Rolling for Change: What Is the Evidence for Tabletop Role-Playing Games in Psychotherapy?

Tabletop role-playing games have moved a considerable distance from the cultural stereotypes that once surrounded them. Games such as Dungeons & Dragons are increasingly being used in schools, community programmes, occupational therapy, counselling and psychotherapy. Specialist organisations now train clinicians to facilitate therapeutic role-playing groups, while a small but growing academic literature is examining whether these practices produce measurable psychological benefits.

The idea is intuitively appealing. Tabletop role-playing games combine collaborative storytelling, structured rules, imagination, problem-solving and social interaction. Participants create fictional characters and work together to navigate challenges within a shared world. Unlike many competitive games, success generally depends on communication, cooperation and the capacity to respond flexibly to unexpected events. However, an intervention can be plausible, engaging and personally meaningful without yet being established as an evidence-based treatment. What, then, does the research actually show?

What is a tabletop role-playing game?

In a tabletop role-playing game, participants usually assume the roles of fictional characters within a story facilitated by a Game Master. The Game Master describes the world, portrays supporting characters and introduces situations requiring decisions. Dice and rules introduce uncertainty, but players retain considerable freedom over what their characters attempt. This produces an unusual combination of structure and openness. The rules provide boundaries, predictability and shared expectations, while the story allows experimentation, creativity and multiple possible solutions.

A therapeutic tabletop role-playing game uses this activity deliberately within a psychological, developmental or educational framework. The facilitator may design situations that provide opportunities to practise cooperation, assertiveness, emotional awareness, perspective-taking, problem-solving, frustration tolerance or values-based action.

It is important to distinguish between three overlapping ideas:

A recreational game may be psychologically beneficial without being therapy. A therapeutically applied game may be facilitated to support developmental or psychosocial goals. Psychotherapy using a role-playing game involves a suitably qualified clinician who integrates the game with assessment, formulation, treatment planning, ethical practice and an established therapeutic approach. The game is therefore not automatically the therapy. It is a possible vehicle through which therapeutic processes can be facilitated.

Is there a systematic review or meta-analysis?

The research field remains young. As of July 2026, no published meta-analysis specifically examining tabletop role-playing games as psychotherapeutic interventions could be identified. This is probably because the available studies are too few and too heterogeneous to combine meaningfully. There are, however, several systematic and scoping reviews.

A 2022 scoping review by Arenas, Viduani and Araujo examined role-playing games across psychotherapy and mental health. The authors screened 4,069 records and included 50 sources. Half involved computer role-playing games and approximately 44% involved tabletop games, and around 70% of studies focused on adolescents. Only 16% of the included studies were experimental, and substantial differences in definitions, methods and outcomes prevented a conventional systematic review or meta-analysis. The authors concluded that role-playing games showed potential as complementary therapeutic tools, but that stronger empirical studies were required. (SAGE/Simulation & Gaming)

A more TTRPG-specific scoping review by Yuliawati, Wardhani and Ng, published in 2024, examined research produced between 2013 and 2023. It reviewed 51 papers, but much of this literature was qualitative, theoretical or review-based. Only 12 studies used quantitative designs and four used mixed methods. The review identified possible benefits involving psychosocial skills, cognitive development, stress reduction, social anxiety, depressive symptoms and autistic participants, while also emphasising major limitations in research design, a strong Western/US skew in the literature, and the need for more experimental studies. (Dove Press)

A 2025 review focused specifically on neurodivergent participants, by Thompson and Majumder. It found only five relevant studies: three journal articles and two dissertations or theses. The included literature predominantly concerned autistic participants rather than the wider range of people who may identify as neurodivergent. The review reported promising findings concerning communication, social connection and cooperative decision-making, but highlighted very small samples and narrow participant groups, and specifically flagged ADHD as an area needing future research. Importantly, this publication appeared as a conference abstract, and the journal notes that it did not undergo the journal's standard peer-review process. It should therefore be treated as a useful mapping exercise rather than definitive evidence. (Cambridge University Press & Assessment)

The overall conclusion is reasonably clear: there is an emerging evidence base, but not yet a mature one. Current research supports further investigation and cautious clinical application. It does not yet justify describing TTRPG therapy as a well-established standalone treatment for any particular diagnosis.

What have individual studies found?

