Research on Major Depression, Cognitive Behavioural Therapy and Game

BAIM SD4770 Capstone Project Design Proposal

Major Depression x Cognitive Behavioral Therapy x Game Student name: Student ID:

Fong Wai Man 14033685D

Project Instructor:

Huaxin WEI

CONTENT A. Background 1.

2.

Mental health Mood disorder

3.

Personality disorder

4.

5.

World Health Organization stats Beforehand self-evaluation

B. Initial idea 1.

Depressive disorder

2.

Family

3.

Development

C. Refine topic 1.

2.

Depressive disorder  Major depression 

Bipolar I

 

Bipolar II Dysthymic disorder

Multi-factors 2.1. Different aspect 

Environmental/ Developmental: Parenting style

 

Biological/ Genetic: Influence of family history Personality: MBTI, Enneagram



Social/Interpersonal

 2.2.

3.

History/ Past event: Sexual abuse, Childhood trauma 3P of mood disorder



Predisposing(past)

 

Precipitating(now, turning point) Perpetuating(on-going)

Symptoms 3.1.

Positive & negative symptoms

3.2.

4.

3 stages of illness

Recovery 4.1.

4.2.

Level of depression Treatment  Psychotherapy 

Counselling

 

Medication Self-help

4.3.

5.

Approaches  

Pharmacology Human-centered



Cognitive-behavioral



Psychodynamic

In-depth research & reference 5.1.

Cognitive-behavioral therapy  Theory  

5.2.

5.3.

Other forms of therapy  

Group therapy Family therapy



Arts therapy

Other learning from Mental Health First Aid Course  What can non-professional help  

5.4.

6.

Thinking trap Working model

Step to help General leading cause Other learning form Counselling psychology



Ethic

 

Limitation In what area counsellor help



Step in counselling

Interview with occupational therapist 6.1.

Treatment resistance

6.2.

Components

6.3.

Case therapist vs Workshop therapist

6.4.

6.5.

Generating insight Deal with low motivation  Operant conditioning: Reinforcement 

Peer support group

6.6.

6.7.

Grouping Time and scheduling

6.8.

Stages of change  

Pre contemplation Contemplation



Preparation

 

Action Manteca



Relapse

6.9.

Advise 

Insight: Difficult but worth doing



CBT: Most used but still debatable of it reliability

 Component: Break down and focus only single small part 6.10. Notes from occupational therapy course  7.

The stress process

Design reference 7.1.

Broad game  Dixit 

7.2.

Say Anything

Application  eCBT  

7.3.

Online counselling Panoply Story-telling game



Deemo

 

Monument Valley Journey

D. Proposal 1. Insight and vision adjustment 1.1.

Design problem 

Lack of incentive and motivation to trigger or maintain change of behavior

1.2.

Refine vision  

2.

Stage 1: Interim Stage 2: Research poster

Objective 2.1. Design goal 

Internalize rational thinking style through interesting and

social gaming 2.2. Focus point 

Component: Insight

 

Approach: Cognitive-behavioral Target audience: Well cognitive functioning young adults with mild depression or history of major depression

3.

Future plan 

Content building: In depth study of CBT and domain knowledge



in selected part Constant review from expert

E. Reference list

A. Background "With a rich family history of mental disorder, would you then feel called to see the severity and prevalence of them?"

A1. Mental health In city busy and crowded like Hong Kong, the high-pressured environment highly contributes to stress, and therefore, mental health is an important issue besides physical health which worth the public to pay attention. Like infectious diseases which never come alone, mental disorder may have a negative impact on people around.

A2. Mood disorder

In recent year, mood disorder has become more commonplace. However, especially in Asian countries, the majority of people are still hesitated to seek help because of the labeling effect of psychiatric illness or the lack of

understanding about mood disorder. Besides, there is a shortage of mental health related professions such as clinical psychologists and psychotherapists in Hong Kong. Reacting to the need of maintaining mental health, there is more and more self-help books related to positive psychology aiming at guiding people to lead a happier life published. However, most of the mental illnesses would not recover by self-help only.

A3. Personality disorder

Apart from mood disorder, personality disorders are commonly associated with, and at the same time confused with, mental disorder. Compared to mood disorder, personality disorders are more long-lasting and they are more difficult to change. Both personality disorder and mood disorder are resulting from multi-factors in which most of them are co-factors.

A4. Statistics World Health Organization The world health report Chapter 2: Burden of Mental and Behavioral Disorder

GBD 2000 analysis also shows that unipolar depressive disorders place an enormous burden on society and are ranked as the fourth leading cause of burden among all diseases, accounting for 4.4% of the total DALYs and the leading cause of YLDs, accounting for 11.9% of total YLDs. In the age group 1544 years it caused the second highest burden, amounting to 8.6% of DALYs lost. While these estimates clearly demonstrate the current very high level of burden resulting from depression, the outlook for the future is even grimmer. By the year 2020, if current trends for demographic and epidemiological transition continue, the burden of depression will increase to 5.7% of the total burden of disease, becoming the second leading cause of DALYs lost. Worldwide it will be second only to ischaemic heart disease for DALYs lost for both sexes. In the developed regions, depression will then be the highest ranking cause of burden of disease.

