions are changed through corrective experiences. Reinforcement strengthens new behavior. And as described, the therapist is not only there to step in in an emergency. We have found that — insofar as the clients are basically stable — the therapists’ main task is to remind the clients of their behavioral goals and to give them tips on how to implement specific behavior in the game, for example: “Why are you actually carrying the luggage for the crew? Aren’t you a snooty nobleman?” This also parallels the role of the CBT therapist in an exposure exercise: to nudge clients repeatedly in the direction of the agreed-upon target behavior.
Session 5 and Session 6
Two more group therapy sessions off-game then follow as soon as possible after the larp intervention. Here it is discussed again which target behavior could be maintained and taken into everyday life and at which points the clients still have difficulties. Finally, the hobby of larp should also be “advertised” again, since we generally assume that leisure time larp also can be a healing resource (Lehto 2021).
Indications and Contraindications
We assume that CBT larp is basically suitable for all people with mild to moderate mental illnesses. Above all, however, larp is useful in the case of disorders that are based on problems in the areas of social skills and self-esteem. Contraindications are serious psychiatric disorders such as psychosis or severe depression. In our current research project, we have focused on Internet addiction because it often correlates with deficits in social self-concept (Leménager et al. 2020). At the same time, the larp setting could particularly appeal to MMORPG-dependent people who, according to the research, are otherwise often difficult to motivate for therapy.
Limitations and Difficulties
In our previous work with CBT larp, we noticed two difficulties:
- Clients who intend to play strong and extraverted characters in particular benefit from this behavior in the game. Anyone who decides to become more reserved must be very actively rewarded by the therapist and co-therapist.
- The larp intervention is very short to practice the new behavior. It is much longer than classic role-playing games in CBT and drama therapy, which is why we also believe in its effectiveness. But for the method to be successful in the long term, the larp intervention should be embedded in longer psychotherapy.
One aspect that I discussed in advance in a conversation with Katrin Geneuss from STAR Manufaktur (STARS-Projekt 2022) also remains to be critically examined: Just because we as larp enthusiasts think larp (as a method) is great does not mean it is for everyone who has not have contact with it before. In addition, the aspect of economic efficiency must always be considered. Therefore, the larp described here is designed so that it can be carried out relatively easily by a typical team in a psychotherapy clinic with one licensed therapist and three other therapists such as art therapists or sports therapists.
The Research Project
Finally, our research project should be briefly presented. As explained at the beginning, a medical treatment method must provide evidence of non-inferiority to other methods in order to be accepted in the public health system. From our point of view, CBT larp should not become a completely independent method, but should be used as part of CBT treatments as one of several techniques, e.g., in a rehabilitation clinic or in long-term behavioral therapy. Other techniques have already succeeded in doing this, such as mindfulness-based methods, by evaluating them as effective (see e.g. Raj et al. 2019).
We are currently conducting CBT larps and investigating whether the larp intervention reduces the severity of symptoms in mental disorders. For this purpose, the clients fill out established questionnaires from clinical psychology before and after the intervention. This then happens again several months after the larp. It is a so-called pre-post research design with follow-up examination. In this way, we want to carry out both individual case studies and larger quantitative comparative studies in the coming years. We are convinced that larp is an enrichment for psychotherapy and look forward to cooperation with other larp therapists.
Notes at the End
As a psychologist, I am used to two prejudices. These also fit the CBT larp theme.
- “Psychology psychologizes everything simply because it can.” It is important for me to emphasize that larp continues to be primarily a leisure activity for me. In my opinion, it is a stroke of luck that larp can also be used as a therapy method. And it is logical that it can work, as I hope this article has shown. In the long term, however, I am of the opinion that a different term should perhaps be coined for this in order to distinguish it from recreational larp, just as Katrin Geneuss does with her educational larp (Geneuss 2019, 282).
- “Psychology only examines what we already know anyway.” In the case of CBT larp, this is definitely true for larpers. Elektra Diakolambrianou writes very appropriately, “the fact that larp has psychotherapeutic and transformative potential is certainly not an arcane knowledge in the larp world” (Diakolambrianou 2021). In order to establish larp as a method in the long term, it is still important to prove its effectiveness.
Aschenbrenner, Franz. 2013. „Der Nutzen von Live-Rollenspielen für die Soziale Arbeit“. Unpublished thesis at University of applied sciences Coburg.
Balzer, Myriel. 2008. “Live Action Role Playing. Die Entwicklung realer Kompetenzen in virtuellen Welten.” Marburg: Tectum.
