"Innovation goes through putting the resident at the center of the therapeutic intervention"

This month we are having a conversation with Marc Guilló, Academic Director of Amalgama7. On the occasion of the 4^th  YearsFromNow, we had the opportunity to learn about his work and that of his organization. Specifically, Marc spoke about his organization’s experience in treating behavioural disorders in young people and adolescents as a result of their interaction with ICT.

We spoke with him to find out more about Amalgama7’s work:

• Marc, could you tell us briefly about Amalgama7, who are you and what do you do? (how are you funded and which organisations do you work with?).

Amalgama7 is an organisation which focuses on children, adolescents and their families in the clinical, educational and academic fields. We have been developing therapies, in both a day-care and residential basis, since 1997 (over these 22 years we have opened more than treated some 5,500 individuals).

We’re a private organisation which has made agreements with various public bodies, such as the Generalitat de Catalunya’s Department of Education, the Direcció General d’Atenció a la Infància i l’Adolescència, the Government of Aragon’s Institute of Social Services, the Government of Andorra’s Ministry of Health, Welfare and Work and the Institut Català de l’Acolliment i l’Adopció.

We have our own healthcare network, with outpatient centres in Barcelona and Madrid, and residential therapeutic schools in Berguedà and Camp de Tarragona, as well as a daycentre in Barcelona.

• So you fulfil both a social service and a health service role. How do you combine the two?

We appreciate that it is important to help the individual in every sense. The people we help are not only patients, or exclusively students, or only residents, they are all of these things at the same time. Therefore, we need to offer them comprehensive healthcare which takes into account the individual’s circumstances in each of these areas.

Consequently, in our therapeutic schools we pay attention to these different aspects at the same time, ensuring the academic follow-up of each person, the acquisition of social skills and the understanding and management of the disorder from which they are suffering.

Therefore, it is key that we work together as an interdisciplinary team, which includes educators, teachers, psychologists, psychiatrists, doctors, nurses, monitors and so on and that we pay as much attention to one as the other, since an improvement in any one of these areas can lead to an improvement in another.

• Specifically in the case you spoke about at the 4YFN, what is this line of work or project?

Our main line of work, or the most prevalent cases we have encountered so far, are behavioural disorders and dual illnesses (behavioural disorders associated with drugtaking), but we increasingly see cases of abuse and addiction to what have been called new technology, though it’s less and less new since it’s becoming the norm.

Therefore, we would like to point out that the existing manuals of mental disorders (DSM-5 and CIE 10) do not see addiction to technology and video games as a disorder (although they do consider betting to be addiction), and that, in our opinion, we ought to speak of a new dual diagnosis which is increasingly common: one that includes a behavioural disorder associated with an addiction to technology, without substance abuse necessarily also being present.

Until recently, it seemed as if the cases of hikikomori (young men who never leave their bedrooms and who spend hours staring at their computer screen) you hear about in Japan would never happen here, due to cultural and social differences. Nowadays , we can say that we are dealing with them, that we’ve treated such cases in our country and that, therefore, it’s something which will increase over time. We increasingly find teenagers who do not have the right tools to enjoy life in society, and who feel more comfortable living an artificial life via the computer screen, shut away in their room.

Faced with this growing problem, we see how a large part of the video game and entertainment industry are developing more

attractive and more addictive products, but we rarely see them propose technologies to help detect and treat addictions to these products if they are not used properly.

For these reasons, we would like to encourage the technological and audio-visual sector to create programs, apps, games and so no to help raise awareness among users of the existence of such addictions, so they can use them in a healthy, responsible way.

• How do you identify the young people who need your help? Are there a typical set of symptoms or signs?

Normally, the families contact us because they can’t deal with the situation at home, or a professional (whether clinical or academic) refers a case to us if they feel like we can help.

In general, we talk about addiction or the abuse of a substance or resource when someone fails to carry out their responsibilities (domestic, academic, social and so on) in order to persist in an excessive use or abuse of an activity, substance or resource. In 2018, the WHO (World Health Organization) established that, in order to be diagnosed as an addiction, the behaviour needs to continue for a minimum of 12 months. They also recognized the addiction to technology as an illness listed in the International Classification of Diseases. The same year, the Ministry of Health’s National Addiction Strategy included non-substance addictions for the first time.

In the vast majority of cases which we come across, there are a typical set of indicators common to them all: feelings of discomfort on the part of the teenager, a loss of interest in their life, a failure to maintain their circle of friends, a failure to meet academic responsibilities, delusional thinking, the consumption of drugs, poor relations with their family, a failure to adhere to schedules and carry out domestic duties, impulsivity, immediacy, mistreatment of their family (whether physical or psychological), etc.

Fulfilling one or more of these indicators does not mean that the person needs direct help, since they may be more or less common, but if several of these situations are taken to extremes, they may end up preventing an individual from maintaining a healthy lifestyle and from fulfilling their responsibilities.

• Could you describe the elements which help identify behavioural disorders?

There are certain beneficial factors which can help someone maintain a healthy routine and exist in a therapeutically positive environment, although when dealing with individuals there are no magic formulas or solutions which are 100% effective. Some of these factors are: participating in sports in a regular, regulated and social manner; the fulfilment of academic obligations; participating in activities which involve social cohesion (for example, attending a youth-centre); the participation in cultural activities (such as music, theatre, painting), etc.