One of the more frequently cited quantitative studies, by Merrick, Li and Miller, involved 25 community participants who played one hour of Dungeons & Dragons each week for eight weeks. Participants showed statistically significant reductions in self-reported depression, anxiety and stress, alongside increases in self-esteem and self-efficacy. Eighteen of the 25 participants also completed a one-month follow-up assessment. (PubMed)

These results are encouraging, but the study used a repeated-measures pre/post/follow-up design without a randomised control group. We therefore cannot be certain that the improvements were caused specifically by the role-playing game. Benefits could also have arisen from regular social contact, positive expectations, novelty, group belonging or changes occurring naturally over time.

A 2025 clinical paper by Rosenblad and colleagues described case examples involving young people (ranging from age 7 to 19) using RPG-informed therapy for concerns including anxiety, depressed mood, dissociative identity, identity exploration, and trauma-related difficulties, alongside group examples involving autistic adolescents, LGBTQ+ adolescents and women in residential substance-use treatment. The cases illustrate possible methods of practice but do not provide the type of controlled evidence needed to demonstrate treatment efficacy. (MDPI)

The evidence is therefore best understood as a combination of preliminary trials, qualitative investigations, case reports and clinical theory. These sources can help us understand how TTRPGs might work and how participants experience them, but they cannot yet provide precise estimates of effectiveness.

How are tabletop role-playing games used therapeutically?

Tabletop role-playing games are not tied to one therapeutic model. Clinicians have integrated them with cognitive-behavioural therapy, acceptance and commitment therapy, drama therapy, interpersonal group therapy, family systems approaches, narrative therapy and psychodynamic thinking. The Game to Grow model, for example, describes therapeutically applied RPGs as a flexible gaming structure layered over established therapeutic processes rather than as an independent school of psychotherapy. Several forms of therapeutic work are possible.

Practising behaviour within a safer fictional context

Players can rehearse asking for help, setting boundaries, negotiating disagreement, tolerating uncertainty or responding to mistakes. Because the action belongs partly to the character, experimentation may feel less personally exposing than direct behavioural rehearsal.

A character might need to speak to an intimidating authority figure, admit an error to the group or cooperate with a rival. After the scene, the therapist can explore what the player noticed, what made the action difficult and whether any part of the experience connects with life outside the game.

Developing psychological flexibility

Role-playing games repeatedly require players to respond to events that do not unfold as planned. Dice fail, plans collapse and other players make unexpected choices. Within an appropriately supportive group, these moments can provide practice in adapting, remaining engaged and choosing another course of action.

From an acceptance and commitment therapy perspective, the game may create opportunities to notice difficult thoughts and emotions while continuing to act in the service of chosen qualities such as courage, loyalty, curiosity or compassion.

Exploring identity

Characters can act as experimental versions of the self. A player may explore being more assertive, socially confident, compassionate, unconventional or vulnerable. They may also explore aspects of culture, gender, disability, morality or belonging.

This process can offer what is sometimes called aesthetic distance: enough separation from everyday identity to make exploration tolerable, but enough emotional involvement for it to remain meaningful. However, therapists should not assume that a character directly represents the player. Sometimes a warrior is simply a warrior. Interpretations should be collaborative rather than imposed.

Supporting interpersonal learning

TTRPGs create a natural miniature social system. Players share attention, communicate intentions, make collective decisions, respond to frustration and repair misunderstandings. These processes can be observed as they happen rather than discussed only in retrospect.

The therapist can help participants notice patterns, but the goal should not be to police every interaction or enforce a narrow model of "correct" social behaviour. The group can instead develop reciprocal communication, explicit expectations, conflict-repair skills and respect for different interaction styles.

Externalising problems through metaphor

A fictional monster, curse, maze or oppressive kingdom can sometimes provide a useful metaphor for fear, avoidance, shame, perfectionism or inflexible rules. Metaphor may allow people to approach difficult material indirectly. The risk is that the therapist may design an allegory that is too obvious or too controlling. Therapeutic meaning often emerges more effectively through collaborative reflection than through forcing the story to deliver a predetermined lesson.

Building mastery and participation

Characters gradually acquire knowledge, relationships and abilities. Players also develop real competencies: learning rules, contributing ideas, speaking within a group, remembering shared events and solving increasingly complex problems. This may support self-efficacy, particularly for people whose everyday environments repeatedly frame them in terms of deficits.

