Introduction

Video games are no longer a fringe pursuit, if they ever truly were. The Entertainment Software Association (ESA) estimates that video games grossed over $36 billion in the US in 2017 (ESA, 2018). This represents over 600% growth from estimates in 2000 (Interactive Digital Software Association [IDSA], 2002). The ESA (2018) noted that there were, on average, two video game players in each US household with dedicated video game devices, and approximately two out of three US households own a video game device (console or computer for video games). Wizards of the Coast – publisher of the oldest commercial tabletop roleplaying game (TTRPG) Dungeons & Dragons (D&D) – estimates that 8.8 million people played D&D in 2017 and 9 million people watched at least one of the 7500 different live broadcasts of others playing D&D (Weiss, 2018). These estimates do not include those who play any other the hundreds of other commonly available TTRPGs. Odds are, if you are a practicing clinician, you are working with gamers whether you know it or not. As video games and TTRPGs grow in ubiquity, there is a growing need for clinicians who understand the experiences of those who play and identify with various aspects of gaming culture. Given that identification as a gamer (a loose term used to describe one who identifies with video game culture, tabletop game culture, or both) is voluntary, why should this merit consideration and understanding?

Game Community Needs and Moral Panic

The authors of this article work for a mental health nonprofit that serves both the consumer and production sides of the game industry. We give frequent educational talks and mental health trainings at major game conventions, and many of these conventions attract tens of thousands of attendees each weekend. Our organization runs a mental health resource program at many of these events; this program has served approximately ten thousand people since we began tracking utilization numbers in 2016. When we discuss mental health resources with gamers, especially how to find a therapist, two worries gamers frequently express are, “Will they judge me negatively for loving games?” and “Will they even understand what I’m talking about?”

The latter question is something we hear especially from those who earn a part-time or full-time income as online content creators and broadcasters – as well as professional, competitive video game players (known as “esports” – pronounced “EE-sportz”). Some of the gamers we talk to who see therapists describe the emotional burden and annoyance at having to pay for the time to educate their therapists on the nuance of game culture before they can address some of the stressors they face. Some of the complexities of these issues often require multiple sessions simply to explain the context. While our experience with gamers is anecdotal (though fairly extensive), there is current and historical evidence to validate the worries we hear.

There is a long history of moral panic by well-meaning but poorly informed experts at the advent of new media. Psychiatrist Fredric Wertham (1954) passionately argued the dangers of comic books. He claimed they contributed to antisocial behavior and sexual deviance in youth. Despite his outlandish claims, this resulted in a decades-long censorship code for the comic industry – ostensibly to protect youth – and similar arguments have been made with video games for the last several decades (Bowman, 2016). A common media narrative portrays video games as the source of violent behavior (Campbell, 2018). This is despite the fact that violent crime in the United States decreased overall by nearly 27 percent between 1996 and 2017 (Federal Bureau of Investigations, 2013; 2018) while video game sales have simultaneously increased (ESA, 2018; IDSA, 2002).  During the 1980s and 1990s, many “experts” on games like D&D received national attention while simultaneously displaying a lack of knowledge of the actual game (e.g., CBS Productions, 1985; Pulling & Cawthorn, 1989).

What happens to clients when mental health professionals draw conclusions based on moral panic or incomplete evidence? Despite the lack of evidence for its critics’ claims that D&D increases teen suicide and loosens perceptions of reality (Lancaster, 1994; Laycock, 2015), a survey of Canadian psychiatrists found that twenty-two percent of respondents still associated D&D with psychopathology (Lis, Chinara, Biskin, & Montoro, 2015). Beyond the lack of consensus on the nature of video games and violent behaviors (Ferguson & Konijn, 2015) and the overall decrease in violent crime in the US since the 1990s (Federal Bureau of Investigations, 2013; 2018), Ferguson’s (2015) survey found that 39.5% of respondents believe that the effects of video games on violent assaults is a problem for society. The majority of the same respondents (61.5%) believe that addiction effects, due to playing video games, are a problem for society; this ignores that two dozen prominent, international video game researchers uniformly and emphatically opposed the inclusion of Gaming Disorder in the upcoming ICD-11 (World Health Organization, 2019) for several reasons. These reasons include how the symptoms are too broadly defined and lack adequate scholarly agreement, there is a general lack of quality research on the topic, and the diagnosis has an over-reliance on addiction-based models without agreement on the underlying causes of problematic technology use (Aaseth et al., 2017). All of this points to a serious disparity with the current state of popular media and how it is represented by mental health professionals. We must bridge the gap between our understanding of games, gamer culture, and clients’ lived experiences.

