Grumpy dwarves and 20-sided dice: Therapist uses Dungeons & Dragons to model self-acceptance

Charlene MacPherson remembers the precise moment she fell in love with the fantasy role-playing game Dungeons & Dragons.

She was a freshman at the University of Mary Washington in Fredericksburg, Virginia, with only a vague idea of what she wanted to do after college. It was her first time playing. Her friend from the school’s nerd-dominated fencing team was the dungeon master, a role somewhere between a narrator, an omniscient team captain and a god.

Someone rolled a 1, traditionally the worst possible score on the game’s iconic 20-sided die, and everyone groaned. But instead of saying the player dropped their sword when they meant to cut a magical tablet in half, the dungeon master said they accidentally stabbed a goblin and would have to spend the entirety of their next turn trying to shake the goblin’s body off their sword.

“I was like, ‘Oh, my God, that’s so funny!’” MacPherson said.

MacPherson’s love of the geeky adventure game has only grown over the years. But now, she appreciates it for more than the goofiness it can inspire. As a licensed clinical social worker, she’s been using the tabletop game since 2019 to provide group and individual therapy to autistic people, as well as people with depression, anxiety and other mental health diagnoses.

Through her work as a certified therapeutic game master based in Linthicum, Maryland, MacPherson has watched her clients learn how to set firm boundaries, make healthy friendships, voice their opinions and celebrate what makes them different — all in an accepting fantasy world where mistakes don’t have scary consequences.

A big part of the magic of Dungeons & Dragons, and why it’s so effective as a framework for group therapy, is that it provides a safe space where people can test out social skills and other strategies they learn in individual therapy without fear of being judged, mocked or rejected, MacPherson said.

For example, MacPherson said, she may assign the character of a grumpy dwarf to someone who struggles to set healthy boundaries.

“They’re playing this grumpy dwarf who says, ‘No,’ all the time and everybody’s laughing and having a good time,” MacPherson said. “Then, the client gets to see, ‘Oh. When you set boundaries, it’s not dangerous all the time.’”

MacPherson is still only one of a handful of mental health providers around the world who use Dungeons & Dragons — first published in 1974 — to provide therapy, but their numbers are growing. At least two U.S. organizations — Geek Therapeutics and Game to Grow — train therapists how to use D&D and other tabletop games in their practice.

Geek Therapeutics, based in Fort Worth, Texas, has certified more than 400 mental health providers as therapeutic game masters, said Anthony Bean, the company’s founder and a licensed clinical psychologist. Game to Grow also has trained hundreds of therapists — including MacPherson — in its methodology, said Adam Davis, the Seattle-based nonprofit’s co-founder and executive director.

“People have been using stories to connect and grow since we crawled out of the ooze,” Davis said. “The idea of using tabletop role-playing games for insight, growth and change — as new as it is, it’s also very, very old.”

Megan Connell, a licensed clinical psychologist based in North Carolina, recently released a guide for therapists who use Dungeons & Dragons and other role-playing games as part of their practice.

Having clients work on skills in the context of a game where they’re playing a character alleviates some of the awkwardness they may feel acting out scenarios as themselves, Connell said.

“When we’re role-playing a character, we have this freedom to try things,” Connell said. “And if things go badly, well that wasn’t me, that was my character.”

MacPherson started offering Dungeons & Dragons therapy groups in 2019 while she was working at St. John’s College in Annapolis. She later began offering D&D therapy groups through her private practice, and eventually accumulated enough clients to transition to a full-time private therapist. Now, she sees around 27 clients per week in group sessions. Most are older than 30, and are female or nonbinary, she said. About 80% identify as LGBTQ+ and about 20% are people of color.

Many of MacPherson’s neurodiverse clients grew up being shamed for their style of communication and atypical problem-solving skills. Having a fantasy world where creative thinking isn’t just accepted, but encouraged, can help heal old wounds, MacPherson said.

“Like 90% of my job as a therapist, honestly, is to get people to stop beating themselves up in their heads — the shame, the blame, all of it,” she said. “It makes everything worse.”

MacPherson knows from personal experience how validating it can feel to be appreciated in a game like Dungeons & Dragons. She was recently diagnosed with ADHD and feels insecure about her tendency to talk over people or talk too much when she gets excited. She remembers how good it felt when the character she played in a 2017 online D&D campaign became a favorite of the group’s.

During the campaign, MacPherson’s character and others in the game captured a pirate ship and had to choose a captain. The group immediately chose MacPherson’s character — a frog-like humanoid bard named Brip Von Bripinstien III. The experience made her realize how much her clients would benefit from having similar ones.

A tiny model of the character still sits on her desk.