Why Therapy Is Like A Game

Game-playing often has negative connotations in the field of psychiatry.  We have all sorts of erudite ways of describing what laypeople call “mind games.” A great example is in the language of Axis II personality disorders.  People are borderline, dependent, avoidant, narcissistic, antisocial, and the most FABULOUS of them all, histrionic.  These words attempt to describe the psychological conditions which motivate problematic behaviors.  Serious business indeed.

But come right out and say that therapy is like a game, even a kind of game, and that gets a lot of hackles up.  Therapy is serious business, and games are anything but serious, right?  Wrong.

To describe something as a game is not to minimize it or take it less seriously, but I suggest to describe what Bernard Suits calls the “lusory attitude.”  This is the state of mind, the psychological attitude, required of any player when they play a game.  The most succinct way Suits describes the lusory attitude is to say that it allows the “voluntary attempt to overcome unnecessary obstacles”

An example of this, not mine originally, is that of golf.  The activity is directed at achieving the goal of getting a ball into a hole.  But instead of just creating an activity where we find a ball and drop it into a big hole, we take the hole, make it small, say you can’t use your hands to drop the ball in but must use a metal club, and start you off hundreds of feet away from the hole.  That’s golf, and it is so full of unnecessary obstacles!  There is no reason to make it so challenging, EXCEPT that that challenge is what makes it fun, and frustrating, and more fun.  And nobody drags you into the wilderness, gives you a golf club and points a gun at your head to golf.  It is a voluntary act.  People love to, choose to, spend hours with sticks hitting balls from great distances with the hope of getting them into little holes.  Why choose to do something so weird and difficult?  Because they are playing.  They have voluntarily attempted to overcome unnecessary obstacles.  They have adopted a lusory attitude.

Life is hard.  And for many of therapy patients, life has been extremely hard, and cruel.  And yet, how often do we notice that they are making life even harder on themselves in some ways?  Perhaps unconsciously, perhaps subtly, but more difficult nevertheless.  That neurosis, the reenactment of the past, is what I would suggest is the unnecessary obstacle.

For example let us take PTSD-precipitated by child abuse.  The abuse was serious, hurtful, sadistic, real.  It happened.  But in the case of the adult patient, the abuser is no longer there.  The introjects, the learned stuff, the unconscious stuff, that is all there, but the perpetrator has fled the seen of the crime long ago.  They were real obstacles, but trauma recreates them as unnecessary obstacles in the here and now.

Another example would be a phobia.  Why not be fearful of everything?  Spiders aren’t the only thing that we could fear:  There’s death, and hurricanes, and black cats, and dirt, and blindness, and the next presidential election.  But we don’t fear everything in the world that is or is perceived as harmful to us.  Phobias are very specific, that is why there are so many clever names for them.  They are again, unnecessarily specific obstacles.

Again, I want to stress that by calling these unnecessary obstacles that I am not at all saying that phobias or PTSD or not serious, painful, debilitating, conditions.  What I am saying is that they are unnecessary to the life of the patient.  Even as compromise solutions they have outlived their usefulness if the patient is in the here and now experiencing distress as a result of trying to defend against or cope with the past encroaching on their present.  The repetition compulsion is a game of both danger and optimism.  We do the same things over and over, often with disastrous results, true; but we keep doing it because on some level there is an urge to get it right.  And like a video game, the repetition compulsion doesn’t just get defeated one day; rather we get progressively further in the game, acquire new levels and skills.

When our patients arrive at our office, they are in a state of lusory attitude, they are really trying to resolve the problems the best they can, and they have sought out our help to that end.  If they are mandated to treatment, this is less likely to happen.  But for a majority of patients, they choose to show up.  And from a psychological point of view, showing up must be voluntary for therapy to work.

In order to do therapy, we also have to adopt together a lusory attitude.  Both therapist and patient volunteer to work together to overcome the unnecessary obstacles.  The therapy time and space are in some ways unnecessary obstacles: we choose to limit the session to the 45-50 mins, in a specific office, with only two “players” if it is individual therapy.  These may be the warp and woof of therapy but they are also arbitrary distinctions that create unnecessary obstacles.  We could rotate different therapists in, or meet for varying times whenever we both want, and hang out at Dunkins, but that would be therapy in the sense we are talking about would it?  No, therapy, like games, must have agreed-upon rules.

Although I’m speaking in clearly psychodynamic terms here, doesn’t it seem that more behavioral approaches would find the concept of lusory attitude applicable as well?  Surely we don’t try to extinguish behaviors we think are necessary.  The behavioral approach also implies that the obstacle (behavior) is unnecessary and tries to over come it.

Having a lusory attitude is not always about being lighthearted, although it can be, but it is about taking play very seriously, engaging in it and often having an immersive experience.  Psychotherapists who engage in play therapy with children often have an easier time understanding this than those who do adult psychotherapy.  There is a general tone from our profession of, “we need to be taken seriously,” which I think has lots of its roots in the tendency of the medical profession in the past to have considered it less important.  And somehow being taken seriously becomes equated with being important or being valuable.

