Creative Methods and Digital Media: Supporting Psychological Therapies

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In this podcast, we are joined by Professor Lina Gega, professor of mental health at the University of York and honorary nurse consultant in psychological therapies at Tees, Esk & Wear Valleys NHS Trust. Lina is also a joint editor of the Child & Adolescent Mental Health (CAMH) journal, one of the three journals produced by the Association for Child and Adolescent Mental Health.

Lina sets the scene by providing an insight into how she came to specialise in cognitive behavioural therapy and digital mental health, as well as what makes digital media so applicable to child and adolescent mental health.

With the COVID pandemic having been an accelerator for digital technologies, Lina discusses her recently published paper on the impact of digital technology during the pandemic, including what conclusions she drew and how this impacts children and young people.

Lina also talks us through her work on several interesting projects and provides insight into their aims, plus findings. For a number of her projects, Lina has teamed up with colleagues from outside of academia to develop prototypes for digital tools for children with different emotional vulnerabilities.

Lina discusses what barriers and challenges she has faced when translating research into practise and explores how to overcome these to make a real difference to families.

Furthermore, as Lina has published over 70 papers, books, and book chapters, plus has worked with publishers, universities, NHS services, charities, and grant-awarding bodies as a research advisor and reviewer, Lina shares her advice for researchers, in particular those early in their careers who want to achieve and maintain high standards in the conduct and reporting of research.

Please subscribe and rate our podcast from your preferred streaming platform, including; SoundCloudiTunesSpotifyCastBoxDeezerGoogle Podcasts, Podcastaddict, JioSaavn,
Listen notes, Radio Public, and (not available in the EU).

Professor Lina Gega
Professor Lina Gega

Lina is Professor of Mental Health at the University of York, in a joint appointment with Hull York Medical School and the Department of Health Sciences. She holds an honorary clinical appointment as Nurse Consultant in Psychological Therapies at Tees, Esk & Wear Valleys NHS Trust.

As a senior member of the Mental Health and Addiction Research Group, she leads two research themes: Digital Mental Health and Child and Adolescent Mental Health. In her role as Chair of the Postgraduate Programmes Board at Hull York Medical School, she oversees the progression of masters and doctorate students and the quality of taught and research programmes across the two host Universities. Her expertise is in the clinical utility of digital media as means to specialist interventions in mental health. Her recent work focuses on improving practice and outcomes for children and young people affected by mental health problems. Previously, Lina was Programme Director for Cognitive Behaviour Therapy and Branch Lead for Mental Health Nursing at King’s College London, where she received a College Teaching Excellence Award, a College Teaching Fellowship and a Vice Chancellor’s nomination for a National Teaching Award. She served as Clinical Lead for the commissioning (Norfolk) and provision (Northumberland) of psychological therapy services in primary care and the community. Currently, she is Joint Editor for Child and Adolescent Mental Health (CAMH), having previously served as Guest Editor for Frontiers in Psychiatry and Associate Editor for Cogent Psychology. (Bio from Health Sciences, University of York)


Jo Carlowe: 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 Lina Gega, professor of mental health at the University of York and honorary nurse consultant in psychological therapies at Tees, Esk & Wear Valleys NHS Trust. Lina is also a joint editor of CAMH. CAMH is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces the JCPP and JCPP Advances. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Lina, welcome. Can you start by introducing yourself?

Professor Lina Gega: Hello, Jo. Thank you very much for inviting me. I am professor of mental health at the University of York and Hull York Medical School. And my expertise is in cognitive behavioural therapy and digital mental health. But my current work focuses on children and adolescents, especially, using creative methods and digital media to support psychological therapies within the NHS but also wider in the community.

Jo Carlowe: Lina, how did you come to specialise in this area? And also what makes digital media so applicable to child and adolescent mental health?

