Video-game therapy

1. Introduction

Version followed: no single manual exists. This guide follows the integrated, session-by-session approach of Robert Rice, Video Games in Psychotherapy (Routledge, 2022/2023; narrative, collaborative and CBT-informed), with Anthony M. Bean's clinician's guide (Working with Video Gamers and Games in Therapy, Routledge, 2018) and the electronic-gaming-therapy practice of Brian H. Moyer, Drew C. Messer and colleagues (Electronic Gaming Therapy, Inc., Williamsville NY), as set out in their review Horne-Moyer, Moyer, Messer & Messer (2014), Current Psychiatry Reports 16:520. The Horne-Moyer review sources the therapist roles, game-selection criteria, office set-up, the group social-skills sequence, in-the-moment shaping and the cautions; the IGDS9-SF screening questionnaire is described from its validation papers; PEGI labels from a PEGI parents' guide and a console maker's ratings page. Rice's and Bean's books have no legitimate public preview, so Rice's own session-by-session framework, worksheets and game list, and Bean's specific methods, are not reproduced here [uncertain]; Rice's range of in-session uses (from drawing an avatar to co-play and biofeedback) comes from an author interview description. Steps not tied to a source are the writer's synthesis and are marked that way. [source: Routledge and Karnac pages for Rice; Routledge page for Bean; What Your Therapist Is Reading podcast, ep. 12; Electronic Gaming Therapy site; Horne-Moyer et al. 2014]

Video-game therapy is not a separate, regulated therapy. It is the planned use of commercial (off-the-shelf) video games, gaming culture and game metaphors inside an existing psychotherapy, mostly with children, adolescents and young adults. Games can serve as:

a shared language for building rapport;
a medium for play and projection, through characters, avatars, genres and play styles;
a source of metaphors that help externalise problems;
a live setting for practising self-regulation, coping and social skills, individually or in groups.

[source: Rice, Routledge description; Bean, Routledge description and TOC; Moyer/Messer]

Core idea of change: young clients are already invested in games. Meeting them there increases engagement and trust. Rice describes games as offering a "phenomenal array of potentially therapeutic metaphors" that let clients "externalize problems and talk about them more comfortably and openly". He centres the work on the client's moments of competence. Skills practised during real, emotionally charged play (frustration, losing, cooperating) are then generalised to daily life. [source: St. John Fisher University news release on Rice, 2023; Electronic Gaming Therapy site] The Horne-Moyer review adds that games can raise motivation and attention and make difficult techniques easier to introduce, and that they work best with an actively involved therapist who links in-game events to real-life situations. [source: Horne-Moyer et al. 2014]

Boundary with digital therapeutics: prescription digital therapeutics (regulated medical devices delivered as games, such as EndeavorRx for ADHD) are not covered here; see Domain IX. Purpose-built serious games tested in trials, such as SPARX and MindLight, are also outside this guide (see 4.19). [source: Contemporary Pediatrics report on the FDA decision, 17 June 2020; Zayeni et al. 2020]

2. Framework

No published source sets out a fixed phase model, session count or criteria for moving between phases. Rice's publisher and bookseller pages describe a "practical session-by-session framework" with example therapist questions, responses and activities, case examples, templates and worksheets, and a review of over 40 games, but the framework itself is not publicly available. [uncertain] The Horne-Moyer review describes therapist roles and selection rules, not phases. The phases below are therefore the writer's synthesis, arranged around the topics the authors cover. [source: Karnac page for Rice; Horne-Moyer et al. 2014] [synthesis]

Professional frame:

No regulated profession, protected title or required credential exists for "video-game therapy". A practitioner uses it within their existing licence as a psychologist, counsellor, social worker, psychotherapist or play therapist, and within that discipline's ethics. [synthesis]
Specialist training exists. Bean founded Geek Therapy Training, which teaches what it calls "Leyline's Geek Therapy Techniques". [source: National Register page on Bean] He is described as executive director of The Telos Project, a non-profit mental-health clinic in Fort Worth, Texas, and as founder of Leyline Publishing; the Geek Therapeutics stand at PAX East 2023 sold his books. None of the sources cited names a formal certification, hours or curriculum. [source: TechRaptor feature; Boss Rush, 27 Mar 2023] [uncertain on the current training offer]
When games are used as a play-therapy medium with children, the play-therapy standards of your jurisdiction apply: for example APT (RPT) in the US, or BAPT or PTUK in the UK. Do not present yourself as a play therapist without that training. [synthesis]

The framework has four phases plus a cross-cutting element.

Phase 0: Suitability and safety screening (session 1–2).

Goals:
- Take a gaming history.
- Screen for problematic gaming.
- Screen for photosensitive epilepsy and other medical cautions.
- Agree which games are allowed, using PEGI or ESRB age ratings and content descriptors, and matching each game to the client's age, cognitive level, presenting problem and skill level, with input from the client, the parents and manufacturer ratings. [source: Horne-Moyer et al. 2014]
- Agree the rules on online play and purchases.
- Obtain consent (carer) and assent (child), and agree how parents or carers will be involved.
Move on when: the risks are known and documented, and a game list and session rules are agreed in writing. [synthesis]

Phase 1: Engagement (about 1–3 sessions).

