And sometimes it’s within a game world’s digital boundaries that patients may feel more safety and freedom to work through intense emotions. Kim Wheeler Poitevien, a licensed clinical social worker in Pennsylvania who counsels children and teenagers, saw more young Black patients gravitate toward games like Fortnite in response to racial violence during the summer of 2020. Kids were “terrified of the police,” so the idea was, “I want to protect myself,” she says. “They’d have these backstories about how they’re good people but the police think they’re bad.”
Gaming can help build emotional regulation skills, too. Poitevien grew up in a family of gamers and played Atari as a toddler. Today she frequently plays video games with her clients during sessions, but she doesn’t just let them win. “We are competitive, we go.” That can be an opportunity for children to practice “frustration tolerance,” she says, if, for example, they’re losing to her in a game of Mario Kart. And dealing with inevitable glitches, like when a game lags or kicks the player out, helps kids develop patience.
Online gaming has been a critical supplemental resource during the pandemic. “Every therapist I know is wildly overbooked right now,” Daramus tells me. When clients can’t get in to see her right away or want to practice coping techniques between sessions, she often prescribes mental health-focused games like Sea of Solitude, Night in the Woods, and Gris.
Concerns About Addiction
Some experts have voiced concerns about screen time and online gaming addiction, especially in children. Recently, China tightened its already stringent regulations limiting online gaming time for kids under 18. Though the World Health Organization recognizes gaming disorder as a condition, estimates of its prevalence vary. A 2020 review of 53 studies determined the worldwide prevalence of the disorder to be approximately 3 percent of gamers.
Larry Rosen, professor emeritus and former chair of the Psychology Department at California State University, Dominguez Hills and coauthor of The Distracted Mind: Ancient Brains in a High-Tech World, says gaming can promote behavior modification that can develop into an addiction. The more we play, the more feel-good chemicals we experience—primarily dopamine, serotonin, and other chemicals, says Rosen.
On the flip side, gaming can help us get rid of undesirable feelings, namely anxiety. The daily login streak—a concept popularized by (but by no means originated by) Snapchat—is a perfect example. “You keep the streak up because you’re anxious,” Rosen says. “You want to be responsible and fulfill your social obligations.” When we log in to keep the streak alive, that unpleasant feeling begins to dissipate.
Ultimately, online games are fantastically engaging because their success depends on gaining our attention. The longer we play, the more likely we are to buy something, and the more money gaming companies earn. “The bottom line is their goal is to keep you there,” says Rosen.
While remaining mindful of gaming’s possible pitfalls, therapists are careful to avoid stigmatizing the activity. Rather than telling a client to stop gaming, Poitevien finds a more effective approach is to talk about balance. She might ask, “How do you feel when you play video games until 4 o’clock in the morning? What are the natural consequences to that?”
Goldman agrees. He dislikes the word “addictive” to describe gaming but acknowledges the potential to veer into harmful habits. If we overuse gaming as a coping strategy, once we log off “we’re still left with the same problems we were avoiding,” he says. And those challenges likely “have become even bigger because we’ve spent more time gaming and less time maybe applying for that job, going to school.”
Beyond the Pandemic
As online gaming continues to grow, clinicians need tighter ethical guidelines around using it, Daramus tells me. The challenge is ensuring that “we don’t do therapy in the way that’s fun for us; we do therapy in the way that’s right for the client,” she says. If a patient wants to spend the entire session playing Animal Crossing, how does the clinician link that activity back to a specific treatment goal—for example, honing social skills or building distress tolerance?
Even when the pandemic eventually ends and in-person counseling can resume, clinicians see reasons to keep online gaming in their toolkits. If traditional talk therapy has failed, gaming can be a crucial last-ditch opportunity to help patients. Goldman regularly gets calls from parents of high school and college kids who hated therapy but still need to speak with someone. Families find him because of his non-judgmental approach and enthusiasm for gaming.
“Therapy can be intimidating and difficult,” says Goldman. Connecting with patients in the realm of gaming where they feel safe can make a big difference, even if it means offering to meet up on a World of Warcraft server. “Whatever it takes to get you in the door.”
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