Professor Lina Gega: Well, I started over 20 years ago. This was the time where when we had to connect to the internet, you had that characteristic sound of– [MAKES MODEM SOUND] And we had to store data and floppy discs before Wi-Fi and tablets and smartphones were invented. So at the time, I was working with a remarkable person– Professor Isaac Marks at the Institute of Psychiatry in London. So Isaac was a pioneer. He was ahead of his time. And at the time, he was training nurses like me to become specialists in behavioural psychotherapy, something that was unheard of at the time. Remains quite a rarity in many countries. Psychological therapies are traditionally delivered by psychologists and psychiatrists rather than nurses but at the time. So this produced a generation of nurse therapists.

And then the other thing that Isaac was quite a pioneer was that he set up the very first clinical service worldwide that operated exclusively with computerised self-help systems as a way of delivering therapy for conditions like phobias, obsessive compulsive disorder, depression, anxiety, and the revolution was not only in terms of using technology, but also having a primary care model where service users could self-refer or just walk into the clinic. And at the time, the only model that used that was general practise and sexual health clinics.

So that visionary work that I was very, very privileged to be part of really was the precursor to the current Improving Access to Psychological Therapies Programme which is a major government initiative and has attracted hundreds of millions of pounds in investment. So that was really how I started in digital mental health, and since then, you know, the world has billions of internet users and billions of smartphone users, and we went from just a few hundred products to sort of hundreds of thousands of apps about mental health and internet programmes.

With regard to the second part of your question, we would think that sort of digital interventions are ideal for children and young people because they are digital natives. They cannot imagine a world without smartphones or computers like I couldn’t imagine a world without electricity that often my grandparents were talking about.

But surprisingly, digital media really have not been widely used to support child and adolescent mental health care, especially, not in the NHS. And even research in digital mental health is only a fraction of what is done for adults.

Jo Carlowe: Of course, the COVID pandemic has been an accelerator for digital technologies. And Lina, you recently published a paper on the impact of digital technology during the pandemic. Lina, what conclusions did you draw?

Professor Lina Gega: Ah, yes. That paper was sort of called The Good, the Bad, and the Indifferent because technology has contributed to all these three things. The good, the bad, and the indifferent effects of the pandemic on mental health. When we talk about some of the positive experiences that some people have had during the pandemic, technology mediated that because people were able to carry their work remotely at the same time we spend more time doing enjoyable things, reconnecting with friends.

So that’s the good in terms of neutralising some of the negative effects of the pandemic. The technology really promoted the adoption of telepsychiatry and digital interventions through routine care that became the norm. However, still technology accentuated some of the negatives of the pandemic– that limited access to care and social isolation because some of the most vulnerable people in our society are also digitally disadvantaged.

So the conclusion was that really, we can capitalise on the momentum that we gained and the culture shift that occurred in using technology during the pandemic to scale up the provision of mental health care. But also we need to really be mindful of those vulnerable groups that may be digitally disadvantaged.

Jo Carlowe: And does that include children and young people?

Professor Lina Gega: Yeah, absolutely, because it is– I mean, the children who really live with families that have complex needs are the ones that wouldn’t have access to smartphones or the internet or the private space to use that.

Jo Carlowe: Yeah, it’s really important to emphasise. Lina, I want to turn to your work with MHARG— this stands for the Mental Health and Addiction Research Group. What is MHARG and its aims?

Professor Lina Gega: MHARG is part of the University of York. Is a research group within the University of York. Is a group of about 75 colleagues– researchers, academics, support staff, administrators. It was founded and it is directed by Professor Simon Gilbody. And really what we do is, we do research but also teaching and broader scholarly activities to improve our understanding of mental health and addiction problems. But most importantly, develop and evaluate interventions that can prevent or improve these problems.

Our signature research is really large, pragmatic randomised controlled trials of such clinical interventions. For example, psychological therapies or smoking [inaudible] programmes for people with mental health problems. And the work can inform care pathways and policy within and outside the NHS.
Now, another interesting strand of work within MHARG is at the interface of physical and mental health. And this is looking at improving the physical health of people with mental health problems that is often disproportionately affected compared to the general population. But also understanding how poor mental health can be affected and also, in turn, affect physical illness.

