Critical Skills: Tabletop Role-Playing Games Enhance Social Skills in Psychiatry Residents

A novel study employing a qualitative design and adhering to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines has revealed the significant potential of tabletop role-playing games (TTRPGs) in enhancing the social skills and emotional development of psychiatry residents. The research, conducted between March and September 2021, utilized Dungeons & Dragons (5th edition) as a framework for social skills training, aiming to bolster empathy, communication, leadership, cooperation, and interpersonal connection among participants. This approach is particularly relevant given the inherent stressors and complex interpersonal dynamics of medical residency, further amplified by the isolation experienced during the COVID-19 pandemic.

The study, titled "Critical Skills," was meticulously designed to explore how medical residents experienced a TTRPG-based intervention and its impact on their social skills and broader personal domains. The methodology was grounded in principles of Cognitive-Behavioral Therapy (CBT), incorporating behavioral reappraisal, emotional identification, and perspective-taking, which align naturally with the interactive and reflective nature of role-playing activities.

Rigorous Methodology and Experienced Research Team

The qualitative study employed a robust framework, guided by the COREQ guidelines, ensuring a high standard of reporting for healthcare qualitative research. The research team comprised experienced professionals in both qualitative research and the therapeutic application of gaming. Dr. JRNV, a psychologist and researcher, served as the primary game facilitator (Dungeon Master), orchestrating the narrative scenarios and introducing structured social dilemmas aligned with targeted interpersonal competencies. Dr. VHOO, a psychiatrist, acted as co-facilitator. Individual interviews were conducted by Me. RAC and Me. JVCG, both psychologists who also provided crucial logistical support.

Crucially, all researchers possessed prior experience with role-playing games. This familiarity facilitated the technical management of the intervention format, ensuring a smooth and engaging experience for participants. Importantly, this experience did not involve pre-existing therapeutic relationships with the residents, preserving the objectivity of the research.

Recruitment and Participant Engagement

The study involved a convenience sample of 11 psychiatry residents from the Santa Casa de São Paulo School of Medical Sciences (ISCMSP). Recruitment occurred following ethical approval obtained in January 2021. During their initial week of residency, supervising physicians introduced the "Critical Skills" project. A subsequent videoconference provided detailed explanations of the project’s objectives, procedures, study phases, and ethical safeguards, after which informed consent was obtained.

While participants were informed about the general goals of social skills development, they were not briefed on the specific narrative structure or pedagogical framework. This deliberate approach ensured informed and voluntary participation while minimizing potential priming effects that could influence spontaneous in-game behavior. Residents were assured of their freedom to decline or withdraw at any time without academic or professional repercussions. No participants withdrew from the study, and all were over 18 years of age and provided written informed consent.

A Phenomenological Approach to Social Skills Development

The study adopted a phenomenological approach, seeking to understand the lived experiences of medical residents during the TTRPG-based intervention and how these experiences related to their social skills development. The intervention itself was designed as a Social Skills Training (SST) environment, drawing upon the theoretical-practical model of Del Prette and Del Prette (2019). This model categorizes social skills into essential behavioral classes—communication, empathy, assertiveness, conflict management, group coordination, and public speaking—which directly correspond to the interpersonal demands of medical residency.

The TTRPG format was intentionally crafted as a structured social simulation. By embodying fictional characters within a guided narrative, residents engaged in real interpersonal dynamics with a crucial layer of psychological distance. This facilitated exposure, emotional regulation, and perspective-taking, core mechanisms within CBT. The Dungeon Master strategically designed narrative conflicts that mirrored clinical realities, such as negotiating under pressure or resolving group disagreements, thereby eliciting the targeted interpersonal competencies. For instance, a scenario might involve negotiating a peace agreement, requiring assertiveness and collaboration, or confronting a challenge, necessitating collective decision-making and conflict management.

The evaluative construct of "Social Competence," defined as the integration of thoughts, feelings, and behaviors across various interpersonal contexts, served as the conceptual anchor for interpreting participants’ perceived changes in social functioning. The study design thus ingeniously combined a theoretically grounded SST framework, CBT-oriented narrative immersion, and phenomenological examination of lived experience. This allowed the TTRPG sessions to function as experiential simulations aimed at strengthening the crucial interpersonal competencies required in residency.

