Professor Gary O’Reilly,

Director

Doctoral Programme in Clinical Psychology,

University College Dublin

E-mail: gary.e.oreilly@ucd.ie

Pesky gNATs!: Using Technology in CBT with

Young People

@peskygnats

www.PeskyGnats.com

1. What we have learnt from using technology to

tackle the lack of availability of mental health

services

2. Our experience at Pesky gNATs of using

technology to help young people understand

complex psychological models

Today…

Twomey, C. & O'Reilly, G. (2016). Effectiveness of a freely available computerised CBT programme (MoodGYM) for

depression: meta-analysis. Australian and New Zealand Journal of Psychiatry

Mood Gym 850,000 registered users

11 RCT studies demonstrated

MoodGYM’s effectiveness for

depression symptoms at post-

intervention, with a small effect size

(g=0.36).

6 RCT studies demonstrated

MoodGYM’s effectiveness for

anxiety symptoms at post-

intervention, with a medium effect

size (g=0.57,)

6 RCT studies did not yield

significance for MoodGYM’s

effectiveness for general

psychological distress

symptoms

Works equally in clinic/community

Developer/Non Developer no diff

Best when therapist assisted

Local origin works better

Drop-Out rates 0-73%

What have we learnt about building on-line mental health tools?

Therapist Personal Characteristics: 1. Empathic2. Respectful3. Kind 4. Sincere & Genuine5. Interested6. Confident

Are there benefits to blending technology

with traditional face to face therapy?

Therapist Relationship Positions: 1. Collaborative

2. Impartial 3. Curious

4. Open-minded5. Non-Collusive

6. Appropriately self-disclosing

Therapist Behaviours: 1. Communicates clearly2. Rewarding and encouraging3. Encourages active participation4. Reflective listening5. Directive

Therapist Behaviours: 6. Asks open-ended questions

7. Spends appropriate time on issues 8. Deals with frustration + difficulties

9. Non-confrontational challenging 10. Appropriate use of humour

The benefits of a high quality therapeutic relationship

We can support the client & therapist while maintaining their relationship

Children:

Anxiety & Low Mood

www.PeskyGnats.com On-line Training

www.PeskyGnats.com On-line Training

www.PeskyGnats.com On-line Training

• Psychological Well-Being Practitioner

• Post Graduate Degree Qualification in

an evidenced based form of

Psychotherapy,

• Post Graduate Qualification in CBT,

• Clinical Psychology,

• Educational Psychology,

• Counseling Psychology,

• Child and Adolescent Psychiatry, or

• Social Work.

A CBT computer game played in-session

with your therapist

Stimulus

Co

gnit

ive

Pro

cess

es

Schemata

Positive, neutral, negative

automatic thinking

feelingbehaviour

Automatic mode of processing stimuli

Interpretation

Memory

Attention

Attitudes/Beliefs

Cognitive

Behaviour

Therapy

Aw

aren

ess

& S

kill

Level 1: Surface Level

Cognition

Level 2: Intermediate

Cognitive Processes

Level 3: Deeper

Cognitive

Organisation

The Cognitive Behavioural Model

Dozois, D. & Beck, A. (2011) Cognitive therapy. In J. D. Herbert, & E. M. Forman (eds). Acceptance and Mindfulness in Cognitive Behaviour

Therapy. Understanding and Applying the New Therapies. New York: Wiley.

Therapist Personal Characteristics: 1. Empathic2. Respectful3. Kind 4. Sincere & Genuine5. Interested6. Confident

Therapist Relationship Positions: 1. Collaborative

2. Impartial 3. Curious

4. Open-minded5. Non-Collusive

6. Appropriately self-disclosing

Therapist Behaviours: 1. Communicates clearly2. Rewarding and encouraging3. Encourages active participation4. Reflective listening5. Directive

Therapist Behaviours: 6. Asks open-ended questions

7. Spends appropriate time on issues 8. Deals with frustration + difficulties

9. Non-confrontational challenging 10. Appropriate use of humour

CBT: Delivering a model developed for adults to children?

