(I’m advised that, as this article discusses mental health and possible ways to treat it, or at least alleviate some of the issues and symptoms, that I need a standard disclaimer here ... so ... The information presented below is offered for educational and informational purposes only, and should not be construed as personal medical advice. I am not a doctor; you should consult with your own medical or mental health practitioner about any treatment or advice they have.)

In the late 1980s I wrote a paperⁱ as part of a university honor’s project on using fantasy role-playing games (D&D in particular) as therapy, similar to the ways role-playing and thematic apperception tests were being used. At the time, D&D was still seen as being either a) the devil’s own handservant, luring children into the clutches of Satan (or rock music, or something equally hellish) or b) creating mental problems in susceptible college students and causing them to break with reality, suddenly deciding that they were really wizards or elves and wandering off into the woods or killing their fellow students in the delusion that they were enemy dragons or somesuch (the hysteria stemming from, I think, one or a few actual cases where something like this happened and a swarm of fiction that followed). My paper was probably not the first of its kind or anything that groundbreaking, but it certainly seemed like it when I wrote it.

Also around that time, writing as therapy (either official-like, with a guiding therapist, or as self-help) was becoming a thing, but was still viewed with skepticism as to whether it was more than generally helpful (James Pennebaker had only just written about his studies of expressive writing as therapy starting in 1986,ⁱⁱ and in the early 90s some mainly thought of it as beneficial as “emotional catharsis [getting it off one’s chest].”ⁱⁱⁱ Although authors had probably used fiction writing itself as a sort of therapy for hundreds of years (Dickens’ David Copperfield, for instance^iv), fiction itself has only recently been more “officially” discussed as therapy.

The point here being that anything actually intended as therapy wasn’t fictive, and wasn’t to be found in either character development or role-playing.

Times have changed in the 30 years since I wrote that paper (and changed, and changed again), and I wondered ... has anyone tried to use these things in different ways, as therapy for any number of mental health problems? And do authors see their work as therapeutic, for either themselves or others, when they write it?

As many of you know, I suffer from anxiety and OCD myself. This is not new; my first memories of both conditions are from my childhood, and were entwined in ways that tied religion and the fear it can engender (if you do anything wrong—step on that crack, don’t step on that other crack, go the wrong way round that table, don’t say you’re sorry to God every time you do some tiny thing that may offend Him—you’re sentenced to Hell and damnation). This grew worse over time, sometimes spiraling quite out of control. I ended up in a ball on the floor of my room, in the center of the concentric circles of my braided rug, mentally asking for forgiveness and a new beginning, negotiating a way I could be released from these “habits” that I might be able to function, to leave my room, to go out in the world and not be compelled to do these things that would make me the subject of ridicule (although I got really good at hiding what I was doing so that, at least out in the world, people couldn’t tell that I was counting five of this and five of that, stepping in certain ways over/on cracks in the walk, and so forth).

Reading, then writing, and then fantasy RPGs were a few of my escapes from this world. And to a certain extent I guess I did escape—at least, I gained control over the worst of it, the truly suicidal parts of it, with a few exceptions during which I did get counseling, most recently (ironically) just before the pandemic—which has done its own job of exacerbating my anxiety.

However, if there is good that has come of it, the pandemic has also introduced a lot of mental health issues (and awareness) into the public domain, anxiety chief among them. Surveys have shown that 28%+ of adults in the US have reported dealing with anxiety in the past year,^v and there has been a surge in demand for therapy,^vi also indicating increased awareness that it is a real problem, not just “in someone’s head.” With this awareness, there’s an increased possibility of real help, and of further explorations of ways to treat, or at least lessen, anxiety and other issues. And interestingly, these explorations include the many ways we create ... well, stuff.

Creativity as Therapy?

Art as therapy has been an accepted part of professional treatment since the 1940s, and although its effectiveness has sometimes been questioned, many studies have shown it to be effective in treating trauma and depression. It is also used for anxiety and many other disorders, as well as a way to cope with physical issues.^vii With the guidance of a therapist, one is able (in a best-case scenario) to “’decode’ the nonverbal messages, symbols, and metaphors often found in these art forms, which should lead to a better understanding of their feelings and behavior so they can move on to resolve deeper issues.”^viii For myself, while I realize one doesn’t need to be an artist to use art as therapy, my ability to draw or paint (er, inability to draw or paint as well as I would have liked) didn’t really help me; I looked around at others’ works, far better than mine, and I actually felt worse about myself. I know (and knew) it wasn’t a competition, but I was still beset by worry: Why couldn’t I get the visions in my head onto paper? I couldn’t even paint models or figures very well; picture the paint mostly on my hands, rarely on the figures, flaking away the moment it dried. I needed another avenue.

