Using Popular Games Therapeutically
Play and games have different meanings in play therapy literature (Schaefer and Reid, 1986). Play is usually spontaneous, has no particular purpose, and is motivated by a desire to have fun (Csikszentmihalzi, 1976; Erickson, 1950; Garvey, 1977). Play has an unrestricted, unstructured quality, whereas games are formal and have more restrictive rules for how the game is played. Although games can also be fun, they usually involve some sort of a contest between/among the players. Avedon and Sutton-Smith (1971) call this “an exercise in voluntary control systems, in which there is a contest between powers, defined by rules, in order to produce a disequilibrial outcome (someone ends up a winner).” This competition usually results in more involvement of participants and more enjoyment for them (Holmes, 1964; Rapoport, 1966; Steele & Tedeschi, 1967).
I use games in therapy to have fun and establish a good relationship with patients. I find that I can also do therapeutic work with games I select for specific purposes. Playing games is an activity with which most children and adolescents are familiar, and it helps them relax in the therapy session and “open up” with less inhibition. Sometimes the games I use are new to children who play most of their games on computers, smart phones and tablets, or video game terminals. The tactile experience of a non-computerized game affords these children a new experience they generally like. Using games also helps patients master social skills. We talk about what it feels like to win and lose and about doing so gracefully, all of which are important social skills. Other important social skills such as learning to shuffle and deal a deck of cards can help children fit in better with peers. We talk about not cheating by trying to see another player’s cards, taking turns, finishing the game, and putting the games away at the end of play. Children and adolescents who have some difficulty with reading social cues and pragmatic language tend to take communication literally and seldom understand the concept of “trash talk” during a competitive game. However, they almost universally enjoy this feature once it is explained to them. Aside from these benefits, some games lend themselves to teaching and practicing specific skills, such as impulse control, self-expression, communication skills, scanning and processing, using rules and strategies, organizing information and objects, developing better working memory skills, learning not to give up, and planning. My focus here is to share some of the games I use, therapeutically, for dealing with patients who have specific diagnoses and needs.
I seldom use “therapeutic” games like the “Talking, Feeling, and Doing Game” (Gardner, 1973) in therapy. Some children, mostly very young children, enjoy these games; but many of the children I see would rather play a store-bought or “real” game. Since an important reason for using games in therapy is to create a space where the relationship can develop and grow, it is essential that the games selected be interesting and acceptable to patients. I will discuss a few of the games that have universal appeal and address multiple issues.
“Pass the Pigs.” One of the first “difficult” teens I saw during my pre-licensure year was a boy, Tim, who lived in a group home. He was polite enough but did not really participate in the therapeutic process, only giving monosyllabic answers and being guarded about opening up. I stumbled across a game called “Pass the Pigs” (Moffat, 1977) and took it out to play with him. This game consists of rolling two little rubbery pigs onto the table and scoring points for the different positions in which they land. A turn ends when the pigs land in a “pig out” position with each one on opposite sides, and all points scored in that turn are lost. The pig out position occurs frequently. Players have the option of stopping their turn at any point and banking their points toward the winning goal of 100 before they lose their turn and points. This game can be won in one turn, and Tim gambled on this option nearly every time. I won more games than he did, but he still persisted with his gamble.
I spoke to my supervisor about how all Tim seemed to want to do was play this game and was told to be patient. Then one day Tim came in upset and said he did not want to play any game. He cried as he told me that he had disappointed his grandfather by breaking one of the rules. For the first time, we explored his experience and feelings and talked about his plans. I realized that if I had not played all of those games with him, he would not have felt comfortable opening up to me. We had established a safe space/relationship through playing the game together. We continued to play the game each week, and we talked more as we played. One day, I asked him what rule he used to play. He said he had not used any rule and asked what rule I used. I told him that I went for 20 points in a turn and then stopped my turn. He decided to take 5 chances in a turn before stopping and did much better than before. We talked a little about how rules can be helpful, and I believe he began to see rules differently, as a way of winning rather than as a restriction to be defied. Several months later, Tim graduated from the group home and went back to live with his grandfather. He called me a few months after our termination to let me know how well he was doing. Playing “Pass the Pigs” with Tim helped us to create a relationship and to work on his rule-breaking behavior. Instead of thinking of playing a game as being an adjunct to therapy or a method just to establish a relationship, I realized that playing well-selected games with patients can also be therapy.
