Why Therapy Is Like A Game

Tissot-hide-seek-detail

Game-playing often has negative connotations in the field of psychiatry.  We have all sorts of erudite ways of describing what laypeople call "mind games." A great example is in the language of Axis II personality disorders.  People are borderline, dependent, avoidant, narcissistic, antisocial, and the most FABULOUS of them all, histrionic.  These words attempt to describe the psychological conditions which motivate problematic behaviors.  Serious business indeed.

But come right out and say that therapy is like a game, even a kind of game, and that gets a lot of hackles up.  Therapy is serious business, and games are anything but serious, right?  Wrong.

To describe something as a game is not to minimize it or take it less seriously, but I suggest to describe what Bernard Suits calls the "lusory attitude."  This is the state of mind, the psychological attitude, required of any player when they play a game.  The most succinct way Suits describes the lusory attitude is to say that it allows the "voluntary attempt to overcome unnecessary obstacles"

An example of this, not mine originally, is that of golf.  The activity is directed at achieving the goal of getting a ball into a hole.  But instead of just creating an activity where we find a ball and drop it into a big hole, we take the hole, make it small, say you can't use your hands to drop the ball in but must use a metal club, and start you off hundreds of feet away from the hole.  That's golf, and it is so full of unnecessary obstacles!  There is no reason to make it so challenging, EXCEPT that that challenge is what makes it fun, and frustrating, and more fun.  And nobody drags you into the wilderness, gives you a golf club and points a gun at your head to golf.  It is a voluntary act.  People love to, choose to, spend hours with sticks hitting balls from great distances with the hope of getting them into little holes.  Why choose to do something so weird and difficult?  Because they are playing.  They have voluntarily attempted to overcome unnecessary obstacles.  They have adopted a lusory attitude.

Life is hard.  And for many of therapy patients, life has been extremely hard, and cruel.  And yet, how often do we notice that they are making life even harder on themselves in some ways?  Perhaps unconsciously, perhaps subtly, but more difficult nevertheless.  That neurosis, the reenactment of the past, is what I would suggest is the unnecessary obstacle.

For example let us take PTSD-precipitated by child abuse.  The abuse was serious, hurtful, sadistic, real.  It happened.  But in the case of the adult patient, the abuser is no longer there.  The introjects, the learned stuff, the unconscious stuff, that is all there, but the perpetrator has fled the seen of the crime long ago.  They were real obstacles, but trauma recreates them as unnecessary obstacles in the here and now.

Another example would be a phobia.  Why not be fearful of everything?  Spiders aren't the only thing that we could fear:  There's death, and hurricanes, and black cats, and dirt, and blindness, and the next presidential election.  But we don't fear everything in the world that is or is perceived as harmful to us.  Phobias are very specific, that is why there are so many clever names for them.  They are again, unnecessarily specific obstacles.

Again, I want to stress that by calling these unnecessary obstacles that I am not at all saying that phobias or PTSD or not serious, painful, debilitating, conditions.  What I am saying is that they are unnecessary to the life of the patient.  Even as compromise solutions they have outlived their usefulness if the patient is in the here and now experiencing distress as a result of trying to defend against or cope with the past encroaching on their present.  The repetition compulsion is a game of both danger and optimism.  We do the same things over and over, often with disastrous results, true; but we keep doing it because on some level there is an urge to get it right.  And like a video game, the repetition compulsion doesn't just get defeated one day; rather we get progressively further in the game, acquire new levels and skills.

When our patients arrive at our office, they are in a state of lusory attitude, they are really trying to resolve the problems the best they can, and they have sought out our help to that end.  If they are mandated to treatment, this is less likely to happen.  But for a majority of patients, they choose to show up.  And from a psychological point of view, showing up must be voluntary for therapy to work.

In order to do therapy, we also have to adopt together a lusory attitude.  Both therapist and patient volunteer to work together to overcome the unnecessary obstacles.  The therapy time and space are in some ways unnecessary obstacles: we choose to limit the session to the 45-50 mins, in a specific office, with only two "players" if it is individual therapy.  These may be the warp and woof of therapy but they are also arbitrary distinctions that create unnecessary obstacles.  We could rotate different therapists in, or meet for varying times whenever we both want, and hang out at Dunkins, but that would be therapy in the sense we are talking about would it?  No, therapy, like games, must have agreed-upon rules.

Although I'm speaking in clearly psychodynamic terms here, doesn't it seem that more behavioral approaches would find the concept of lusory attitude applicable as well?  Surely we don't try to extinguish behaviors we think are necessary.  The behavioral approach also implies that the obstacle (behavior) is unnecessary and tries to over come it.

Having a lusory attitude is not always about being lighthearted, although it can be, but it is about taking play very seriously, engaging in it and often having an immersive experience.  Psychotherapists who engage in play therapy with children often have an easier time understanding this than those who do adult psychotherapy.  There is a general tone from our profession of, "we need to be taken seriously," which I think has lots of its roots in the tendency of the medical profession in the past to have considered it less important.  And somehow being taken seriously becomes equated with being important or being valuable.

I often supervise interns who repress any sense of enjoyment that comes from making an interpretation that moves a patient forward, or seeing theoretical elements manifest in the treatment, and try to help them see that enjoying the process of learning psychotherapy and learning about the patient is not the same as having fun at her/his expense.  As Sutton-Smith says, “The opposite of play isn’t work.  It’s depression.”  In this regard I agree with him:  When engaging in a lusory attitude with patients we are working with them.  Removing those obstacles is very hard, dangerous work, and it is deeply and seriously playful.

To add gamers and video games into the mix, I would suggest that approaching video games as an addiction is a step in the wrong direction.  This is not to say that I don't think that some people play video games to the detriment of their lives and relationships.  I do think that happens, just like I think people engage in a number of activities at times to the detriment of their lives and relationships.  But to label them as pathological is to miss the point.  Even if we rule out the cultural incompetency of the clinician around video games which often masquerades as dismissal or villainization, we need to understand that we are in essence asking the patient to adopt the same lusory attitude with us that is often there already for them with video games.  We are saying, "don't play that game, play this game of therapy instead."

(Unless you have this view of psychotherapy:

http://www.youtube.com/watch?v=Ow0lr63y4Mw&feature=related

Psychotherapy needs to stop taking the lusory attitude for granted.  What if we became more mindful of our lusory attitude?  We all have them, over coffee with a colleague when we look at each other and say, "this is such a weird profession!"  It's like golf in that respect, it seems; so intricate and complicated with rules we take for granted that make a particular human relationship much more complicated than it has to be.  Try that on the next time you are trying to discuss your fee with someone:  "I charge you $150 an hour because this is a weird relationship that has intricate rules and is much more complicated than human relationships have to be."

I think that there are strong parallels between therapy, neurosis, and games, and that the thread that links them together may be the lusory attitude.  In games, the design always boils down to a voluntary attempt to overcome and unnecessary obstacle.  In neurosis, the attempt to repress intolerable conflicts and feelings creates an unnecessary obstacle even as the patient tries to remove the unnecessary obstacle of those same conflicts and feelings.  (Game designers may recognize an interesting resemblance to the concept of iterative design here.)  Finally, in therapy, the neurosis or symptom becomes the unnecessary obstacle that the therapist and patient voluntarily attempt to overcome.

What do you think?  Does this jibe with your experience as a therapist, patient, gamer or game designer?

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