Each weekly session followed a structured five-step format: (i) rapport-building, (ii) task discussion, (iii) goal setting, (iv) gameplay, and (v) feedback. Gameplay was designed to elicit specific interpersonal behaviors, immediately followed by guided reflection that linked in-game decisions to real clinical challenges. This progression—from simulated practice to reflective integration—constituted the pedagogical mechanism through which gamification supported social skills development and insights related to mental health.

Data Collection: Individual Reflections and Group Dynamics

Data collection involved two primary methods: semi-structured individual interviews conducted prior to the intervention and focus groups held via videoconferencing after its conclusion.

Pre-Intervention Interviews: These interviews aimed to assess participants’ perceived social skills, prior role-playing experience, familiarity with game systems, and overall mental health during their residency. All interviews were audio-recorded for transcription and subsequent qualitative analysis.

Post-Intervention Focus Groups: Conducted separately from gameplay sessions to foster a structured reflective space, these focus groups addressed three key domains: experiences prior to the intervention, experiences during the RPG sessions, and perceived impacts on mental health, social skills, and quality of life. Three focus groups were conducted across two participant groups (n=6 in Group 1 for two sessions, n=5 in Group 2 for one session), with each session lasting between one and two hours. Transcriptions were reviewed for accuracy, and participants had the opportunity to clarify statements. While formal data saturation was not fully achieved due to the exploratory nature of the study, the material was deemed sufficiently rich for thematic analysis.

Audio and video data from intervention sessions were also recorded, and all materials were securely stored on password-protected servers and in restricted-access archives, adhering to institutional ethics protocols.

Intervention Design: Dungeons & Dragons as a Therapeutic Tool

The intervention utilized the tabletop role-playing game Dungeons & Dragons (5th edition), a collaborative narrative system where participants assume fictional characters to engage in structured social problem-solving. Despite its medieval fantasy setting, the pedagogical value lies in its interactive mechanics, which necessitate communication, negotiation, cooperation, conflict management, and decision-making under uncertainty—skills directly transferable to clinical environments.

A custom narrative campaign was developed to mirror interpersonal challenges commonly encountered in residency, such as coordinating treatment decisions, managing disagreements, responding empathetically to distress, and navigating emotionally charged interactions. The Dungeon Master, acting as facilitator, presented dilemmas, portrayed non-player characters, and modulated narrative complexity to ensure balanced participation and targeted skill practice.

Through character embodiment and collaborative storytelling, participants rehearsed interpersonal behaviors within a psychologically safe context. This structure ensured that the RPG sessions functioned not merely as entertainment but as intentional experiential simulations directly linked to the social and emotional competencies required in medical training.

Data Analysis: Uncovering Emerging Themes

The collected qualitative data underwent an inductive content analysis process to identify emergent themes from each developmental phase of the intervention. Two researchers independently and iteratively analyzed the transcripts, validating their findings through mutual consensus. Themes, categories, codes, and excerpts from participant narratives were managed using Miro, an online whiteboard platform with restricted researcher access. The analysis revealed four main themes: Individual Experiences of the Medical Residents During Isolation, Social Interactions Among the Medical Residents, The Experience of Playing RPG in the Critical Skills Project, and Impacts on Mental Health by Playing RPG.

Results: A Deep Dive into Resident Experiences

The findings from the content analysis painted a comprehensive picture of the residents’ experiences, highlighting both the challenges and the profound benefits of the TTRPG intervention.

Individual Experiences of Medical Residents During Isolation

The COVID-19 pandemic significantly exacerbated the already intense pressures faced by medical residents. Isolation protocols compounded long hours, difficult patient cases, and limited social interactions, leading to increased emotional and psychological strain. Residents struggled to balance professional demands with their mental well-being, resulting in heightened emotional and behavioral difficulties.

Stress-Related Residency Experiences

Participants reported a significant escalation in stress levels as their residency progressed, directly linked to growing work demands, including higher patient volumes and more complex clinical cases. These challenges were particularly acute at the CAISM (Center for Integrated Attention to Mental Health), a specialized service for patients with severe psychiatric disorders. Resident 5 articulated this burden: "I’m really stressed out at CAISM (Center for Integrated Attention to Mental Health), like really stressed. It’s ruining my life at this stage."

Emotional and Behavioral Difficulties

Beyond work-related stress, pandemic-induced isolation amplified existing challenges like shyness, anxiety, and a lack of assertiveness. The inability to interact in person heightened feelings of detachment and inadequacy, hindering the development of crucial communication and leadership skills. Resident 2 shared their struggle with assertiveness outside the game: "Outside the game, I struggle to impose my opinion. If I have any doubts, I am not sure what I want to do, it is my difficulty to impose what I think is right, what I think I want."