“Set.” I began to think of how using other games that were fun for kids and teens might serve multiple purposes as well. When I found “Set” (Falco, 1988), I immediately thought that the cards resembled items on the Wisconsin Card Sort test and wondered if this game might also address executive functioning deficits and mental flexibility. This is a card game in which each card has one, two, or three items of the same shape on it. There are three kinds of shapes possible, three possible colors, and three possible types of shading. I present the rules to patients in a way that helps them activate and use working memory. Before I even show the cards to patients, I ask them to say “color, number, shape, shading” in that order several times and to remember it. Then I show them cards with each color, number of items, shapes, and shadings on them. I tell them that a set consists of three cards that either are all the same or all different in color, number, shape, and shading. We then look at examples of sets. The cards are shuffled and 12 are laid on the table face up. The first person to see a set calls out “set,” takes up the cards, and explains why they constitute a set, citing the color, number, shape, and shading on the cards in that order. The players are required to pay attention, scan the layout, apply the rules and relevant set definition, and curb their impulses until they find a set. Calling out “set” and being incorrect means that the player loses three cards. The player with the most cards at the end wins. This game addresses visual attention, scanning, working memory, processing speed, impulsivity, and the social skills involved in winning and losing—and it is fun! I use this game with patients who have Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum traits, and with older patients who fear they are losing some of their cognitive sharpness. I have played this game with children as young as four years old. We talk about strategies for finding sets, and I often give hints to younger children about what a set I see on the table looks like.
Dorothy was a six-year-old first grader when her parents brought her to therapy to deal with her ADHD symptoms, which were beginning to cause her problems in school. The results of testing indicated that she was bright, but had significantly lower scores on tests of working memory and processing speed, a typical pattern for those with ADHD. She received accommodations at school to help her deal with slow processing speed and working memory issues. One of the games we played frequently in our therapy sessions was the “Set Game.” Dorothy especially enjoyed this game; once she got pretty good at it, she no longer wanted me to give her any hints about whether there was a set on the table and what characteristics it had. Her school performance improved steadily, and I had the opportunity to test her again several years later. Her working memory scores improved, and her processing speed scores improved by more than one standard deviation. Clearly, this is only anecdotal evidence and does not constitute a valid research study, but it was encouraging to me. Currently, Dorothy is a good student in middle school and is able to finish her work on time. It seems that practicing the skills she needed to improve helped Dorothy to master them and generalize them outside of therapy.
“Catch Phrase.” “Catch Phrase” (1994) is a universally accepted game among my patients, and I use it with individuals and families. This game resembles “Password,” a television game show in which players give clues for others to guess the word or phrase on the game screen. In addition to helping to establish and enhance the therapeutic relationship, Catch Phrase also helps some children who seem to have trouble expressing themselves, such as some of those whose diagnoses fall on the Autism Spectrum. Once these children get used to talking in order to play the game, they seem to be more comfortable talking in sessions in general. It also serves as a structured and fun way to address taking things literally, since we always talk about what the phrase that is guessed actually means as opposed to its literal meaning. Frequently, players can guess syllables in the word or phrase if they are not familiar with the whole word or parts of the phrase; this encourages flexibility in thinking. Usually, I turn off the timer, because as the timer ticks away faster and faster it seems to make the clue-giver more anxious. I also seldom keep score for this game, unless with a larger group or family; the guessing and giving of clues is inherently fun. This game offers the therapist an excellent opportunity to observe family dynamics and for some troubled families to have fun with each other.
“Uno.” “Uno” (Robbins, 1971) is a popular card game that follows basic card game rules but is simpler that using a regular deck of cards. Instead of four suits, there are four colors; game play consists of discarding one card at a time or drawing cards if the player cannot match the color or number of the top card on the discard pile. The object of the game is to be the first to get rid of all of one’s cards. Very young children can learn to play this game, sometimes by initially playing as a team member with a parent. Patients learn how to shuffle and deal cards, how to organize their hand, how to take their turns in order, and how to deal with the ups and downs of having their turn skipped and having to take on extra cards. Once the cards are dealt, I tell the players to organize the cards in their hands by color and show them how I organized my hand. During play, we engage in trash talk like, “You rascal, I’m going to get you next time!” We also talk about scoring, some basic strategies, not revealing what’s in one’s hand, and not looking at other people’s cards.
