International Journal of Group Psychotherapy

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The Impact of Unstructured Games of Fantasy and

Role Playing on an Inpatient Unit for Adolescents

Lee I. Ascherman

To cite this article: Lee I. Ascherman (1993) The Impact of Unstructured Games of Fantasy and
Role Playing on an Inpatient Unit for Adolescents, International Journal of Group Psychotherapy,
43:3, 335-344, DOI: 10.1080/00207284.1993.11732597

To link to this article: http://dx.doi.org/10.1080/00207284.1993.11732597

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 INTERNATIONAL JOURNAL OF GROVP PSYCHOTHERAPY, 43(3) 1993

The Impact of Unstructured

Games of Fantasy and Role
Playing on an Inpatient Unit
for Adolescents
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LEE I. AS C HER MAN, M.D., M.P.H.

ABSTRACT
Games offantasy and role playing such as Dungeons and Dragons (1983)
have become increasingly popular among adolescents and young adults. This
article reviews the negative impact of such games on an adolescent inpatient
treatment setting. The unrestricted play of such games contributed to the disrup-
tion of a treatment setting, resistances to treatment, reinforcement of character
pathology, disruption of individual treatments, and to the normalization of vio-
lence. When such games begin to be played on a psychiatric inpatient unit or
are prominent in discussions of individual patients, treaters should examine them
in the context of their potential to reinforce and foster resistance and maladaptive
patterns of relating to the environment. Treaters are also encouraged to attempt
to understand the meaning and risks of such games in the context of an individual
patient's psychiatric difficulties and of group dynamics, both within the patient
group and between patients and treaters.

In recent years, games of fantasy and role playing such as Dungeons

and Dragons (Baldwin & Baldwin, 1978; Dungeons and Dragons, 1983)
have become increasingly popular, especially among adolescents and
young adults (Alsop, 1982; Elshof, 1981; "The Gameslayers," 1981;
Gits, 1982; Hewson, 1980; Holmes, 1980,johnson, 1980; Mills, 1980;
Weathers & Foote, 1979). Despite their popularity and potential im-

Lee I. Ascherman is Director of an adolescent hospital unit in the Children's

Division of the Menninger Clinic; an instructor in the Karl Menninger School of Psychia-
try; and a member of the Menninger Group Psychotherapy Service.
The author would like to express appreciation to the staff of the Division of
Scientific Publications at The Menninger Clinic for providing editorial assistance in the
preparation of the final draft of this manuscript.

335
 336 ASCHERMAN

pact on patients in psychiatric treatment, these games have received

little attention in the psychiatric literature. A search of the Psycl.I'T
data base for the years 1974-1990 and the MEDLINE data base for
the years 1985-1991 found few articles on the subject. Zayas and
Lewis (1986) described the use of Dungeons and Dragons in a group
of latency-age boys as a means to foster adaptive social interactions.
DeRenard and Kline (1990) found that players expressed feelings of
cultural estrangement when compared to nonplayers, and that those
who spent more money on the game and played the game more fre-
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quently expressed feelings of alienation. Fewer players expressed feel-

ings of meaninglessness than nonplayers (DeReynard & Kline, 1990).
Simon (1987) found no significant correlation between years of playing
the game and players' emotional stability. The popular literature has
given some attention to games of fantasy and role playing, sometimes
in the context of concerns about acts of violence linked to an individ-
ual's engrossment in a game (Adler & Doherty, 1985; Alsop, 1982;
Baldwin & Baldwin, 1979; Elshof, 1981; "The Gameslayers," 1981;
Gits, 1982; Hewson, 1980; Holmes, 1980; Johnston, 1980; Mills, 1980;
Shuster, 1985; Sutton, 1984; Weathers & Foote, 1979).
Authors describe these games as complex and elaborate, with many
rules (Baldwin & Baldwin, 1979; Gits, 1982; Hewson, 1980) that pro-
pel players "deeply into the realization of a fantasy world consisting
mainly of contest, violence, and aggression" (Baldwin & Baldwin, 1979,
p. 126). Medieval themes are common. Players become a "charac-
ter-an entity created by the roll of dice and the imagination of the
player" (Baldwin & Baldwin, 1979, p. 127). Characters belong to the
classes of fighters, wizards, thieves, and clerics who "adventure in the
dungeon master's world ... [of] cities, forest swamps, castles, and
anything else he wants because he creates the world" (Baldwin &
Baldwin, 1979, p. 127). Trolls, elves, dwarfs, and "a crew of marauding
monsters known as dragonewts, lycanthropes, baboons, and basilisks
to name a few" (Gits, 1982, p. 107) also can exist. The "dungeon
master" has been described as "a combination of God, ringmaster and
referee, who masterminds the game" (Johnston, 1980, p. 32).
Violence is prominent in the games. One author depicted "escala-
tions in weapon and counterweapon, changes in the powers of charac-
ters and a constant development of traps and tricks" (Baldwin & Bal-
dwin, 1979, p. 126). Another stated, "There is hardly a game in which
 GAMES AND ROLE PLAYING 337