So what about writing? Does it help?

Well, it does seem that expressive writing has also become much more a tool in counselors’ toolboxes; journal prompts created by a therapist or books of prompts are being used to help with trauma, stress, and now even physical issues, much as art therapy is used, although with even more caveats (for example, just using it to vent emotions has not been shown to be as helpful as trying to understand those emotions, and can in fact trigger distress).^ix Writing actual fiction, however, has not become so much a part of the therapist’s arsenal. Which, I suppose, is to be expected; most people seeking counseling are probably not looking to start writing short stories or novels just to get through their anxiety and therapy. But can writing fiction actually work in this way? Do authors set out on a journey of self-therapy in addition to the work involved in trying to write an interesting story?

Jay Bechtol, an author and social care worker whose work “The Fall” appeared in these pages and in our “Best of” anthology last year, says he doesn’t write as a form of self-therapy, but that “like any artistic expression, drawing, singing, knitting, etc. these are great ways to explore and express feelings that might be harder to express in a simple conversation with someone. Any kind of writing, whether for publication or for a private journal, can be very therapeutic.” He believes that “[f]or general health and wellness purposes, self-directed writing can be [a] wonderful means of taking care of yourself. However, if you are having more significant issues, a good therapist will encourage you to be open and clear about the direction therapy should take. Patient directed therapy is very effective. And, a good therapist will call you on your shit (hopefully in a thoughtful and supportive way), [and] some of those things that an individual might ignore (intentionally or unintentionally) a therapist will help explore. Those explorations are often the keys to recovery. ”

Author and filmmaker Lenore Sagaskie is even more enthusiastic about the idea. “Writing is my go-to self-therapy for my anxiety. Ever since I can remember, I’ve put my thoughts and feelings down when I’m thinking about something a little too hard, not only to purge them from my head but giving me an outlet to process them. I know some people swear by keeping a journal and writing entries daily. I’ve never done that because it’s only the stray thoughts that trickle in from time to time that I need to keep in check. I utilize the notes app on my phone or one of the plethora of notebooks I have strewn around my house and car.”

She continues, “I think writers have incredibly rich imaginations because we spend a lot of time in our own heads, sifting through our thoughts, trying to make enough sense of our stories to put them into words. Sometimes that’s an easy process and it flows effortlessly. That is the part of the process we live for: when it flows well, we vibe with it, get it out of our head, then free up space for new ideas and stories. It makes sense that we process and reflect while we write, and through our stories we create characters dealing with the same emotions and feelings and thoughts that readers have experienced themselves or can relate to. When I wrote my short story, “The Remaining One” (Penumbric vol v, issue 4, and forthcoming in our “Best of, vol v”), it was to process the loss of my sister to cancer a few years ago. While my story was about two sisters with supernatural abilities, I wrote it as a form of self-therapy, processing the pain of her loss and dealing with an unknown future. It helped me to understand her loss and acknowledge that I didn’t always have to be strong when I was dealing with the heartache of losing someone important to me.”

About therapy, Sagaskie agrees with Bechtol that finding the right therapist is important. “I have social anxiety and trust issues. Initially, therapy was a difficult process. I was lucky to find a therapist that understood that I’m a good communicator when it comes to completing tasks and getting jobs done but that I lose that ability when it’s time to communicate my feelings and deal with my anxiety. She understood that writing was an outlet and part of my process, and actively encouraged me to continue.”

And the writing doesn’t even need to be published, or publishable, to be helpful. Author and artist Marge Simon, a frequent contributor to Penumbric, gave one example: “In the late 70’s, I was a single parent. It was a very bad time for me, at work. My principal was horrible. I took to my typewriter and wrote sad prose things, ugly poems late into the night. Kind of “pouring out my soul and heartache, etc.” I wrote nothing worth saving, but it was just for myself. I didn’t feel like talking to anyone, there were no goals involved. I think it helped get me though, just like painting (which I went back to after I’d saved enough for a house down payment, moved to a new school and a great principal!). Yes, you can use yourself as a resource!”

