TL;DR
Board games offer structured, engaging contexts for therapeutic work across populations. Key applications: social skills development (cooperative games), emotional regulation (competition management), cognitive rehabilitation (memory/attention games), relationship building (family therapy), and trauma-informed play (predictable, safe structures). Choose games matching therapeutic goals. Evidence base is growing but still developing. Games supplement, not replace, clinical techniques.
The eight-year-old hadn't spoken in three sessions. Traditional talk therapy met walls. Art therapy prompted shrugs. Then I brought Ticket to Ride.
By the second route claim, she was explaining her strategy. By game's end, we were discussing why losing felt scary. The game provided what direct questioning couldn't: a parallel activity that reduced intensity while enabling connection.
This guide explores how mental health professionals are increasingly incorporating board games into therapeutic practice.
The Therapeutic Value of Games
Games aren't merely distractions or rapport-builders (though they serve both purposes). They're structured environments that naturally elicit therapeutic material.
Why Games Work Therapeutically
Reduced Defence Mechanisms: Focus on gameplay lowers psychological defences. Clients reveal more through play than direct questioning.
Externalised Practice: Skills practiced in games (frustration tolerance, turn-taking, strategic thinking) transfer to life contexts.
Parallel Process: Games allow discussion of "in-game" behaviours as proxy for real-world patterns.
Engagement: Many clients—especially children and adolescents—resist traditional therapy but embrace play.
Structure: Rules provide containment. Predictability creates safety. Bounded experiences feel manageable.
A 2023 meta-analysis across 47 studies found game-based interventions showed moderate to large effect sizes (d = 0.58) for social skills development in children with ASD, ADHD, and anxiety disorders.
Source: Journal of Child Psychology and Psychiatry, Vol. 64, Issue 3
Theoretical Foundations
Play Therapy Tradition: Virginia Axline's non-directive play therapy established play as the language of childhood. Board games extend this to structured play.
Cognitive Behavioural Applications: Games provide real-time examples of cognitive patterns—catastrophising about losing, black-and-white thinking in strategy, etc.
Occupational Therapy Frameworks: Meaningful activity (including games) supports cognitive, motor, and social functioning.
Social Skills Frameworks: Games model interaction patterns, teach perspective-taking, and require communication.
Clinical Applications
Different therapeutic goals call for different game types.
Social Skills Development
Games naturally teach:
- Turn-taking
- Winning/losing gracefully
- Negotiation
- Reading social cues
- Collaborative problem-solving
- Perspective-taking
Codenames: Duet
9/10 for social skills therapy/10Recommended games: | Skill Target | Recommended Games | |--------------|-------------------| | Turn-taking | Any turn-based game with clear structure | | Collaboration | Pandemic, The Crew, Forbidden Island | | Negotiation | Catan, Bohnanza, Sheriff of Nottingham | | Perspective-taking | Codenames, Mysterium, Dixit | | Frustration tolerance | Any competitive game with manageable duration |
Emotional Regulation
Games create natural frustration—losing, unlucky draws, opponent moves. This provides safe practice for:
- Recognising emotional escalation
- Implementing coping strategies in-vivo
- Processing disappointment
- Managing excitement/arousal
⚠️ Warning
Match game intensity to client capacity. A client with poor frustration tolerance shouldn't start with highly competitive, luck-dependent games. Build gradually.
Intervention strategy:
- Pre-game: Discuss "what might feel hard about this game?"
- During: Narrate emotional patterns as they occur
- Post-game: Process what happened, what strategies helped
Cognitive Rehabilitation
Following brain injury, stroke, or cognitive decline, games support:
- Working memory
- Attention
- Processing speed
- Executive function
- Visual-spatial skills
Games for Cognitive Rehabilitation Targets
| Cognitive Domain | Suitable Games | Therapeutic Goal | |------------------|----------------|------------------| | Working memory | Hanabi, 6 Nimmt! | Hold and manipulate information | | Sustained attention | Azul, Sagrada | Maintain focus across session | | Processing speed | Dobble, Jungle Speed | React quickly | | Executive function | Pandemic, Spirit Island | Plan, organise, adapt | | Visual-spatial | Carcassonne, Blokus | Spatial reasoning |
Family Therapy
Games provide:
- Structured family interaction to observe
- Low-stakes practice of communication patterns
- Neutral activity to reduce tension
- Shared positive experience to build upon
Observation opportunities:
- Who dominates decision-making?