players do not indulge in murder, arson, torture, rape or highway

robbery" (Holmes, 1980, p. 88). Still another described "implications
of sadism and the occult. Of the satanic. Of schizophrenic withdrawal
from reality" (johnston, 1980, P: 32). This author refers to an uniden-
tified child psychiatrist's concern about "primitive sadism" expressed
in dice rolls that determine characters' fates such as "genitals torn off
... guts ripped out ... entire head pulped and splattered over a wide
area" (johnston, 1980, p. 39).
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AN INDEPENDENT TREATMENT UNIT

This article is a review of my observations of the impact of such games

on an inpatient treatment unit. These observations were made while
directing an inpatient unit for adolescent males, age 15 to 18. Patients
on the unit suffered from psychiatric disturbances that were inade-
quately responsive to outpatient and brief inpatient interventions.
Most had several past hospitalizations and a history of serious behav-
ioral difficulties, including severe oppositionalism, substance abuse,
suicidal action, and antisocial behavior, including truancy, assault,
theft, and destruction of property. Characterological disturbances in
the borderline/narcissistic/antisocial cluster, concurrent with Axis I dis-
turbances of mood or thought were common among these patients
(American Psychiatric Association, 1987). Treatment efforts empha-
sized the milieu ofthe unit, group meetings, individual therapy, family
therapy, medication as indicated, and close collaboration with on-cam-
pus teachers and instructors oriented toward meeting the educational
needs of these emotionally disturbed adolescents (Rosenbaum, 1990).
Patients began to play fantasy games such as Dungeons and Dragons
when several individuals with a history of strong involvement in the
games were admitted to the unit. Some staff members endorsed the
games as an opportunity to help patients who had difficulty expressing
themselves communicate their needs, wishes, and fears-a play ther-
apy of sorts for adolescents.
Shortly before my appointment as director of the unit, the games
had achieved their greatest prominence, nurtured and perpetuated
primarily by two patients, each with a history of engrossment in this
activity-to the neglect of alternative, more appropriate, develop-
mental tasks. The games began to dominate life on the unit. Cryptic
 338 ASCHERMAN

communication with macabre, violent themes was pervasive. For pa-

tients, the unit had become a dungeon of sorts, filled with references
to cells, dragons, sorcerers, and torture. The treatment staff strained
to understand and contain this new demon: "the games."
The term "games" deemphasized the disturbance manifested in
this play. Primitive group and individual dynamics flourished. Para-
noid ideation, accompanied by violent themes of destruction and sadis-
tic fantasy, became prominent under the guise of play. At times, the
culture of the unit seemed more grounded in the rules of a medieval
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fantasy kingdom than in those of a treatment site. The games became

recognized as a force disruptive to a functional treatment environment
and contrary to the treatment needs of individual patients. The phe-
nomena could perhaps be understood best as a "fight-flight" response
to instability of leadership on the unit at a time of transition in leaders
(Rioch, 1970).

Disruption of the Treatment Setting

The inpatient psychiatric milieu for adolescents facilitates treatment

by providing structure, reliability, containment, supervision, and nur-
turance, all of which enables patients to establish therapeutic relation-
ships with staff members. Patients are encouraged to express doubts,
fears, and worries directly. The treatment relationships become re-
sources for support, reflection, constructive self-examination, and a
shift to less maladaptive patterns of perception and interaction. With-
out a calm, predictable, and reliable setting, the establishment of rela-
tionships that allow for such psychological growth becomes difficult,
if not impossible (Rosenbaum, 1990). The treatment unit becomes
oriented toward containment rather than change.
The games contributed to an atmosphere in the patient peer group
that was contrary to the treatment environment goals. In this case, they
facilitated the empowerment of more narcissistic/antisocial character
types to subvert the operation of the treatment unit. As the games
continued over time and across sites within the hospital, direct commu-
nication between patients and treaters began to compete with cryptic
communication between patients. With only marginal ability to super-
vise these underground communications, staff members felt devalued
 GAMES AND ROLE PLAYING 339