In certain instances, when an individual enters adolescence they stop doing some of these activities. Suddenly ceasing many of these them can function as an indicator that something is not right, especially if they are replaced by static activities (video games, hanging around in parks, the excessive use of social networks and so on) with new friends (who are unknown to their parents) or distancing themselves from their family. These changes in habits with regard to activities, and the change of attitude towards domestic responsibilities (from a collaborative attitude to more disruptive behaviour) may indicate a situation that may result in a behavioural disorder.

Another factor that can alert us is a tendency towards social distancing. While it is true that during adolescence individuals typically become aware of their environment and, as a result, become more selective and stop engaging in certain activities or put an end to certain friendships due to a change in their preferences, suddenly distancing themselves from their family environment, becoming more secretive and withdrawn. This can give suggest that something is not right, and it might lead to a behavioural disorder.

• Once a problem has been identified, what is the procedure for offering young people help?

By procedure we are talking about what to do to ensure young people begin treatment. At this point, it-s vital that parents have a certain moral authority over their son or daughter in order to make them understand that they need to come and see us. Without this initial obligation on behalf of the family, it’s very hard work with a boy or a girl, since they are unlikely to want to come by themselves if their family doesn’t oblige them to.

Once they visit the clinic, we can assess their behaviour, understand how the individual themselves perceives the situation and make them aware of how they are living and how they react to various stimuli, in order to suggest a course of treatment, if necessary, whether on a day-care or residential basis.

• Do you work in conjunction with mental health centres?

Yes, especially in the early stage (when reaching a diagnosis) and the final stage (designing a monitoring program once they are discharged). At the start, we need information from each of the organisations which will be working with the individual and, therefore, we contact other institutions they have previously visited to find out what treatment they received and any changes in the person’s condition as a result.

Meanwhile, when a person signs up to a monitoring program, they are sometimes tracked through our outpatient centres in Barcelona or Madrid, while in other instances they can be monitored by other external professionals. In such cases we work closely with them to ensure the case is handled correctly and that we are aware of any treatment recommended by the professional.

In the same way, during the treatment, we work with health centres to clear up any doubts about whether our clients have been treated before and to make shared decisions and establish guidelines.

As a result, we work closely with CSMIJ, UCA, day hospitals, private therapists, the SPPIJ and so on.

In addition, we are currently part of the Vice Presidency of the Clúster de Salut Mental de Catalunya.

• To what extent do your patients stick to their treatment plan?

When speaking about following through with treatment, one needs to distinguish between day-care and therapeutic schools.

In terms of day-care therapy, since they attend in person but go about their daily lives, it’s obviously more difficult to ensure they adhere to their treatment plan. The person continues to be exposed on a daily basis to certain stimuli or incentives that can distract them from their therapy and, therefore, over time it may cause them to abandon their treatment and make their willingness to change their lifestyle decline.

In terms of in-patient care, since the person is living in a therapeutic space 24-hours a day and all their efforts are aimed at getting better, the degree to which individuals continue with their treatment is much higher, at around 100 %.

• One of our tasks is to assist the health and social care system in adopting and implementing technological tools to improve the quality of the care they offer. Do you think that technological solutions can be used to treat an addiction to technology?

Undoubtedly. In fact, we’re currently conducting tests involving biological markers to detect ADHD through the use of a video game (B-Gaze). Young people find it really easy to use and it provides us with very interesting, reliable information.

What’s more, if an individual is aware that they have a problem involving the use or abuse of video games and technology in general, parental controls can always be used in order to block access to certain activities, so the individual doesn’t always have temptation within reach. Of course, the person first needs to have the self-awareness to admit to the fact that they have a problem.

Other examples of simple ideas to make users aware of the use they are making of certain technologies are the counters which some video games have to record the number of hours they are being used, though they are often used as a means of competing with players rather than reducing the time they use the game.

Nowadays you can find virtual reality technology which encourages human interaction to deal with and overcome social phobia, so I’m convinced that technology can be developed to detect and work on many other illnesses, including the addiction to technology.

• What do you understand by the term innovation?

We don’t see innovation as only involving the tools used in a treatment. Instead it has more to do with one’s methodological approach.

At Amalgama7, innovation involves putting the resident at the centre of the therapy. This means that every person attending Amalgama7 has a tailor-made therapy, which includes the type of therapy (outpatient, residential or daycentre), the type of treatment, therapeutic objectives and the duration of treatment. Therefore, every person follows their own diagnostic program, treatment program and follow-up program.

In terms of the treatment program, every resident has a unique plan for their stay, both in terms of duration, as well as the objectives that must be achieved in each area (academic, clinical and educational), meaning we can meet the needs of the person as a whole to make changes in every one of these aspects.

Therefore, we believe that innovation is not about using the most modern devices and the most advanced technology, but rather adapting the therapeutic process to the situation and needs of every individual we serve.

• Could you comment on some of the key conclusions you’ve drawn from this project? What are the needs and objectives for the future?

It’s clear that the presence of technology in our day to day lives is on the rise, and that the problems which arise from abuse and addiction are increasingly commonplace. This doesn’t mean that professionals should be afraid of progress in this field, only that we ought to encourage people to use it responsibly and we ought to study the way in which technology can help us in designing the most effective, tailor-made treatment.

In no instance should access to these products be prohibited or restricted, since this would create an even stronger temptation to abuse them. There is a need to promote education as to the responsible use of all existing devices and technologies, so that the user themselves can be aware of to what degree they are dependent on them, or that the device itself can alert the user to any warning signs.

To this end, awareness-raising campaigns already exist as to the use of and dependence on smartphones, such as the Desconect@ program, but we believe it would be a good idea to encourage companies in the technology sector to focus even more on the detection and treatment of the addictions which some of their products are liable to generate.