Depression can affect individuals at any stage of the life span, although the incidence is highest in the middle ages. There is, however, an increasing recognition of depression during adolescence and young adulthood (Lewinsohn et al. 1993). Depression is essentially an episodic recurring disorder, each episode lasting usually from a few months to a few years, with a normal period in between. In about 20% of cases, however, depression follows a chronic course with no remission (Thornicroft & Sartorius 1993), especially when adequate treatment is not available. The recurrence rate for those who recover from the first episode is around 35% within 2 years and about 60% at 12 years. The recurrence rate is higher in those who are more than 45 years of age. One of the particularly tragic outcomes of a depressive disorder is suicide.

Around 1520% of depressive patients end their lives by committing suicide (Goodwin & Jamison 1990). Suicide remains one of the common and avoidable outcomes of depression.

A5. Beforehand self-evaluation Personal background I have a number of family members and relatives who were diagnosed with various mood disorder and psychoses. This added to the tensed environment in the family and adversely affected each family member.

Besides, I am interested in psychology and I like taking a look on the material related to personality and mental disorder in leisure. Regarding my personality, doing something related to human minds and involving interpersonal interaction will be of my biggest interest. With the urge to have deeper understanding of mental health management, mental health will be a nice topic to choose despite the predictable huge amount of domain knowledge required.

Relevant course covered 2013 Semester 1 - Introduction to Psychology Relevant course covered during the project 2015 Semester 1 – Counselling Psychology: Understanding and Helping Each Other 2015 Semester 1 – Mental Health First Aid (Certificated by Mental Health Association)

B. Initial idea

Depressive disorder x Family x Development According to the World Health Organization (WHO), depression will become the second major illness in the world by 2020. In Hong Kong, depression sufferers are about one-fifth of the population. Unhealthy development environment and lack of support network are two of the fundament al factors of developing depression. Regarding t he above factors and heritability, there is higher risk for members in family with depression history to develop the illness.

Tragically, patients without proper treatment may add to coercive parenting style and make their children more vulnerable to mental illness.

Thus, the quality of family relationship is of paramount importance to treat or prevent depression.

Design can help reinforce family relationship. The families can also be educated

that depression is prevalent and remediable. Therefore, it will be encouraging for patients and their family to face the problem and establish good relationship between family members.

The design will be hum ani stic and emotionally resonant with depressed people. Hopefully it can also facilitate empathy building.

C. Refine topic C1. Depressive disorder

There are several types of depressive disorder. The most common one is major depression (also called unipolar depression), which is also the easiest to lead to self-inflicted injury and suicide attempt. Bipolar I and II combine symptom of depressive episodes with different degree of hypomania stages. Therefore,

treatment plan for bipolar disorder is more complicated than major depression.

Luckily, bipolar is more uncommon to lead to death compared with major depression. Dysthymic disorder is a kind of depressive disorder which is comparatively chronic but mild.

Comparison of different mental disorders involve depressive episode:

After balancing the prevalence, severity and complexity, I decided to focus on major depression.

C2. Multi-factors

The causes of major depression are divided into numerous aspects. I have chosen two approaches which seems more helpful to classify them into groups.

C2.1.

Different aspect 

Environmental/ Developmental: Parenting style

 

Biological/ Genetic: Influence of family history, Personality: MBTI, Enneagram



Social/Interpersonal



History/ Past event: Sexual abuse, Childhood trauma

C2.3.

Three “P”s of mood disorder

Unluckily, most of the factors attributing to major depression are unchangeable.

The seemingly most manageable part is stress management.

C3. Symptoms

C3.1.

Positive & negative symptoms

Positive symptoms

Negative symptoms

Suicidal thought, attempts and plan

Low motivation, lasting depressed mood, social withdrawal

C3.4.

3 stages of illness and stages of grief

C4. Recovery

C4.1.

Level of depression

Psychotherapies are preferred for all level of depression expecting some special case such as cognitive malfunctioning, intelligence damages and high resistive patients. For moderate to several cases, medication is included to help biologically managing negative emotion.

C4.2.

Treatment

C4.3.

Approaches 

Serotonin Banana, chocolate

Pharmacology



Human-centered

Believe people are the expert of their own lives; ones should only help someone to find their answer rather than telling them what to do.

People have the potential to become fully functioning and actualize themselves with given appropriate condition including safety, security and unconditional positive regards.



Cognitive-behavioral

Cognitive-behavioral approach suggested that cognition, behavior and emotion are interdependent. Changes in thinking, feeling and behaving will have the impact on the other two. Therefore, if we can manage one part of them, we can somehow manage the others.

C5. In-depth research & reference C5.1.

Cognitive-behavioral therapy 

Theory



Thinking trap



Working model

C5.2.

Other forms of therapy 

Group therapy

Modelling effect 

Family therapy Family as an organic system, family style is treated in the therapy Involve more than one family member 

Arts therapy

Expensing tools for self-express, Arts as a reflect/ re-explore/ reshape past experience 

Play therapy

Expensing tools for self-express, Helpful to associate the abstract things to concrete things Help children or mentally retarded people to express their feeling.

