In this podcast Dr. Jessica Schleider talks about the Lab for Scalable Mental Health, single-session interventions, and the challenge to develop interventions that are both personalised and deliverable at scale.
In her work Dr. Jessica Schleider tries to break down the barriers that prevent young people from reaching services, whilst providing accessible interventions to help reduce mental health problems that scale. She does this through her research, testing novel approaches to dissemination in non-traditional settings.
Jessica L. Schleider, PhD is an Assistant Professor of Psychology at Stony Brook University, where she is a core faculty member in the Clinical Psychology Doctoral Program and a Faculty Affiliate at the Alan Alda Center for Communicating Science. Dr. Schleider directs the Lab for Scalable Mental Health, where she and her team develop and evaluate brief, accessible interventions for youth depression and anxiety. Dr. Schleider has published dozens of scientific articles and book chapters; she has also developed or co-developed web-based, virtual reality technology-based, and school-based intervention protocols for youths and parents. Dr. Schleider completed her PhD in Clinical Psychology at Harvard University, along with a Doctoral Internship in Clinical and Community Psychology at Yale School of Medicine. Bio courtesy of Stony Brook University.
Interviewer: Hello. Welcome to the ‘In Conversation’ podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. If you’re a fan of our in-conversation series please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and share with friends and colleagues. Today I’m interviewing Dr. Jessica Schleider, the Assistant Professor in Clinical Psychology at Stony Brook University, New York.
Jessica is the Director of the Lab for Scalable Mental Health and her research on brief scalable interventions for youth depression and anxiety has been recognised by a numerous awards. Jessica, thanks for joining me. Can you say a little about yourself by way of an introduction?
Dr. Jessica Schleider: Of course, and thank you so much for the invitation to join you today. As you shared I’m an Assistant Professor in Clinical Psychology at Stony Brook University, and I direct the Lab for Scalable Mental Health and I am very, very interested in ways to fill in the gaps of the current mental health ecosystem to ensure that more youths are able to get access to some sort of mental health treatment. Primarily mental health treatment that is evidence-based.
Interviewer: Just taking you a step back can you explain what the Lab for Scalable Mental Health is? How did it come about and what is its primary aim?
Dr. Jessica Schlieder: The Lab for Scalable Mental Health I was able to found it two years ago when I started my Assistant Professorship at Stony Brook after graduating from Harvard’s Clinical Psychology Programme, and the mission of our lab is to address the reality that despite a lot of progress and identifying effective youth mental health interventions rates of child and adolescent mental illness have remained stable and high for decades, and low access to treatment is a big contributor to this challenge.
So in the United States, for example, between 50% and 80% of children and adolescents in need of psychological service will never actually receive them. So the mission of our lab and of our research is threefold. The first is to develop brief and highly accessible interventions to hopefully help reduce the burden of youth mental health problems on a larger scale than we’re currently accomplishing.
We’re very interested as a second goal to identify mechanisms of change that underlie these brief accessible interventions and ways to pair children and adolescents with interventions that are tailored to their needs, and third we’re very interested in testing novel ways to disseminate these brief interventions to non-traditional settings. So outside of the clinic to places where children and adolescents naturally are. So schools, paediatric primary care clinics, their homes, their smartphones.
Interviewer: Before we look at your work you said that in the United States up to 80% of young people in need of psychological services aren’t able to access them. Can you describe some of the barriers that prevent young people from reaching services?
Dr. Jessica Schlieder: Absolutely and barriers are multifarious and very complex, but I can name a few of the common ones that tend to come up. So cost is definitely an issue and mental health treatment is not cheap.
It’s very expensive and despite efforts and some progress towards achieving parity in coverage for physical and mental health treatment that hasn’t quite been accomplished in the United States across the board. The cost issue is compounded by the fact that much of the types of treatments that are offered are very long. There are many weeks or even months, instead of considered brief can be 16 sessions to 20 sessions on average.
That’s very high in terms of a level of commitment for families that are busy and are struggling to take care of things from a week to week basis, let alone this as well. Additionally there are challenges of stigma. So families may be hesitant to receive or to seek out Mental Health Services because of what it implies about their child’s difficulties or themselves as a parent. There’s also people with negative past treatment experiences who’ve had treatments that haven’t worked in the past, may be less inclined to seek out services in future.
So I think there are many different challenges that work together to keep people from seeking care when they need it. The provider shortage is also a huge one. There simply aren’t enough providers, even if everyone was fully comfortable seeking out services to meet the needs of all kids.
Interviewer: Your work focuses on developing brief, accessible interventions to help reduce mental health problems that scale. Can you tell us more about this important work?