Piaget

Vygotsky

Donaldson

Bandura

Cognitive

Development

Zone of Proximal

Development

Social Cognitive

Development

Social Learning

Theory

Sensori-motor

phase (0-2yrs)

Pre-operational

phase (2-7yrs)

Concrete

operational

phase (7-12yrs)

Formal

operational

phase (12yrs +)

Abstract thinking

1. Attention to essential features of the model's behaviour;

2. Retention in memory of the model's behaviour so it can be

replicated in the absence of the model;

3. Motoric reproduction of the behaviour symbolically represented in

memory;

4. Reinforcement and motivation for the behaviour’s retention.

Therapist scaffolds the child’s application

of CBT concepts to his/her life

Concrete

operational

phase (7-12yrs)

Formal

operational

phase (12yrs +)

Abstract thinking

Children’s thinking is at its most

sophisticated in social contexts

Cognitive

Development

Zone of Proximal

DevelopmentSocial Cognitive

Development

Social Learning

Theory

Young person [& parent?]Therapist

Beck’s CBT

Model

filtered

through

Delivered by

a computer

game

Therapeutic Relationship

Piaget

Vygotsky

Donaldson

Bandura

The young person experiences a child friendly CBT intervention delivered through

a computer game played within the supportive relationship with their therapist

O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy Programme for

Children & Adolescents. Version 1.0

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Extremely"Poor" Below"Average" Average" Above"Average" Excellent"

Ireland"(n"="644)"

UK"(n"="265)"

USA"(n"="220)"

Overall"(n"=1142)"

Ratings of 1142 mental health professionals from Ireland, UK & USA of their overall impression of cCBT game Gnats Island

Key point!

93.7% of mental

health professionals

from 3 countries

rate Gnats Island as “above average” or

“excellent”

Pesky gNATs A CBT computer game for young people with anxiety

or low mood

Prof Gary O’ Reilly and Dr David Coyle

1. In-session computer game features: Avatars

Standardised measures of psychological

functioning used in CY-IAPT are embedded into

the game. They are completed, scored,

profiled and displayed to the young person

instantly

- The Revised Children’s Anxiety and

Depression Scale (RCADS)

- The Children’s Outcome Rating Scale

(CORS)

- The Children’s Session Rating Scale (CSRS)

2. In-session computer game features: Measures

Individually monitoring engagement and outcome

A child friendly concrete metaphor for standard CBT

ideas that unfolds in each level of the game:

1. Intro to the CBT model = TFBs go together

2. Negative Automatic Thoughts (NATs) = gNATs or little flies

that sting without you noticing.

3. Thought Monitoring = gNAT trapping.

4. Cognitive Restructuring becomes gNAT swatting.

5. Identifying Core Beliefs becomes gNATs Hive Hunt.

6. Core Belief challenging = Splat a Hive

7. Relapse prevention = Future World Cinema

3. In-session computer game features: MetaphorsCognitive

Development

Played with your therapist…

1. All the benefits of a therapeutic relationship

2. Allows for zone of proximal development for CBT

concepts

3. Ensures integrity of CBT programme delivery combined

with a nuanced personal experience of the intervention

4. Pace of progress through the game can be determined by

the therapist and supplemental material or consolidation

of skills added as appropriate

5. With younger children it can be very helpful to play the

game with a child and a parent together

UsingcomputergamestodeliverCogni veBehaviourTherapytoyoungpeopleduringtherapysessions

Therapist

Youngperson&parent

4. In-session computer game features: AssistedZone of

Proximal

Development

A social story delivered through the narrative of

the game world to support a young person’s

introduction to these CBT concepts

The child plays a computer game where they control a

custom built Avatar who represents them on a visit to

an island where they help a world famous explorer

called David gNATenborough and his team of

investigators.

As the narrative of the game unfolds they learn about

themselves, gNAT trapping, gNAT swatting, and

tracing gNATs back to their hive by helping with

experiments devised by David gNATenbourough and

his team in the world’s first gNAT lab.

5. In-session computer game features: StoriesSocial

Cognitive

Development

3. Young person &

therapist work together

apply that CBT concept

to young person

4. Young person transfers that learning

to their home, school & community with

a between session task

2. An in-game “previous player”

provides a social model of how that

CBT concept applied to them

6. In-session computer game features: Structure

1. A game character

defines a single CBT

concept in each level

Social

Learning

Theory

7. Game Features: Content: Pesky gNATs Level 1

Session 1: Meet Prof Alannah Karr who

teaches you that thoughts, feelings and

behaviours go together

Game Features: Content: Pesky gNATs Levels 2 & 3

Sessions 2 & 3 : Meet Scott

Livingstone, an explorer who is

an expert on catching gNATs.