I often supervise interns who repress any sense of enjoyment that comes from making an interpretation that moves a patient forward, or seeing theoretical elements manifest in the treatment, and try to help them see that enjoying the process of learning psychotherapy and learning about the patient is not the same as having fun at her/his expense.  As Sutton-Smith says, “The opposite of play isn’t work.  It’s depression.”  In this regard I agree with him:  When engaging in a lusory attitude with patients we are working with them.  Removing those obstacles is very hard, dangerous work, and it is deeply and seriously playful.

To add gamers and video games into the mix, I would suggest that approaching video games as an addiction is a step in the wrong direction.  This is not to say that I don’t think that some people play video games to the detriment of their lives and relationships.  I do think that happens, just like I think people engage in a number of activities at times to the detriment of their lives and relationships.  But to label them as pathological is to miss the point.  Even if we rule out the cultural incompetency of the clinician around video games which often masquerades as dismissal or villainization, we need to understand that we are in essence asking the patient to adopt the same lusory attitude with us that is often there already for them with video games.  We are saying, “don’t play that game, play this game of therapy instead.”

(Unless you have this view of psychotherapy:

 

Psychotherapy needs to stop taking the lusory attitude for granted.  What if we became more mindful of our lusory attitude?  We all have them, over coffee with a colleague when we look at each other and say, “this is such a weird profession!”  It’s like golf in that respect, it seems; so intricate and complicated with rules we take for granted that make a particular human relationship much more complicated than it has to be.  Try that on the next time you are trying to discuss your fee with someone:  “I charge you $150 an hour because this is a weird relationship that has intricate rules and is much more complicated than human relationships have to be.”

I think that there are strong parallels between therapy, neurosis, and games, and that the thread that links them together may be the lusory attitude.  In games, the design always boils down to a voluntary attempt to overcome and unnecessary obstacle.  In neurosis, the attempt to repress intolerable conflicts and feelings creates an unnecessary obstacle even as the patient tries to remove the unnecessary obstacle of those same conflicts and feelings.  (Game designers may recognize an interesting resemblance to the concept of iterative design here.)  Finally, in therapy, the neurosis or symptom becomes the unnecessary obstacle that the therapist and patient voluntarily attempt to overcome.

What do you think?  Does this jibe with your experience as a therapist, patient, gamer or game designer?

 

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Comments

  1. Mike,
    I quickly scanned through your methaphor comparing the psychotherapeutic process and joining in with clients to a GAME. I find your irreverence to the exact science of psychotherapy refreshing, and your paradigmatic belonging a very relativistic one. However, as a clinician soon to become an LICSW, I would be beyond cynical to think of diagnosing symptoms that a client reports to me as A GAME. I get your provocative methaphor about the process of dignosing Axis II symptoms-it may appear to some as a MATCH-UP GAME; how sad if that had happen to you or someone you love. I’d like to encourage you to heal…Speaking for myself and only with my integrity-as much as I struggle to label and put people in boxes according to nuances of their human characteristc/personalities; I do it in order to be able to link persons to services they need. In life, whenever a game ends there are usually winners and losers…..if a clinician is to adopt a stanza of being comfortable to watch as a spectator the winners and losers and he or she feels that is a GAME- that very person ought to re-examine their conscience…Mike Langlois, I see that you help folks create businesses and develop their savvy and that’s terrific. I, on the other hand, chose to witness peoples pain and sucesses and chose to become a clinician that offers attachment to human suffering-therapeutic alliance is a relationship, it is a transforming experience; a therapist agrees to suffer and rejoyce with her clients and offers to work through all the hurt and pain and triumphs-it’s more of a walking Golgota than Playing Mind Games. Take care! Rilka

  2. I agree with your points, Mike, and I like your view on what you do.

  3. Sandra Hutton, Ph.D. says:

    Provocative premise: The word “game” is open to so much linguistic—-well, fuzziness, to chose a fairly imprecise descriptor. Any of us who remember Eric Berne’s 1964 “Games People Play” and its even more famous cousin “I’m OK, You’re OK” as sources for Transactional Analysis think of “game” in a different way than do online gamers in our grand new century. That fun old movie “War Games” focused on the win-lose game of nuclear annihialation, in which, as in tic-tac-toe, the only way to win is to Not Play.

    If we think of psychotherapy as a win-win game, which in some ways I do, then I’m with you. We can symbolically set up a game in which patient and therapist are seeking the same outcome. Then we could play, instead of Berne’s “Let’s You and Him Fight,” a Really Fun game like “Let’s You and Me Figure Out How You Got Stuck with all these Wacked-out Rules for Living—and then Come Up with Better Ideas!” (Feel free, anyone, to change the words so they produce a cool acronym!)

  4. Shaun Higgins says:

    I LOVED this Mike! GREAT ideas! Loved the Bob Newhart clip! Sounds like MY therapist!
    All the Best, In Him, Shaun

  5. Shaun (photographer, veteran) says:

    I LOVED this MIKE! GREAT IDEAS! And LOVED the Bob Newhart clip. Sounds like MY therapist!
    All the Best,
    In Him, Shaun

  6. Nathan Grimm says:

    I think your analogy of a psychological problem to a game because of the arbitrary rules involved is very thought-provoking. I think the main difference is that in therapy you are ideally trying to get rid of the arbitrary rules that have created the psychological problem whereas in an actual game the rules cannot be changed.