Jo Carlowe: And within MHARG you are a co-investigator, trainer, and supervisor for ASPECT which stands for Alleviating Specific Phobias Experienced by Children Trial. This was a large study comparing one session treatment versus multi-session CBT for children with phobias. I believe the trial has been recently completed and the results are about to be published. What are the findings that you can share with us today.

Professor Lina Gega: Great. So Jo, you can have a scoop today because I’m able to reveal the results. And Jo, as you said, ASPECT compared one-session therapy which is graded exposure therapy with multi-session CBT– cognitive behaviour therapy. And this was for severe and debilitating phobias in children and young people. So we arrived at two conclusions. The first one was that one-session treatment has similar clinical effectiveness to multi-session therapy. Which means that the symptoms of the phobias like avoidance and distress improved to a similar extent with both therapy modalities. The second important conclusion was that one session treatment is highly likely to save money for the NHS compared to multi-session traditional therapy. And this is not surprising because traditionally, therapy takes 6 to 12 weekly sessions each 30 to 60 minutes as opposed to one-session treatment which is delivered within a single three-hour window after a one-hour assessment. So you can see the difference in the time demand.

Jo Carlowe: Does that sort of sound the death knell, though, for the multi-session therapy?

Professor Lina Gega: No, in fact you would think that one-session therapy would be readily taken up, but even a simple thing as the appointments for therapists been configured in half-hour slots or one-hour slots and then having to– to have available a sort of half a day slot which is three hours. That throws a lot of logistical problems– so really, is not something that I think would have both potentially in services depending on how the service is configured and also the preference of the young people and their families.

Jo Carlowe: You’ve also led a couple of other projects in which you teamed up with colleagues from outside of academia to develop prototypes for digital tools for children with different emotional vulnerabilities. So one example is the DIG4IT project which includes the development of Fight your Fears– the digital game to teach children how to overcome phobias. How does Fight your Fears work, and how did you bring together the expertise of therapists, game designers, software engineers, children, and parents to develop the game?

Professor Lina Gega: Yeah, Fight your Fears was a project– was this collaboration with industry and with software engineers, clinicians. So it was a big collaborative project. And the actual product– it has two components. It is all an overarching game of levels that can be unlocked. So the first component of Fight your Fears is a series of mini games that educates young players about phobias and graded exposure therapy. So players learn about fear and its different presentations by using characters that have different symptoms. So then they learn about ranking, really, the different triggers for a phobia on a ladder of intensity– something we call a fear hierarchy, which is quite a difficult concept to grasp. And you have to do that in the game without actually talking about it or explaining it. So it is really show and do rather than speak.

So in the second part of Fight your Fears, then players are guided through gainful activities to apply what they’ve learned about phobias and about graded exposure therapy to apply this to their own therapy plans. So the game adaptively generates and suggests real-life exposure tasks, and each of these task comes with instructions for the support person like the family member to help the young person complete the exposure task. So that’s sort of the game Fight your Fears. And as I said, it was a true sort of collaborative, collective effort between different people. Everyone brought in their different skills and it was like building a house.

You need the architects, and the builders, and the people who live in it, and the neighbours who haven’t yet deployed or evaluated the game. It was just really developing it and having a sort of co-production process to make sure that it was fit for purpose.

Jo Carlowe: What age group is it aimed at?

Professor Lina Gega: It was for early 7 to 16-year-olds.

Jo Carlowe: It’s quite broad. Another project is I See Me Do which produced virtual environments to enable children to practise social communication skills. What can you tell us about this scheme?

Professor Lina Gega: This was another example of a successful partnership between academia and industry. So what we did was developed a system that uses green screen technologies and this is also sort of referred as chroma-key video captures like what you see if you see yourself flying within outer space, then that sort of green screen technology. So we use that and digital films to create virtual environments that reflect day-to-day difficult situations that children experience like speaking with a teacher who is critical or saying no to friends who ask you to do something naughty like throwing stones, responding to bullies, speaking with a stranger without disclosing personal information.

