Qualitative Synthesis of Young People's Experiences With Technology-Assisted Cognitive Behavioral Therapy: Systematic Review.

BACKGROUND: Cognitive behavioral therapy (CBT) for young people is increasingly being provided using technology-assisted formats. Although there is increasing evidence regarding the efficacy of such approaches, as illustrated by quantitative systematic reviews, the literature has also highlighted challenges with implementation factors, including high attrition rates and variable user engagement. Qualitative review methods can help to address the factors that impact young peoples' experience of technology-assisted cognitive behavioral therapy (tech-assisted CBT) and, thus, enable us to better understand such implementation factors. To date, no such qualitative synthesis exists. OBJECTIVE: The primary aim of this review was to systematically identify and synthesize the qualitative literature concerning the experiences of young people who have used tech-assisted CBT. METHODS: This systematic review applied Thomas and Harden's 2008 qualitative thematic synthesis approach. This involved line-by-line coding of the results sections of included studies and an inductive analysis on identified themes, followed by the generation of analytical themes through a process of iteration and interpretation of the descriptive themes. PsycINFO, ACM Digital Library, PubMed, EMBASE, and JMIR Publications databases were searched. The inclusion criteria were (1) studies involving school-aged young people over preschool age (6 years) but under the age of 18 years, (2) use of any form of tech-assisted CBT for any time period, (3) a stated focus of qualitative data to document the experiences of participants, and (4) studies published in English. The exclusion criteria were (1) interventions only provided face-to-face with no technological component, (2) only focused on the performance of the technology rather than participant experience, and (3) numerical data that sought to represent qualitative data. RESULTS: A total of 14 studies were included in this review. Overall, these studies represented interventions for low mood and anxiety (n=10), trauma or self-harm (n=2), and physical difficulties (n=2). Overall, 5 analytical themes emerged on young people's experiences with tech-assisted CBT: (1) helpfulness, (2) therapeutic process, (3) transferability, (4) gameplay experience, and (5) limitations. In addition, these analytical themes contained the following subthemes: positive experiences, tech-assisted CBT versus face-to-face CBT, understanding of a CBT model, process of change, skills development, application to everyday life settings, parental involvement, character relatedness, playability, negative experiences, and broad content. CONCLUSIONS: Overall, young people's experiences with tech-assisted CBT were mostly positive. The use of gaming environments, relatable characters, concrete metaphors, and age-appropriate narratives contributed to these positive experiences. Evidence suggests that technology can help to mediate face-to-face relationships with therapists and help young people to understand the CBT model. Clear barriers also emerged, including over-reliance on reading and writing skills and dissatisfaction with overly generalized content and comparison with commercial technologies. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42018103388; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018103388.

Experiences and wellbeing of Samaritans crisis line volunteers in Ireland during the COVID-19 pandemic: A qualitative study.

BACKGROUND: The literature demonstrates that working in a crisis line volunteer role, despite being rewarding, poses a risk of adverse effects on health and additional pressure exists with the COVID-19 pandemic. Despite this, there is limited research on the experiences of such volunteers. AIMS: This study aimed to explore the experiences of Samaritans volunteers in Ireland during the COVID-19 pandemic, thereby contributing to the overall knowledge of crisis line volunteering, and gaining an understanding of how this role is impacted by the pandemic. METHOD: A qualitative approach was taken, and semi-structured interviews were conducted with volunteers from Samaritans branches in Ireland (n = 13). Data were then analysed using thematic analysis. RESULTS: Four overarching themes were identified: (1) responding to calls in the context of COVID-19, with sub-themes being change in the nature of calls, reliance on existing approach in handling calls and varying emotional responses to calls, (2) sense of loss, with sub-themes being loss of older and vulnerable volunteers, reduced social connectedness and restricted aspects of the service, (3) positive experiences, with sub-themes being supportive culture, new personal skills and perspectives and volunteering as an escape from lockdown and (4) adaptation challenges, with sub-themes being logistical changes and concern for sustainability of the service. CONCLUSIONS: Findings highlight important insights into the experiences of Samaritans volunteers in Ireland, revealing that the pandemic brought about challenges, but also gave rise to some positive experiences. Implications of these findings are discussed in the context of the existing literature and recommendations made.

Using TikTok for public and youth mental health - A systematic review and content analysis.

