We are delighted to have the opportunity to talk to Professor Sally Merry, the Cure Kids Duke Family Chair in Child and Adolescent Mental Health.
We talk to Sally about her key research focus which is on e- therapies, and in-depth about the award-winning computerised intervention to help adolescents with depression ‘SPARX’. Sally discusses the effectiveness of digital programmes comparing offline and online, in relation to CBT when it comes to keeping young people engaged. She also explains about the development, implementation, and scalability of these therapies aimed at prevention, and improving outcomes in young people.
We also hear how her research is improving the early environment for very young children in families facing social, and economic, challenges, which includes working with Maori families.
Plus her important role in teaching and workforce development in the child and adolescent mental health sector, and what more needs to be done to help recruitment and retention.
Professor Merry is a child and adolescent psychiatrist and the Cure Kids Duke Family Chair in Child and Adolescent Mental Health. She is Joint Editor of CAMH.
Professor Merry’s research focus has been on the development and implementation of effective therapies in child and adolescent mental health including computerised and mobile phone-based interventions. She led the development of SPARX, a computerised intervention for depression using a fantasy game format. This effective therapy attracted international awards and has been available as a national e-therapy service in New Zealand since 2014. She has carried out a number of large clinical and prevention trials to find better ways of delivering psychological therapies for mental health for children and adolescents. She established and led a team to develop and test an ecosystem of digital therapies, HABITS (Health Advances through Behavioural Intervention Technologies) for young people as part of the National Science Challenge, a Better Start E Tipu E Rea. This work has included the development of online screening, web and native apps and chatbots to support emotional regulation in younger and older adolescents, to address problems of self-harm and substance abuse and to provide online support for parents of younger children with behavioural or emotional problems.
Professor Merry has worked clinically in a number of settings with children and young people from pre-school age to late adolescence, mostly in community settings.
Interviewer – Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing Professor Sally Merry, Cure Kids Duke Family Chair in Child and Adolescent Mental Health and Head of the Department of Psychological Medicine at the University of Auckland. Sally’s research focuses on developing and implementing effective interventions for young people, and their families. And particularly using e-therapies to make therapies more readily available.
If you’re a fan of our In Conversation series please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Sally, thank you for joining me. Can you start with a brief introduction of who you are and what you do?
Professor Sally Merry – Thank you Jo. It’s a pleasure to be here. And warm greetings from New Zealand to everybody listening to the podcast. I am a Child and Adolescent Psychiatrist. And I have a role at the University of Auckland, which focuses on teaching and research. I’m currently the Cure Kids Duke Family Chair in Child and Adolescent Mental Health, which means that my research is supported by a generous philanthropic donation from the Duke family who are well known in New Zealand. And this is administered through Cure Kids which is one of the major charities here.
I’m actually in a process of transition. I have been the Head of Department of Psychological Medicine for most of the last decade. And I’m in the process of handing over to the very able team of researchers and academics who I’ve been working with for the last 20 years or so.
Interviewer – Sally, how did you come to be interested in child and adolescent mental health?
Professor Sally Merry – It has been an interesting journey. I started off by being a medical doctor, obviously. And as I was coming through the training, I actually found, to my surprise, that psychiatry was one of the things that interested me most. I’ve also been a fan of children my whole life, really. I really love the whole process of development. And so, it became natural, really, I think, for me to do psychiatry, and then to specialise in child and adolescent psychiatry.
Interviewer – When it comes to mental health, what, from your experience, are the most common, and important, issues that young people face today?
Professor Sally Merry – I think young people these days are facing a huge number of crises and challenges that impact on their mental health. COVID is the obvious one and I think that has had an enormous…taken an enormous toll on young people as they’ve been dislocated from friends and from school. And so many children, and young people, have had lockdowns for such long periods of time. And I think that has had some positives in providing closer contact with their families, but has also been very challenging, I think, both for parents and for children.
I think the climate change looms over us all. And we need to be taking action to look after our world better. I think young people have been very frustrated with the lack of action from my generation. And then too many of our children grow up in poverty. And, actually, surprisingly, in New Zealand, that’s actually one of our major problems. People think about New Zealand as being this little paradise, and it is, in many ways, but for too many of our children, and young people, there’s too great a degree of disparity in the country.