So all these situations, you can imagine them they were like filmed to scripted scenarios that children themselves actually told us what the scenarios could be. So this concept of I See Me Do refers to the experience of the children being able to see themselves in real-time interacting within these virtual environments with these characters. And as the child interacts within the film, then a therapist or a teacher can control what the characters say. So it’s a bit like the Wizard of Oz paradigm although it has the impression of being automated. In fact, it is actually controlled by a person behind the stage.

Jo Carlowe: Right, it sounds amazing actually. How effective is it? Has it been evaluated?

Professor Lina Gega: No, that’s it. Well, we finished actually. We produced that just before the first lockdown. And we were about to use it with a school with special needs children. So we haven’t deployed it and then lockdown happens. So the next really step is to really deploy it and evaluate it in a large scale. But as far as we– we could sort of– when we did a little bit of a sort of testing pilot, the children, the parents, and the teachers who used it, they could see now a huge potential application for children with different social and communication difficulties.

Jo Carlowe: Lina, you’re also leading ComBAT— a research programme on Community-delivered Behavioural Activation for Depression in Adolescents. Can you elaborate for us on this project?

Professor Lina Gega: Yeah, thank you for asking about this because we just really launched this project and is a major project funded by the National Institute for Health Research– NIHR. So it’s a five-year Programme and it focuses on behavioural activation. Behavioural activation is a brief psychological therapy that is mainstream for adults and has been used with children and young people in the UK and abroad. But we don’t have any really evidence about its effectiveness and cost effectiveness.

So what ComBAT does is streamlining Behavioural activation by developing a lean standardised and simplified version that can be delivered outside the NHS without the need of mental health specialists. And then once the intervention is developed and it’s lean version, then we will evaluate it with around 300 young people in a randomised controlled trial. And within that, it would be an economic evaluation too. Well, this, as I said, it just started and we have a lot of NHS services but also schools and youth charities coming on board where we train different professionals to be able to deliver it and then we collect information about symptoms of depression in the young people who receive intervention versus usual care. We evaluate it against what is currently offered to them.

Jo Carlowe: I’m sure there are other active projects that I’ve missed. What else feels important to mention?

Professor Lina Gega: It is worth mentioning that Closing the Gap Network— which is also an initiative funded by UK Research and Innovation, Simon Gilbody, the director of MHARG leads this, but I lead the digital theme within it and also support some of the network’s activities relevant to young people. Closing the Gap aims to improve the physical health of people with severe mental illness. And most of this work has focused on adults, but recently we set up a specialist interest group to include under-18s who have serious mental health problems and they are actually in acute inpatient psychiatric hospitals. Now, the physical well-being of these young people is affected not only by the side effects of medication, but also the restrictive environments of the inpatient wards. So looking at their physical well-being is important for the recovery, for the quality of life, but also a way of connecting with young people within a challenging environment by sort of shifting the attention slightly from the severe mental health problems into their physical well-being.

Jo Carlowe: But Lina, in all these schemes, the central agenda is to improve the mental health of children and young people. What barriers and challenges do you face when translating research into practise? And how do you overcome these to make a real difference to families?

Professor Lina Gega: This is such an important question and one that researchers and research funders increasingly are asking. So thank you for raising it. I think one of the main challenges is disseminating the knowledge and research findings to non-academic audiences like reaching families and young people. Professionals who look after them, commissioners who fund the services. So one barrier in doing this is that academics focus too much on academic output, such as publications in scientific journals, long reports that nobody reads, and then we have this barrage of information generated by researchers and academics.

So filtering through this information, especially, if you are a young person or a family under distress is not easy. And then not forget that sometimes research projects do not have significant results. We have trials that find no differences between a new and an old treatment. Or we have very small experimental work that has a real lead to direct benefits for young people and families. So what do we do about it?