Goals:
- The client teaches the therapist their games.
- The therapist learns "the language of gaming" (Bean's phrase).
- Rapport and a working alliance are built.
Move on when: the client talks freely and can name at least one treatment goal. [source: National Register page on Bean; Moyer/Messer on rapport with resistant youth] [synthesis for timing]

Phase 2: Exploration and meaning (variable).

Goals: work with genres, characters, avatars, archetypes, immersion and metaphors to understand the client's identity, relationships and problems. Externalise the problem and find moments of competence.
Move on when: there is a shared formulation expressed in the client's game language. [source: Bean TOC; Rice description] [synthesis]

Phase 3: Skills and change (core of treatment, variable).

Goals:
- Self-regulation training using live play.
- Graded anxiety work.
- Social and coping skills, often in structured gamer groups with exercises before and after play.
Move on when: the skills appear in play and are reported outside sessions by the client, parents or school. [source: Rice TOC chapters 4, 5 and 7; Moyer/Messer group format] [synthesis]

Phase 4: Generalisation and ending.

Goals:
- A healthy-gaming and family media plan.
- Carers taking over co-play.
- Planning for setbacks.
- Reducing in-session gaming.
End when the goals are met and gaming at home is balanced. [synthesis; Bean ch. 11 addresses families, content not publicly described]

Format. Individual sessions use the usual 45–60 minutes, with play kept to a bounded part of the session and time left to process it. Group work in the Moyer/Messer school-based programme combined:

skills exercises before play;
multiplayer cooperative play;
trained volunteers who modelled and reinforced appropriate behaviour during play;
skills exercises after play;
a parallel parent support group.

[source: Electronic Gaming Therapy site] Engagement can wane: in one trial of a biofeedback game, adolescents were bored after about four sessions. Rotate or vary games. [source: Zayeni et al. 2020]

3. Guiding principles

[source for the principles: Rice and Bean descriptions; Moyer/Messer; PEGI and ESRB pages; Wang et al. 2019; Epilepsy Ireland. Practical meanings are synthesis unless cited.]

Games are the medium, not the treatment. Name the underlying therapy model (narrative, CBT, play therapy) and the goal for every game used. [source: Rice]
The client is the expert. Let them teach you the game; you do not need to be a gamer. Rice states he is not one himself. [source: SJF news release]
Curiosity before judgement. Set stereotypes aside, especially the automatic links between gaming and addiction or violence; ask what the game means to this person. [source: Bean, Routledge description]
Learn the language of gaming. Learn genres, mechanics and community terms well enough to follow and reflect accurately. [source: National Register page on Bean]
Work through metaphor and externalisation. Use game structures (bosses, levels, save points, respawns, party roles) to talk about problems at a safe distance. [source: Rice]
Look for competence. Notice and amplify skill, persistence, strategy and leadership shown in play. [source: SJF news release on Rice]
Play is real practice. Frustration, losing and cooperating during a game are live material for regulation and social skills. Debrief every time. [source: Rice TOC; Moyer/Messer]
Age ratings and content descriptors are the floor. Use only games whose PEGI or ESRB rating fits the client's age, and check the content descriptors against the client's history and triggers. Weigh the client's maturity as well as their age. A PEGI rating does not cover online interaction with other players. [source: Ask About Games (PEGI); ESRB; Games Denmark PEGI guide; Horne-Moyer et al. 2014]
No monetisation in session. Play no in-session games that ask for real-money purchases or sell paid random items (loot boxes, gacha, card packs). [source: PEGI and ESRB definitions] [synthesis for the rule]
Keep online play under control. In session, prefer offline or local multiplayer, with chat off and no contact with strangers. [synthesis]
Screen before prescribing more screen time. Rule out gaming disorder or hazardous gaming before using games therapeutically, and avoid overdiagnosing normal heavy players. [source: Wang et al. 2019]
Medical safety first. Ask about epilepsy and flicker sensitivity, and follow the precautions against flashing and patterns. [source: Epilepsy Ireland]
Families are partners. Involve parents and carers in game choice, rules and home co-play. [source: Moyer/Messer parent group; Bean ch. 11]
Safeguarding governs everything. Disclosures made during play, online grooming or exploitation, and abusive in-game content trigger the usual safeguarding and mandatory-reporting duties. [synthesis]
Bounded and purposeful. Time-limit play within each session, and plan from the start to fade gaming out as goals are met. [synthesis]
Do not over-interpret. Avatar choice, game preference and play style are material for discussion, not diagnostic evidence of disorder, trauma or abuse. No validated diagnostic manual for this exists in the sources. [synthesis]

Further principles from the Horne-Moyer review:

The therapist is an active player, not a supervisor. Model play, give hints and prompts, co-play, and talk through in-game events, linking them to real-life situations. [source: Horne-Moyer et al. 2014]
Match the game to the goal. Classify candidate games by complexity and by how much social interaction they involve, and pick the style that fits the objective; the review links attention goals to question-and-answer formats and communication goals to simulation games. [source: Horne-Moyer et al. 2014]
Consider who the client is. Gender, developmental stage, culture and socioeconomic status affect how a client responds to a game; ask rather than assume. [source: Horne-Moyer et al. 2014]
Favour social play over solitary heavy play. Long or frequent play has been linked to social-emotional and educational problems, while co-playing and in-person social play appear protective. [source: Horne-Moyer et al. 2014]

4. Intervention inventory

The sources name the topics and formats listed below. Their step-by-step scripts are not publicly available, so all steps are [synthesis] unless a source is given. Example language is illustrative throughout.