C5.3.

Other learning from Mental Health First Aid Course 

What can non-professional help Final step is encouraging them to seek professional help 

Active listening

Step to help



General leading cause

Stress management is the key of breakout Inadequate sleep is a symptom presents in almost all people with mood disorder C5.4.

Other learning form Counselling psychology 

Ethic



Limitation



In what area counsellor help Step in counselling



C6. Interview with occupational therapist Interviewees’ background 23, fresh grade, work rehabitation for psychairt patient

What is occupation theray? occupation → fulfill role in daily life 咪係學生重溫佢哋開嗰個呢→ meaningful life client center, client know what they need, workout together what role they want to fulfill elderly to children, physical & psychological

Outcome mesure → functional is okay, family okay → can leave

How they find OT? Refer from doctors, e.g. suicide attemp, criminal, rehap phase

Mixed approach CBT→ used in many hospital irrational thinking, clinical psy 做, severe case need to find clin psy

Level Doctor > Clin psy > OT

CBT 3 years course to practice & learn 認受性唔係通用

do they know they have problem→ e.g. 鑽牛角尖, they may not award themselves

腦入面嘅化學物質可能係搞極都搞唔到，只有食藥搞到 有啲復發一兩次就搞掂 有啲呢就放下返好多次嘅主要轉好多次都搞唔掂。 有啲住醫院住好耐，我見有啲人住醫院住成世都要繼續着。一嚟就可能因為個病情難控制啦，二 來都可能因為出院有啲問題。

Treatment resistance 我上過好多堂嫁喇喎，我已經知道晒啲嘢架喎，不過都仲係咁。有啲中國嘅人呢就覺得我識嘅係 唔好嘅，我出到醫院 keep 住食藥係咪姐我未好返呢？我傷風感冒好返就唔使食藥架啦咁精神病 係咪應該都一樣咁呢？不過其實啲老分泌係要食藥去控制住嘅，跟住就會五依時食藥嘅然後就會 有呢個問題。

Low motivation 之後就係 motivation 啦我好攰啦我唔想聽你講嘢啦我唔想出聲。問佢你想點啊，你今日覺得點呀？ 跟住佢就唔出聲，全程都唔出聲。用到嘅方法就可能係要慢慢慢 build up 大家嘅 trust。好似話： 呀，你今日精神幾好喎，讚兩句呀，講兩下。build up 大家之間嘅 trust 同 relationship。

Continuous factor: chronic illness 跟住之後就係一啲症狀嗰啲啦，同埋有時有啲嘢好難解釋，如果個人本身身體唔好所以佢就執笠 啦。即係可能係佢本身身體病痛啦。跟住食左藥又好唔返，成日俾啲痛楚纏繞着，跟住就唔想做 人啦，跟住佢哋就會想自殺。跟住我地同佢傾，最多都係教下佢點樣唔好俾啲痛楚影響日常生活， 其實也不能夠減輕他們的痛楚。這些情況其實很容易復發。

Comment for game More complicated, specific, individualize, each clients is different

Need for clinical usage Scinificiant research Case therapists vs workshop therapists

Irrational belief → irrational beliefs type → translate → help

我哋一啲嘅 case therapist 呢有時都會自己整啲嘢比 clients 用嘅。可能有啲 case，佢嘅 irrational beliefs 好勁嘅，咁可能就會有啲野 list 左一般人嘅 irrational beliefs 有邊幾 types 嘅，姐係非黑 即白啊嗰啲咁。咁都係借啲意咁啦，即係好似話只要你英文 OK 喎不如幫我翻譯左佢做中文得唔

得呀，跟住佢就攞去翻譯啦，跟住佢就自己睇，以呢樣野好似幾似我喎，跟住我可能就會同佢傾 番「咁你覺得呢樣野可以點樣形容返係你身上面呢？」「吖係喎，我有啲咁嘅問題問題 ……」等 佢自己睇唔好格硬逼佢。即係同佢講：「喂呢個係你嘅問題喎，有啲人會抗拒。但係咁樣借兒佢 就會自己接受到多啲，同埋我哋好強調一樣野係要佢自己發現。好多野 都唔可以我哋姐講，如果 唔係嘅話呢一你可能佢哋未必信啦，二來同埋都印象深刻。真係好似我教書乜都塞晒俾你，其實 你都唔會識好多，但係如果你自己諗出嚟嘅話呢咁就會差好遠。

Case OT→ in charge of case,睇自己時間, insight,對精神病認識 Workshop OT→ WS performance, 當返工

如果係 case OT 嘅話我哋就會睇自己嘅時間，或者有時一啲 inisght 啊，或者佢對精神病嘅認識 啊。或者有時 depression 冇 motivation，跟住的時間表亂晒籠，可以去瞓覺訓 16 個鐘，跟住整 返啲時間係床上面攤下，或者係食下飯咁就算嫁啦。點樣 "吞"個 timetable 俾佢，等佢 restructure 返，我地叫 lifestyle redesign。