Globally, TikTok is now the fastest growing social media platform among children and young people; but it remains surprisingly under-researched in psychology and psychiatry. This is despite the fact that social media platforms have been subject to intense academic and societal scrutiny regarding their potentially adverse effects on youth mental health and wellbeing, notwithstanding the inconsistent findings across the literature. In this two part study, we conducted a systematic review concerning studies that have examined TikTok for any public health or mental health purpose; and a follow-up content analysis of TikTok within an Irish context. For study 1, a predetermined search strategy covering representative public and mental health terminology was applied to six databases - PSYCINFO, Google Scholar, PUBMED, Wiley, Journal of Medical Internet Research, ACM - within the period 2016 to 2021. Included studies were limited to English-speaking publications of any design where TikTok was the primary focus of the study. The quality appraisal tool by Dunne et al., (2018) was applied to all included studies. For study 2, we replicated our search strategy from study 1, and converted this terminology to TikTok hashtags to search within TikTok in combination with Irish-specific hashtags. As quantified by the app, the top two "most liked" videos were selected for inclusion across the following three targeted groups: official public health accounts; registered Irish charities; and personal TikTok creators. A full descriptive analysis was applied in both studies. Study 1 found 24 studies that covered a range of public and mental health issues: COVID-19 (n = 10), dermatology (n = 7), eating disorders (n = 1), cancer (n = 1), tics (n = 1), radiology (n = 1), sexual health (n = 1), DNA (n = 1), and public health promotion (n = 1). Studies were predominately from the USA, applied a content analysis design, and were of acceptable quality overall. In study 2, 29 Irish TikTok accounts were analysed, including the accounts of public health authorities (n = 2), charity or non-profit (n = 5), and personal TikTok creators (n = 22). The overall engagement data from these accounts represented a significant outreach to younger populations: total likes n = 2,588,181; total comments n = 13,775; and total shares n = 21,254. TikTok has been utilised for a range of public health purposes, but remains poorly engaged by institutional accounts. The various mechanisms for connecting with younger audiences presents a unique opportunity for youth mental health practitioners to consider, yet there were distinct differences in how TikTok accounts used platform features to interact. Overall, there is an absence of high quality mixed methodological evaluations of TikTok content for public and mental health, despite it being the most used platform for children and young people.

Commenting and connecting: A thematic analysis of responses to YouTube vlogs about borderline personality disorder.

Borderline Personality Disorder (BPD) is an often misunderstood and stigmatized mental health difficulty. Increasingly, social media has been used as a forum to share dialogue on such difficulties. This research analysed YouTube comments in response to personal vlogs about living with BPD. The key term 'Living with Borderline Personality Disorder Vlog' was inputted into a YouTube Ireland search, results were displayed by relevance and the top four vlogs that met the criteria were chosen for analysis. A total of 1197 comments (approximately 55,574 words) were analysed using inductive thematic analysis (Braun and Clarke, 2006). Five distinct themes were identified: 1) Sharing advice, support and encouragement, 2) Vlogs destigmatizing, informing and educating, 3) Solidarity, relatability and personal connection, 4) Intense, unstable intrapersonal and interpersonal functioning, 5) Prompting disclosures about mental health struggles. The vlogs gave people insight and understanding, increasing empathy towards those suffering with BPD or with their mental health. The overall picture drawn from the data was one of solidarity, support, de-stigmatization, normalization, sharing, comfort and encouragement. Further research into people's attitudes towards BPD, their opinions and knowledge of the disorder, may help make important changes, inform policies and practice, and ultimately improve the lives of those living with the disorder.

Pesky gNATs for children experiencing low mood and anxiety - A pragmatic randomised controlled trial of technology-assisted CBT in primary care.

BACKGROUND: Compared to the evidence base for adult populations, less is known about the effectiveness of technology-assisted CBT interventions for children aged 12 and under in real-world settings. AIMS: This study aimed to evaluate the effectiveness of a technology-assisted CBT intervention called Pesky gNATs in primary care psychology services. METHODS: A 2 × 3 (group by time) waitlist randomised controlled trial design was applied (n = 122), using the total internalising score from the Child Behaviour Checklist (CBCL) as the primary outcome measure; and a range of secondary outcomes. Participants were recruited from primary care services across Ireland and were assessed at baseline (Time 1), post-intervention (Time 2), and a follow-up at 3 months (Time 3). Repeated measures ANOVAs were used to analyse the data; in addition to Cohen's d for effect sizes, and the reliable change index (RCI) for clinically meaningful change. RESULTS: Overall, no significant between-group differences were found on primary or secondary measures. Both intervention and waitlist control groups experienced significantly positive change across all timepoints. However, participant retention rate at Time 2 was 66%; and fell to 44% at Time 3. Intervention group feedback from children and parent at Time 2 indicated high levels of acceptability and satisfaction with Pesky gNATs. The RCI showed a statistically significant result at Time 2: more participants from the intervention group (n = 9) moved from clinical to non-clinical levels on the primary outcome than did waitlist control participants (n = 0); but no differences were found at Time 3. CONCLUSION: This RCT did not demonstrate that Pesky gNATs is effective in providing clinically significant levels of change for low mood and anxiety. However, participant feedback showed high levels of acceptability and positive experiences However, given the high attrition rate and implementation challenges, further research is required to ascertain the effectiveness of technology-assisted CBT interventions such as Pesky gNATs.

