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"Gaymers" and Telehealth

LGBTQ+ video-game therapy.

Alex Stitt
A PS4 and XBOX Controller on a Pride Flag
Source: Alex Stitt

When asked what they did with their week, many of my clients shrug and say “not much.” If they’re a gamer, however, this is probably a lie. In actuality, they were going on epic adventures fighting space-demons, staying up all night coordinating campaigns with their friends online, or exhausting hundreds of hours building a massive architectural wonder in Minecraft!

But they’re not likely to admit that. There is a stigma around internet culture and gaming culture. Perhaps it’s considered nerdy, or childish, or not serious enough to explore with a therapist, though nothing could be further from the truth. We are influenced by the content we consume, and these days many video games are epic sagas as emotionally tumultuous as a classic work of literature. To be honest, I think my generation is still recovering from when Sephiroth stabbed Aerith in Final Fantasy 7.

Since more and more therapists are using telehealth, it’s time to explore why games are so important, especially within the LGBTQ+ community. Today there are huge online forums dedicated to Gaymers and Trans-Gamers, as we connect online to have authentic, uncensored fun. Just like in the real world, LGBTQ+ gamers band together to fight off the toxicity of heterophobic or transphobic players shouting obscenities through their headsets. United by our similarity, we may form bonds with teammates in our massively multiplayer online role-playing games (MMPORG) or team-based shooters. These bonds can last for years, and sometimes even evolve into real-world relationships. Yet for some reason, this online community of supportive gamers—this whole playful aspect of our lives—is rarely explored in-session.

Helping clients shore up their self-care process can be difficult while social distancing, and when I see tele-therapists struggling to engage their clients it often seems like they’re trying too hard. Play a game with your client. Become a part of their online world. The pathways of open communication naturally form as a byproduct of mutual authenticity. You can’t force it, which is where video games can actually serve as a dynamic, therapeutic tool.

In recent years, video games have been used as a form of cognitive distraction from the physical pain associated with fibromyalgia,1, and the anxiety and nausea related to chemo and surgery.2,3 In the rehabilitation field, memory and pattern recognition games can also aid individuals with traumatic brain injuries,4 cognitive decline,5 and stroke.6 Tackling mental health issues, games like Bejeweled and Peggle have been used to treat depression,7 while racing and adventure games may benefit those with ADD.8 For those with active PTSD, Tetris has been used to prevent intrusive traumatic memories,9 and military first-person shooter games have been implemented with veterans as a form of exposure therapy.10 For more information on these studies, I highly recommend reading Carras et al. (2018) Commercial Video Games as Therapy.

Yet how can online games foster authenticity?

My mentor Laura Moidel Acevedo, LMHC, has been integrating video games into her practice long before the telehealth boom of 2020, primarily with clients working through trauma, and gender-variant clients who are self-actualizing. Laura uses an adapted person-centered approach to play the game with the client. The purpose is not just to play, but to talk out the ethical options within the game, and notice what the client finds exciting or frustrating. While this definitely builds a lot of rapport with kids and teens, it is also a very useful way to help people slowly open up about trauma or personal identity.

Probably the two most versatile games Laura uses in her practice are Skyrim, from the Elder Scrolls franchise, and the virtual world of Second Life. Both can be screen shared remotely on a PC, providing different routes to insight and catharsis. For example, a whole session can be spent in Skyrim just creating the character, allowing the dialogue to dive into inner archetypes, ideals, values, or even segue into aspects of gender or body image.

Jungians can have a field day exploring why the client wants to slay the beast, or why they relate to the devious thief or perhaps the reluctant hero. Unlike shooters, which demand attention by bombarding the senses, open-world role-playing games provide plenty of time to talk, which is an easier pace for person-centered therapy. Naturally, as long points of the game are spent walking across vast lands, clients tend to open up about how they’re feeling, as people often do on a long road trip, sharing personal insights that may have little or nothing to do with the actual activity.