有時有啲 irrational belief，我透過問問題問返，問一啲 guding question，等佢自己諗下自己係 咪 irrational。

Clients’ qualification: cognitive, education --> not appliable for elderly, Maybe use some stories, it is always easier to see others’ problems



33:05 -

Comment for game More

34:20 OT-Children occupation→ play, play as treatment PD 發育遲緩→ 肌肉無力，,唔識分左右手，玩遊戲做返多啲 skill→ workable → can go back to normal life

MR→ 少用，都有要管理 Oprant conditioning→ -ve/+ve reinforcement

41:00 Sand play, sand+lot of toys→ play and introduce and explain

Through some way to let people get into their world and know what they’re thinking e.g. Autism

Diagnosis→ doctor, lot of people talk to the client Therapy→ 佢地自己做完再傾 唔會幫佢地 identify 啲 problem,而係就住有問題嘅部分比啲 treatment 佢 for my game → 邊分面有問題先玩呢個, 而唔係 general depression 就玩得, deal with different symtom

low motivation → restructure timetable, award Need of social support → e.g. church(very supportive), peer-support group 飲茶,行山,psychological social activities 其實都係有人陪下

45:11 Peer support group→ recovered people 日間醫院活動-->referal by doctor, $60 each time

Hospital: secondary health OT: tertiary health → before illness, prevent relapse

50:00 Family boardgame→ talk and share thoughts→ construct family relationship, good social support

52:00 精神病可 prevent, skills 好--> 1.

social skills,

2.

problem solving,

3.

stress management,

4.

cognitive

Interviewing skills → patient fall in trap → 自己發現, e.g. irrational thinking: all people are bad → any evidence? any exception? does your thought adaptive to everyone?

01:03 Insight group, 發完組無人覺得自己有問題, effect 唔多, 有個人直頭講, 我當增長下知識先黎上堂嫁咋, 姐係完全唔可以 apply 落自己個到囉, 但係我就已經發完

跟 prototype 做,有埋講稿, 可能 modify 下, 講下精神病知識, 有啲咩 symtoms, 通常成日都係到 問，我成日都係到"chok"佢地，問下咁你覺得自己有無咩問題呀？通常都話無，有啲就會好醒咁 講，如果我答有你係咪會叫我點嫁，跟住我心諗……所以好難做

問下佢有無類似經歷，覺得似唔似呀，但通常都用第三身角度同佢講，有呢個病嘅人通常都有呢 啲問題。

我哋都有啲關於 irrational belief 嘅 group program 嘅，咁係關於一啲精神病嘅個案，佢哋有嘅 irrational thinking 係多啲嘅。可能佢太早 jump to conclusion。但係打完之後，個姑娘同我講返， 唔知係佢技巧差定係點喇，其實冇乜收到貨，所以 insight 呢家野係幾難做。同埋 irrational belief 都係難搞。

「因為我自己有做過 CBT 嘅，我覺得係幾有用嘅。少少啦。」 「你 open 唔 open 先？我嘅意思係你係咪 open to 人哋嘅 comment 呀？人哋嘅 opinion 呀？如 果唔係，尤其係一啲俾人捉入嚟醫院嘅，確信覺得我無事。 01:07 Grouping 「咁如果你哋呢 d 分組使唔使揀嗰啲人架？」 「要咁又睇啦，如果係我頭先講嗰啲 irrational belief 係精神病先最多，所以我哋會左精神病嘅， 咁 program 都係 for 精神病嘅。跟住之後就揀啲醒架啦，因為啲 cognitive function 渣嗰啲呢就唔 能夠明白到嗰啲抽象嘅概念，真係同佢哋講話太快跳去嗰 concluison 佢哋唔知咩嚟嘅，係真係 get 唔到個意思，所以上黎都係嘥氣嘅，所以就唔敢搞佢地啦。」

「我睇 CBT 有一個限制係要知識水平高同埋自我控制能力好嘅人。」 「無錯，因為好多時候都係要佢靠佢哋自己轉變。」

01:08 「呢你三個 approach 其實都冇對立嘅嘢，Client-Centred 同埋 CBT 我哋特別用得多囉。」 「係咪 Mix 埋黎用要睇唔常 situation 啦，但係一開始覺得對人的信任嘅時候呢，要講一啲佢哋 關心嘅嘢。來我關心一陣間食嘢嘅嘢嘅，咁你同我講一陣間食乜嘢咁會好開心都好嘅，戴咗你同 我講一陣間做運動嘅，我就覺得你唔理解我呀佢做乜嘢啊我唔係好想了解運動呢樣野喎。咁佢哋 就會有一種感覺囉，所以就 deal with 佢哋有興趣嘅嘢。」

Timing 「咁有兩個問題啦，第一個呢係個遊戲究竟係你鍾意幾時玩就玩，唔玩就唔玩，定係話要好有系 統有結構，話你星期要玩兩次，跟住半年先至完成嘅，又或者係要玩兩個月嘅，因為係有個時間 表，定一話係幾時都得。第二個問題就係到底係自己一個玩，定係要一組人咁係玩。」