Bellack, Alan S., Randall L. Morrison, Kim T. Mueser, Julie H. Wade, and Steven L. Sayers. 1990. “Role play for assessing the social competence of psychiatric patients”. Psychological Assessment: A Journal of Consulting and Clinical Psychology 2 (3): 248-255. https://doi.org/10.1037/1040-35188.8.131.52
Beltrán, Whitney “Strix.” 2012. “Yearning for the Hero Within: Live Action Role-Playing as Engagement with Mythical Archetypes.” In The Wyrd Con Companion Book 2012, edited by Sarah Lynne Bowman and Aaron Vanek, 89-96. Los Angeles, CA: Wyrd Con, 2012.
Beltrán, Whitney “Strix”. 2013. “Shadow Work: A Jungian Perspective on the Underside of Live Action Role-Play in the United States.” In The Wyrd Con Companion Book 2013, edited by Sarah Lynne Bowman and Aaron Vanek, 94-101. Los Angeles, CA: Wyrd Con, 2013.
Bowman, Sarah Lynne. 2014. “Returning to the Real World.” Nordic larp, December 8, 2014. https://nordiclarp.org/2014/12/08/debrief-returningto-the-real-world.
Burns, Dylan. 2014. “The Therapy Game: Nordic Larp, Psychotherapy, and Player Safety.” In The Wyrd Con Companion Book 2014, edited by Sarah Lynne Bowman, 28-41. Los Angeles, CA: Wyrd Con.
Butler, Andrew C., Andrew C. Butler, Jason E. Chapman, Evan M. Forman, and Aaron T. Beck. 2006. “The empirical status of cognitive-behavioral therapy: a review of meta-analyses”. Clinical psychology review 26, 1: 17-31. DOI: https://doi.org/10.1016/j.cpr.2005.07.003
Cierjacks, Martin. 2002. “Life-Action-Roleplaying als Methode des Teamtrainigs”. Mannheimer Beiträge zur Wirtschafts- und Organisationspsychologie 1/2002: 17-27.
Diakolambrianou, Elektra. 2021. „The Psychotherapeutic Magic of larp“. Nordic larp, April 19, 2021. https://nordiclarp.org/2021/04/19/the-psychotherapeutic-magic-of-larp/.
Department of Game Design at Uppsala Universitet. 2022. “Transformative Play Initiative”. Last modified February 13, 2022. https://www.speldesign.uu.se/research/games-and-society-lab/transformative-play/Transformative-Play-Initiative/
Edejer, Tessa-Tan-Torres , Rob M.P.M. Baltussen, Taghreed Adam, Raymond Hutubessy, Arnab Acharya, David B. Evans, and Christopher J.L. Murray, eds. 2003. Making choices in health: WHO guide to cost-effectiveness analysis (Vol. 1). Geneva: World Health Organization.
ECW Jugendbildung e.V. n.d. “Erwecke den Helden in dir.” Accessed March 29, 2022. https://www.ecw-event.com/erwecke-den-helden-in-dir.
Fatland, Eirik. “A history of (live) roleplaying.” Talk at Larpwriter Summer School July 2016, Ruta, Lithuania. Accessed April 18, 2022. https://www.youtube.com/watch?v=KNY_qT_1xpQ
Fliegel, Steffen. 2020. „Rollenspiele“. In Lehrbuch der Verhaltenstherapie, edited by Jürgen Margraf and Silvia Schneider, 579-586. Berlin/Heidelberg: Springer.
Game to Grow. n.d. “Critical Core. Harness the power of therapeutic gaming with Critical Core.” Accessed March 29, 2022. https://www.criticalcore.org/
Geneuss, Katrin. 2019.“‘Die waren ja mittendrin!‘: Ganzheitliches Lernen im Rollenspiel. Edularp: Grundlagen-Wirkungen-Einsatz im Deutschunterricht.“ PhD thesis at Ludwig-Maximilians University, Munich. https://edoc.ub.unimuenchen.de/24863/7/Geneuss_Katrin.pdf
Hamamci, Zeynep. 2006. “Integrating psychodrama and cognitive behavioral therapy to treat moderate depression.” The Arts in Psychotherapy 33 (3): 199-207.
Hayes, Steven C., and Stefan G. Hofmann. 2017. „The third wave of cognitive behavioral therapy and the rise of process‐based care.” World psychiatry 16 (3): 245-246. DOI: 10.1002/wps.20442
Hinsch, Rüdiger, and Ulrich Pfingsten. 2015. „Gruppentraining sozialer Kompetenzen“ (6th edition). Weinheim: Beltz.
Joshi, Ankur, Saket Kale, Satish Chandel, and Dinesh Kumar Pal. 2015. “Likert scale: Explored and explained.” British journal of applied science & technology, 7 (4): 396-403. http://dx.doi.org/10.9734/BJAST/2015/14975
Jung, Carl Gustav. 1990. Archetypen. Munich: DTV.
Kaczkurkin, Antonia, and Edna Foa. 2015. “Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence”. Dialogues in clinical neuroscience, 17 (3): 337-346.
