Sally Merry, University of Aukland
Traditionally, counselling sessions have involved fact to face meetings between patients and doctors or therapists but they didn’t suit everybody and it wasn’t always convenient to go and sit down for an hour to meet somebody. But now, Sally Merry who is at the University of Auckland has developed an online solution to the problem using an eTherapy video game that she calls Sparx. She explains why they came up with this idea...
Sally - It does seem obvious although I think that there are a number of steps along the way. So, I have been met with a great deal of scepticism by therapists who say, “How on Earth can you replace face to face therapy?”
Chris - Do you think they might have a vested interest?
Sally - They could, possibly. But I think they also do make a good point in that, interactions between two people are quite complex and there are a lot of subtleties within that. And how do you actually get a computer which is basically metal and plastic and so on, and get an interaction that somewhat mimics what you might actually do in that therapy session. I think what we’d actually done in Sparx is, we’ve actually taken both afantasy game format but also, some of the eLearning theories where you actually think about how do people interact with computers and what are the things that make it compelling. What keep people in there and how might you actually – what we’re actually trying to do here is change habitual ways of thinking and deliver basically a cognitive behavioural therapy through the medium of an interaction online.
Chris - Or if you link it to 888 Poker or online bingo you'd be sorted, wouldn't you?
Sally - Yes, I think that might be some slightly some for interaction of course.
Chris - But I mean, what sorts of conditions could you treat with this?
Sally - Well, I think we’re just at the start of exploring what might be done here. So, what we’ve actually done is, this is actually targeted to depression in young people and the cognitive behavioural therapy model that we’ve actually used is one that's being proven in fact to face therapy. I think one of the things that makes it one of the easier things to perhaps put online is that we’ve actually got quite a clear theory behind it where the whole idea that your feelings just happen to you is not actually true. What you actually think about things and what you actually do impact on your feelings. You don't just have to be passive recipient. We can extend that very easily to anxiety disorders and there are effective eTherapies for anxiety disorders as well. We’re thinking about where can we go next. So, might we use it to help substance use disorders or can we help parenting, and can we teach people social skills, and should we and can we be using some of the social media to create therapeutic communities online and so on. So, I think there's a huge number of things that we can do. There's quite a lot of things where we could perhaps link into some of the biology. So, if you're stressed, your heart rate variability goes down. Generally speaking, your heart rate fluctuates and if you're not stressed out then there's quite a big fluctuation with how you breathe. If you are stressed out then your heart rate variability goes down because your heart rate is at a higher level. You can actually measure this obviously using pulse things and there are actually some games as – there's a lovely game called “Journey to the Wild Divine” and it’s played with clips on people’s fingertips. You clip in and then you just do it with your mind. So, you can go into this game and you can spin wheels, you can shoot arrows, you can balance rocks, and you have to do it, just with how you're thinking.
Chris - So, if you think yourself into a calm mental demeanour thinking, you make a programme so that the success in the programme is linked to somebody adopting the right sort of physiology, the right level of calmness. And this, without them even realising it, their thinking themselves into a calm place. And so, your sort of app would approach this in the same sort of way?
Sally - Sparx doesn’t do this. This is actually looking to where we might be going. Sparx is actually very active. So here, when we were developing it, a lot of people have taken cognitive behavioural therapy, they put onto box and then putting it onto lines. Lots of people have put, what I think about as manuals online. So, there's lots of writing and this stuff that tells you what you can be doing. And we tried some of this approach with young people some of our early iterations. The nice thing about working with young people is they do give you very honest feedback. They say, “This is really boring. It sucks. We don't want to do this. We don't want to read anything. We want to do stuff.” Particularly, the boys wanted to shoot stuff. This is a game or an intervention for depression so we didn’t want anybody to die. So, we had to think about what we’re going to do. So, we created a story in every bit of cognitive behavioural therapy that we could think of, we tried to think about, what could you do in a fantasy game format? So, one of the things that we actually did was, we had to deal with a shooting issue. So, in the game the idea is that the world has been infested with nets which are gloomy negative automatic thoughts. And so, we decided that's actually quite a good thing that you could shoot. So, we shoot this.
Chris - On a swat?
Sally - Yeah.
Chris - Splat with a swatter.
Sally - That's right, but you also want to convert them and think about how you can actually change things. People are prone to depression, tend to take a bit of a negative view on life and then interpret the world in a negative way. How can you actually change that and how can you transform that? So, we have swamp province which is infested with nets and the nets come flying at you and they say awful things like, “You're a loser” and then you have to work out, “What kind of a net is this?” If you can classify it correctly, you get nice little Sparx. The Sparx sends with smart, positive, active, realistic X-factor thoughts. So, if you can classify your net properly then out comes the spark that tells you, “You're not a loser at all. You're just giving it a good go and you need to think about yourself in a different way.” So, it’s actually changing things and trying to help, that's called cognitive restructuring people to do that.
Simon - Does it actually work? Have you been able to measure its success and how effective this is versus face to face because...?
Chris - I thought you're going to say versus Facebook.
Sally - There's a whole another story. Yeah, it does work. We’ve done a big trial in New Zealand. We tested it with 187 young people in New Zealand. We randomised them to have their treatment as usual which is mostly face to face counselling with mostly very good counsellors and Sparx was as good as the face to face therapy.
Chris - I think it also is popular or effective because people do it on their terms when they want to do it whereas if you say to someone, “You've got to turn up to this appointment at this time.” if someone is not in the mood for whatever reason for going and engaging in that appointment at that time, it’s not going to work as well.
Sally - Absolutely and in fact, I'm a child and adolescent psychiatrist. I don't find that young people are necessarily beating their way to my door. So yes, this means that people can do it anywhere anytime in privacy. Mental illness still carries quite a stigma to it. But the other thing is, we don't have enough therapists. Depressive disorder is one of the most common and most expensive illnesses in the world. About three quarters of young people with depressive disorder will never get any help for it.