So I think this then has a knock on effect to a number of the very common mental health problems, anxiety and depression. And it can manifest in behaviour that is not necessarily very helpful, within the family, or in wider society, or at schools, so, disruptive behaviour.
Interviewer – Sally, as mentioned in the introduction, a key focus of your research is on e- therapies. So, developing, and implementing, practical, scalable, and effective, therapies aimed at prevention, and improving outcomes in young people. Why e- therapies? What makes this approach so effective?
Professor Sally Merry – This has been quite a long path for me. More than 20 years ago, I was working in a community mental health centre where we were very short staffed. And I was working part time, because I had young children at the time. And I was the only child psychiatrist for quite a big area. And we just couldn’t get through the workload, and this continues to this day. And I was thinking that if we took a population based approach to trying to tackle depression, perhaps we would be more effective in doing so.
So my first research started before, really, the digital revolution. And I was looking at doing groups within schools to see if we could teach the cognitive behavioural strategies that are one of the most effective ways of dealing with depression and anxiety, and started off with a prevention trial. And then a GP friend of mine actually said to me that she was seeing a lot of young people with depression and that it would be good if we could take CBT and put it on, in those days, a CD rom that she could run in her GP clinic.
And this sparked an idea of how technology could perhaps increase the reach. And I thought, at that time, that that was an excellent idea. If we could do something on a CD rom, we could provide these very cheaply across the country and perhaps that would work. I have a very talented researcher working with me, Dr. Karolina Stasiak, and she did her PHD with me, back in the day, and developed a little CD based programme called ‘The Journey’ and did a small pilot trial against a placebo programme and showed that it was effective.
At that time, the Ministry of Health was looking for e-therapies and we were able to get funding from the Ministry of Health to develop an e-therapy. And, of course, everybody’s on the internet now and everybody has got Smartphones. This was not something that we predicted in the early part of the century. But the reach is enormous. I think the potential reach is one of the biggest things. Things that we develop here can be exported to other parts of the world, that is very promising.
Does come with fishhooks, though. Because like any other health intervention, exercise, diet, and so on, people might know that this might be effective, but they don’t always do it. And I think this is our next challenge.
Interviewer – One of the programmes that you’ve developed is SPARX, that’s spelt SPARX, award winning computerised intervention to help adolescents with depression. Can you tell us more about SPARX? Who is it aimed at and how does it work and how effective is it?
Professor Sally Merry – SPARX is basically a computerised avatar based game that uses a fantasy game format to deliver cognitive behavioural therapy. We developed SPARX after the work that Karolina had done, developing the journey on CD-ROM. And feedback from young people that she had, from her little intervention, which was really based around education, this is what CBT is, this is how you would do it, with a few…with quite a lot of mini games and little graphics and things. The feedback from the young people was that they didn’t want to read anything. They wanted to do things. So that led us to this idea of gamification. We’ve also used e-learning theory in SPARX. So there’s this idea of a bicentric frame of reference where you have an immersive experience. And for us it’s a third person avatar based game. Then we have created a format where you can stand back and learn from what you’ve just done in this immersive experience.
And I think it’s a bit like doing chemistry experiments where you might mix chemicals, see what actually happens, and then you learn about the chemical interactions and what has actually happened. And so, we’ve got this format. We have a first person interaction with an avatar called The Guide, and we’ve been very lucky to have an excellent actor in New Zealand, Te Arepa Kahi, who is the voice behind this. And he gives psycho education about depression. And then the young person goes into the game and overcomes a number of challenges in seven provinces that are all loosely linked to cognitive behavioural therapy constructs.
So they learn to solve problems in the mountain province. They learn to fight gnats, which are gloomy, negative, automatic thoughts throughout. And we try to teach cognitive restructuring. So how to recognise negative thoughts and how to challenge those negative thoughts, how to do problem solving relaxation and activity scheduling, which are all the core components of CBT. It’s aimed at 12 to 19 year old young people. We did a randomised controlled trial comparing it with usual care, which was usually face to face therapy, on average, four to five sessions of around 40 to 50 minutes each, depending on the service that we used with it.