    ~Nathan Grimm

  7. Barbara Jennings says:

    Hello, Mike–

    I was going to respond to your entire post. But just for fun, and I hope to stimulate dialogue, I thought I would just address the statements you wrote “People are borderline, dependent, avoidant, narcissistic, antisocial, and the most FABULOUS of them all, histrionic. These words attempt to describe the psychological conditions which motivate problematic behaviors. Serious business indeed.”

    People are not borderline. But some people who present to some clinicians are diagnosed according to the current DSM as suffering from Borderline Personality Disorder” (BPD). Further, several of the criteria must be met in very specific behavioral contexts.

    Yes, some people are dependent all or some of the time on something or somebody. But the DSM refers only to the theoretical concept Dependent Personality disorder (DPD).

    And so on. A bigger issue is why Axis II is important to psychiatric diagnosis.

    Later, I would like to discuss the connection you hint at that connects the Axis II diagnoses with the psychoanalytic constructs “introject” and so on. That is also where the Axis II connect with the other Axes.

    Barbara

    • Mike Langlois, LICSW says:

      Why hello, Barbara, awesome to hear from you. I hope that you will say more about how you see Axes I and II connect here.

      The colloquial language in the post is deliberate, and mirrors what I suspect you (and I share this opinion if you hold it) could take issue with, which is the lack of specificity made by clinicians when bandying about these terms. More later.

      • Barbara Jennings says:

        Hello, Mike–

        Awesome indeed. Your very subtle humor regarding clinician lack of specificity, as you so aptly state, relates quite well to how Axes interconnect. I suppose a good starting point would be the basis of Axis II, and the central theoretical construct involved. This is personality theory. Without a working personality theory there would not be any sense of defining personality disorder. The first includes ideas about functional, usual, predictable personality traits. There is a world of research connected to personality theory. There is for example the very well known (to psychologists) Big 5. There personality gets defined according to very specific and observable criteria.

        Then there is the personality and the potential for personality disorder theory related to interpersonal theory and research. I don’t want to spin out here, but one of the leading members on the committee for Axis II in DSM IV and V was an interpersonal psychologist and researcher named Lorna Smith Benjamin. She carried on from Harry Stack Sullivan and others beginning with part of Sigmund Freud’s phenomenology that includes the concept of introject. I call it “phenomenology of suffering.” It is also about the interpersonal origin of psychic pain, and so on.

        Benjamin’s work is crucial because her interpersonal predecessors had very well developed theory without reliable evidence of an unconscious. And you have almost no hope for clinical intervention in the phenomenology of suffering (Freud calls this neurosis) without research that advances the theory of the unconscious. Because, for one reason the unconscious wishes and hopes (whether healthy and good or dysfunctional and painful) drive behavior, ideation, and on the suffering end, self destructive and unwanted behaviors, ideation, symptoms, etc.

        All statements above can be discussed or narrowed as needed. I’ve tried to summarize. I have all the source research.

        Later, Barbara

        There is also the

  8. Thank-you Mike;
    <<>>
    <<>>

    It is a dance, it takes sensitivity, projecting value in the individual who has been treated with no value, aka, trauma experiences…

  9. I agree with Nathan here. Therapy and game may be compared but the rules and ethics are very different. Anyway, you made interesting points in the article.

    • Barbara Jennings says:

      Hi, Mike–

      You wrote: “Finally, in therapy, the neurosis or symptom becomes the unnecessary obstacle that the therapist and patient voluntarily attempt to overcome.”

      Yes! This is one of the most important central ideas across the psychotherapies. Does anyone remember Eric Berne?

      Berne, Eric (1964). Games People Play – The Basic Hand Book of Transactional Analysis. New York: Ballantine Books. ISBN 0-345-41003-3

  10. I often feel psychotherapy to be a game. Maybe a highly evolved form of RPG. For example, I come away from some sessions and feel like I just levelled up as a therapist. Or that me and my client just unlocked a part of the gameworld that was previously inaccessible.

    I’m a gestalt therapist, so more in the humanistic/existential direction, and experiencing therapy as a game is deeply existential for me because of the meaning that gives to doing and being. How many people feel like they’re only winning at life if they hit the right cultural milestones at the right time? There was even a board game called The Game of Life that made all this explicit; the aim of the game was to get promoted at work, get married, have kids, buy a house etc.

    I think a very telling existential intervention would be to ask “if your life was a game, what game would it be?”. To explore the metaphysics that inherently define what that person thinks is possible.

    And therapy does have an aim after all. It’s just that some therapies have behavioural change objectives, whereas others (like gestalt) have process goals.

    Lots of food for thought here, thanks! 🙂

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  1. […] the majority of gameplay, that I was being challenged but would eventually be able to overcome the unneccessary obstacle.  On those occasions I called getting stuck, I began to experience feelings of victimization and […]

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