「Clinical 上面如果第一個問題啦，如果係太長嘅 program 呢佢哋係唔會用嘅。因為嗰啲 lenght of stage 係好短嘅，三個月到已經係 Maximum 咁滯，如果串中地地冇乜特別大問題嘅，無乜出 院困難，好似 adjustment disorder 適應困難呢，可能過一過嚟、見一見醫生，開解下佢就得啦。 咁就睇 out patient 啦，follow up 啦。所以最好係三至四個星期內做到嘅就最好啦，因為大部份 都係咁嘅 length 嫁姐。跟住之後我地宜家開嘅 group program 呢，就可能一個星期兩堂到，好 似今個星期開二四，下個星期都係二四咁。目的係對佢哋有啲時間可以消化，同埋希望佢哋可以 generalize 係佢哋自己個啲事到。因為我哋上堂教嗰啲嘢呢，好難可以 generalize 到佢哋日常生 活之中嘅，點形容呢，同埋呢啲野好複雜架嘛，即係好似數學我教你一加一等於二，咁你點樣計 三加三等於幾多，呢個係佢哋自己整出嚟，所以有空檔比佢哋去自己消化啦，同埋都唔可以太長。 使唔使跟時間表話幾時做幾時做呢，只要 fulfill 到頭先個講個兩樣嘢嘅話呢，其實唔需要特別限 制佢話要幾耐幾耐。不過你可能要諗下佢一個叫玩幾耐，可能係三個鐘啦。同埋 group program 嘅好處呢就係 modeling 嘅 effect 出現咗啦，我哋呢件事可能有咁嘅睇法啦，咁係好個喎，咁隔 離嗰啲就學到，又或者係一啲 behavioral 嘅 reinforcement 入面呢，咁佢講得好好喎，俾啲掌聲 佢，鼓勵。咁係社交上面啦咁佢就覺得有啲優越感，第二啲人又想要個，咁佢哋做盡力表現得好 啲喇。咁同埋都可以有啲 peer social support，完咗之後可以傾吓計，頭先個遊戲點樣點樣可以 做得好啲啊，咁就會好過自己做完之後無從抒發啊等等啦。

而一般人嘅 attention spend 得 20 分鐘姐，真係好鍾意好鍾意一樣野焦距做，說考慮係 20 分鐘 內。或者可以考慮放個 break 比佢哋。放多五分鐘，玩左二十分鐘咁樣，咁係最好嘅。同埋嗰個 介面有趣啲呀，可能會多啲 reinforcement 咁就更加好。

近排我地做緊個 project 係做 VR，但係我哋就冇咁先進嘅，可能係用電腦來模擬一啲環境，咁 呢個 program 嘅好處就係幫佢 generalize 係生活之中，同埋可能係一啲 work-related 嘅嘢，好 似餐廳，咁你見到張枱污糟左，咁可能有個 function 就係抹乾淨佢，就好似啲電腦遊戲咁，就可 以 achieve佢。咁佢哋第時返工嘅時候就可以 generaliz e到，我見到張枱污糟左咁我就要抹返佢。 大概就係咁啦，醫院而家做緊，但係仲未出到 research。仲未搞，同埋大學教授都仲傾緊呢一 樣野。

近排我哋 promote 緊一個叫做??? learning，但係呢個係俾一個雞程度啲嘅人去做嘅，係做嘢做 得渣啲嘅，咁我哋就不斷喺度 reinforce 佢。因為我哋相信 urrant 係好過 urrant ful，因為 urrant fu 係唔好嘅，咁就有啲唔開心啦，有啲負面嘅感覺啦，係咪有啲人呢，例如精神分裂嘅人呢， Condition 渣渣地架呢，咁要去再婚邊啲行為啱嘅呢係咪錯，咁有啲失敗 嘅 experience 時，佢哋 唔識得剔除佢哋，所以就要不斷講啲啱嘅野俾佢聽，等到佢自己 conditioning 左，每次我見到呢 樣嘢，我咁做一定啱，醫院就做緊呢個 program。

01:15 「我想問吓你哋平時 grouping 會考慮啲咩因素？」

「我哋平時分組呢就會考慮呢，通常要搵一兩個醒嘅，同埋幾個咋咋地嘅，咁個醒嘅就可以教下 佢哋啦，咁就等啲渣渣地嘅都可以有啲目標。

第二樣嘢就係我哋要睇吓個 group 嘅性質係點啦，有時我哋會全部都搵啲同一個病嘅，有時我哋 就唔會嘅，就可能唔同病嘅人都入得去。因為要睇個 group 嘅 dynamic，有啲人可能好多野講， 有啲人可能係唔講嘢，成日唔出聲，有啲人可能係成日講嘢、好多嘢講，有啲就可能唔出聲，淨 係坐係度，如果成堂都唔出聲，成班都唔出聲嘅話呢，就好緊要嘞。」 「真係將個狂燥症同一個正嘅拜拜一齊？」 「係啦，差唔多啦，咁樣最好。同埋要睇性格啦，要係佢哋係咪穩定啦，如果唔穩定呢你坐埋一 齊贊嗌交，如果 OK 嘅咪可以玩下囉。同埋男女啦，係可以有特別多嘅問題。因為一啲係光盤嘅 case。如果五個男一個女啦，咁個女就無嘢講啦。同埋要睇吓個年紀啦，有時太老同體學生傾 唔到計嘅。有無 common sense 啦，好多時都係。同埋要睇個認知程度，有啲好蠢頓嘅，有啲 好醒嘅，咁全場咪俾個好醒嘅玩晒囉，咁其他咪冇野做囉。如果可以溝淡啲嘅咁就好啦。」