And SPARX was at least as good. And on some of our analyses, somewhat better than the face to face therapy. So it does work. And I think it works by teaching cognitive therapy strategies. And it’s now available as a national programme in New Zealand with multiple changes to the technology. We’ve had to go from CD-ROM to Web based and moved it onto a mobile phone interface, which is a bit clunky at the moment. So we’re just in the process right now of specifically designing something suitable for smartphones.
Interviewer – If people wanted to find out more about SPARX, is there a website, or something they can look up?
Professor Sally Merry – What we should probably say is SPARX is only available in New Zealand. But there is a website. And the website is SPARX.org.nz. And there’s information about it there. And there are also little trailers on YouTube.
Interviewer – But SPARX gained international attention, which resulted in research collaborations in the UK, the US and beyond, I believe? What other projects arose from SPARX?
Professor Sally Merry – Well, probably just a couple more things to say about the international attention. SPARX has been translated into Japanese and is available on an app in Japan and has been available there for the last several years. There’s a project in Canada in the Inuit territory where it has been translated into Inuit. And we have just had news of a successful bid for quite substantial funding for a programme of research from Nottingham University.
And SPARX will be a part of that. Leading on from SPARX , as I mentioned, there are, I think, probably two major challenges to its uptake. So one of them is for young people to know about SPARX and to know that it’s there and the other thing is to actually try and get them to do the whole thing. So we have…we’ve collected data, over the last seven years, to have a look at how well SPARX works if people do it just from the website. We’ve shown that it still, for a substantial number of people, improves symptoms in depression, if people do it, but they tend to drop out.
So our projects that have come on from this have actually been looking at tackling both those problems. And we’ve got a big project which we call the HABITS Project, which is Health Advances through Behavioural Intervention Technologies. And our idea there was to build a digital ecosystem which could become the go to place for mental health for young people and their families. So somewhere where you could go and test out your symptoms, or parents could say, “Should I be worried about my young person?” And then have links to a range of digital resources like SPARX, and others, that could then be used as perhaps a first step or could provide links to existing services, face to face services.
As part of that, we’ve developed online screening, and a range of interventions really across the lifespan. So we’ve got two digital interventions for parents of preschoolers which are being tested right now. Those are both apps. We’ve got another Web based app which we have tested in Christchurch following the earthquakes there for parents, and families, who are struggling with what they describe as big emotions, following on the trauma of the earthquakes. And we’ve tested that and shown that it is effective. And we’re just looking at how we might implement that.
And then we’ve got a range of interventions for teenagers from apps through to chat bots. And the chat bots can be quite readily changed to suit particular circumstances. Those are the major ones that we’ve actually used.
Interviewer – I’m just wondering, when you mentioned about the difficulty in getting young people to complete the programme, I’m assuming that’s a problem for CBT anyhow beyond digital? So I’m wondering how it compares. What is the comparison between offline, and online, CBT when it comes to keeping young people engaged?
Professor Sally Merry – That’s an excellent question, Jo. Yes, a lot of people will only attend face to face therapy once or twice also. So it’s not that different. We haven’t really got a very good head to head comparison to actually know that. But retention rates in CBT are not high either. We did do a head to head comparison, in our initial randomised control trial, and the dropout rates were very similar between face to face and SPARX. But I think for that, young people were being recruited to a clinical trial.
So I think they’re a particular group. It probably doesn’t compare too badly with it. I think one of the things that we have got to be careful of is inadvertent barriers to the use of the technology. So I think, being researchers, we sometimes perhaps try to collect too much information, and we should just let them get onto the app better. It also raises quite an interesting dilemma because obviously computer games are designed to suck you in and keep you going with it.
Now SPARXs is only seven sessions. So one of the questions I get is, you know, “Will people get hooked on SPARX ?” I can reassure everybody that nobody’s going to land up with an addiction to SPARX. There are only seven levels. But whether or not or to what degree we should be using the strategies to encourage continued use is, I guess, a bit of a philosophical dilemma.