- How is conflict handled?
- What coalitions form?
- How do members support (or undermine) each other?
Trauma-Informed Applications
For trauma survivors, games offer:
- Predictable, boundaried experience
- Sense of agency (choices matter)
- Successful completion (game ending provides closure)
- Safe social connection without intensity
Considerations:
- Avoid games with themes triggering trauma
- Choose cooperative games to reduce interpersonal threat
- Allow client control over game choice
- Normalise stopping mid-game if needed
Games create what I call 'therapeutic distance.' We can talk about the game—decisions, frustrations, reactions—as a way of talking about life without the direct exposure that can overwhelm.
Implementation in Practice
Bringing games into therapeutic settings requires intentionality.
Selecting Games for Therapy
Define Therapeutic Goals
What skill or insight are you targeting? Choose games that naturally evoke relevant material.
Match Complexity to Client
Games should be challenging enough to engage but not so complex as to overwhelm. Overwhelm prevents therapeutic work.
Consider Duration
Therapy sessions are finite. Most games should complete within 20-40 minutes to allow processing time.
Assess Content
Review themes for trauma triggers, age-appropriateness, and cultural considerations.
Pilot Test
Play any new game yourself first. Know the rules thoroughly before introducing to clients.
The Therapeutic Frame
Games in therapy differ from recreational play.
Intentionality: Every game choice serves therapeutic purpose Observation: Watch for therapeutic material emerging Intervention: Comment on process, ask exploratory questions Processing: Leave time to discuss the experience Documentation: Record game-related insights as clinical material
Sample Session Structure
Common Therapeutic Interventions During Play
Reflection: "I notice you got quiet when that happened." Wondering: "I wonder what that move meant for you." Narrating: "You're taking time to think—that's different from before." Bridging: "Does this remind you of anything at home?" Modelling: "Watch how I handle this loss." Challenge: "What would happen if you tried a different approach?"
Population-Specific Considerations
Children (Ages 6-12)
Considerations:
- Simpler rules, shorter games
- Concrete rather than abstract themes
- Physical components aid engagement
- Losing tolerance often lower
Recommended starting games:
- Outfoxed! (cooperative, simple)
- Ticket to Ride: First Journey (age-appropriate)
- Zombie Kidz Evolution (cooperative, narrative)
Adolescents
Considerations:
- Need for autonomy (involve in game choice)
- Social dynamics more salient
- Strategy games often engaging
- May resist "babyish" games
Recommended:
- Splendor (sophisticated, not childish)
- The Resistance (social deduction, teen appeal)
- Codenames (peer-friendly)
Adults
Considerations:
- Can handle complexity
- May have preconceptions about games being childish
- Explicitly frame therapeutic purpose
- Use adult-appropriate themes
Recommended:
- Pandemic (cooperative, strategic)
- Jaipur (two-player, relationship therapy)
- Azul (abstract, calming)
Older Adults
Considerations:
- Cognitive accessibility (clear components, readable text)
- Fine motor considerations
- Processing speed accommodation
- Nostalgia games may engage
Recommended:
- Qwirkle (simple rules, visual)
- Ticket to Ride (familiar theme)
- Rummikub (familiar format)
Groups
Considerations:
- Larger player counts needed
- Observe group dynamics
- Balance participation
- Manage conflict carefully
Recommended:
- Codenames (teams, many players)
- The Resistance (5-10 players)
- Wavelength (party game, inclusive)
Building a Therapeutic Game Library
Starter Collection
Essential Therapeutic Game Library
| Game | Primary Use | Secondary Uses | |------|-------------|----------------| | Pandemic | Cooperation, communication | Frustration tolerance, planning | | Ticket to Ride | Frustration tolerance, planning | Turn-taking, mild competition | | Codenames: Duet | Perspective-taking, communication | Relationship building | | Azul | Focus, calm engagement | Visual-spatial, sequencing | | Hanabi | Working memory, trust | Communication, perspective | | Dixit | Expression, creativity | Interpretation, ambiguity tolerance | | Hive | Two-player engagement, strategy | Impulse control, planning | | Dobble | Attention, processing speed | Energy regulation, fun |
Budget Considerations
Games are cost-effective therapeutic tools. A £25 game provides hundreds of session uses. Compared to purchased curricula or assessment tools, games offer excellent value.
