Enhancing Adolescent Mental Health through Digital Single Session Interventions

1. Improving Adolescent Mental Health with Digital SSIs Erica Szkody, PhD Stony Brook University

2. Mean # sessions in evidence-based mental health treatments: 16 Mean # of sessions attended: 3.9 Modal # of sessions attended (whether in-person or digital/self-guided): 1

3. WHY ARE TREATMENT GAPS SO LARGE FOR YOUTH MENTAL HEALTH? Youth are structurally disempowered from accessing care on their own terms Treatments don’t fit how youth want to (or actually do) engage with support—briefly, as- needed) Supports aren’t located where youth seek help (online!) 32% of teens who couldn’t access care cite parents as primary barrier (N = 211) Mora Ringle, Sung, Roulston, & Schleider, 2023, Journal for Adolescent Health Youth need mental health supports that: (1) are embedded in spaces where they already seek help (2) empower youth to access support when and how they want it (3) are quantifiably better than nothing,per rigorous trials (many existing supports are not!)

4. WHAT ARE SINGLE SESSION INTERVENTIONS (SSIs)? “specific, structured programs that intentionally involve just one visit or encounter with a clinic, provider, or program” SSIs may be accessed on one or many occasions (“one at a time”—not “one and done”); they may be self-guided or human-facilitated; and they may be accessed within or outside of formal healthcare settings, on an as-needed basis In all cases, SSIs drop the (often false) assumption that people will return for session two and instill the belief that meaningful change is possible at any moment, however brief. Source: Schleider et al., 2020, Journal of Clinical Child and Adolescent Psychology

5. SSI ASSUMPTIONS Key Assumptions: • Something good can come from one session, and one session may be the last. (Change expectancies are set high) • Change can, and is expected to, occur in the moment. “Parkinson’s Law in Psychotherapy” – the tendency for therapy to expand or contact to fit the time allotted (Appelbaum, 1975) • Clients already have the inner capacity to alter their thoughts, emotions, and behaviors in order to bring about significant and beneficial changes – a “context of competence” (Hoyt, 2009). This empowers the client inherently.

6. WHY & HOW CAN ONE SESSION BE HELPFUL? • Motivated clients: Capitalizes on client motivation by providing services when people seek them/without a long wait • Happy clients: Clients are pleased/relieved to receive a session of counseling with minimal wait-time • Happy therapists: Motivated and happy clients are very rewarding to therapists! • Positive change happens early in therapeutic process: Decades of research suggests that the largest gains occur in the earliest sessions of therapy (Owen, Adelson, Budge, Wampold, Kopta, Minami, & Miller, 2015) • Can reduce over-treatment • May reduce wait-lists (either by reducing total treatment time or eliminating need for multi-session therapy)

7. Our lab’s evidence-based, digital single-session interventions have now served >40,000 young people 9,000+ via grant-funded clinical trials, 31,000+ via nonprofit and community partnership, in 8 languages Two SSIs certified by Blueprints for Healthy Youth Development as “Dissemination-Ready” Built via co-design with minoritized youth (e.g. LGBTQ+ teens, Hispanic/Latine teens) All SSIs are accessible as needed, with or without parent involvement Single Session Consultation Each SSI targets a modifiable, short-term belief or behavior where short-term improvements in perceived control, autonomy, and hope have been shown to spur upward spirals of meaningful, long-term change.

8. In an NIH-funded RCT (N = 2,452 teens, 80% LGBTQ+, 50% racial/ethnic minoritized youth), two online SSIs (one teaching growth mindset, one teaching behavioral activation) reduced 3-month depression symptoms versus a supportive control (ps < .001) Effects did not differ by race, ethnicity, sexual orientation, gender identity — and sample was dramatically more diverse due to parental consent waiver Funded by NIH Office of the Director & National Institute of Mental Health COVID supplement to grant NIH Early Independence Award, DP5OD028123, PI J. Schleider

9. B.E.S.T. PRINCIPLES •Brain science to normalize concepts • Empower youth to helper/expert role • Saying-is-Believing exercises to solidify learning • Testimonials & evidence from valued others

10. SSI THEORETICAL FRAMEWORK SSIs can be understood as operating via self-determination theory: By promoting client’s senses of competence, autonomy, & relatedness a brief intervention can spur motivation & downstream behavior change

11. PROJECT PERSONALITY (Teaches malleability beliefs) We need your help! We are scientists from Stony Brook University. Every day, we work with kids who are going through challenges and changes in their lives, like starting at a new school, making new friends, or learning to cope with difficult emotions and life events. We also study personality and the brain, and how these things relate to dealing with challenges in everyday life. We ask questions like “Can people change?” and “If they people can change, how do they do it?” Kids often tell us that this science is interesting, and that it may help kids who are going through difficult times in their lives. But we need your help explaining it in a better way to help more kids like you. Please help us and and other kids like you by completing this activity carefully.

12. Here is a story from R.J., a 10thgrade student…

13. But good news: By ACTING differently, you can actually build NEW CONNECTIONS between neurons in your brain! When neurons form new connections, people’s personalities can change. They can have different types of thoughts and feelings. And they can learn to cope with life’s challenges in better ways. And so people aren’t stuck being “shy,” “sad,” or “left out.” Over time, neurons can ALWAYS make new connections. Everyone’s brain is a “work in progress.”