Why might TTRPGs be particularly useful for neurodivergent people?

There are several reasons tabletop role-playing games may be accessible and appealing to some neurodivergent individuals. These should be viewed as possibilities rather than universal characteristics.

Structured social interaction

Everyday conversation often contains unclear expectations, rapid changes and ambiguous turn-taking. A role-playing game provides an explicit shared topic, defined participant roles and rules governing many aspects of interaction. Social engagement takes place around a common activity rather than requiring conversation for its own sake. This can reduce the pressure to generate unstructured social interaction while still allowing relationships to develop.

Interest-based participation

Many neurodiversity-affirming approaches emphasise building participation around interests rather than treating strong interests as obstacles. Fantasy, science fiction, history, storytelling, tactical systems, character design or world-building may provide highly motivating routes into social connection.

Interest alone is not a therapeutic mechanism, but it can increase willingness to attend, persist and participate. An enjoyable intervention may be more accessible than one organised entirely around correcting perceived deficits.

Multiple communication channels

TTRPG participation does not have to depend on rapid spoken improvisation. Players may use character sheets, maps, text chat, visual prompts, written notes, digital dice or pre-prepared statements. Online groups may allow participants to combine voice, text, images and other forms of communication.

In a 2026 pilot study by Pappagianopoulos and colleagues, nine autistic adolescents participated in an eight-session online intervention called Guild Chronicles, run over Discord and Roll20. The format allowed communication through speech, text, video and images.

Preliminary results suggested improvements in caregiver-rated cooperation, assertion and engagement, with gains maintained at three-month follow-up; overall social skills improved significantly by follow-up though not immediately post-intervention, and self-esteem gains were not statistically significant. Participants also reported reduced loneliness, sustained at follow-up, and valued opportunities for authentic interaction. Because this was a small, uncontrolled pilot with 100% retention among a self-selected, fantasy-interested group, its results should be treated as preliminary. (Springer)

Predictability combined with flexibility

Rules, character abilities and turn-taking can make interaction more predictable. At the same time, the story remains open enough to allow creative choices. This combination may be particularly helpful for participants who benefit from explicit structure but dislike highly scripted social-skills exercises.

Reduced real-world social consequences

Trying a new behaviour through a character may feel less risky than trying it directly. A character can make a social mistake, change course or attempt something unusual without the same consequences that might occur at school, work or in a peer group. This does not mean that the emotional experience is unreal. Rather, the fictional frame may provide a more manageable level of distance.

Belonging without requiring sameness

TTRPG groups can create community around a shared practice. A qualitative study of an online D&D campaign involving autistic adults, by Atherton and colleagues, found that participants experienced fewer social difficulties during play than they commonly encountered in everyday interactions. Participants described the structured game environment as supporting social connection, friendship, empowerment and opportunities to experience themselves differently through their characters. (PubMed)

This finding is important because the value of the game may not lie primarily in teaching autistic people to imitate neurotypical behaviour. It may lie in creating a context in which autistic communication, shared interests, explicit rules and collaborative imagination work well.

What does the autism-specific evidence show?

The autism-specific literature is promising but remains limited. A Brazilian study by Henning and colleagues followed six autistic participants through 12 two-hour TTRPG sessions delivered over a year. Improvements were observed during the initial face-to-face phase, although changes were less evident after the intervention moved online during the COVID-19 pandemic. The tiny sample, interrupted delivery and absence of a control group limit the conclusions that can be drawn. (PubMed)

The qualitative D&D study by Atherton and colleagues provides richer information about lived experience, including feelings of safety, social belonging and empowerment. However, qualitative research tells us primarily how participants understood their experiences; it does not establish that the intervention reliably changes clinical outcomes. (PubMed)

The Guild Chronicles pilot adds preliminary evidence of feasibility and acceptability among autistic adolescents. Nevertheless, it included only nine participants and required an existing interest in fantasy role-playing games. The results may not generalise to autistic young people who dislike fantasy, find group storytelling overwhelming, have substantial language or cognitive support needs, or prefer other forms of play. (Springer)

The current evidence therefore supports a cautious conclusion: TTRPGs appear capable of creating socially meaningful and psychologically supportive environments for some autistic people. Evidence that they constitute an effective treatment for autism-related difficulties remains preliminary.