and increasingly peripheral to patient activity (Alsop, 1982). In the

context of the games, patients alluded to staff members as objects of
violent acts (e.g., decapitation), increasing the alienation between unit
staff members and the patient group.
The games' persecutory themes also promoted paranoid feelings
in both the patient and staff groups. Those patients who controlled
the course of the game in roles such as the "Master" exerted major
influence over life on the unit. As the demands of the game began to
pervade unit life, these powerful figures seemed to compete with the
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unit staff for control of the patients and the unit (Rosenbaum, 1990).
Patients increasingly assigned to staff members the persona of dun-
geon keepers or torturers, leading to further deterioration in staff-pa-
tient alliances. Paranoid projections abounded as the unit came to be
experienced as the dungeon or holding cell. Projective identification
became a powerful and prominent force in interactions between staff
members and patients. The anger and paranoid assumptions within
the patient group began to be experienced by the staff group. Staff
members became increasingly distrustful of patients and began to
perceive themselves as taskmasters, even using such terms as
"reamed," "busted," and "nailed" to describe how they placed appro-
priate boundaries on inappropriate behavior. Containing the potential
violence that seemed to pervade many facets of unit life became the
desperate priority of every staff member.

Resistance to Treatment

The games served to coalesce patient resistance to change. The pa-

tients who were most hostile to treaters and treatment efforts (and
most fearful of change) were those who were most invested in the
games. Prolonged refusal to participate in school and therapy and
hostility toward staff members trying to establish relationships were
considerably more evident in patients who were most central to the
prominence and continuity of a game. These patients constantly com-
peted with staff members for control of other patients and the unit
milieu. The games provided a seemingly more legitimate vehicle for
these controlling efforts because they were covert and 'just play." Yet
who would dare challenge the "Master"? For these youths, the pro-
 340 ASCHERMAN

jeered personification of their treaters as evil taskmasters reflected

chronic maladaptive defenses against anxiety about trust and fear of
relationships.

Reinforcement of Character Pathology

The consequent reinforcement of a maladaptive character style was

most apparent in patients with a serious narcissistic and schizotypal
personality. The two patients who were most involved in the
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games-they adamantly defended their value and perpetuated their

play-both suffered from severe narcissistic personality disturbance.
They reveled in their role as "Master," which allowed them to control
the course of the games and, even more important, the actions of
other patients. Both youths initially refused to attend and participate
in school and psychotherapy. They channeled their fear of relation-
ships into reinforcing the perception of staff members as dungeon
masters who could not be trusted. Another schizotypal youth who was
obsessed with the games seemed equally absorbed in the fantasy they
provided, consistent with his history of retreating from relationships
and of becoming preoccupied with odd, idiosyncratic thoughts. For
all these youths, the games seemed to be a desperate effort to escape
from the difficult reality of increasing developmental expectations and
norms, compounded by alienating behavior that reinforced their sense
of isolation.

Disruption of Individual Treatment

The impact of the games also disrupted the treatment needs of pa-
tients less centrally invested in them. One youth with severe borderline
pathology and a history of suicidal ideation, homicidal ideation, and
brief psychotic episodes of paranoid thinking became episodically con-
vinced that other patients intended to kill him. He responded to this
conviction by fearfully telling a staff member of his need to defend
himself against assault (johnston, 1980). At other times, the youth
shared his delight in macabre fantasies associated with the games- tor-
turing victims, tearing scalp hair from their flesh (Adler & Doherty,
1985; Baldwin & Baldwin, 1979; Elshof, 1981; Gits, 1982; Holmes,
1980; Johnston, 1980; Shuster, 1985). Another more regressed and
 GAMES AND ROLE PLAYING 341

undersocialized youth with a significant history of abuse spent much

of this time psychiatrically disabled by psychotic symptoms in a more
isolated back "cove" area of the unit.

Normalization of Violence

Perhaps the most distressing impact of these games on the unit milieu
was the normalization of violence. A daily diet of fantasized assault,
defense, and torture insidiously created an atmosphere in which vio-
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lence and sadism became less alien, less bizarre, and less ego dystonic.
The normalization of violence seemed to have been reached with the
aggressive, premeditated assault of a night staff member by two pa-
tients who had significant borderline and antisocial pathology. These
youths later stated that their intent, if they had succeeded in disabling
the worker, was to murder the most vulnerable patient on the unit
and then to escape. Their assault on the staff member occurred when
the games were at their peak. Although apparently having no direct
connection to the fantasy play, it certainly seemed congruent with the
atmosphere of violence, siege, and defense engendered by the games.
The assault also occurred the week that a change in unit directors was
occurring and seemed to be influenced by patients' feelings of rage,
abandonment, and fear of the future evoked by the transition.

