Testing the feasibility of Orygen Virtual Worlds: a virtual world platform for delivering youth mental health services

Our research group has developed a purpose-built virtual world platform called ‘Orygen Virtual Worlds’ (OVW) which will be the first virtual world specifically to be used for young people accessing mental health services including for delivery of mental health education, engagement and treatment. Virtual worlds use “avatars” or computer representations of a person to participate in activities or communicate with others. The user accesses a digitally simulated world where they can interact with objects in the environment and thus experience a degree of presence. By meeting with others in this virtual space, social processes can occur which provide a platform for therapeutic benefit through social connection and peer support. A prototype of the OVW platform has been developed using user centred design principles, alongside a group of 10 - 15 young people and 6 clinicians to ensure it is purpose built to fit their needs. The platform enables users to securely login via invite from a moderator and choose an avatar to visually represent themselves in the virtual world. They are then able to access 'worlds' alongside others also invited to join the session and who are also represented as avatars within the environment. The 3D beach environment can be explored with a mouse and track pad, with system controls enabling voice and text chat with all or select users (under the control of moderators). Screens within the environment can be controlled by moderators to show images, PDFs and videos, and act as a 'white board' which can be edited by users. Users can play games in the virtual environment and specific features enable group discussions (e.g. passing a ball between users whilst sitting around a campfire, a spin wheel of programmable questions to facilitate discussion on particular topics). Teaching and gamification features support therapeutic learning. For example, waves on the beach are used to guide breathing and mindfulness exercises. Users are only allowed to access the world during therapy sessions via a secure invite link. The aim of the current trial is to evaluate the feasibility, acceptability and usefulness of the platform for delivering standard treatments (individual, group and peer therapy). As such, three therapy modalities were chosen representing common service delivery modes within youth mental health services. Specific interventions were then co-designed with service providers at Orygen, an Australian youth mental health service based in Melbourne. In this trial, participants will receive only one of the treatments described however the focus of the trial is to evaluate the platform as a whole therefore outcomes will be pooled across treatment arms to determine feasibility and acceptability. As the aim of this trial is to test the feasibility and acceptability of this platform for differing different types of treatments, the treatments themselves are not being compared directly but rather the overall feasibility of the platform for delivering each of the interventions. The details of the different treatment arms are as follows: Individual intervention A 8 session (1-hour per session, approximately weekly) intervention consisting of skills-based, psychological one-on-one treatment delivered by a registered psychologist, focusing on improving skills in emotion regulation and distress tolerance based on concepts derived from Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT) and Behavioural Activation (BA). These interventions are typically employed within Orygen Specialist Services, have a strong evidence base in youth populations (Orygen Evidence Summary, 2018), and were endorsed by both clinicians and young people as being suitable for the current research and relevant to young people’s mental health needs at the current time. ACT and DBT presume that unhelpful/harmful behaviours result from attempts to avoid or suppress unpleasant thoughts, feelings, or bodily sensations (maladaptive coping). When effective, these treatments help individuals to shift their distress responses to adaptive coping activities. Treatment will focus on the acquisition of four key skills drawn from ACT, DBT and/or BA: a) acceptance and willingness, which directly teaches the art of “doing nothing” in the face of negative affect (rather than trying to rid oneself of it through some impulsive action); b) cognitive defusion, which teaches separation between self and ongoing thought processes; c) self-soothing/”healthy distraction” techniques, which give healthy alternatives for calming oneself during the peak of affective distress; and d) mindfulness and relaxation, which teaches the art of coming into the present moment to assist with managing feelings of tension and discomfort. In particular, session one will focus on building engagement and rapport between the therapist and participant, and involve individual avatar customisation, a tour of OVW and an overview of treatment goals and rationale. Sessions two to five will focus specifically on skills training, making use of features within the virtual world such as mindful observation of trees and waves in the ocean. At the conclusion of each session participants will be encouraged to practice the newly-learned skill/s between sessions to promote generalisation of skills acquired. The final session (session six) will provide a review previously taught skills in participants ‘toolbox’ and conclusion. Group intervention An 8-session (1-hour per session, approximately weekly) group intervention adapted from an existing manualised group-based program currently being delivered through Orygen’s Specialist Services, Psychosocial Group Program called ‘Relate’. This intervention was selected on the basis of recommendations from clinicians within the Psychosocial Group Program where this intervention is currently being implemented and evaluated, and was endorsed by both clinicians outside this program and young people as being suitable for the current research and relevant to young people’s mental health needs at the current time. The content of the Relate-OVW group will be adapted from the original manual and based on consultation with the original Relate program designers and translatability to the virtual world environment. Group discussion and activities are facilitated by a therapist and focus on topics related to social challenges experienced by young people attending the clinic, and are designed to simultaneously focus on effectiveness in interpersonal relationships (including the development of social skills) while also providing a positive relational experience, leaving participants feeling accepted and empowered. This includes activities such as spinning a wheel which lands on a group discussion topic (e.g. how mood affects social interactions). The Relate-OVW group will be offered as a closed group (e.g., no new group members after session with up to 8 group members plus one facilitator. Peer support intervention A 6 session (1-1.5 hours per session, approximately weekly) peer support intervention for young people with experiences of psychosis. This intervention was selected by the lead peer worker (in collaboration with the lead investigators) on the OVW project in consultation with Orygen Peer Work specialists (including 6 peer workers), and was endorsed by both clinicians and young people as being suitable for the current research and relevant to young people’s mental health needs at the current time. Discussion and activities aim to address subjective distress, model social behaviours through upward comparisons, build a positive collective identity and encourage acceptance through the sharing of experiences. The aims and focus of the group will be guided by the principles of Intentional Peer Support (IPS; Mead, 2015), which is an established and widely adopted model for peer support used throughout Orygen services (Fava et al, 2020). Specifically, the three governing principles of IPS are learning instead of helping, building relationships and fostering hope in place of fear. In line with this, the overall aim will be to empower participants and instil hope for the future. The group will also aim to improve social connectedness amongst the participants. Sessions will be semi-structured and peer-led, with the opportunity for members to contribute topics and content they wish to explore with the wider group. Activities will include reflective exercises on relevant lived experiences, guidance seeking, interpersonal learning, psychoeducation and self-management strategies. The peer group will be offered as a closed group (e.g., no new group members after session 1) with up to 8 group members plus 2 peer facilitators.