Mental health professionals as influencers on TikTok and Instagram: What role do they play in mental health literacy and help-seeking?

Background: Mental disorders are recognised as the leading causes of disability worldwide. Despite high rates of incidence, few young people pursue formal help-seeking. Low levels of mental health literacy have been identified as a contributing factor to the notable lack of formal help-seeking by young people. Social media offers a potential means through which to engage and improve young people's mental health literacy. Mental health influencers could be a means through which to do this. Objective: The objectives of this study were two-fold: (1) to systematically identify the most popular mental health professionals who could be classified as 'influencers'; and (2) to determine whether their content contributed to mental health literacy. Methods: The search function of Instagram and TikTok was used to generate a list of accounts owned by mental health professionals with over 100,000 followers. Accounts not in English, in private, with no posts in the last year or with content unrelated to the search terms were excluded. Accounts were assessed for number of followers, country of origin, verified status and whether a disclaimer was included. Using content analysis, the five most recent posts dating back from 15 November 2021 were analysed for purpose and dimensions of mental health literacy as outlined by Jorm (2000) by three separate reviewers. Results: A total of 28 influencer accounts were identified on TikTok and 22 on Instagram. Majority of the accounts on both TikTok and Instagram originated from the United States (n = 35). A greater number of accounts included disclaimer and crisis support information on Instagram (12/22, 54.55 %) than on TikTok (8/22, 36.36 %). A total of 140 posts were analysed on TikTok and 110 posts on Instagram. When addressing elements of mental health literacy from this sample, 23.57 % (33/140) TikTok posts and 7.27 %. (8/110) posts on Instagram enhanced the ability to recognise specific difficulties. Conclusions: These platforms and accounts provide a potential means through which to make mental health information more accessible, however, these accounts are not subjected to any credibility checks. Careful consideration should be given to the impact of content created by mental health professionals and its role in supporting help-seeking.

Can Identity Buffer Against the Detrimental Effects of Threat? The Case of the Qatar Blockade.

In 2017, the blockade of Qatar Gulf states caused a plethora of effects on the country. This paper sought to examine the resulting threat effects of this blockade in terms of lowered self-esteem and well-being, and the potential buffering effects of an overarching identity. Using self-report questionnaire data from Qatari secondary school students (N = 1,410), multiple moderated mediation models investigated the predictive effects of youngsters' perceived threat, via self-esteem, on their well-being, and the mitigating roles herein of, respectively, national, Gulf region, and Arab identity. Perceived threat was indeed related to lower well-being via lower self-esteem, and this relationship was equally strong for those low and high in social identity. In terms of the three facets of identity, the overarching Gulf identity seems the most predictive, and it even (marginally significantly) buffers the negative relationship between threat and reduced self-esteem.

Moral Identity Predicts Adherence to COVID-19 Mitigation Procedures Depending on Political Ideology: A Comparison Between the USA and New Zealand.

Reducing the spread of infectious viruses (e.g., COVID-19) can depend on societal compliance with effective mitigations. Identifying factors that influence adherence can inform public policy. In many cases, public health messaging has become highly moralized, focusing on the need to act for the greater good. In such contexts, a person's moral identity may influence behavior and serve to increase compliance through different mechanisms: if a person sees compliance as the right thing to do (internalization) and/or if a person perceives compliance as something others will notice as the right thing to do (symbolization). We argue that in societies that are more politically polarized, people's political ideology may interact with their moral identity to predict compliance. We hypothesized that where polarization is high (e.g., USA), moral identity should positively predict compliance for liberals to a greater extent than for conservatives. However, this effect would not occur where polarization is low (e.g., New Zealand). Moral identity, political ideology, and support for three different COVID-19 mitigation measures were assessed in both nations (N = 1,980). Results show that while moral identity can influence compliance, the political context of the nation must also be taken into account.

Is the Automation of Digital Mental Health Ethical? Applying an Ethical Framework to Chatbots for Cognitive Behaviour Therapy.

The COVID-19 pandemic has intensified the need for mental health support across the whole spectrum of the population. Where global demand outweighs the supply of mental health services, established interventions such as cognitive behavioural therapy (CBT) have been adapted from traditional face-to-face interaction to technology-assisted formats. One such notable development is the emergence of Artificially Intelligent (AI) conversational agents for psychotherapy. Pre-pandemic, these adaptations had demonstrated some positive results; but they also generated debate due to a number of ethical and societal challenges. This article commences with a critical overview of both positive and negative aspects concerning the role of AI-CBT in its present form. Thereafter, an ethical framework is applied with reference to the themes of (1) beneficence, (2) non-maleficence, (3) autonomy, (4) justice, and (5) explicability. These themes are then discussed in terms of practical recommendations for future developments. Although automated versions of therapeutic support may be of appeal during times of global crises, ethical thinking should be at the core of AI-CBT design, in addition to guiding research, policy, and real-world implementation as the world considers post-COVID-19 society.