「不過如果你話 board game 嘅話呢，一係就好似電腦版嘅多啦 A 夢大富翁，或者就係 board game，會唔會諗下 iPhone 對打？不過好似唔多幫到。」

「我得治療當中同人溝通個位先係最重要。」 「咁你不如會唔會考慮下做 social skill？」 「我近排成日俾人提示嘅即係唔可以太貪心，咁就係要有 specific 嘅問題啦，同埋你究竟想佢哋 唔得都幾多嘢囉，因為左好多資料、太資料成畀晒佢哋嘅話呢，你比多十樣嘢佢，可能最後收到 你嘅嘢，咁 effectiveness 究竟 o 唔 ok 呢，同埋係咪打到個目標呢？相反可能你一堂講兩樣嘢， 咁佢就收足兩樣嘢喇喎，咁會唔會好啲呢？」

01;19 Specific/mixed target? 「我哋 OT 呢成日講 component 嘅，咁就係將一樣好大嘅拆做好多細嘅嘢，如果 physical 嘅容 易睇啦，例如我拎杯野飲跟住放返低佢，咁入面 involve 左啲咩 component 呢，咁可能我隻眼要 望住佢啦、手眼協調啦、肌肉嘅控制啦、幾時大個口識 得放手、幾時張開口等等啦，同埋你會唔 會控制到自己係適當嘅時候做適當嘅嘢。所以我就諗緊會唔會將佢再拆細啲，比如係 social skill， 點樣識新朋友、點樣同佢對話。」

「其實我有一樣野都好想解決嘅，因為呢一班 irrational thinking 好強嘅人呢，系會嚇走晒佢身 邊所有嘅人嘅。」 「要睇佢哋嘅 irrational thinking 係乜嘢，你啱架。咁如果有啲咁嘅 case 嘅話呢，就要睇佢嘅 irrational thinking 啦，咁佢嘅社交技巧都有問題啦，控制唔到自己去做社交適當要控制嘅嘢，情 緒控制啊嗰啲都要啦，如果要搞嘅主要大方向都係幾樣野。我哋 OT 有個 Model 記得二嘅，叫 moho，咁佢會將一個人嘅夜查做好多細嘅 component，例 motivation, interest, values 嗰啲啦，

早啲野都會影響一個人嘅價值同埋佢嘅價值觀，咁我哋都會就住呢樣嘢你搞好佢啲 irrational thinking。

咁佢覺得社交仲唔重要架，佢嘅價值係點樣嘅呢？佢有無 interest 去 social 嫁？佢有無 capacity 去 social 嫁？咁個 environment 有無 facilitate 佢去 social，可能細個環境，爸爸媽媽成日都要返 工，得佢自己係屋企。自己係屋企嘅時候十年都唔出聲個喎，咁久而久之佢又唔出街玩，變左 social ability 又低左，咁就要考慮呢一堆野，hoslitic 咁去諗佢究竟有咩問題令到佢 social 嘅能力 低左，咁都要砌得好細好細。」

01:23 「咁我頭先同你傾咁耐，我發覺到你最 focus 都係 irrational thinking 同埋 communication，咁我 哋有諗下要縮窄啲啦。」

Communication 我醫院就做緊一啲好 situational based 嘅嘢，咁即係點呢，要將啲嘢拆到好細 好細嘅——我哋同人爭執嘅時候，你會點反應呀？佢可能會講一句咁嘅說話，咁你會有咩表現呀？ 咁你會講啲乜嘢啊？咁就咁樣同佢傾囉。我諗緊會唔會參考老人科嗰個大富翁咁樣，咁如果一個 人鬧你嘅話你會點樣面對佢呢？有啲選擇題俾你嘅 I 佢解釋下，或者叫佢哋講下佢有啲咩原因要 咁做呀，邊個係 tune 到做得最好嘅方法啊，真係解決到件事呀。但係之前你可能要上下堂啦， 睇吓邊個先至係最好嘅方法先去 train 佢地。」

01:28 「我想解決嘅問題就係嗰班人令到人哋覺得同佢地接觸好辛苦。其實佢哋最鍾意關心同埋愛護， 但係佢哋自己本身有一種阻力令人哋對佢做唔到呢樣野。咁就變咗會越嚟越嚴重，好極都好唔返， 跟住久而久之就變咗好容易有抑鬱症、或者抑鬱症復發。」

「但係咁樣就係 social cognition 嘅問題都好有的概念可能唔係太 OK ,唔知道合適嘅情況應該點 樣做好令到佢哋有咁嘅情況出現。可能未必關 irrational thinking 事， habit → used to be alone