Incidentally, Simon goes more for self-directed therapy. “Everyone I know of with anxiety issues etc., pays for a counselor/shrink, etc. By the same token, some of them come to me for advice and share their problems. Anyway, after unloading on me, they go right on seeing their shrink or psychologist, etc. Perhaps they feel if money for time listening is involved, it raises the quality of the experience, although no actual advice, no solutions or cures are directly given. I’m for self-directed therapy, personally.”

I too have often been able to stave off the worst of my anxiety, and even OCD, by delving deep into writing. This can devolve into unpublishable nastiness that I’ve discovered is me yelling at myself, but sometimes it really helps me to work things out by, in effect, separating myself out into different characters and playing the different roles, the different points of view. This can end up being very archetypal, however—Anxiety itself as a character, or Mr. Justice—which only works well in very specific situations, story-wise. This is where, for me, a good counselor has been able to take a look (or listen) and give me a little direction, even just a little nudge toward something a little more epiphanic.

But I’m Not Writing, I’m Reading

What about from the other side? Can one be involved in a non-interactive situation (like reading a book, or playing a set story in a videogame)^x where one has a therapeutic experience? My own experience has been a bit spotty in this regard—reading or playing has helped get me thinking, but almost inevitably goes in a direction at some point that doesn’t quite fit (even though I might love the story the author or RPG has told). And I don’t go out there looking for something to be therapeutic; sometimes the experience just ... happens.

Bechtol has had a more personal experience. “I wrote a story called ‘Off the Furrow’ that was published in Rock and a Hard Place, it follows a woman on the road searching for drink of alcohol. I had a couple people mention that it hit close to home for them, but was it therapeutic? Not sure. Having said that, I think any story can be therapeutic if it connects with the reader. And yes. I've read plenty of stories that I would say were therapeutic for me, right time, right character, right theme, right tone, right issue/plot. There's a poet up in Canada named Richard LeDue and his poems almost always hit me right, make me feel less alone in my insecurities. Ephiny Gale, down under, writes some strange Sci Fi stuff that also hits me right as well; also, another Canadian, Patrick Malka, writes some horror that does wonders for me.”

What about “interactive storytelling”?

While I have found writing on my own to be the most helpful, in some instances the interactive storytelling of fantasy rpgs (not the videogame kind, but with a human DM/gamemaster) has been the best way to get at issues (although I can’t think of a reason that it can’t be other types of rpgs). I think in an interactive game story it is important for the story (and characters within) to be directed in some way by someone trained to do these sorts of things as therapy—and the character created for the game can be the kind of person one wishes one was, or can be a stand-in for oneself in some ways, and the interactions that character has with others and with the general storyline can lead to greater understanding of oneself and possibly some partial resolution of issues. At least, that’s what I claimed in my paper in the wayback times.

Creating such RPG experiences would be, I think, more work for the therapist/counselor than just doing expressive writing sessions, or asking the patient to journal and then discussing what comes of that. Tailoring an interactive story takes time, and while some elements could possibly start out as generic (the landscape, some of the background characters), the actual adventure and close companions of the player/patient would probably have to be individualized. (This is part of why I created my AI engine, actually ... I thought it might be able to create and develop NPCs in ways that could help the therapist by taking some of the development load off of them.)

There are a lot more articles about using RPGs as therapy today, and they’re generally positive. They tout the development of problem-solving skills and working with groups (e.g., Matt Nolan of North Texas Counseling Associates, who actually have a Dungeons & Dragons Therapy group). They allow clients to explore different solutions in experiences without real-world consequences, practice projection and empathy, and look at things from an outside-themselves point-of-view.^xi From personal experience (not in a counseling situation), I would caution that some people take the “no real consequences” thing a bit too far, in ways similar to those that happen on the Internet—which is why I’d hope that an actual therapist would be able to direct such situations in some way (such as Nolan describes), or actually provide in-game consequences that mirror those in reality and discuss what happened after in a sort of “post-game talk.” But as a whole, it seems RPGs—in an interactive, in-person, counselor-directed sort of way—have indeed become a therapeutic tool.

Whatever You Do ...