4.1 Gaming history interview ("language of gaming")

Purpose: to understand what, how, when, with whom and why the client plays, and to learn their vocabulary. Use it at intake with any client who games. [source: National Register page on Bean; Bean TOC chapters on genres, online relationships and immersion]
Steps:
1. Ask for their current and favourite games, platforms and genres.
2. Ask for a typical day and week of play, including time of day and whether they play solo, with friends or with strangers online.
3. Ask what each game gives them: challenge, story, escape, social connection, creativity or mastery.
4. Ask about main characters, avatars and classes.
5. Ask about voice or text chat and online friendships.
6. Ask about spending money and purchases.
7. Ask about conflicts at home over gaming.
8. Write down the client's own terms and use them back accurately. [synthesis]
Example language (illustrative): "Walk me through the last time you played. What were you doing in the game, and who was with you?" "What does a good session feel like, compared with a bad one?"
Watch for: gaming used mainly to escape distress or avoid people. Watch also for sleep disruption, contact with strangers, and spending the client is secretive about; these lead on to 4.2 and safeguarding. It is working when the client starts correcting and teaching you.

4.2 Problematic gaming screen

Purpose: to separate high but healthy engagement from hazardous gaming or gaming disorder before games become a therapy tool. Use it at intake and again if concerns arise. [source: Wang et al. 2019]
Steps:
1. Check the core features ICD-11 describes:
  - impaired control over gaming;
  - gaming given increasing priority over other interests and daily activities;
  - gaming continued or escalated despite negative consequences.
2. Check that the pattern has typically lasted about 12 months and causes significant impairment in personal, family, social, educational or occupational functioning.
3. ICD-11 also has a separate category for hazardous gaming. DSM-5 lists Internet Gaming Disorder only in Section III, as a condition needing further research, with nine criteria; five or more within 12 months meet the research threshold.
4. If you use a brief questionnaire, the Internet Gaming Disorder Scale–Short-Form (IGDS9-SF; Pontes & Griffiths, 2015) is one validated option. It has nine self-report items, one per DSM-5 criterion, rated on a five-point scale from "never" to "very often" for the past 12 months. In the authors' recommended scoring a criterion counts only when rated "very often", and endorsing five or more is the proposed threshold; a total-score cut-off of 32 has also been suggested. It has a one-factor structure, with Cronbach's alpha about 0.91–0.92 in adult and adolescent (12–19) samples. It is a screen, not a diagnosis: confirm with a clinical interview. Use the published scale from the authors' paper without reproducing or altering its items. No licensing statement is given, so check terms before routine use. Other instruments (for example the Game Addiction Scale) are not covered here. [source: Pontes & Griffiths 2015 (NTU repository record); Gomez et al. 2019; Luo et al. 2022] [uncertain: licensing; use with children under 12]
5. Assess for comorbid conditions such as depression, anxiety and ADHD. [source: Wang et al. 2019 for 1–3 and 5]
6. If gaming disorder is likely, do not add therapeutic gaming. Treat the gaming problem itself; the review names CBT, group and family approaches. [source: Wang et al. 2019] [synthesis for the decision rule]
Example language (illustrative): "Have there been times you meant to stop and couldn't? What has gaming pushed out of your week?"
Watch for: overdiagnosing normal heavy players, which the review cautions against, and parents' fears outweighing the evidence of actual impairment.