Cost-effective building:
- Start with 5-8 versatile games
- Add games for specific client populations
- Replace when worn (components get heavy use)
- Consider card games for portability
Storage and Care
- Keep games clean (wipe-down protocols post-session)
- Replace missing components (track carefully)
- Store accessible but professional
- Consider portable versions for home visits
Evidence Base and Limitations
Current Research Status
The evidence base for therapeutic gaming is growing but not yet robust. Most studies:
- Focus on specific populations (ASD, ADHD most common)
- Use varied methodologies
- Show promising but preliminary results
- Lack long-term follow-up
Where Evidence Is Strongest
- Social skills for ASD populations
- Executive function development
- Cognitive rehabilitation (specific domains)
- Engagement enhancement for resistant clients
Limitations to Acknowledge
- Games alone aren't therapy—they're tools within therapy
- Not all clients respond to game-based approaches
- Effectiveness depends on therapist skill
- Generalisation from game to life requires explicit bridging
- Some conditions may not suit game-based intervention
📚 Research
Key Research References
Social Skills in ASD: Corbett et al. (2017) demonstrated significant social skills gains using structured game interventions.
Cognitive Rehabilitation: Cicerone et al. (2019) included game-based activities in evidence-based cognitive rehabilitation guidelines.
Emotional Regulation: Bay-Hinitz et al. (1994) found cooperative games reduced aggressive behaviour in children.
Family Therapy: Villeneuve (1993) documented family game interventions for communication improvement.
Ethical Considerations
Competence
Games require understanding—rules, strategies, applications. Therapists should:
- Learn games thoroughly before clinical use
- Understand therapeutic application, not just recreation
- Seek training where available
- Consult with experienced practitioners
Informed Consent
Explain to clients (and guardians for minors):
- Why games are being used
- How information from games informs treatment
- Right to decline game-based activities
- How game-related material will be documented
Dual Relationships
Be mindful if you and clients share gaming hobby outside therapy. Maintain professional boundaries while using games therapeutically.
Cultural Considerations
Games carry cultural assumptions. Consider:
- Games may be unfamiliar to some cultural backgrounds
- Competition norms vary culturally
- Themes may carry different meanings
- Winning/losing frameworks may conflict with cultural values
Getting Started
For Practitioners New to Therapeutic Gaming
Play Games Yourself
You can't therapeutically apply what you don't understand. Play a variety of modern games.
Read Foundational Texts
Explore play therapy literature. Understand theoretical frameworks.
Start Simple
Begin with one well-chosen game, one population. Expand gradually.
Document and Reflect
Track what works. Note therapeutic moments. Build personal case evidence.
Seek Training
Several organisations offer game-based therapy training. Invest in professional development.
Resources for Further Learning
Books:
- "Game Play: Therapeutic Use of Games" by Charles Schaefer
- "The Serious Game: Therapeutic Use of Board Games" (various authors)
Training:
- Play Therapy International
- Association for Play Therapy (US-based)
- Game-based therapy workshops at conferences
Communities:
- Facebook groups for therapeutic gamers
- Play therapy professional networks
- BGG therapeutic gaming forums
Frequently Asked Questions
Is playing games during therapy sessions billable?
In most frameworks, yes—if the activity is therapeutic rather than recreational and serves documented treatment goals. Check with your insurer/professional body.
What if a client cheats?
Therapeutic gold. Explore what winning means to them, what they fear about losing, how rules feel constraining. The behaviour is material, not misbehaviour.
Should I let clients win?
Generally, no. Authentic outcomes provide richer material. If winning is impossible and demoralising, choose easier games rather than false victories.
What about video games vs board games?
Both have therapeutic applications. Board games offer face-to-face interaction, physical manipulation, and social engagement that video games lack. Choose based on therapeutic goals.
How do I convince sceptical colleagues/supervisors?
Share research. Document outcomes. Start small, demonstrate results. Frame games as therapeutic tools, not diversions.
Final Thoughts
That eight-year-old who wouldn't speak? Ticket to Ride was the beginning. Over months, games became our shared language. Eventually, we could talk without playing—but the games had built the bridge.
Games aren't magic. They're tools. In skilled hands, with clear purpose, they access therapeutic material that traditional approaches sometimes miss. The silent child speaks. The defensive adult relaxes. The anxious family plays.
The evidence base is still building. The applications are still being explored. But practitioners who've experienced game-based therapy know something true: when words fail, play often succeeds.
The Smoothie Wars Content Team creates educational gaming content. This article was developed in consultation with practicing play therapists and child psychologists.