The RPG sessions provided a therapeutic release for some, allowing them to explore alternative behaviors in a safe environment. Resident 1 noted the empowering effect: "It would be more courageous, because I’m very worried, anxious, afraid of things going wrong, I do everything righter, and then with the character, this is not necessary, the world goes on without you being like this. It gave me more courage."

Challenges with Imagination in a Fantasy-Based RPG World

While many embraced the fantasy elements, some residents struggled with the imaginative aspects of the game. The abstract and symbolic nature of RPGs posed a mental block for those accustomed to structured, real-world medical environments. Resident 9 expressed this difficulty: "I have a huge mental block when it comes to imagining things, to the point that I struggled a lot with the scenario we created for the project, which was entirely unrealistic and completely unfamiliar to me."

Furthermore, two participants found it difficult to generalize behaviors learned within the RPG to real-life situations, feeling the fictional nature created a barrier. Resident 7 lamented: "The biggest difficulty I have to incorporate the gains I feel with Radja (participant’s character during the project) in my real life is because I know that the situations are unreal, they are all parts of a game."

Internet Use to Build Friendships

Pandemic-induced isolation significantly limited traditional friendship-building opportunities. While some residents were uncomfortable with online methods, others found it a viable alternative, especially within the structured RPG environment. Resident 5, with prior online RPG experience, found it familiar: "I used to play roleplaying games, but even when I played RPG on a forum that was just storytelling, I made some very lasting friendships."

Motivation for Playing RPG

Motivations varied. Some were driven by curiosity about RPGs, having never had the opportunity to play before. Resident 3 stated: "I had always been very curious to play, but I had never had the opportunity." Others, particularly those unfamiliar with games, were motivated by the social isolation of the pandemic. Resident 4 admitted: "I’ve never been into playing games, I’ve never been into video games. And I participated more because of the… Honestly, for being totally bored at home during this pandemic thing."

Social Interaction Among Medical Residents

The study revealed how the RPG intervention fostered social connections among residents who had limited prior interaction.

Relationship Between Residents Before Playing RPG

Before the RPG sessions, participants described limited social interactions due to the demanding nature of residency and pandemic-related barriers. Resident 1 felt a strong sense of isolation: "I think I was the one who knew people the least because I hadn’t studied with them. I’m not in anyone’s group."

Group Interactions on the RPG

The RPG format introduced unique dynamics. While characters were initially strangers, mirroring residency, some participants found it difficult to separate in-game relationships from real-life bonds. Resident 9 observed: "I didn’t feel that we built this friendship in the story. I felt that we were never able to separate the friendship from real life."

Fear of judgment also influenced decisions. Resident 10 described internal conflict: "I was very stuck, like, ‘Oh, what is the group going to think? What will the group think if I act too crazy here now?’ which I think is a trait of mine that I couldn’t get rid of during the game."

The Experience of Playing RPG in the Critical Skills Project

Participants developed distinct preferences and encountered various challenges during the RPG sessions.

Preference Among RPG Narratives

Some residents favored systems like "The Call of Cthulhu" for their grounded, reality-based storylines that mirrored ethical dilemmas in medicine. Resident 3 noted: "I was just thinking that for the general public… maybe Cthulhu would fit better, because it doesn’t require so much immersion and doesn’t have a complex fantasy."

Others preferred the high-fantasy of Dungeons and Dragons, appreciating the freedom to explore new behaviors without real-world consequences. Resident 6 explained: "I felt that in the fantasy world I had a lot more options to… to ‘trip’ and to be much more protected from the consequences of my actions." The inclusion of shorter "one-shot" sessions was also suggested for diversifying experiences.

Preferences Among Game Modes

Preferences varied between face-to-face and online modes. Many favored face-to-face for direct communication and non-verbal cues. Resident 5 stated: "I prefer it face-to-face because I think there’s a part that we lose from playing online, which is a character interpretation thing, eye to eye and reaction." Conversely, some appreciated the online format for its convenience and reduced social anxiety. Resident 7 felt more "protected" online. A hybrid model was suggested to combine the benefits of both.

Character Creation

Character creation offered a powerful avenue for self-exploration. Many created characters mirroring themselves, allowing them to address personal challenges. Resident 6 shared: "I created a character totally projecting myself. It was who I am, expansive, inappropriate and sometimes unhappy in most of its comments, but I was trying, as time went on, to use the session to work out some things I do that bothers other people on a day-to-day basis."