Interviewer – Do you plan to develop any digital interventions to help young people deal with the mental health fallout from the COVID pandemic?
Professor Sally Merry – We have. And this was actually done to my team really, my pleasure to work with a really lovely group of researchers, most of whom I’ve known since they were doing their Masters and their PHD and they’re now senior researchers. I think two or three of them sat down, over a weekend, with the COVID-19 pandemic and developed Aroha, which means love in Maori, and Aroha is a very appealing chatbot character. And they then developed content that was specifically around anxiety related to COVID and had funding from the Ministry of Health to release this.
So we’ve had that out there and we’ve been tracking the use of that. And the plus about that is that we’ve been able to tailor the content as it goes. So, initially, it was the sense of impending doom. And, of course, I think people know that in New Zealand, we have been very fortunate in that our governments managed the problem very well. So we’ve got off pretty lightly. It has still had a pretty major effect though and a lot of people have lost their jobs.
The concern around the insecurity. We’ve had several lockdowns in Auckland, so, people have been in and out of school and that has led to anxiety around education, and so on. So we’ve been able to tailor the content to deal with those particular problems.
Interviewer – Can you imagine that being sort of rolled out internationally? Because, as you say, some countries the situation is more intense and live at the moment than perhaps it is in New Zealand?
Professor Sally Merry – I would love to make it available internationally. If I could I would just release everything. But it’s actually harder than it seems. We have quite a robust backup system for young people using all our apps. So we’re backed by helplines, by 24/7 crisis services, and so on.
So the question is, what does one do if the app is not effective or young people need more help? And so, it works best for us if we can partner with people in other countries so that we can tap into whatever is available there as the next step.
Because we’re a research team and we’re collecting data to try and show that things work, because it counts as health data and there are very strict regulations about where health data are stored, and the security around it, and most countries will not allow health data to be stored off their piece of land.
So it’s quite difficult, from New Zealand, to actually do that and to meet the requirements, say, in the EU, or elsewhere, and then also releasing it to places that are non English speaking as it is another issue. So what we’ve tried to do is work very actively, for example, with the group in Japan. So we try to make the resources available at a really affordable rate, and then let them set up the internal infrastructure, which is why the research in the UK is exciting.
It would be lovely if we could do that there.
Interviewer – Sally, your research also focuses on improving the early environment for very young children in families facing social, and economic, challenges, which includes working with Maori families. Can you tell us something about this important work?
Professor Sally Merry – Actually, I should clarify that in New Zealand, it’s a requirement under the Treaty of Waitangi that we ensure that all our research is done in accordance with the treaty so that Maori have a right to access to that. And for research that might impact on them that we work closely in partnership with them. And because Maori families, and their young people, face greater disparity, within New Zealand, that means that any mental health intervention needs to be done with that very much in mind.
Maori and actually our Pacific families face greater poverty and a host of socioeconomic challenges. And it has been my pleasure to work with two very wonderful Maori women who have been doing their PHDs and both have actually completed it doing work in South Auckland, which is one of the areas where there’s a high population of both Maori and Pacific people. And both of them have worked very much with families in that area. So the first project I’d like to tell you about is one run by Lyn Doherty, who now has her doctorate, and she set up and plays a major role in running Ohomairangi Trust, which is a Maori organisation working with the Maori community in South Auckland.
And she has tested a programme called Hoki Ki Te Rito. And that has been developed from a programme originally developed in Glasgow by Christine Puckering called Mellow Parenting. So this has been adapted to be suitable for delivery within the Maori community. And Lynne has run these programmes, which is basically once a week. She gets families facing really major problems as family disruption, family violence, a huge degree of poverty, unemployment, and so on, where they really want to do better for their children.
And the families come in for a day, and they learn about parenting, but also have a chance to explore the way that they were parented, and the challenges that their parents had in their turn. And the programme runs for 14 weeks. And she has run this programme and collected data to show how effective this programme has been in changing the way these parents are able to parent their pre-schoolers. She adapted it for fathers, originally, it was developed for mothers. And has collected some of the most moving accounts from some of the fathers who have been in prison and have been in gangs and have had really tough lives.