There is even less direct intervention research involving ADHD, dyslexia, developmental coordination differences, Tourette syndrome or other forms of neurodivergence. Although clinicians frequently discuss the possible relevance of TTRPGs for attention, impulse regulation, planning and frustration tolerance, these claims currently rest more on clinical reasoning and participant experience than on condition-specific trials. The 2025 neurodiversity review specifically identified ADHD as an important area for future research. (Cambridge University Press & Assessment)

Moving beyond deficit-based social-skills training

Any discussion of TTRPGs and neurodivergence needs to consider what the intervention is trying to achieve.

Traditional social-skills programmes have sometimes treated neurotypical behaviour as the desired endpoint. This can encourage masking: suppressing natural communication, movement or emotional regulation strategies in order to appear more socially typical.

A neurodiversity-affirming TTRPG group should not become an imaginative method for teaching compliance or camouflage. Its aims might instead include:

• developing mutually understandable communication;

• expressing needs and boundaries;

• finding compatible communities;

• recognising different perspectives without assuming one is inherently correct;

• negotiating disagreements and repairing ruptures;

• increasing agency and confidence;

• experimenting with valued ways of participating;

• creating genuine relationships around shared interests.

The emphasis shifts from making the neurodivergent person appear more typical to creating conditions in which communication and participation become more workable for everyone.

What are the risks and limitations?

Role-playing games are not automatically safe or inclusive.

Group conflict can occur. Some participants may dominate attention, while others may feel pressured to perform, improvise or remain in character. Complex rules may create excessive cognitive load. Loud environments, miniatures, screens or overlapping conversation may produce sensory overload.

Fictional content can also evoke difficult experiences. Themes involving abandonment, coercion, discrimination, confinement or loss may be distressing even when presented metaphorically. Emotional "bleed" can occur when feelings from the character and player affect one another.

Clinical groups therefore require careful preparation. This may include informed consent, collaborative goal setting, clear behavioural expectations, accessible rules, predictable session structures and agreed methods for pausing or declining content. Connell's clinical guide places considerable emphasis on ethics, client selection, session zero, safety tools, documentation and treatment planning. (books.google.com)

Facilitators also need competence in two different areas. Clinical training does not automatically make someone an effective Game Master, while extensive gaming experience does not qualify someone to provide psychotherapy. Therapeutic use requires an integration of both skill sets.

Useful books for clinicians

Three books published in 2023 provide particularly useful starting points.

Therapeutically Applied Role-Playing Games: The Game to Grow Method Written by Elizabeth Kilmer, Adam Davis, Jared Kilmer and Adam Johns, this is probably the most comprehensive manual for clinicians interested in structured therapeutic groups. It covers treatment planning, population considerations, group development, session design and facilitation. The method draws from ACT, family therapy, drama therapy and interpersonal group processes. It is particularly relevant to clinicians working with groups and neurodivergent populations. (Routledge)

Tabletop Role-Playing Therapy: A Guide for the Clinician Game Master Megan Connell's book offers a detailed guide to planning and running applied TTRPG groups. It includes discussion of ethics, diversity, safety tools, therapeutic encounters, documentation and adapting games for different clinical presentations. It may be especially useful for clinicians who already understand psychotherapy but are less familiar with TTRPG facilitation. (W. W. Norton)

Role-Playing Games in Psychotherapy: A Practitioner's Guide Daniel Hand's book focuses substantially on integrating role-playing games into individual psychotherapy. It moves through character creation, setting, obstacles, storytelling, applying one's therapeutic modality and concluding therapy. This makes it a useful complement to the more group-focused texts. (Springer)

These are clinical practice books rather than treatment manuals supported by multiple randomised trials. Their value lies in conceptual guidance, practical structure and ethical reflection, not in proving efficacy.

Where should the research go next?

The field now needs to move beyond asking whether participants enjoy therapeutic role-playing games.

Future studies should include larger samples, comparison groups, randomisation where appropriate and independent replication. Researchers should distinguish the effects of the game from the benefits of receiving attention, joining a group or engaging in an enjoyable shared activity.

There is also a need to examine who benefits, under what conditions and for which outcomes. A game may improve belonging without reducing anxiety. It may support group participation without changing standardised social-skills scores. These are different outcomes, and all may be meaningful.

Research should include more diverse neurodivergent participants and should not be limited to verbally fluent autistic adolescents and adults who already enjoy fantasy games. Participatory research involving neurodivergent players in the design of interventions and outcome measures will be essential.