Introduces young player to the

gNAT gallery & teaches them

how to set a gNAT trap…aka

Thought Monitoring

Game Features: Content: Pesky gNATs Level 4

Session 4: Meet Shona, the young

person who played the game before

you who shares her examples in each

level

Learn how to swat gNATs…aka

cognitive restructuring

Game Features: Content: Pesky gNATs Levels 5 & 6

Sessions 5 & 6: Hunt gNATs back to

their hive with Kirsten Katcher with

some help from Shona & Pesky Pup.

Learn how gNATs come from

Hives…aka Core Beliefs and how to

gather your gNATs into their Hives.

Game Features: Content: Pesky gNATs Level 7

Session 7: Work with David Gnatenborough to Develop a Future Life Plan

Game Level Core CBT Concept

1 Thinking-Feeling Behaviour Go Together

2 Cognitive Monitoring: Introducing 6 Types of Negative Automatic

Thinking

3 Cognitive Monitoring: Introducing 5 More Types of Negative Automatic

Thinking

4 Cognitive Restructuring

5 Identifying Core Beliefs

6 Challenging Core Beliefs

7 Relapse Prevention

7. Game Features: CBT content

Lots of mindfulness, relaxation, breathing

and activity scheduling skills available

within the game.

1. Controlled Breathing

2. Progressive muscular relaxation

3. Activity Scheduling

4. Mindfulness of sounds

5. Leaves on a stream

6. Mindfulness of an object

7. Mindfulness of what’s on your mind

8. Mindful seeing

This Leaves on a stream video is available on Youtube

8. In-session computer game features: Skills

Transfer learning to home, school & community

Young person & parent

8. In-session computer game features: App & Workbook

• Its free!

• Available for Android and iOS

• Searching on iTunes you will only find it as an iPhone

app (not while searching for iPad Apps) even though it

works for both

• We collect no data from young people

• Content is locked-down on download from Google Play

or iTunes Store

• Young person requires an individually generated access

code from a registered Pesky gNATs therapist to unlock

the app

• You create this code for them by logging into your Pesky

gNATs account

8. In-session computer game features: Pesky gNATs App

8. In-session computer game features: App & Workbook

1. Reminders of the content of each

session

2. Between session practice of CBT skills,

mindfulness skills and relaxation

3. Beautifully illustrated

9. In-session computer game features: Workbook

Children:

Anxiety & Low Mood

Children:

PTSD; abuse;

trauma

Children:

Mindfulness Relaxation

Adults:

ID and a MH difficulty

A gift for you from today’s talk…

Mindful Gnats App

free from the iTunes store or Google Play

www.MindfulGnats.com

1. What we have learnt from using technology to

tackle the lack of availability of mental health

services

2. Our experience at Pesky gNATs of using

technology to help young people understand

complex psychological models

Today…

Thank you…

• Areaman Productions

• BBC

• Dr Mary Belton

• Ann Blackwood

• Connie Booth

• Dr Jessica Braham

• Laura Canavan

• Prof Alan Carr

• John Cleese

• Patricia Cooney

• Sadhbh Coyle

• Laura De Burca

• Alan Delahunty

• Dr Roger Davies

• Dr Gavin Doherty

• Chris Donnelly

• Dr Clodagh Dowling

• Patricia Duggan

• Yagiz Erkin

• Eamon Franklin

• Caroline Gill

• Clare Gormley

• Katie Hendrick

• Prunella Scales

• Staff at HSE Galway

• Staff at NEPS Fredrick Court

• TEDxUCD

• Conal Tunney

• Dr Cait Verling

• Darren Walsh

• & everyone who has tried to

help us

• Catherine Jackman

• Muriel Keegan

• Dr Yvonne Kelly

• Rob Kennedy

• John Mathews

• Dr Nicola McGlade

• Gavin O’Connor

• Maurice O’Donoghue

• Paul O’Donoghue

• Aisling O’Dwyer-O’Brien

• Nicholas Offer

• Charlie O’ Malley

• Tomas O’Suilleabhan

• Doireann ni Chorragain

• NOVA UCD

• Opposable Games (EVERYONE!)

• Dr Karl Quinn

• Dr Aisling Ryan

• Andrew Sachs

• SBRI Healthcare

• Dr John Sharry

• Jackie Shipp