Games as Culture

As noted above, one’s identification with game culture is a voluntary one, dissimilar to other forms of cultural recognition (e.g., ethnicity, gender, sexuality, or country of origin). Anyone can be a gamer. Still, a growing number of clinicians and researchers are aware of gamer culture and already embrace it (also superheroes, comics, D&D, etc.) in their clinical practices and teachings (e.g., Bean, 2018; Berkenstock & Blakley, 2019; Boccamazzo & Connell, 2019; Game to Grow, 2018; Scarlet, 2017). Unfortunately, Ferguson (2015) found that only 9.1% of clinicians and researchers identify as gamers. This number is staggering when one compares it to the number of players (ESA, 2018). This means that the vast majority of mental health professionals do not identify with a pastime in which a majority of people participate.

It is not a requirement that all practitioners enjoy gaming, but the ubiquity of the gaming experience alone (ESA, 2018) should be enough to warrant mental health professionals to better understand the nuances of it and critically examine their biases regarding gaming. It is difficult to relate to clients when a person does not understand the subtle nature of clients’ experiences. There are significant differences in the phenomenological and social experiences of clients who say they preferred playing competitive MOBAs (“multiplayer online battle arena”) over single-player games like survival mode of the game Minecraft (Mojang, 2011). Could you describe those differences? As of the beginning of 2018, there were over 175,000 people earning at least some income from the streaming service Twitch (Perez, 2018). If a client was a full-time streamer, could you identify the unique job stressors they commonly face? The winning three -person team at the 2018 International – an esports tournament for the game Dota 2 (Valve, 2013) – earned a prize of over $11 million USD (Budhwani, 2018), and esports are viable careers if players are skilled enough. How would you react if a client told you they were a professional esports player? GamerGate was a monumental event in the gamer community stemming from a harassment campaign in 2014 with ramifications to this day (Dewey, 2014; Mortensen, 2018). If a client stated that they were targeted by the GamerGate harassment campaign, would you understand the nature of the potentially life-threatening events they faced?

Beyond simply understanding the unique, nuanced experiences of gamers, a greater number of mental health providers must begin to treat gaming and gamers as a subculture worthy of consideration. In early research on TTRPGs, Fine (1983) used the following criteria to define a distinct subculture: population size; economic significance; shared language, unwritten rules, and values; communication networks; identification with the culture from within; and identification of membership by those outside the group. While not every criterion is clearly met, there are enough to warrant some consideration among clinicians. The size of the population of players and economic impact of video games are clearly indicated by the ESA/IDSA revenue and participation figures discussed above (2018, 2002). Gamer communication networks are readily apparent. Aside from vast networks such as Twitter and online gameplay, major video game conventions like Penny Arcade Expo (PAX) and Electronic Entertainment Expo (E3) host tens of thousands of convention goers at each convention.

One potential complication in Fine’s (1983) criteria is defining clear, internal and external indicators of gamer culture identification. This may be due, at least in part, to the ongoing argument within the community. Identification with gamer culture and its values is something that is of frequent debate, vitriol, and even violence (Mortensen, 2018). This was particularly exemplified during the GamerGate controversy that remains a defining and bitterly divisive event in gamer culture with ramifications to this day. Stemming from a harassment campaign, GamerGate perpetrators predominately targeted well-known women in gamer culture (in many cases with rape threats and death threats), as well as any who defended them, and the perpetrators’ heinous acts were often wrapped in professed concerns over threats to gamer identity (Dewey, 2014; Mortensen, 2018).

Conclusion

With hundreds of millions of gamers in the United States alone (ESA, 2018), it behooves mental health practitioners to have at least basic familiarity with games and gamer culture. This may seem like an arduous undertaking; there is great value in understanding it as it grows. Gaming has developed from more than just a leisure activity – it is a cultivator of individual and community identity. Rather than considering individuals and their choice to play as separate things, the authors urge you to consider how gaming is part of your clients’ identities and part of your own, including any negative biases you might have. The stories, roles, and adventures that clients experience in the games they play might have an immense impact on their lives and worldviews. Giving clients a chance to embrace their culture without fear might make immense difference in their clinical growth.

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Raffael Boccamazzo, Psy.D.

Raffael Boccamazzo is a doctor of clinical psychology and the clinical director of Take This, the first mental health nonprofit dedicated to serving the game industry and game community. Outside his work with Take This, he is a frequent speaker on the applied use of tabletop role playing games, a chapter author in the book Video Games and Well-being: Press Start, as well as a co-author of Gardens of Fog – a best-selling, mental health-themed, charity, adventure module for Dungeons & Dragons.