14. Scientists say it’s like the connections in our brains are made with pencil, not permanent marker. That means it’s possible for us to erase old connections and write new ones. Of course, changing brain connections is not as easy as making a pencil drawing. We need patience and effort, and we need to be kind to ourselves if things don't change right away. It takes lots of practice using new ways of thinking. But with the right help, anyone can change over time.

15. So, people can change – but do they? Science says YES. Some people think that our personalities don’t change much during our lives. But the longest-ever study of personality proved that idea wrong! Scientists from the University of Edinburgh, in Scotland, gave 1,200 14-year-olds a personality test. Then, the scientists found those same teenagers 63 years later, when they were 77 years old, and had them do the same personality test again. The scientists found that almost everyone’s personality changed in at least one positive way from age 14 to 77. Some became more creative, others were more hard working and responsible, and others changed into happier people who felt better about themselves. This amazing study tells that our personalities usually do change for the better across our lives.

16. Imagine it is your first day of school. When you are hanging out by your locker, you see one of your good friends from last year. You don't know too many other people in your grade, so you say hello to him and smile. But instead of saying hello back to you, he turns around and walks the other way. He starts talking to a couple of other kids nearby. How do you think you would feel if this happened to you? What kind of thoughts do you think you would have? Please write 2-3 sentences in the box below.

17. SSI EXAMPLES Just a few examples… • Schleider & Weisz, 2017: Across FIFTY clinical trials, single-session interventions benefited anxiety, behavior problems, and (in some cases) depression for youth ages 4-19 — in many cases, just as much as long-term therapy • Harper-Jacques & Foucault, 2014: of 98 adult clients who completed a walk-in therapy service in Canada, 44% reported that one session was sufficient—and one session significantly improved hope and decreased distress 1 month later • Weir, Wills, Young, & Perlesz 2008: In Victoria, Australia, across >100,000 clients and found that 42% chose to have a single session even when more sessions were offered • Basoglu, Calcioglu, & Livanou, 2007: Single-session exposure therapy reduced PTSD symptoms in adults exposure to a natural disaster (earthquakes); gains maintained at 2-year follow-up for 88% of participants • Lamprecht et al., 2007: Single-session solution-focused therapy cut 12-month re-hospitalization rates in half among adults presenting to emergency room for self-harm

18. EMBEDDING SSI’S INTO SOCIAL MEDIA PLATFORMS DOBIAS, MORRIS, & SCHLEIDER, JMIR FORMATIVE RESEARCH, 2022 SSIs were embedded into Tumblr as ’just-in-time’ supports, based on on search patterns SSI length was reduced from ~25 to ~6 minutes SSIs were completed by 6,179 teens within one year Hopelessness reduced at least as much in Tumblr-based SSIs as in our RCTs …But completion rates increased by 50% vs. prior naturalistic dissemination efforts

19. SUPPORTING PATIENTS ON WAIT-LISTS Single-Session Consultation (SSC) Project • Schleider, J. L., Sung, J. Y., Bianco, A., Gonzalez, A., Vivian, D., & Mullarkey, M. C. (2021). Open Pilot Trial of a Single- Session Consultation Service for Clients on Psychotherapy Wait-Lists. The Behavior Therapist, 44(1), 8-15. • Sung, J. Y., Bugatti, M., Vivian, D., & Schleider, J. L. (2023). Evaluating a telehealth single-session consultation service for clients on psychotherapy wait-lists. Practice Innovations, 8(2), 141–161. https://doi.org/10.1037/pri0000207 Hopelessness showed a 86.59% chance of decreasing from before to after the SSC Perceived agency showed a 92.36% chance of improving from before to after the SSC Psychological distress showed a 76.40% chance of declining from before the SSC to two weeks later (while waiting for therapy)

20. SUPPORTING PATIENTS ON WAIT-LISTS VIA SSC-TELEHEALTH SUNG, BUGATTI, VIVIAN, & SCHLEIDER, 2022 Single-Session Consultation (SSC) Project N = 65 clients on waiting lists received SSC via teletherapy (Zoom) Hopelessness showed an 85.18% chance of decreasing (p < .001, d = 1.04) Readiness for change showed an 80.87% chance of increasing (p < .001, d = 0.83) Anxiety decreased (d = .32) and depression decreased (d = .20) 2 weeks later (increases in symptoms while waiting for care are the norm!) The SSC is being delivered to adults, teens, and parents on clinic waitlists, in schools, in primary care, and in emergency departments in at least seven US states and five countries (that we know of!)

21. CURRENT AND FUTURE DIRECTIONS Focusing on Implementation Structural Access Barriers & Facilitators Extending and Adapting Interventions

22. Thank you! Questions? Our Open-Access Digital SSIs schleiderlab.org/yes | projectrestore.info/our-programs SSC manual & Action Plan: osf.io/xnz2t/ Questions/Comments/Request for More Information: EricaSzkody@gmail.com