4.3 Game selection and safety check

Purpose: to make sure every game used in session, or set as homework, is age-appropriate, clinically suitable and safe. Do this before first use of any title. Choose by the client's age, cognitive level, presenting problem and skill level, using client recommendations, manufacturer ratings, parent input and clinical judgement. [source: Ask About Games (PEGI); ESRB; Epilepsy Ireland; Horne-Moyer et al. 2014]
Steps:
1. Age rating. Check the rating:
  - PEGI: 3, 7, 12, 16 or 18.
  - ESRB: E (Everyone), E10+, T (Teen), M (Mature 17+), AO (Adults Only 18+). Use only games rated at or below the client's age.
2. Content descriptors. Read the descriptors against the client's history:
  - PEGI's descriptors are violence, bad language, fear/horror, sex, drugs, gambling, discrimination, in-game purchases (added 2018) and paid random items such as loot boxes (added 2020); the last two can appear at any age level. A separate PEGI Online label marks online interaction with other players, which the age rating itself does not cover. [source: Ask About Games; Games Denmark PEGI guide]
  - Avoid horror and fear content with anxious or traumatised children unless it is a planned exposure target.
  - Avoid gambling content altogether.
3. Purchases. Check for in-game purchases. PEGI flags these at every age level. Check for paid random items: PEGI and ESRB print "In-game Purchases (Includes Random Items)", and ESRB names loot boxes, gacha and card packs as examples. In session, use a device and account with purchases disabled and no stored payment method. [source: PEGI and ESRB pages] [synthesis for device set-up]
4. Online settings. Turn off chat and online matchmaking with strangers, and use offline or couch co-op modes. Set up the console's family account (PlayStation, Xbox or Nintendo) to control who the child can interact with, and turn on purchase approval before handing over the device; Xbox offers a Family Settings app for managing a child's play from a phone. [source: Games Denmark PEGI guide; Xbox game-ratings page] [uncertain for ESRB-specific guidance]
5. Photosensitivity. Ask the client and carer about epilepsy and any seizures or flicker sensitivity. Epilepsy Ireland's guidance says games do not create a seizure tendency where none exists. Flashing lights or geometric patterns can provoke seizures in a small number of sensitive people; reported as 3–5% of people with epilepsy. Risk depends on the type of flicker, glare, and how much of the visual field the image fills. Precautions:
  - flicker-free (LCD) screens with anti-glare filters;
  - frequent breaks;
  - avoid play when overtired. Also read the game's own photosensitivity warning and accessibility settings, and stop play at any visual disturbance, twitching or altered awareness. [source: Epilepsy Ireland] [synthesis: stopping rule, distance, room lighting]
6. Physical safety for motion and exergames. Clear the space and secure cables. Adapt for motor difficulties. [synthesis]
7. Record the approved games list, and the carer's agreement to it, in the notes.
Example language (illustrative, to a parent): "Before we use any game, I check its age rating, whether it sells mystery items, and that online chat is off. Does your child have any history of seizures or sensitivity to flashing lights?"
Watch for: a client pushing for an over-age title, and games that change after an update by adding shops or events. Re-check titles periodically.

Office set-up [source: Horne-Moyer et al. 2014]: the review suggests keeping consoles and games in a separate room, which reduces damage and stops clients reaching age-inappropriate titles. For group play, check that the game allows several players on one console; newer versions of some multiplayer games need one console per player. The review lists seizures and muscle strain as physical risks of all electronic games, and notes that motion-based games can be physically demanding.

4.4 Consent, assent and the session agreement (children and young people)

Purpose: to make the gaming component explicit, voluntary and bounded. [synthesis; general child-practice duties]
Steps:
1. Explain the rationale to the carer and obtain consent from whoever holds parental responsibility, under local law.
2. Explain it to the child in age-appropriate terms and obtain their assent. Tell them they can say no to playing and still come to therapy.
3. Explain the limits of confidentiality. In particular, things said or seen during play, including online contacts, will be shared if someone is at risk.
4. Agree the session rules: play time, what happens when the timer ends, no purchases, no streaming or recording, and screenshots only with consent.
5. Agree what carers will hear and how they will be involved.
Example language (illustrative): "We'll play for about 15 minutes, then talk about what happened. If you'd rather not play one week, that's fine."
Watch for: play used as a reward the child must earn, which clashes with its therapeutic purpose; and carers expecting the therapist to "fix" the amount of gaming.

4.5 Client-as-expert engagement

Purpose: to build rapport and trust with reluctant or resistant young people. Moyer reported that games used this way improved trust and treatment compliance in a residential setting. [source: Electronic Gaming Therapy site; Rice SJF release]
Steps:
1. Invite the client to teach you a game they love, either by describing it or by playing it in session.
2. Ask genuine questions.
3. Reflect their skill and knowledge back to them.
4. Gradually link game talk to their goals. [synthesis]
Example language (illustrative): "I'm a complete beginner. Teach me how you'd get past this part."
Watch for: sessions that never move beyond game talk. Set a goal by session 3 (see section 5).

4.6 In-session co-play (games as a play-therapy medium)

Purpose: to observe frustration tolerance, persistence, turn-taking, help-seeking, planning and emotional expression in real time, and to intervene as they happen. Rice compares using games to "a natural progression from using crayons and construction paper". [source: SJF release; Moyer residential use]
Steps:
1. Choose a pre-checked game (4.3) with short rounds, preferably local cooperative or turn-based play.
2. Set a timer.
3. Play alongside the client (co-play). Model how to play where useful, live or with a short gameplay video, give hints and prompts, and narrate what you observe, both the client's feelings and their strategies. [source: Horne-Moyer et al. 2014 for modelling, prompts and co-play]
4. Pause at emotional peaks such as a loss or a stuck point.
5. After play, debrief: what happened, what they felt, what they did, and what they could try next time.
6. Discuss in-game events and connect them to real-life situations. [source: Horne-Moyer et al. 2014]
Example language (illustrative): "That was the third time that boss beat you, and your shoulders went right up. What's going on inside right now?"
Watch for:
- escalating dysregulation;
- the therapist competing rather than attending;
- play crowding out the debrief. Keep at least a third of the session for processing. [synthesis]