Kiresuk, Thomas J., Aaron Smith, and Joseph E. Cardillo. 2014. Goal attainment scaling: Applications, theory, and measurement. New York: Psychology Press.
Kohler, Ivo. 1962. “Pavlov and his dog.” The Journal of Genetic Psychology, 100 (2): 331-335.
Lehto, Kerttu. 2021. “Role-Playing Games and Well-Being.” International Journal of Role-Playing 11: 72-93. https://ijrp.subcultures.nl/wp-content/uploads/2021/12/IJRP-11-Role-Playing-Games and-Well-Being-Kerttu-Lehto.pdf
Leménager, Tagrid, Miriam Neissner, Thomas Sabo, Karl Mann, and Falk Kiefer. 2020. ““Who Am I” and “How Should I Be”: a Systematic Review on Self Concept and Avatar Identification in GD.”Current Addiction Reports 7 (2): 166-193. DOI: https://doi.org/10.1007/s40429-020-00307-x
Leyline Education. 2020. “Integrating geek culture into therapy. Geek Therapeutics.” https://www.geektherapeutics.com/
Linnamäki, Jori (Pitkänen). 2019. “Formas o Métodos Para el Cambio. ¿Cómo contribuyen al cambio el Psicodrama, el Sociodrama, el Teatro Playback y el Role Playing educativo de acción en vivo o EDULARP.” La Hoja de Psicodrama 28, no. 71 (May).
Lothane, Henry Zvi. 2018. “Free association as the foundation of the psychoanalytic method and psychoanalysis as a historical science.” Psychoanalytic Inquiry 38 (6): 416-434. DOI: https://doi.org/10.1080/07351690.2018.1480225
Mastermind Adventures LLC. n.d. “Quest! Adventure Game for Social Skills Mastery.” https://www.mastermindadventures.com/quest-training/
Mendoza, Jonathan. 2020. “Gaming Intentionally: A Literature Review of the Viability of Role-Playing Games as Drama-Therapy-Informed Interventions”. Thesis (M.A.) at Lesley University, Cambridge, MA. https://digitalcommons.lesley.edu/expressive_theses/322
Montola, Markus. 2010. “The Positive Negative Experience in Extreme Role-playing.” In Proceedings of DiGRA Nordic 2010: Experiencing Games: Games, Play, and Players. Stockholm, Sweden, August 16. http://www.digra.org/digital-library/publications/the-positive-negative-experience-in-extreme-role-playing/
Mühling, Stephan, and Andreas Podrack. 2011. “Kognitive Therapieverfahren.“ In Klinische Psychologie und Psychotherapie (2nd edition), edited by Hans-Ulrich Wittchen and Jürgen Hoyer, 543-564. Heidelberg: Springer.
Raj, Saurabh, Swati Akshay Sachdeva, Rubina Jha, Shivantika Sharad, Tushar Singh, Yogesh Kumar Arya, and Sunil K. Verma. 2019. “Effectiveness of mindfulness based cognitive behavior therapy on life satisfaction, and life orientation of adolescents with depression and suicidal ideation.” Asian Journal of Psychiatry 39: 58-62. DOI: 10.1016/j.ajp.2018.12.001.
Staddon, John E. R, and Daniel T. Cerutti. 2003. “Operant conditioning”. Annual review of psychology 54, 1: 115-144. DOI: https://doi.org/10.1146/annurev.psych.54.101601.145124
STARS-Projekt. 2022. “STARS Live Roleplaying Games”. Accessed March 29, 2022. https://starmanufaktur.lima-city.de/english.html
The Bodhana Group. n.d. “Tabletop Games +Therapy. Thebodhanagroup.org.” Accessed March 29, 2022. https://www.thebodhanagroup.org/
Ullrich, Rüdiger, and Rita de Muynck. 2002. „ATP: Anleitung für den Therapeuten: Einübung von Selbstvertrauen und sozialer Kompetenz” (2nd edition). Stuttgart: Klett-Cotta.
White, Rachel E., Emily O. Prager, Catherine Schaefer, Ethan Kross, Angela L. Duckworth, and Stephanie M. Carlson. 2017. “The ‘Batman Effect’: Improving Perseverance in Young Children.” Child Development 88, 5: 1563-1571. DOI: https://doi.org/10.1111/cdev.12695
Wölfling, Klaus, Kai W. Müller, Michael Dreier, Christian Ruckes, Oliver Deuster, Anil Batra, Karl Mann et al. 2019. “Efficacy of short-term treatment of internet and computer game addiction: A randomized clinical trial.” JAMA psychiatry 76 (10): 1018-1025. DOI: 10.1001/jamapsychiatry.2019.1676
Cover photo: The talismans for the clients/players. Image © 2021 by Ingke Burchardt-Clausen.