And to hear their voices coming out and describing how much this programme has touched them has been amazing. So she’s still running that programme and is training others to do it. And the second programme was done by Tanya Cargo, who’s a Maori Senior Clinical Psychologist who works with us in the department. And she did Parent Child Interaction Therapy, which is one of the programmes that’s being developed in the US, but is used very widely across the world, which teaches parenting skills, parent management, training to families.
But this is quite an intensive one that’s usually done within clinics, and uses a bug in the ear and a one way screen or can be done with the therapist sitting in the room actually coaching parents through how to make good connections and good attachment with their families, and how to set limits in a way that’s actually safe for the little ones. And she has actually done that with parents who have been on the last chance of really keeping their children because of family violence and had some excellent results from that.
And Tanya has actually gone on then and taken some of these and developed an app which we’re testing now called Super Kids. So trying to actually get these skills disseminated.
Interviewer – How complicated is it to translate research into practice? And how have you managed to be so successful at this?
Interviewer – I think it’s quite difficult, actually. I think I’d probably like to talk about two examples. One is SPARX where we’ve actually done the research.
And I think we were incredibly lucky in that our research was running parallel to some of the government incentives so that we were able to get money from the Ministry of Health to develop SPARX, showed that it was effective, and the government, the Ministry of Health, was really interested in releasing e-mental health interventions. And the then Prime Minister, Sir John Key, had a particular initiative for youth mental health. And so, he made available some funding that allowed us to release SPARX into the community.
So I think that was luck, really. Trying to make some of our apps and things available now, widely, once they actually work, has been harder. And I sort of realised that researchers are really not business people. It’s not my strength at all. So I think that has been quite lucky. The research into practice from Lyn Doherty’s programme Hoki Ki Te Rito, for example, is an example of something that was being done in the community and where we’ve actually put the research behind it to show that it works in New Zealand.
So that has actually been good. We’ve also had an initiative that goes back for the last 30 years. We set up 20 years ago. We set up the Werry Centre for Child and Adolescent Mental Health. And there was a programme for workforce development. And I actually initiated this project and then had, around me, some very able people. And so, our goal then was to identify research based interventions, things that have been shown to work and to introduce them into New Zealand.
And I think, again, partly because successive governments have been aware of the need to do this. We’ve been able to do some of that. So, for example, we’ve rolled out training in incredible use, which is research based in triple P parenting, which is research based. And the Werry Centre now remains a research and teaching centre. But we have a whole different organisation called Werry Workforce Whāraurau, which actually is there to support good practice by clinicians working in child and adolescent mental health.
I think it’s really important to have an infrastructure to allow for some of these initiatives to actually happen.
Interviewer – What more is needed in terms of policy changes and resources and training to further research and to better support families?
Professor Sally Merry – Yes, I think Cure Kids has been quite transformational for my team. Because it has allowed me to stop writing the next research application to try and fund the team and myself to do the research. And has freed us up to really tackle…and, like, the HABITs project is an enormously ambitious one. And my team are continuing the work with that and then we have extra funding for that. But I think we lack a proper infrastructure. And I think investing in research teams is a vital part. And, actually, having a good path for clinicians who have worked on the coalface to transfer over, or to do research, is just vital.
In New Zealand we always seem to be starved of funds. The size of the pot is quite small. It’s extremely difficult to get research funding. We don’t have a very good career path. So people can get quite good funding to do a PHD here. But then there’s very few postdoctoral positions available. So trying to actually fund that is really quite difficult. I think families face a huge number of problems. We still have a lot of questions that need answering. And I think actually getting really good minds thinking about what research can be done and thinking outside the box about how we tackle some of these is really vital.
Interviewer – Sally, I want to turn now to child and adolescent specialist training. What has your role been in teaching and workforce development in the child and adolescent mental health sector? And what more needs to be done to help recruitment and retention in this sector?
Professor Sally Merry – Quite a big question. So I think the first thing is to make the point that child and adolescent mental health services, be they in specialist or in primary care, are typically multidisciplinary. So there isn’t just one training, there are many. So for me to become a child and adolescent psychiatrist, I actually did the full adult psychiatry training, and then added child and adolescent training, and then added research training and being a mum. So it was one of the longest trainings I think ever.