Studies should also assess possible adverse experiences, dropout, sensory accessibility, masking pressure and the transfer of learning beyond the game. Qualitative research remains important because conventional symptom measures may fail to capture belonging, authenticity, playfulness, agency and community participation.

A promising medium, not a magical treatment

Tabletop role-playing games bring together many processes already recognised as potentially therapeutic: play, metaphor, behavioural rehearsal, narrative, social learning, creativity, group cohesion and exposure to manageable uncertainty.

The early evidence is encouraging, particularly in relation to engagement, social connection, self-efficacy and the experiences of some autistic participants. It is also consistent with what many players have described informally for decades: role-playing games can provide friendship, experimentation, competence and a place to belong.

Yet enthusiasm should not outpace evidence. No robust meta-analysis currently establishes the effectiveness of TTRPG psychotherapy, and most available studies involve small samples, uncontrolled designs or qualitative reports.

The most responsible conclusion is neither that tabletop role-playing games are merely entertainment nor that they constitute a proven treatment. They are a flexible, engaging therapeutic medium whose value depends on the goals, participants, facilitator, context and quality of the underlying clinical work.

For some neurodivergent people, their greatest contribution may not be teaching conventional social behaviour. It may be creating a structured but imaginative space in which different forms of communication, identity and connection are genuinely welcomed.

Selected references

Arenas, D. L., Viduani, A., & Araujo, R. B. (2022). Therapeutic use of role-playing game in mental health: A scoping review. Simulation & Gaming, 53(3), 285–311. https://doi.org/10.1177/10468781211073720

Atherton, G., Hathaway, R., Visuri, I., & Cross, L. (2025). A critical hit: Dungeons and Dragons as a buff for autistic people. Autism, 29(2), 382–394. https://doi.org/10.1177/13623613241275260

Connell, M. A. (2023). Tabletop Role-Playing Therapy: A Guide for the Clinician Game Master. W. W. Norton.

Hand, D. (2023). Role-Playing Games in Psychotherapy: A Practitioner's Guide. Palgrave Macmillan. https://doi.org/10.1007/978-3-031-31740-8

Henning, G., de Oliveira, R. R., de Andrade, M. T. P., Gallo, R. V., Benevides, R. R., Gomes, R. A. F., Fukue, L. E. K., Lima, A. V., de Oliveira, M. B. B. Z. N., de Oliveira, D. A. M., Werpp, M.,

Moraes, L., & Lotufo Neto, F. (2024). Social skills training with a tabletop role-playing game, before and during the pandemic of 2020: In-person and online group sessions. Frontiers in Psychiatry, 14, Article 1276757. https://doi.org/10.3389/fpsyt.2023.1276757

Kilmer, E. D., Davis, A. D., Kilmer, J. N., & Johns, A. R. (2023). Therapeutically Applied Role-Playing Games: The Game to Grow Method. Routledge.

Merrick, A., Li, W. W., & Miller, D. J. (2024). A study on the efficacy of the tabletop roleplaying game Dungeons & Dragons for improving mental health and self-concepts in a community sample. Games for Health Journal, 13(2), 128–133. https://doi.org/10.1089/g4h.2023.0158

Pappagianopoulos, J., Smith, J. V., Menezes, M., Howard, M., & Mazurek, M. O. (2026). Pilot study of a novel role-playing game-based social skills intervention for autistic adolescents. Journal of Developmental and Physical Disabilities.https://doi.org/10.1007/s10882-026-10058-8

Rosenblad, S. R., Wolford, T., Brennan, R. S., III, Darnell, J., Mabry, C., & Herrmann, A. (2025). Mastering your dragons: Using tabletop role-playing games in therapy. Behavioral Sciences, 15(4), Article 441. https://doi.org/10.3390/bs15040441

Thompson, M., & Majumder, V. (2025). Systematic review: Are table-top roleplaying games a useful therapeutic tool for people with neurodiversity? BJPsych Open, 11(S1), S74. https://doi.org/10.1192/bjo.2025.10240

Yuliawati, L., Wardhani, P. A. P., & Ng, J. H. (2024). A scoping review of tabletop role-playing game as psychological intervention: Potential benefits and future directions. Psychology Research and Behavior Management, 17. https://doi.org/10.2147/PRBM.S466664