4.6a In-the-moment shaping with if-then rules

Purpose: to shape behaviour during play with clear, immediate contingencies that the client can later carry into other settings. The Horne-Moyer review describes therapists using if-then statements in the moment, for example a cool-off period after a controller is thrown, and generalising them to other settings. [source: Horne-Moyer et al. 2014]
Steps: [synthesis around the source's example]
1. Before play, agree two or three if-then rules with the client, stated positively where possible (for example: if the urge to throw the controller comes, put it down and step back).
2. State the consequence plainly, such as a short cool-off pause before play resumes.
3. Apply it calmly and immediately each time, without lecturing.
4. Praise the client when they use the alternative behaviour.
5. Afterwards, ask where the same rule could apply at home or school, and share it with carers or teachers so it is used consistently.
Example language (illustrative): "Remember our rule: if the controller gets thrown, we take a two-minute break, then try again."
Watch for: rules that turn punitive or remove play entirely, and therapist and carers applying them differently. It is working when the client starts the cool-off themselves and carers report the same rule working at home.

4.7 Avatar, character and archetype exploration

Purpose: to use the client's chosen or created characters as a projective, identity-focused conversation: who they are, who they wish to be, and what they fear. Bean devotes chapters to archetypes, video-game archetypes, and why players identify with particular games and characters; his specific method is not publicly described. [source: Bean TOC and description] [uncertain on Bean's specific method] Rice names having the client draw their avatar as the simplest in-session use of games. [source: What Your Therapist Is Reading podcast, ep. 12 (2023), episode description]
Steps:
1. Ask the client to describe, show or draw their main character or avatar: appearance, abilities, weaknesses, backstory and role in the party. (Drawing: Rice, per the podcast description above.)
2. Explore why they chose it and how it differs from them.
3. Ask what the character would do in a current real-life problem.
4. Note recurring patterns across their characters, such as always the healer, the lone wolf or the tank.
5. Offer tentative links, never interpretations presented as fact. [synthesis]
Example language (illustrative): "If your character walked into your school tomorrow, what would they do differently from you?"
Watch for: reading avatar features as diagnostic evidence, which is not supported. Discuss gender or body choices respectfully and let the client lead their meaning. It is working when the client can use their character as a resource ("what would my ranger do?").

4.8 Genre, play-style and immersion exploration

Purpose: to understand needs and motivations through what the client plays and how they play it. Genre and immersion are among Bean's core topics. [source: Bean TOC: genres; immersion; play and imagination]
Steps:
1. Map the genres they play, such as competitive shooters, sandbox building, role-playing games, puzzle and narrative games.
2. Ask what each gives them: competition, mastery, exploration, creativity, story, social belonging or escape.
3. Explore their style: completionist, explorer, speedrunner, team leader, solo.
4. Explore immersion: when it restores them and when it becomes avoidance.
5. Link the needs identified to treatment goals and to offline ways of meeting the same needs. [synthesis]
Example language (illustrative): "You pick games where you can build anything. Where else in your life do you get to build?"
Watch for: immersion that is used mainly to numb distress, which returns you to 4.2 and a risk review.

4.9 Gaming metaphors and externalisation

Purpose: to name the problem in the client's game language so it can be discussed and fought from a distance. This is central to Rice's narrative approach. [source: Rice, Routledge description and TOC chapter "Metaphors Be With You"; SJF release]
Steps:
1. Choose a metaphor with the client, for example anxiety as a boss, OCD as a glitch, anger as a rage meter, a hard week as a difficult level, coping skills as an inventory, supports as a party, relapse as a respawn, a save point as a safe baseline.
2. Give the problem a name and describe its "moves".
3. Map when it wins and when the client wins.
4. Plan "strategies" (skills) and "power-ups" (supports).
5. Use the metaphor consistently in later sessions and in written plans. [synthesis for steps; Rice's own worksheets not reproduced]
Example language (illustrative): "If your worry were a boss, what are its attacks? What's its weak spot? Which items in your inventory work against it?"
Watch for: metaphors that minimise real danger, for example a "respawn" metaphor with a client who self-harms. Do not use death and respawn imagery when there is suicide risk. [synthesis]

4.10 Finding moments of competence (unique outcomes)

Purpose: to build self-efficacy by noticing the skills the client shows in games and transferring them. [source: SJF release on Rice's narrative focus on moments of competence]
Steps:
1. Ask about their greatest gaming achievement.
2. Work out the skills involved: persistence after failure, learning from mistakes, planning, cooperating, staying calm.
3. Name those skills explicitly.
4. Find times they used the same skill offline.
5. Plan one offline use before the next session. [synthesis]
Example language (illustrative): "You failed that level 40 times and kept adjusting. What did you tell yourself that kept you going?"
Watch for: the client dismissing their game skill as "just a game". Validate the effort as real.