Jonah is a smart, four-year-old patient with problems with social skills, emotional dysregulation, and ADHD. He learned to play Uno in our session with his mother as his helper. He can organize his hand and take his turn. He initially had problems with losing, and did not understand trash talk, taking offense until I explained it to him. Now he delights in being called, and calling me, a rascal when we play. He can continue playing the game even when it looks like he will lose and understands that if he quits when he is losing, then others may not want to play with him.
“Ungame.” The Ungame (Zakich, 1973) is a board game and resembles the “Talking, Feeling, & Doing Game” in several ways. However, this game has no winners or losers and does not require players to do silly things. Questions are geared for players of all ages. The game proceeds when players roll the die and land on spaces that either indicate that they have to draw a card from the pile and answer the question, move their pawn to a location based on how they are feeling and talk about that feeling, or make a comment or ask a question. One rule is that players may not make comments about other players’ questions and answers unless they land on the question/comment space. They are given paper and pencil to write short notes to help them curb their urge to interrupt with a comment. I use this game with younger children, teens, and families. It encourages children to control their impulses, especially important for children with ADHD, begin to learn to take notes as a helpful process, open up in a structured way, and improve relationships with family members and with me. The competition aspect is removed with this game, and that can be helpful for children and families that engage in high levels of conflict and/or do not know how to win and lose graciously.
I also use other games in therapy such as “Mancala” for patients with Obsessive Compulsive Disorder and ADHD. This game helps with planning and slowing down. “Chess” and “Connect Four” are good games to encourage visual scanning and planning skills. “Rush Hour” helps patients with map-reading skills, visual scanning, putting the problem into words, and planning. “Pick up Sticks” helps curb impulsivity, encourages planning, and helps with concentration and slowing things down. “Skip-Bo” (Bowman, 1967) encourages patients to appreciate order and strategy. The most important thing is to use each game in a way that encourages the patient to develop and enhance needed skills.
 Identifying information has been changed to protect client confidentiality.
Cite This Article
Hill, M. D. (2016). Using popular games therapeutically. Psychotherapy Bulletin, 51(2), 22-28.
Avedon, E. M., & Sutton-Smith, B. (1971). The study of games. New York: Wiley.
Bowman, H. (1967). Skip-Bo [Card game]. El Segundo, CA: Mattel.
Catch Phrase (1994). [Party game]. Pawtucket, RI: Hasbro.
Csikszentmihalyi, M. (1976). What play says about behavior. Ontario Psychologist, 8(2), 5-11.
Erikson, E. (1950). Childhood and society. New York, NY: W. W. Norton.
Falco, M. J. (1988). Set [Card game]. Fountain Hills, AZ: Set Enterprises.
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Thank you for the very informative and candid arcticle. I’m in the process of setting up my therapy room and having some concrete useful examples of games was very helpful when the field useually plays down their importance and place in current clinical work
Amazing information you have shared in this article. This article helps me a lot and also I found some unknown information in this article. Thank you for the information.
I am looking for an old game called The Normal Game. Any idea if it is still in use or available?
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Board/card games teach important social skills, such as communicating verbally, sharing, waiting and taking turns. It can also foster the ability to focus and lengthen one’s attention span by encouraging the completion of an exciting, enjoyable game. Check this newly found card game https://lagimcardgame.com/ and see how interesting and creative it is.
Donkey Kong and Mario Kart over Chrono Trigger and Super Metroid, really??!! Chrono Trigger revolutionised one of the most prominent and important video game genres (RPG), and is often considered to be the greatest role-playing game ever made. And Super Metroid was definitely the most atmospheric game of its time. It was way ahead of its time, and it’s still enjoyable to play in 2018. I’m not saying Donkey Kong and Mario Kart are bad games; undoubtedly they are great, but they just can’t be compared to these two masterpieces. Chrono and Metroid totally destroy the other two in terms of story, atmosphere, soundtrack and voice acting, gameplay, ambition and overall impact on the industry. Earthbound deserves a place in the top 10. Final Fantasy 6 could be a little bit higher (I’m not even that big a Square Enix fan, and I don’t even like JRPG’s that much). Super Mario World and LoZ rightfully deserve the top two spots.
I enjoyed reading your story as a therapeutic game developer. It helped me a lot. Thank you.
This feeling in my chest is brutal, to consider DKC anything but a top 3 game let alone the best game on the system. Then again, I realize I’m on the outside looking in when it comes to Zelda. I do like Link to the Past, but it never had that feeling of pure joy, awesomeness from literal minute 1. That, and it has one of the best overall soundtracks ever. Visually the game was stunning back then, and it still holds up well today with a very good art style.