We are getting better at knowledge dissemination in terms of producing non-academic evidence briefings. And one way to overcome the tediousness of producing reams and reams of written information is actually using creative methods such as storytelling, social media, graphics to capture the key messages as I sort of said before. Show, don’t tell. And this would be more appealing for children and young people and families. And even, I guess, if the ultimate results of a research project are not significant or directly applicable, there might still be some value in raising awareness about a particular mental health condition or need, options that are available for managing it, self-directed interventions that might be publicly available. So that we have the research findings. The way to disseminate them have to be more creative. But even if we feel that we have some positive findings like in the ASPECT trial that we found that one particular intervention is the most cost-effective and equally effective than the existing ones, there are also another set of challenges that have to do with time and money because professionals and services to adopt new interventions and change practise, they have to be trained and supervised.

You have to have support to implement it, as I mentioned. You have to reconfigure a whole service that has sort of hourly slots for therapy into having one big three hours slot. So the way really to overcome this barrier is not necessarily doing more, but doing things in a different way and having the sort of economic evidence to back this up with service managers and commissioners. So then they invest in making this changes because they will pay off short and long term.

Jo Carlowe: Does that mean that academics should be playing the role in lobbying for funding and resources?

Professor Lina Gega: I think they could make a strong case. Yes, absolutely. They can only– I guess, they can only sort of put forward the evidence as to why that would be a wise investment and that would be to the benefit of the services and the patients. And they do have a loud voice for that. So I think it’s part of disseminating, really, information and making sure that we can sift through the noise to give people the message. That is the most important.

Jo Carlowe: Lina, you have published over 70 papers, books, and book chapters. You’re a joint editor of CAMH, you have edited a number of other publications, and you work with publishers, universities, NHS services, charities, and grant-awarding bodies as a research advisor and reviewer. What advice do you have for researchers? Particularly those early in their careers who want to achieve and maintain high standards in the conduct and reporting of research?

Professor Lina Gega: It’s another great question, actually. So I’m thinking back to some of the research I have done or supervised or assessed in various capacities like an editor of CAMH that you mentioned. So really the question is, what makes one piece of research better than another? So the first thing I look at is the “so what” of the research. What contribution does it make to our knowledge? Does it raise an important issue, flag a problem, or focus on an underrepresented group of people even before we come to the results. So that links to the question that the research asks. My first piece of advice would be, nail your questions. That is, what do we ask? And then good research follows a very clear process. So we ask specific questions, the “so what” of the research, and then we choose the right methods to answer the questions, which is the research design. The methods need to be applied correctly. So these are the science skills. We need to bring in different people– statisticians, health economists, clinicians, follow ethical principles– something that we look for in that paper or a piece of research, and then communicating really the findings into whether what we found can answer our research questions.

Now, we interpret the findings in a proportionate and balanced way. Not overstating their importance, but also making the most out of what we found. There are specific guidelines, like the EQUATOR Network and the Cochrane Collaboration. They have specific guidelines about the conduct of research. So we follow usually that. But good research is expensive and it’s time-consuming. So I would say, more emphasis on quality and less emphasis on volume that would be, I think, the next step for science.

Jo Carlowe: Thank you, yeah. Excellent. That’s very clear and very helpful. Lina, is there anything else in the pipeline that you would like to mention?

Professor Lina Gega: It’s worth, perhaps, mentioning that at the moment, we’re exploring culturally informed mental health interventions for children adolescents. And Behavioural activation, the one that– the intervention that ComBAT is all about is a good exemplar because it taps into young people’s values and build activities around these values. So what we’re interested in understanding is what defines the cultural fabric of a young people? How we can make it an intervention like Behavioural activation culturally diverse. And the ultimate question of our research would be whether culturally diverse interventions have an added value in reaching and engaging underserved groups of children and families.

Jo Carlowe: Thank you. And finally, what is your take-home message for those listening to our conversation?

Professor Lina Gega: I think, when it comes to mental health, we need to be creative and flexible in the way we engage children and young people and those who look after them. And lean scalable interventions and digital media can support our efforts.

Jo Carlowe: Lina, thank you so much. For more details on Professor Lina Gega, please visit the ACAMH website, and Twitter @acamh. ACAMH is spelled, A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

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