4.11 Self-regulation training with games

Purpose: to practise noticing and calming physiological arousal during the frustration and excitement that games reliably produce. Rice gives a chapter to using games for self-regulation, described as including psychophysiological self-regulation. [source: Rice TOC chapter 4; Routledge description] [steps: synthesis]
Steps:
1. Before play, teach one regulation skill, for example slow breathing or a body scan.
2. Agree a 0–10 arousal scale.
3. Choose a challenging but age-appropriate game.
4. Pause play at set intervals or at peaks; the client rates their arousal and uses the skill.
5. Resume play.
6. If you have biofeedback equipment (heart rate, heart-rate variability) and training in it, the client can watch the signal while playing. [Rice lists biofeedback among in-session uses of games: podcast description; set-up: synthesis]
7. Debrief and set home practice, for example "use your breath every time you die in the game".
Example language (illustrative): "You're at a seven. Hands off the controller, three slow breaths, rate it again, then back in."
Watch for: frustration escalating to aggression; have a stop signal and a cool-down plan. It is working when arousal ratings fall faster after each frustration and carers report calmer endings at home.

4.12 Graded exposure through games (anxiety)

Purpose: to approach feared stimuli or situations gradually, using game content or game-related social situations. Rice has a chapter on games for anxiety disorders; its procedure is not publicly described. [source: Rice TOC chapter 5] [uncertain; steps: synthesis]
Steps:
1. Do a standard anxiety assessment first.
2. Obtain consent for exposure from the carer and assent from the child.
3. Build a fear hierarchy with game-based steps, for example:
  - watching a mildly tense game scene;
  - playing a level with a time limit;
  - losing on purpose;
  - playing cooperatively with a peer;
  - speaking on approved voice chat with a known friend.
4. Carry out each step until anxiety reduces, without safety behaviours.
5. Debrief and move up the hierarchy.
6. Transfer to real-world exposures.
Contraindications and safety:
- Never use horror content beyond the game's age rating.
- Do not use trauma-related content (war, assault) for trauma exposure; that belongs within a trauma protocol delivered by trained clinicians, not improvised with commercial games.
- Watch for dissociation and stop if it appears.
- Stop if seizure warning signs occur. [synthesis]
Example language (illustrative): "This time, let's lose the round on purpose and see what your worry predicts will happen."
Watch for: the game itself becoming the avoidance, with the client playing instead of facing real situations.

4.13 Gamer groups (structured cooperative group play)

Purpose: to build social, communication and coping skills through multiplayer games in a group. The Moyer/Messer school-based programme:
- chose multiplayer games that promote cooperation and communication between teammates;
- ran exercises before and after play that taught social and coping skills;
- used trained volunteers to model and reinforce appropriate behaviour during play;
- ran a parallel parent support group. Rice has a chapter on gamer groups. One trial cited in Zayeni et al. used a commercial sports game with autistic children in supervised groups of 2–4. The Horne-Moyer review also describes GAMELAB, a structured group protocol for children with acquired brain injury in which game roles are used to target each child's individual goals (protocol details not publicly described). [source: Electronic Gaming Therapy site; Rice TOC chapter 7; Zayeni et al. 2020; Horne-Moyer et al. 2014]
Steps:
1. Screen members (4.2, 4.3) and keep groups small. Choose games that let several players share one console; newer versions of some multiplayer games need one console per player. [source: Horne-Moyer et al. 2014 for the console point]
2. Agree the group rules: respectful talk, taking turns on controllers, no trash talk, phones away.
3. Teach the target skill before play using a behavioural skills sequence: define the skill, model it, have pairs role-play it, then give feedback and prompts. Targets in the protocol reviewed included giving compliments, taking turns and making positive comments after a game. [source: Horne-Moyer et al. 2014]
4. Play a cooperative local-multiplayer game, with staff prompting and praising the target skill.
5. Debrief what worked.
6. Set a home or school practice task.
7. Hold a parallel or periodic carer session. [synthesis for ordering, based on the Moyer/Messer format]
Example language (illustrative): "Today's skill is calling out what you need from your team. I'll be listening for anyone who asks for backup."
Watch for:
- competitive escalation;
- exclusion or scapegoating;
- more skilled players taking over. Rotate roles and use cooperative rather than competitive modes.

4.14 Let's Plays and gameplay videos

Purpose: to use watching gameplay (YouTube "Let's Play" videos or streams) as a lower-arousal shared activity and a source of discussion material. Rice includes a chapter on this. [source: Rice TOC chapter 8] [steps: synthesis]
Steps:
1. Preview and choose a short clip that fits the client's age. Check the language and the comments section.
2. Watch it together.
3. Pause to discuss the player's emotions, choices and coping, and how the client would respond.
4. Link to the client's goals.
Example language (illustrative): "He just lost his whole save. What do you notice about how he handled it?"
Watch for: unvetted autoplay, advertising, and streamer content unsuitable for the client's age. Use embedded or offline playback with autoplay off.

4.15 Distraction during medical or distressing procedures

Purpose: to reduce distress during medical procedures through absorbing play. Moyer and Messer describe using handheld games this way. [source: Electronic Gaming Therapy site]
Steps:
1. Agree the plan with the medical team and the carer.
2. Have the child choose a familiar, pre-checked game.
3. Start play before the procedure begins.
4. Coach the child to stay focused on the game.
5. Debrief afterwards and praise their coping. [synthesis]
Example language (illustrative): "Your job is to get as far as you can in this level while the nurse does her job."
Watch for: do not use it where the child needs to watch or cooperate actively, and use it alongside medical pain management, not instead of it.

