CAMHS Campfire - Tech delivered CBT for anxiety Tuesday 24 May 2022, 5pm UK Abridged version, names shortened other than panelists 17:11:15 From CB to Everyone: Can I ask what type would you recommend for a very intelligent autistic 13 yr old, with high anxiety which makes him non-verbal in most situations? 17:11:18 From Marco to Hosts and panelists: Any comparison between face to face and internet guided ? 17:12:41 From Amna to Everyone: hi what would you recommend a smart 15 year old who would self harm due to anxiety? 17:12:42 From Douglas Badenoch to Everyone: Marco, there are some blogs here that address your question (i.e. direct comparisons). NB - includes studies on adults: https://www.nationalelfservice.net/tag/computerised-cognitive-behavioural-therapy/ 17:13:22 From Marco to Hosts and panelists: 👍 17:13:27 From Maria Loades to Everyone: Marco, thanks for the question about face to face vs internet guided. There is some evidence of equivalence e.g. see this review in adults https://www.ijpvmjournal.net/article.asp?issn=2008-7802;year=2021;volume=12;issue=1;spage=153;epage=153;aulast=Esfandiari 17:14:39 From Maria Loades to Everyone: Amna, it's a great question. It depends on what the understanding is of the self-harm, what function it serves and how risky it is, but it sounds like perhaps something that builds distress tolerance, be it tech delivered or face to face, is important 17:16:33 From Maria Loades to Everyone: CB, thanks for the question: Can I ask what type would you recommend for a very intelligent autistic 13 yr old, with high anxiety which makes him non-verbal in most situations? - my response is that of course it depends, but CBT can be used in more visual ways, but there are also gaming apps which have been developed as therapeutic games (e.g. SPARX for adolescent depression) 17:17:15 From Laurie to Everyone: Does that treatment as usual comparison with computer-based CBT include face-to-face treatment? 17:17:21 From Marco to Hosts and panelists: Does that mean that young people on waiting list will be offered tech guided support but would that substitute therapy or only support till they are seen? 17:18:24 From Maria Loades to Everyone: Marco, care pathways seem to differ in different places, and I hope that there would always be options for young people - e.g. for those who do not want digital input, there should be other options 17:18:52 From Maria Loades to Everyone: Laurie, I'm not sure which study you are referring to specifically? 17:18:59 From Marco to Hosts and panelists: 👍 17:19:16 From Paula to Hosts and panelists: Theres a difficulty I have found with young people especially those experiencing social anxiety on the ASD spectrum as I am both a Therapist also with a child aged 15 with ASD and ADHD and SPD. What works for my child is of a regular consistent face to face person that gets involved with my family and that my child has accepted as a person of trust. I feel the main issues stem not from the tools used as he is happy to complete things and is also happy to look at educational information however only the tools of self regulation can in reality be taught face to face with a child with non verbal communication difficulties. C Burrows - What I did recently in a school was got to know the childs focal topic of interest which was actually all around dischord servers and anime and whilst the child taught me we then did the therapy. That was the only way this child with ASD would “buy in to myself as their Therapist”. 17:19:16 From Chloe to Everyone: I would be interested to know whether Digital CBT is advanced enough to tailor itself to a child's goals? A thought that came from what Matti was saying about are they getting out of it what they need? 17:19:23 From Amna to Everyone: Thanks @Maria 17:19:26 From C B to Everyone: Thank you Maria. 17:20:40 From Laurie to Everyone: Maria, I think my typing was lagging behind the discussion a bit! Andre has just covered what I had in mind. Did Matti and colleagues include unpublished, 'grey' studies in their review? 17:21:46 From Douglas Badenoch to Everyone: No grey literature search, Laurie, but they did hand search papers and contact authors 17:21:54 From Arwa to Everyone: Just to clarify, is digital CBT similar to silvercloud, i.e., a course in which the young person completes? 17:22:09 From Paula to Hosts and panelists: Our children are more resourceful than we think. The other day I was shown a dischord server specifically created by a child on the ASD spectrum for those with Personality Disorders. Here on line each childs personality can then talk to the other persons personality! It really opened my eyes to even think that something like this existed. 17:22:28 From penny to Everyone: that is a form of it 17:22:50 From Arwa to Everyone: Okay thank you 17:22:53 From Douglas Badenoch to Everyone: Great point Paula, they are setting up their own spaces to support each other. 17:22:55 From ACAMH to Everyone: Do take a look at a project that Maria is working on - COMET-GB https://upenn.co1.qualtrics.com/jfe/form/SV_28ZieA5BVDp1hTo testing an online intervention for student wellbeing. Plus we have a podcast coming out on Monday all about it. Follow twitter @CometGb 17:23:22 From Maria Loades to Everyone: Arwa, silvercloud is an example of a company who have digital health products - it is based on CBT. 17:23:47 From Claire Pearson - Sheffield CCG to Everyone: I've been surprised how phone appointments over covid worked so well - so can see that without having to manage the physical reactions of the therapist might be helpful 17:23:59 From Arwa Katab to Everyone: Thank you for clarifying Maria 17:24:00 From Marco to Hosts and panelists: When we say better would that mean feedback from Yp or clinical improvement of symptoms ? ( outcome measures) 17:24:48 From Paula to Hosts and panelists: One of the dischord servers also has an in uilt bot which answers intelligently their questions! It was amazing however being involved with the child viewing this I did have my concerns as to safeguarding especially if the child became so stressed they would then go into crisis and there was only a bot responding which would not be appropriate 17:25:07 From Amna to Everyone: yes here to learn. 