DISCUSSION

Shortly after this assault, the new unit director (this author), advised
all staff members and patients that the games were to be discontinued.
The emphases of the games were explained as being contrary to the
goals of the unit milieu and therefore disruptive to individual treat-
ment needs. The games normalized violence, which would not be
tolerated. Not surprisingly, this announcement was met with loud and
angry protests by patients. The two more narcissistic patients, realizing
the threat to their authority, were most outspoken in their opposition
and had the greatest difficulty accepting the idea that the games could
disrupt the treatment of other patients. Arguments relating to the
right to free speech were made, and the staff members were accused
of overreacting to the assault on one of their own. One of the two
youths most involved in the games angrily defended them as an outlet
 342 ASCHERMAN

for anxiety, asking, "What can we do now with our anxiety?" It was
emphasized that anxieties and violent fantasies should be discussed in
therapy sessions or in talks with staff members, not in cryptic commu-
nications that excluded the staff members who were there to help.
Although most staff members had reported feeling threatened
and undercut by the games and alienated by their violent themes (they
"couldn't stand listening anymore"), they were ambivalent about the
decision to terminate the games. They discussed their concerns about
censorship, patients' right of expression, and the expected difficulty
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in enforcing the ban. One staff member cautioned against 'jumping

to conclusions," stating that the rules of the game were so lengthy and
complex that an objective decision about them could not be made until
they were fully understood. Some staff members proposed compro-
mise, perhaps by adapting the games to nonviolent themes or by
forbidding humans from being objects of violence. The decision to
terminate the games seemingly became a metaphor not only for the
patients but also for the staff as to the- kind of dungeon master the
new unit director would be.
The vociferousness of patient protests and the ambivalence among
staff members about the termination of the games fostered doubts
about whether this decision could truly be enforced. Substantial ambiv-
alence became apparent in the patients when, on the day established
as the final game day, all the patients lined up at the unit office with
stacks of their game theme books and workbooks to be returned to
their parents' homes. Their protests subsided quickly, replaced by an
atmosphere of relief that the demons and dragons had been contained
and that the domination by the Master had ended. Within a few weeks,
all the patients had returned to school and, in contrast to the minority
who had previously accepted psychotherapy, all patients were partici-
pating. Relationships with staff members seemed to improve quickly,
as poignantly evidenced by their joint play of more traditional board
games in the unit living area. Soon after the end of the games, staff
members and patients shared in decorating the unit and in preparing
costumes for the hospital Halloween party. After Halloween, their
attention shifted smoothly to school, treatment, and preparation for
the winter holidays. The demons and goblins seemed to have dis-
appeared.
 GAMES AND ROLE PLAYING 343

The two boys most actively invested in the fantasy games shifted
to a more positive investment in treatment. As they became involved
in more age-appropriate activities and academic tasks, they were able to
considerably improve their relationships with peers and staff members.
Eventually, they were able to plan for discharge, addressing educa-
tional and family needs and defining steps toward more independent
living that had previously been inconceivable.

CONCLUSION
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Fantasy or role-playing games such as Dungeons and Dragons can pose

a serious threat to a stable inpatient treatment environment and to
the individual treatment of psychiatric patients. The nature of these
games opposes the goals of the inpatient setting by promoting cryptic
communication of violent, aggressive impulses that normalize vio-
lence; alienate the patient group from treaters; foster paranoid per-
ceptions at individual and group levels; jeopardize the judgment of
more disturbed, fragile patients who struggle to maintain control of
impulses and distinctions between reality and fantasy; and collude with
maladaptive character patterns, particularly narcissistic and schizo-
typal disorders. The events reviewed in this communication also pro-
vide an example of how the lack of clarity in leadership in a group
setting can lead to the creation of a basic "fight-flight" response based
on more paranoid assumptions. When these games begin to be played
on a psychiatric inpatient unit or are discussed frequently by individual
patients, treaters should examine them in the context of their potential
to reinforce and foster resistance and maladaptive patterns of relating
to the environment. Treaters should also attempt to understand the
meaning and risks of such games in the context of an individual pa-
tient's psychiatric difficulties and of group dynamics, both within the
patient group and between patients and treaters.

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Alsop, S., II. (1982, February), TSR hobbies mixes fact and fantasy. INC.,
pp.68-71.
 344 ASCHERMAN

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Colorado Business, pp. 17 - 18.

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Lee I. Ascherman, M.D., M.P.H.

Menninger Clinic
Children's Division
PO Box 829
Topeka, KS 66601