4.16 Exergames as an adjunct for motor and coordination goals

Purpose: to use motion-controlled commercial games to support motor coordination and activity alongside physiotherapy or occupational therapy. Trials reviewed used Wii Fit balance-board, Kinect and PlayStation Eye games with children with developmental coordination disorder, and supervised small-group exergaming with autistic children. [source: Zayeni et al. 2020]
Steps:
1. Coordinate with, or refer to, the child's OT or physiotherapist, who sets the motor goals.
2. The psychotherapist uses exergame sessions for motivation, turn-taking and frustration tolerance.
3. Clear the play space and supervise. [synthesis]
Example language (illustrative): "Your OT is working on your balance; here, let's work on staying cool when you wobble."
Watch for: falls and collisions. Do not set exercise or weight targets; motor goals belong to the rehabilitation clinician. Note that action games did not improve reading in the dyslexia trial reviewed. [source: Zayeni et al. 2020]

4.17 Parent and carer involvement and family co-play

Purpose: to reduce family conflict over gaming, help carers understand the child's games, and carry gains over to home. Bean's final chapter offers "guiding ideas and resources for therapists and families" (content not publicly described). Moyer and Messer ran a parent support group alongside the children's group. [source: Bean TOC chapter 11; Electronic Gaming Therapy site]
Steps:
1. In a carer session, share the formulation in the child's game metaphor (with the child's agreement).
2. Teach carers to check PEGI or ESRB ratings and descriptors, especially "Includes Random Items".
3. Help carers set up console and store parental controls: spending limits, purchase approval, chat restrictions and play-time limits.
4. Coach carers in a weekly co-play time, where the child teaches and the parent is curious and does not criticise.
5. Co-write a family gaming plan that covers:
  - when and where play happens (shared spaces, no devices in the bedroom overnight);
  - warnings before stopping, and how play ends;
  - spending rules;
  - online contact rules;
  - consequences that are not all-or-nothing.
6. Review the plan in later sessions. [synthesis]
Example language (illustrative, to a parent): "Ten minutes of letting her show you her world can do more for the arguments than another ban."
Watch for:
- carers using games only as reward and punishment;
- sudden total bans, which can lead to escalation and secrecy;
- parental conflict over the rules;
- carers' own heavy screen use. Address these with the carers directly.

4.18 Healthy-gaming plan, generalisation and ending

Purpose: to consolidate gains, balance gaming with sleep, school, activity and relationships, and fade gaming out of sessions. [synthesis; Rice's closing chapter, "Avoiding Nature Deficit Disorder", signals attention to offline and outdoor balance; content not publicly described]
Steps:
1. Review the skills learned, using the shared metaphor ("your inventory").
2. Plan offline activities that meet the needs games meet.
3. Agree warning signs of slipping into problematic play, and a plan for them.
4. Reduce in-session play over the final sessions.
5. Hand co-play over to carers.
6. Mark the ending, for example with a "final level" review. [synthesis]
Example language (illustrative): "What goes on your save file from our work, so you can reload it when things get hard?"
Watch for: regression as the ending approaches. Plan booster sessions if needed.

4.19 Serious games and virtual reality (pointer)

Rice includes chapters on serious games, games for health and virtual reality in psychotherapy. The Horne-Moyer review separates electronic games built for psychotherapy (EGP, or serious games, such as MoodGYM, SPARX, PlayMancer and Re-Mission) from commercial entertainment games used as an adjunct (EGE, such as Super Mario Bros., Guitar Hero and Wii Sports); this guide covers EGE. Purpose-built games tested in trials (for example SPARX for depression and MindLight for anxiety), computerised CBT and virtual-reality exposure therapy carry their own protocols and training requirements. Use them only according to their own guidance. Prescription game-based devices such as EndeavorRx are medical devices covered in Domain IX. [source: Rice TOC; Horne-Moyer et al. 2014; Zayeni et al. 2020; Contemporary Pediatrics]

5. Handling problems

Most of this section is the writer's synthesis. The Horne-Moyer review lists cautions (content, usage patterns, physical risks, distraction, impersonality and therapists' practical concerns); these are added, with sources, after the list below. Everything else is synthesis unless a source is given. [synthesis]