17:25:13 From franks to Everyone: My reading of the literature & personal experience is that digital interventions are equally effective as in-person interventions & may be preferred by some. I agree with Yasmin that for some people digital is better as it enables them to be more open about their difficulties. 17:28:05 From CTC Psych to Everyone: What was that acronym, beginning with critical appraisal (CA)? 17:28:17 From Douglas Badenoch to Everyone: Critical Appraisal Skills Programme 17:28:33 From CTC Psych to Everyone: thank you very much 17:29:38 From Douglas Badenoch to Everyone: Sorry about the aspect ratio! Not sure what happened there 17:30:45 From Laurie to Everyone: Could the exclusion of grey literature increase the chance of over-estimating positive effects i.e. confirmation bias? 17:30:51 From Maria Loades to Everyone: Great point Frank, thank you :-) 17:32:38 From Douglas Badenoch to Everyone: That’s definitely possible Laurie, although I think it's unlikely there would be many RCTs in grey literature. Could be wrong though! 17:32:47 From Maria Loades to Everyone: Laurie, I'm sure that Matti has some thoughts about that. It's so tricky with grey literature as that is potentially the risk, given the potential for publication bias. But on the other hand, the peer review process that precedes and gatekeeps publication hopefully means that rigour and robustness in the science that gets published has been assessed and to some degree, at least peer-approved. We couldn't be similarly confident about grey literature which may not be well conducted/reported 17:32:56 From Penelope to Everyone: Useful study about clients with addictions - since COVID pandemic started remote session attendance increased, with time and cost of travel being amongst factors but may have been an adults only study 17:33:40 From Douglas Badenoch to Everyone: Laurie, unpublished research would be a more likely source of bias. 17:34:13 From Maria Loades to Everyone: A real benefit of digital for young people is that the amount of time taken out of school to attend face to face clinics which still, in the UK, tend to be 9-5 Monday to Friday, is reduced, and flexibility increased. But it's not for everyone 17:34:27 From Laurie to Everyone: What was the reason for using odds ratio rather than effects sizes to summarise and compare the findings? 17:34:43 From Adam to Everyone: I have used and recommended phone based and virtual Person Centred Counselling, Mindfulness and other emotional wellbeing approaches, so could easily see CBT being effectively delivered in similar ways. Easy of access has been a clear benefit. 17:36:02 From Matti Cervin to Hosts and panelists: Laurie: I think there is a risk of overestimating effects by only including published papers. We also searched for pre-registered protocols and there were some studies that were not published at the moment (but they are now). Conducting an RCT is a very big investment (time and money) and perhaps this makes unpublished studies less likely. What is often done is that studies get published but that outcome measures may be selected so that effects can be ”proved.” This would not be a problem in this case as we had pre-defined outcome measures. 17:36:14 From Amna to Everyone: Thank you 17:36:22 From Maria Loades to Everyone: Adam, as I understand it, Odds Ratios are a measure of effect size. 17:36:42 From Olga to Everyone: Thank you 17:38:08 From Tatiana to Hosts and panelists: which one of tCBTs would you recommend? 17:39:32 From Maria Loades to Everyone: Tatiana - my answer is that it depends. On availability, presenting issue, age of child, etc. I encourage you to look at the table S1 at the bottom of Matti's published review - https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13485?af=R which gives more detail of each of the interventions included. 17:39:53 From Paula to Hosts and panelists: The government ad the idea that all Mental Health would be able to be routed through via things like the One You App to your Local area giving a range of upto date apps for people to use. I once followed this system yet I could see that if our systems make too many apps then we are in danger of getting lost inside a large computerised pathway. 17:39:55 From Tatiana to Hosts and panelists: thank you 17:41:10 From Paula to Hosts and panelists: https://futurecarecapital.org.uk/latest/new-nhs-criteria-for-digital-health-tools/?utm_source=bing&utm_medium=cpc&utm_campaign=DSA_generic&utm_term=futurecarecapital%20org&utm_content=Entire%20site 17:41:12 From Laurie to Everyone: Looking at it in terms of benefits to all patients or clients, could effects sizes have been more useful in comparing interventions e.g. face-to-face vs tCBT? What about the 6/10 who did not experience remission- did they gain any benefit? 17:41:34 From Paula to Hosts and panelists: The NHS will already be reviewing this as you can see above in terms of technology 17:41:45 From Narges to Everyone: My recent meta-analysis about Internet-delivered versus face-to-face cognitive behavior therapy for anxiety disorders: 17:41:51 From Adebisi to Everyone: As a non-medical person, I'll like to know, Is this widely available or is it still at trial stage? 