Second Life, by contrast, has more inventive possibilities since you can literally create anything in that world. Clients can experiment with trying on new pronouns, or exploring aspects of themselves they’re not yet ready to reveal in real-world settings. Imagine sharing art or poetry with an online audience, with the added safety of being able to sign off if it’s all too overwhelming. Imagine being able to practice small talk, or disclosure, or emotional transparency. The adage “there is no rehearsal for real-life” no longer holds true.

For many LGBTQ+ individuals who feel trapped by the conventional binary, the ability to experiment and play with their personas is a vital step to understanding and expressing their whole self. Any open-world game has the potential of providing archetypal metaphors and segues into deeper exploration, and there are so many games to choose from! Obviously, in a therapeutic session, the point isn’t to just play the game, but to use it as a vehicle for self-understanding. Though whatever game, it’s important for the therapist to be familiar with the gameplay, as nothing will bring a session to a halt quite like forgetting the key commands.

References

1. Mortensen, J., Kristensen, L.Q., Brooks, E.P., Brooks, A.L. (2015) Women with fibromyalgia’s experience with three motion-controlled video game consoles and indicators of symptom severity and performance of activities of daily living. Disability and Rehabilitation: Assistive Technology, 10(1):61–6.10.3109/17483107.2013.836687

2. Redd, W.H., Jacobsen, P.B., Die-Trill, M., Dermatis, H., McEvoy, M., Holland, J.C. (1987) Cognitive/attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy. Journal of Consulting and Clinical Psychology, 55(3):391–5.10.1037/0022-006X.55.3.391

3. Patel, A., Schieble, T., Davidson, M/, Tran, M.C.J., Schoenberg, C., Delphin, E., et al. (2006) Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatric Anaesthesia, 16(10):1019–27.10.1111/j.1460-9592.2006.01914.x

4. Llorens, R., Noé, E., Ferri, J., Alcañiz, M. (2015). Video game-based group therapy to improve self-awareness and social skills after traumatic brain injury. Journal of Neuroengineering Rehabilitation. 12, 1–8. 10.1186/s12984-015-0029-1

5. Jimison, H., Pavel, M., McKanna, J., Pavel, J. (2004) Unobtrusive monitoring of computer interactions to detect cognitive status in elders. IEEE Transactions on Information Technology in Biomedicine, 8(3):248–52.10.1109/TITB.2004.835539

6. Yong Joo, L., Soon Yin, T., Xu, D., Thia, E., Pei Fen, C., Kuah, C.W.K., et al. (2010) A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of Rehabilitation Medicine, 42(5):437–41.10.2340/16501977-0528

7. Russoniello, C.V., Fish, M., O’Brien, K. (2013) The efficacy of casual video game play in reducing clinical depression: a randomized controlled study. Games for Health Journal, 2(6):341–6.10.1089/g4h.2013.0010

8. Pope, A.T., Palsson, O.S. (2001) Helping Video Games Rewire “Our Minds” [Internet]. Arts & Humanities in Public Life Conference: “Playing by the Rules: The Cultural Policy Challenges of Video Games” Chicago, IL (2001). Available from: http://archive.org/details/nasa_techdoc_20040086464

9. Iyadurai, L., Blackwell, S.E., Meiser-Stedman, R., Watson, P.C., Bonsall, M.B., Geddes, J.R., et al. (2017) Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: a proof-of-concept randomized controlled trial. Molecular Psychiatry (2017).10.1038/mp.2017.23

10. Elliott, L., Golub, A., Price, M., Bennett, A. (2015) More than just a game? Combat-themed gaming among recent veterans with posttraumatic stress disorder. Games for Health Journal 4(4):271–7.10.1089/g4h.2014.0104

11. Carras, M.C., Van Rooij, A.J., Spruijt-Metz, D., Kvedar,J., Griffiths,M.D., Carabas,Y., Labrique, A. (2017). Commercial Video Games As Therapy: A New Research Agenda to Unlock the Potential of a Global Pastime. Frontiers in Psychiatry. 2017; 8: 300. Published online 2018 Jan 22. doi: 10.3389/fpsyt.2017.00300

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