But the infrastructure for training child and adolescent psychiatrists, I think here in Australia and certainly in the higher income countries is reasonably good although the number of people coming through is not as high as it should be. And I think trying to attract medical students into psychiatry, let alone child and adolescent psychiatry’s is quite difficult. It has always been a less good speciality, and one that’s less well rewarded, I think. But we’re pretty well off compared with, for example, clinical psychologists and even more particularly nurses, and social workers, and occupational therapists, and psychotherapists. The training in some of the core specialities like nursing, and psychology, in New Zealand, anyway, tends to be much more adult focused.
So there’s no particular stream for child and adolescent. There are specific child psychotherapy trainings that one can do, but that gets you into a job that where your salary tops out quite early and quite low. What we’ve been doing has been in the university. We’ve developed a postgraduate training to try and give specialist child and adolescent mental health training to across the disciplines. So we have a series of courses that look at child development models of understanding mental health problems, and then ways of assessing for these and intervening in these. So people can do a postgraduate certificate and then a diploma.
And we’ve just introduced a clinical Masters programme and there’s a research Masters and PHD programme. And that’s delivered nationally. We have special funding that helps support that. If we had more, we could do more. And particularly for the actual therapy. So we run a cognitive behavioural therapy training here. Typically the adults get the first dibs and then we have to really fight to get the funding for child and adolescent training as well. People go into jobs in child and adolescent mental health services that I think in New Zealand and Australia and the UK tend to be underfunded for the demand.
The demand is absolutely huge. There are wait lists. It becomes very difficult to actually get through the work. The pay is not particularly good and you’ll end up working very long hours, and trying to do more and more with less and less. So I think that we should really…and these services are not expensive compared with things like cancer treatment, or cardiac surgery, or various other interventional things. So I think we should have a clear career path with clear health practitioner registration that is specifically targeted child and adolescent.
I think if people do the training, they should be paid more. And I think we should be valuing our children more so that we think that it’s really important that we do this and that we try to put these services, both the specialist and in primary care and in places like schools with staff who are well paid and really valued.
Interviewer – What else are you working on at the moment? Is there anything in the pipeline that you’d like to mention?
Professor Sally Merry – I think the biggest thing I’m doing at the moment, as a grandmother, is really trying to support the fabulous team that I’ve been working with for years to step out and do their own thing. So I think it’s really important that we think about the next generation and about succession planning. But I think the other things that I’m thinking about are how, perhaps, we can better make the resources that we know are likely to help more available across populations and across the world.
So I think e-therapy is just one part of that. I think face to face therapies are really important. And so, my thoughts have been around how do we integrate, and how do we, for example, create systems that include e-therapies and face to face therapy and get them linked up so that we make things easier to navigate for families and particularly for young people, so that they can access things easily? I’ve still got young people saying, “I didn’t even know SPARX existed.”
We still have young people saying, “Well I don’t really know where to get help.” And there’s still that sort of stigma about, “Oh, I’m not sure that I really want to talk to somebody like you about things that are very personal.” So I think how we make this sort of part of common parlance, but also make it extremely accessible have been thoughts in my mind. And so, how we get governments and researchers and clinicians all singing to the same tune, it’s a major job, and that’s something that I’ve been giving a lot of thought to.
Interviewer – Sally, finally, what is your take home message for those listening to our conversation?
Professor Sally Merry – Our children are our future. And they are the most important thing in our world. And I think we tend not to give adequate care to them. I think workplaces demand a huge amount from people. I think working from home has meant that family space is eroded. And I think it’s really important for governments, for the wealthy, for business people, and so on, to take on board the importance of our generation of children. They are the people who will take over the world.
And I think we don’t support parents and families sufficiently. So my take home message is our children are a precious resource, if you like, and we should be taking better care of them.
Interviewer – Brilliant. Sally, thank you so much. For more details on Professor Sally Merry, please visit the ACAMH website www.acamh.org and Twitter at ACAMH. ACAMH is spelt ACAMH. And don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating, or review, and do share with friends and colleagues.