I wanted to end this article with ... well, what seem to be the usual exhortations to find help, or something helpful, even if it is not ultimately writing, reading, or interactive storytelling. And to say that I know from my own experience that this is not easy. But they’re words that have been said so often, especially in the US, where we are bombarded with anxiety-inducing news at every turn--if we’re not being offered “thoughts and prayers,” we’re being told to find help for our mental distress through various hotlines, etc.

In my own worst moments, I have thought that nothing would help, or even that there was no reason to help me specifically; why would anyone even care? I say this not to gain sympathy (or horror, or disgust). I say it in case you’re out there, ever feeling this way. But ... there’s always someone who will care, people who know you now, people who knew you in the past, people you have not yet met. And there are many different kinds of therapy, some self-directed, some not, that can help us find our way through the dark forests of our minds to the special stories each of us holds within, that can help us to tell our stories, if only to ourselves.

(Again, I am not a doctor or therapist, and the opinions above are meant as informational only, and should not be construed as personal medical advice. You should consult with your own medical or mental health practitioner about any treatment or advice they have. And there are hotlines to help in emergency situations: the National Suicide Prevention Lifeline at 1-800-273-8255, for example, which is both for crisis and emotional distress.)

Interviewee bios

Jay Bechtol has worked in mental health for over thirty years and has a Masters in Social Work from Cal State Los Angeles. He takes care of his own mental health by playing hockey poorly.

Lenore Sagaskie is a Canadian/American writer, director, filmmaker, living in self-imposed exile in Michigan. Lurks on Twitter and Instagram @lenorewrites

Marge Simon is an award-winning poet/writer, living in Ocala, Florida. Her works have appeared in Daily Science Fiction, Dark Moon Digest, New Myths, Silver Blade, Polu Texni, Crannog, JoCCA and numerous pro anthologies. She is a multiple Stoker winner and Grand Master Poet of the SF & F Poetry Association. She recently received the HWA Lifetime Service Award, HWA. Amazon Author page: https://www.amazon.com/-/eB006G29PL6/marge simon

Notes

i. Unfortunately (or fortunately?) I can’t give you a reference for this; it’s somewhere on a floppy disk, and of course was never published anywhere. You’ll just have to take my word I wrote such a thing.

ii. Pennebaker, J.W. & Beall, S.K. (1986). “Confronting a traumatic event: Toward an understanding of inhibition and disease.” Journal of Abnormal Psychology, 95, 274–281.

iii. “Writing therapy: a new tool for general practice?,” www.ncbi.nlm.nih.gov/pmc/articles/PMC3505408/, referencing another article: Pennebaker, J.W. Writing about emotional experiences as a therapeutic process. Psychol Sci. 1997; 18(3):62–166.

iv. “The Therapeutic Benefits of Writing a Novel,” Jessica Lourey, www.psychologytoday.com/us/blog/discover-your-truth/201706/the-therapeutic-benefits-writing-novel.

v. “The Pandemic Raised Mental Health Awareness. Will It Last?,” Sofia Quaglia, www.verywellhealth.com/pandemic-mental-health-awareness-52136 55.

vi. “Online therapy is in high demand as coronavirus anxiety drives people to get help without leaving their homes,” Anna Medaris, www.businessinsider.com/coronavirus-anxiety-leading-people-to-online-therapy-2020-3, ref’d by “The Importance of Mental Health During a Pandemic,” www.nu.edu/resources/the-importance-of-mental-health-during-a-pandemic.

vii. “What Is Art Therapy?,” Kendra Cherry, www.verywellmind.com/what-is-art-therapy-2795755; “Art Therapy,” Psychology Today, www.psychologytoday.com/us/therapy-types/art-therapy.

viii. “Art Therapy,” Psychology Today, www.psychologytoday.com/us/ther apy-types/art-therapy.

ix. “Writing to heal,” Bridget Murray, www.apa.org/monitor/jun02/writing; “Expressive Writing,” John F Evans, www.psychologytoday.com/us/blog/write-yourself-well/201208/expressive-writing.

x. Yes, videogames are interactive ... but generally there is a set storyline from which you cannot deviate very much, if at all. It’s not interactive in the sense that you can change the entire direction of the game.

xi. Matt Nolan, “Therapeutic Benefits of Role-Playing Games,” ntxcounseling.com/2021/01/11/therapeutic-benefits-of-role-playing-games; Rory Lees-Oakes and Ken Kelly, “213 - Using Role-Playing Games in Therapy,” counsellingtutor.com/role-playing-games-in-therapy.