話呢樣好複雜囉，我都唔識喎，可能係要做一啲 treatment plan 去令到佢哋有返啲 insight，仲要 係佢 concern 架喎，即係唔係佢話我無事喎你講嚟做乜嘢啊，有一個好好嘅事既同埋技巧誘導佢 哋中伏。如果係咁嘅話呢，咁曾經都講過啦，講人哋嘅野，咁帶份報紙啦，咁大個睇吓份報紙啱 啱洗啦，未必啱晒嘅，咁就講下呢件事啦哇你幾時好慘呀！你覺得點睇呀？咁就傾下傾下啦，跟 住佢可能就會話「係囉，我都覺得…呀咁可能呢件事呢同佢嘅事都有少少關連，咁就要睇下佢自 己會唔會有啲咩舉動暴露咗出嚟啦，覺得自己可能都有啲咁嘅問題要搞搞佢。但係好高深啊呢個 技巧，我都唔識啊，我都係得閑肥佬下架咋。

總之就要用一個第三身嘅角度啦，不過你可能都有心理準備，未必做一次就一定得，可能要講講 講講講，不過最緊要係 rapport 囉，係要一個好嘅關係囉。真係要俾佢感覺到你做嘅嘢其實係為 佢好。所有野都係，同埋佢要係信得過你，佢先至容易開放少少。同埋 social support 好重要。」

C6.1.

Treatment resistance

Irregular pill taking low motivation chronic illness trust & rapport building C6.2.

Components

components: deal with specific symtom(tertiary health) social skills problem-solving skill stress management cognitive C6.3.

Case therapist vs Workshop therapist

Case: set specific schedule Workshop, for group, target patient with different problem C6.4.

Generating insight

insight → let them figure it out themselves use others’ stories, Third-person narrative guiding question, interviewing skills trust and rapport building C6.5.

Deal with low motivation

enhance/maintain: operant conditioning, reinforcement peer-support group: 日間醫院, recovered people talk about what they concern and interested C6.6.

Grouping

cognitive functioning gender, age type of problems

self-control C6.7.

Time and scheduling

around 20m, 5m break 3-4 weeks need time to ćśˆĺŒ– C6.8.

Stages of change



C6.9.



Pre contemplation Contemplation



Preparation

 

Action Manteca



Relapse



Insight: Difficult but worth doing



CBT: Most used but still debatable of it reliability

Advice



C6.10.

Component: Break down and focus only single small part Notes from occupational therapy course 

The stress process

C7. Design reference

1. Broad game 

Dixit



Say Anything

2.

Application  

eCBT Online counselling



Panoply

They have to talk to someone and express themselves so that they have chance to process and organize their thinking again.

3.

Story-telling game 

Deemo



Monument Valley



Journey

Monument Valley Puzzle game

Journey

Genre

Deemo Music game

Media

Mobile

Mobile

PS4

Story

The girl flow in a secret place

The main character is the

The players should travel to a

where Deemo

princess. Birds in

mountain. In the

plays piano with her so as to grow

the entire specie forget their own

middle they have a partner. But

the tree and help

identity until all

players can only

her get out of the

10 levels were

communicate

place. At the end,

passed.

with the

RPG

the girl find that

environment and

Deemo is her brother who die

the partner with music notes. On

to rescue her in

the way they will

car accident.

get through several extreme climate and

Form of

Animation

delivering the

episodes

Conversation

story

environment.

Players act in the story throughout gameplay

D. Proposal S EM1 FINAL PRES ENTATION S CRIPT HOOK Good afternoon everyone. I’m not going to have my presentation today. See, someone is staring at me. My last presentation should be so worse that people think I’m now waiting their time. Everyone must hate me so much. No, I won’t do it because I will never do it well.

Well, this is a sample situation demonstrating how irrational thoughts influence the behavior and reaction of a depressed person.

BACKGROUND The topic of my project is depression. Depression is so common nowadays and becoming more prevalent. According to the World Health Organization, 1:5 of the population will have experience depression at least once in their life in 5 year time. 30% of people who committed suicide were diagnosed with major depression.

Despite the risk of suicide attempt in the active stage, relapse of depression i s another risk that needs to pay attention. 80% people who suffer a major depressive episode will have recurrent episodes. In which half of them still have depression disorder.

RES EARCH

Two major kinds of negative symptoms that dominate in depression are continuous depressed mood and low motivation. Negative symptoms stay with the client all the way throughout the illness, from prodromal stage to residual stage.

CONTINUOUS DEPRESSED MOOD Although everyone experiences depressed mood, unlike other people, t hese sufferers are trapped in that mood. Suggested by behavior and cognitive psychology, cognition also takes part in building our emotion. For depression patient, it is common to notice that their past experience has contribut ed to learnt hopelessness. They overly underestimate their ability and stuck in self-blame. Strong and overwhelming distorted thoughts results in long-term depressed mood.

Currently, among all kinds of psychotherapies, cognitive-behavioral therapy is proof to be the most effective and helpful one to treat mild to moderate depression. The aim of CBT is to help people replace unhelpful thinking with more helpful one, and therefore, prevent them from going into thinking trap. For the long-term, CBT helps to train logical thinking pattern. We cannot control negative feeling, but we can manage it. CBT is a way to educates people how to make negative feeling manageable.