A qualitative evaluation of Pesky gNATs in primary care - The experiences of assistant psychologists providing computer-assisted CBT to children experiencing low mood and anxiety.

INTRODUCTION: Technology-assisted cognitive behavioural therapy (CBT) is recognized as an evidence-based and cost-effective way to address psychological difficulties in children. Increasingly, these interventions are provided by staff with different levels of psychological training, such as assistant psychologists (APs). However, there is limited qualitative understanding regarding their experiences of providing technology-assisted CBT. METHOD: Semi-structured interviews were conducted with APs (n = 14) in primary care settings in Ireland. This qualitative evaluation is part of an ongoing RCT for the CBT game Pesky gNATs (O'Reilly and Coyle, 2015). All data were inductively analysed using qualitative thematic analysis by Braun and Clarke (2006). RESULTS: Five overarching themes were identified: 1) positive experiences, 2) integrating Pesky gNATs with traditional CBT, 3) managing parental 'buy-in', 4) implementation complexities, and 5) future perspectives. Two subthemes were reported for each overarching theme: benefits for children, AP professional growth, facilitating engagement, different child characteristics, unclear role for parents, child autonomy, managing waitlists, external factors, design considerations and advice to future APs. CONCLUSIONS: Pesky gNATs is well-received by APs in primary care, and is mostly experienced as helpful by both APs and children. However, a number of factors may be impacting the ability of APs to effectively provide the intervention.

Using Computer Games to Support Mental Health Interventions: Naturalistic Deployment Study.

BACKGROUND: Recent research has highlighted naturalistic uptake as a key barrier to maximizing the impact of mental health technologies. Although there is increasing evidence regarding the efficacy of digital interventions for mental health, as demonstrated through randomized controlled trials, there is also evidence that technologies do not succeed as expected when deployed in real-world settings. OBJECTIVE: This paper describes the naturalistic deployment of Pesky gNATs, a computer game designed to support cognitive behavioral therapy (CBT) for children experiencing anxiety or low mood. The objective of this deployment study was to identify how therapists use Pesky gNATs in real-world settings and to discover positive and negative factors. On the basis of this, we aimed to derive generalizable recommendations for the development of mental health technologies that can have greater impact in real-world settings. METHODS: Pesky gNATs has been made available through a not-for-profit organization. After 18 months of use, we collected usage and user experience data from therapists who used the game. Data were collected through an online survey and semistructured interviews addressing the expectations and experiences of both therapists and young people. Thematic analysis was used to identify key themes in the interview and survey data. RESULTS: A total of 21 therapists, who used Pesky gNATs with 95 young people, completed the online survey. Furthermore, 5 therapists participated in the follow-up interview. Confirming previous assessments, data suggest that the game can be helpful in delivering therapy and that young people generally liked the approach. Therapists shared diverse opinions regarding the young people for whom they deemed the game appropriate. The following 3 themes were identified: (1) stages of use, (2) impact on the delivery of therapy, and (3) customization. We discuss therapists' reflections on the game with regard to their work practices and consider the question of customization, including the delicate balance of adaptable interaction versus the need for fidelity to a therapeutic model. CONCLUSIONS: This study provides further evidence that therapeutic games can support the delivery of CBT for young people in real-world settings. It also shows that deployment studies can provide a valuable means of understanding how technologies integrate with the overall mental health ecosystem and become a part of therapists' toolbox. Variability in use should be expected in real-world settings. Effective training, support for therapist autonomy, careful consideration of different approaches to customization, the reporting of deployment data, and support for communities of practice can play an important role in supporting variable, but effective, use.

Transnational Child Sexual Abuse: Outcomes from a Roundtable Discussion.

The phenomenon of men who travel across international borders to engage in child sexual abuse presents significant public health, legal, diplomatic, cultural, and research challenges. Briefed in the current scope of this issue by relevant stakeholders across legislation, research, and social policy, a roundtable discussion held in London aimed to synthesise plenary discussions from multidisciplinary attendees across law enforcement, academia, non-profit, and industry sectors with direct relevance to the UK. Specifically, the roundtable discussions aimed to gather the central themes relating to attendee discussions on the key challenges, affected countries, response strategies, and knowledge gaps. Four key themes were identified from the data, relating to the definition of Transnational Child Sexual Abuse (TCSA), criminal justice, geographical considerations, and issues surrounding tourism/hospitality. The data highlighted four priorities for future development and research, namely developing offender typologies, victim-centric investigative practice, prevalence and definitions, and collaborations. These themes provide insight into the issue of transnational child sexual abuse from the perspective of different disciplines and offer a strategy to prioritise, and collaborate, in the efforts against transnational child sexual abuse.