Stuck in game talk (sessions feel like hanging out).
- Name it kindly.
- Re-contract: game talk first, then a goal segment, with a timer.
- Use the metaphor (4.9) as a bridge rather than dropping games altogether.
- Illustrative: "I love hearing about the raid. Let's save ten minutes to use what you did there on Monday's problem."
Refuses to stop playing when time is up.
- Agree the ending ritual in advance (4.4): a five-minute warning, finish the round, then save.
- Choose games with short rounds and easy save points.
- If the refusals repeat, move to watching gameplay (4.14) or discussion only, and treat the transition difficulty itself as a target. Also look again for problematic gaming (4.2).
Frustration, rage or overwhelm during play.
- Stop the game and switch to the practised regulation skill (4.11).
- Lower the difficulty, or switch to cooperative or turn-based play.
- Debrief once the client is calm, not before.
- With serious aggression, end play for that session and review whether games suit this client at present.
Resistance or disengagement.
- Let the client choose the game (within 4.3) or teach you a new one.
- Boredom is expected; in one trial adolescents tired of a game after about four sessions. Vary the titles and formats. [source: Zayeni et al. 2020]
- Some clients, including some gamers, do not want games in therapy. Respect that and use your usual methods.
Non-adherence to home tasks or the family plan.
- Make tasks small and tied to the game ("one breath every respawn").
- Review the plan with carers, and remove all-or-nothing consequences.
- Check whether the plan was co-written or imposed.
Ruptures. Common causes include the therapist criticising the client's games, beating the client repeatedly, siding with parents about "too much gaming", or misunderstanding the game.
- Acknowledge the rupture and apologise specifically.
- Ask the client to correct you.
- Return to client-as-expert (4.5).
Therapist is not a gamer. You do not need to be; Rice says he is not one. [source: SJF release]
- Be honestly curious.
- Read the game's rating and summary page, and watch a short gameplay clip before the session.
- Do not pretend expertise.
Problematic gaming emerges mid-treatment. Pause therapeutic gaming and assess (4.2). Shift the focus to the gaming problem using CBT and family approaches, which the review names as common treatments. Refer on if this is outside your competence. [source: Wang et al. 2019]
Spending, loot boxes and gambling-like behaviour.
- Ask about spending openly and without shame.
- Help carers turn on spending controls (4.17).
- Explain what "Includes Random Items" means on PEGI and ESRB labels. [source: PEGI and ESRB pages]
- Treat secret or debt-level spending, or chasing losses, as a sign of gambling-related harm: assess, and refer to specialist gambling services where they exist.
Online safety and safeguarding disclosures. Clients may reveal contact from adult strangers, requests for images, threats, sextortion, bullying, exposure to over-age content, or self-harm or radicalisation material in gaming communities.
- Follow your safeguarding procedure and your mandatory-reporting duties, which differ by country, state and profession.
- Touch [synthesis]: co-play needs no physical contact. Keep controllers and devices separate, allow only brief child-initiated contact, follow your service's touch policy, and never any sexual touch.
- Preserve evidence: tell the client not to delete messages, and do not ask them to send you images.
- Inform the safeguarding lead, carers and police as your procedure requires.
- Help with in-game block and report tools.
- Never let an in-session game be used to contact the client outside sessions.
Seizure, or a possible seizure, during play.
- Stop the game, make the area safe, time the event and follow first-aid procedure. Call emergency services as indicated.
- Do not use flicker-heavy games again until there is medical advice.
- Epilepsy Ireland notes that games do not cause epilepsy but can trigger seizures in photosensitive people. [source: Epilepsy Ireland]
Violent or disturbing content raised by the client.
- Explore what the content means to the client and how they relate to it, rather than reacting with alarm.
- Assess any real-world threats or risk in the usual way.
- Remember that age-inappropriate exposure may itself be a safeguarding or parenting issue.
Carer or school objection.
- Explain the rationale, the safeguards and the planned fade-out.
- Offer a non-gaming alternative.
- Document consent.
Remote or telehealth play.
- Prefer shared-screen viewing or games with private sessions limited to the two of you.
- Never use public lobbies or your personal accounts. Use a clinic account with no friends list.
- Keep records of the platforms used, in line with your service's privacy rules.
Over-interpretation risk. Do not cite avatars, game choices or play behaviour as evidence of abuse, trauma or disorder in reports. Describe what was observed, and rely on validated assessments for diagnostic claims.

Further problems named in the Horne-Moyer review [source: Horne-Moyer et al. 2014; the responses are synthesis unless cited]:

The game distracts from the therapeutic work. The review notes that games can pull attention away from therapy. Keep play time-limited, say aloud what each game is for, and stop play if processing time keeps shrinking (see 4.6).
The client finds the work impersonal. Some clients found computerised CBT impersonal. Keep the relationship central: co-play, talk during play, and never leave the client alone with a game or program.
Long or frequent play at home. Extended play has been linked to social-emotional and educational problems, while co-playing and in-person social play appear protective. Build carer co-play and offline social play into the family plan (4.17).
Physical strain. Seizures and muscle strain are risks of all electronic games, and motion games can be demanding. Build in breaks and stretching; see 4.3 and the seizure response above.
Therapist practicalities. Barrett and Gershkovich's commentary, cited in the review, raises keeping up with technology, protecting the relationship, time and payment for game-based work, clients' access to unsuitable interventions, less face-to-face contact, and confidentiality of records. Respond by keeping a vetted game list, noting how much session time went on play, and keeping game accounts and screenshots out of identifiable records unless clinically needed. [synthesis for the responses]
Group play limited by hardware. Newer multiplayer games may need one console per player; choose titles with local multiplayer on one console.

Sources

Pages consulted:

Further pages consulted:

Books cited (details from publisher pages):

Bean, A. M. (2018). Working with Video Gamers and Games in Therapy: A Clinician's Guide. Routledge.

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