Others created characters with desired traits, like assertiveness. Resident 8 found it helpful: "Imposing limits, which is something I have a little difficulty doing in my daily life. And then being in the role of Nina made me a lot more comfortable doing that." Strategic character selection to ensure group diversity and balance was also noted, mirroring medical team collaboration.

However, the complexity of character creation could be overwhelming for beginners. Resident 3 found it difficult: "At first, I was trying to create the character thinking of a story, only making the more technical decisions of skills, class and race, secondarily, and I was finding it more difficult to adapt because I didn’t really know the rules and possibilities of how to execute the ideas." The degree of self-projection in character creation was also debated, with some feeling it limited growth while others found it enhanced self-evaluation.

Character Interpretation

Embodying characters allowed residents to experiment with new roles and attitudes. Resident 2 found it insightful: "One thing that brought me closer was that I took a class I’d never played before and a race I’d never played before. So, I am discovering new things on how to readjust some old habits I had in relation to the game itself."

Moral and emotional complexities emerged when character actions conflicted with personal values. Resident 2 expressed difficulty playing an evil character: "I never play with evil characters because I can’t interact with other characters having an evil character." Some struggled to fully integrate character backstories, mirroring clinical limitations. Playing a character of a different gender presented unexpected challenges for one male resident, prompting reflection on social roles. A competitive mindset, influenced by video game experience, also affected some participants’ engagement.

RPG Analysis and Criticism

Participants offered constructive criticism. Technical issues with online tools sometimes hindered interaction. Resident 3 noted timing issues in online turn-taking. Session duration was also a concern, with some finding four hours excessive. Resident 1 felt it was "a little too much" for newcomers.

Difficulty immersing in the fantasy world was noted by those less accustomed to playful activities. Resident 1 found it hard "to let go and do the role playing myself." Limited understanding of game mechanics also posed challenges. Resident 8 commented on spell selection: "I think it made it difficult for me even in a matter of ‘oh… which spell should I cast?… You know, I had zero knowledge… and barely knew the spells I had."

Suggestions were made for the Dungeon Master to be more active in presenting challenging situations, and for feedback forms to include more open-ended reflection spaces. Resident 7 wished for "some more space" on forms for personal thoughts.

Impacts on Mental Health by Playing RPG

The TTRPG intervention demonstrably impacted residents’ social skills, emotional development, and group dynamics.

Impacts on Social Skills and Emotional Development

Residents frequently discussed the positive effects of RPG sessions on their social skills and emotional well-being. The immersive nature of role-playing provided a safe and supportive environment for practicing assertiveness, empathy, and reflexivity. Resident 5 found it "kind of therapeutic for me in some ways, I’m able to realize some things about my behavior." The low-stakes environment allowed for experimentation and risk-taking without fear of real-world consequences. Resident 6 highlighted this: "I believe one of the great aspects of RPGs is that they allow us to find a certain peace with our decisions and recognize that sometimes, things are beyond our control."

Impacts on Group Relationships, Coordination, and Cooperation

RPGs fostered stronger group cohesion and teamwork. The collaborative nature helped build rapport, particularly among peers with limited prior interaction. Resident 5 emphasized the importance of the bonds formed: "I think the first thing is the bond between us, we play among us who are residents. I think this strengthens our group as a whole, you know?" The non-hierarchical structure allowed leadership to emerge organically, mirroring interdisciplinary teamwork in medicine. RPGs also served as a vital social outlet during pandemic isolation. Resident 4 found it "the way to socialize, you know? To have a minimum of interaction outside your house."

Residents’ Perceptions of Clinical Interventions with RPG

Participants strongly believed RPGs are well-suited for therapeutic interventions with children and adolescents, who may resist traditional treatments. Resident 11 suggested it would have been "really revealing" during their own teenage years, helping develop security and a place to speak.

The potential for RPGs in treating social anxiety and interaction-related disorders was also noted. Resident 2 envisioned it as a "less abrupt exposure" for socially phobic patients. However, caution was advised for patients with cognitive or psychotic disorders, such as schizophrenia or autism, due to the need for abstraction and projection. Resident 2 warned: "Be careful with schizophrenics, okay?! One could go psychotic and start to think he’s the real character." This highlights the need for careful monitoring and tailored interventions.

The "Critical Skills" study underscores the significant therapeutic potential of TTRPGs in enhancing crucial social and emotional competencies among medical residents, offering a unique and effective approach to professional development, particularly in challenging environments.