17:41:55 From Narges to Everyone: https://www.ijpvmjournal.net/article.asp?issn=2008-7802;year=2021;volume=12;issue=1;spage=153;epage=153;aulast=Esfandiari 17:43:26 From Ayesha to Everyone: Great points Maria 17:44:24 From Seetha to Hosts and panelists: Wonder what implications are there for transference and counter transference variables 17:44:35 From Maria Loades to Everyone: Yes Paula, really important point! 17:46:02 From Maria Loades to Everyone: Seetha, that's so interesting, I do think the dynamics of the relationship are different - things like the therapist not being in control of the therapeutic space, how much young people feel heard and listened to, etc are different - and picking up on non verbal cues in both directions is something that is particularly challenging 17:46:57 From MB to Everyone: I have used telemedicine alot in my practice as a developmental paediatrician and found it useful and allowed flexibility depending on the fit with the young person . I have personal experience entirely digital CBT and guided by therapist online CBT , masking was so much easier without specific guidance . I guess one size doesn't fit all but clearly digital medicine adds another string to our bow . 17:47:19 From L to Everyone: after attempting suicide i had to wait 8 months on a waiting list , so when i was offered over the phone CBT i had to take it before it was too late 17:47:37 From Maria Loades to Everyone: Thanks Narges for highlighting this great work https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8724632/ 17:48:04 From Maria Loades to Everyone: Narges, did you include any young people studies? 17:49:28 From Sophie to Everyone: where do we direct young people for the most appropriate tCBT which is accessible (?free) and goal orientated, how would they assess usefulness. what age would it be useful for? 17:50:37 From Maria Loades to Everyone: Sophie, there are digital providers like Healios which is commissioned by the NHS in some areas who offer iCBT etc. 17:50:48 From Narges to Everyone: Many thanks, @Maria! yes, I also included Spence’s study on adolescents aged 12-18. 17:51:03 From Maria Loades to Everyone: @frank who is beside the campfire with us this evening is from Healios 17:51:05 From Sophie Mooncey to Everyone: thanks Maria 17:51:59 From Maria Loades to Everyone: Moodgym for instance is available and relatively well evaluated as a self-help intervention although more focused on depression 17:52:02 From Seetha to Hosts and panelists: Any idea if there has been thoughts on Virtual reality characters like an avatar? 17:52:12 From Majella to Everyone: I think this has been a very thought provoking session 17:52:51 From Maria Loades to Everyone: Seetha - see this great case study by Paul Stallard et al published in CAMH which is an ACAMH journal https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/camh.12326 17:53:06 From Seetha to Hosts and panelists: Thank you Maria 17:54:25 From MB to Everyone: Digital poverty has been a huge problem and people with English as a second language in use of telemedicine though not insurmountable with some flexibility . 17:54:46 From christine to Hosts and panelists: If we accept that t CBT is better than no treatment and services are looking at interpreting it into care pathways how does link with NICE guidance ? As there are different programmes for t CBT - what evidence is there related to which programme offers increased outcomes Thanks 17:54:55 From Seetha to Hosts and panelists: MB, totally agree 17:55:15 From CTC Psych to Everyone: Amazing session, will for sure be joining more! Will be great in my career development and ability to contribute to the system 17:55:54 From Sasha to Hosts and panelists: Something else to consider is how we can adapt tcbt for autistic young people and those with adhd 17:56:13 From Amna to Everyone: true 17:57:56 From Laurie to Everyone: MB makes a good point. In a clinical evaluation, we found that telehealth was less accessible for young people and families from disadvantaged communities that for the more affluent. What about the risk of pathologizing anxiety in general? Anxiety is part of living and developing, some approaches in psychology and psychotherapy would argue. 17:59:36 From Sasha to Hosts and panelists: Agree re pathologising of anxiety, especially when our young people are now experiencing long term effects of Covid pandemic ! 17:59:41 From Maria Loades to Everyone: I do think there is a risk of over-pathologizing, and it would be good to also think about resilience building etc. but of course here, we have focused on those with disorders given that is what Matti's review focused on 18:00:01 From Maria Loades to Everyone: Also need to think about community based approaches 18:00:06 From Paula to Hosts and panelists: LP I agree with you 18:00:18 From N to Everyone: One of my clinical observations of youth with digital CBT in my control trial was their massive demand for content related to their other problems, not just social anxiety! 18:00:19 From G to Everyone: I think the effectiveness of tCBT also depends on the confidence, knowledge and ability of therapists that are delivering or facilitating the digital interventions. Maybe this explains the different findings? 18:00:21 From Maria Loades to Everyone: to address some of the underlying factors that are fuelling the pathologizing 18:00:27 From Paula to Hosts and panelists: We also may miss other research too.