LOW MOTIVATION It sounds great, right? Very unfortunately, the second symptom, low motivation, will simply make CBT useless because patients will not give it a try. They totally believe that there is nothing helpful. They don’t think that things can be c hanged. This is a kind of situation, for which an occupational therapist told me even profession would found it helpless to deal with.

After reviewing several cases of depression, I found that love and care both to others and from others give the greatest motivation for patient to seek help and make changes. Generally speaking, love and care occur between friends and family. However, they may not be empathic enough since they do not have a clear picture of how depression affects the patient. Regarding the clinical practice, therapists or doctor will refer patient to some social-support group gathering both patient and recovered people. It is easier to get along with people facing similar situation for this sensitive individuals. They will feel less unfort unat e and understood. Modeling takes place between peers and that encourages them to learn the positive side of each other.

They are motivated by the group to join various social activities too. Normally, members in the group will have a meal or do some exercise together.

IDEA CONCEPT

Regarding the stages-of-change model, the stage before relapse is maintenanc e. It seems that both CBT and social-support group are powerful resources for patients to maintain psychological health. What if there is something that t akes the advantages of them res pectively to motivate and educate the patient at the same time?

Taking this into concern, my vision is to help and motivate people suffering or recovered from major depression to practice and internalize logical thinking pattern in daily life based on cognitive-behavioral therapy. I would like to have a multiplayer board game, combined with an application. The core mechanism of the game will be changing thoughts of game characters to alter their behavior. The apps will be used to record the game for review and provided players with self-learn material of thinking traps. The goal of the game is to provide a social and interesting way for players to practice and internalize the skills learnt from CBT.

Through practicing, players will develop a habit of being sensitive to notice and replace unhelpful thinking. In the best situation, internalizing these emotion management skills will become helpful for their entire life. It does not only prevent relapses of major depression, but also helps players to develop a more optimistic attitude toward their life.

FUTURE PLAN In the coming future, I’ve planned to do more research on CBT and game theory to learn from the CB T session and see how I can adapt typical CBT process to the game. Plenty of research still need for building content and determine the game structure.

Several times of expert review and playtest will be conducted. At every stage of concept development, I will people work in the psychotherapy field to have comment and review on it.

After developing a game prototype, playtest will be conduct for evaluating the game mechanic, balancing, dynamic and etc. Reward and reinforcement for both the gameplay and applying logical thinking in daily life will be an essential part for the success of the game that I have to work hard on. Before the final output, I will decide a visual style which is suitable and helpful for the game. There are still a lot of variables affecting the future plan. I hope that the project will turn out to be truly helpful for the patient. Thank you.

D1. Design problem Lack of incentive and motivation to trigger or maintain change of behavior D2. Refine vision 

Stage 1: Interim



Stage 2: Research poster

To help and motivate people suffering or recovered from major depression to practice and internalize logical thinking pattern in daily life based on cognitive-behavioral therapy 

Stage 3: Refine after research poster

Through interactive and playful elements, motivate and help young adults with mild major depression or depression history to practice and internalize rational thinking 2.

Objective 1. Design goal 

Internalize rational thinking style through interesting and social gaming

2.2. Focus point  

Component: Insight Approach: Cognitive-behavioral



Target audience: Well cognitive functioning young adults with mild depression or history of major depression

3.

Future plan



Content building: In depth study of CBT and domain



knowledge in selected part Constant review from expert

E. Reference list 1. Kite, N., & Kay, F. (2012). Understanding NLP strategies for better workplace communication-- without the jargon (2nd ed.). London: Kogan Page.

2. Pelz, S. (2010). NLP coaching an evidence-based approach for coaches, leaders and individuals. London: Kogan Page.

3. 《飛過抑鬱的森林（修訂版）》葉子菁快樂,書房有限公司 4. 《我和抑鬱談過戀愛》Lucia Shum, 三聯書店(香港)有限公司 5. Remocker, A. (1992). Action speaks louder : A handbook of structured group techniques / A. Jane Remocker, Elizabeth T. Storch ; fore word by Lila N. Quastel (5th ed.).

6. Morrison, H. (1983). Children of depressed parents: Risk, identification, and intervention. New York: Grune & Stratton.

7. Burke, P. (n.d.). Mood: The key to understanding ourselves and others.

8. Moore, R., & Garland, A. (2003). Cognitive therapy for chronic and persistent depression. Chichester, West Sussex: Wiley.

9. Hall, Tara M., Heidi Gerard Kaduson, and Charles E. Schaefer. "Fifteen Effective Play Therapy Techniques." Professional Psychology: Research and Practice 33.6 (2002): 515-22. Web. 10. Pridmore, S (2006) Download of Psychiatry (with Chapters 3 and 20 translated into French by Désirée FRITSCH). University of Tasmania. http://eprints.utas.edu.au/287/ 11. Pridmore S. Download of Psychiatry, Chapter 8. Last modified: July, 2011