Dr. Jessica Schleider: The reason we focus on brief interventions is partly because of the barriers issue that we just discussed, in that treatments tend to be very long and require a lot of commitment from families who are seeking care for their children. We are very dedicated to figuring out what are the active ingredients in these more lengthy multi-session interventions and to what degree is it possible to condense these longer interventions into the components that really matter.
There’s also the reality that in the United States and in many countries the most common number of sessions that families and children actually access is one. The mean maybe slightly higher between three to four sessions on average look across all children and adolescents in the US, for example, but many, many families present for treatment once and never again. For these reasons we think it’s very important to figure out what are the potential benefits of one very targeted session.
What is it impossible to accomplish with fewer resources in a shorter span of time and if we can systematically study that and isolate what makes one session matter, what can one session support look like that has the optimal, you know, potential to help in some way? Then for those families who are only able to access brief bits of treatment here or there perhaps we can be more effective in meeting some of their needs.
Interviewer: You recently carried out meta-analysis. Evaluating the effects of single-session interventions for youth mental health problems. Can you share some of the findings? I mean did you find that single sessions was sufficient to affect change?
Dr. Jessica Schleider: This was one of the first questions I wondered as I was embarking on this line of research. You know, it’s a nice idea to be able to affect some sort of change in one session, but can you really do that and as a therapist who was not at that point trained in brief modes of intervention I was very sceptical.
This was in graduate school and my adviser John Wise and I ran a meta-analysis looking at all of the randomised trials that had been conducted on a one session interventions for a variety of youth mental health problems. From anxiety disorders and trauma to depression and conduct difficulties and behavioural problems, and what we found was surprising in several ways.
First, we had found that back in 2017 when we conducted this meta-analysis there were already 50 randomised trials of single session youth mental health interventions and I had no idea the literature would be that large. The second surprise was that compared to active and passive control conditions these single session interventions had a significant effect on symptoms, both in the immediate and the somewhat longer term.
Although like multi-session interventions effects of these single session interventions waned over multiple weeks or months. The effect sizes of these single session interventions overall were not all that far off from overall effects of what were on average 16 session interventions. As we found in a different meta-analysis that was led by John Wise and his colleagues. This was all very surprising and hopeful in a lot of ways.
So I suppose you could see these findings as either promising or upsetting given the similarity in the magnitude of the effect size overall of single session versus multi-session interventions, but I was very excited about these results. If properly targeted single session interventions appeared to have some potential to support youth mental health for the better.
Interviewer: Jessica, one of your research goals is to identify mechanisms of change and treatment matching strategies to build potent personalised interventions. It strikes me as quite a challenge to develop interventions that are both personalised and deliverable at scale. How is it possible to achieve both?
Dr. Jessica Schleider: Yes, that is a wonderful question and one that I think about a lot. In terms of balancing potency and personalisation many existing approaches of personalisation involve adapting treatment over a long period of time based on a person’s presenting problems at a given session. For example, accommodating changes over the course of treatment through modular intervention approaches. That’s a very common approach to personalisation.
How I perceive personalisation and how my lab approaches this problem is more of which single session intervention for whom. Not necessarily how do we tailor each intervention for the individual? We have developed a number of single session interventions at this point all of which are online and self-administered. That’s actually another interesting finding from our meta-analysis. We did not find any difference in the effectiveness of single session interventions based on whether they were delivered by a therapist or whether they were self-administered.
Our personalisation is really focusing on the question which single session intervention is best for which individual at which time. One important thing about our approach to this line of work is we don’t see single session interventions as cure-alls or like vaccines. Once you get one you never need another one again. We see them more as in the moment opportunities to address a problem that’s pressing for that individual.
So personalisation wise if an adolescent, for example, is really struggling with a sense of self-criticism or disliking themselves we have specific single session intervention building a sense of self compassion and that skill set as one example. We also have single session interventions that are more targeted towards different types of ideas or skills, such as an intervention called the ABC Project Action Brings Change that teachers in a very succinct way the idea of behavioural activation.
The idea that what we do can affect our mood and we have another single session intervention that teaches the simple idea that people are capable of change. That’s called project personality and we’ve tested that in a couple of randomised trials now and found positive effects on depression for high symptoms. So what we’re really figuring out now is how can we predict which intervention is going to be most useful for an individual?
So we’re looking at both pre-intervention predictors, like severity of a given problem or demographic or socio-demographic characteristics and we’re also looking at immediate response to interventions as an index of their odds of changing or improving in the future after receiving them. So our approach to personalisation is really trying to figure out will this intervention be sufficient for your current needs or what is the likelihood of it being sufficient for your current needs given what you’re experiencing and given what your problems are.
Interviewer: So your work focuses on familiar processes, such as parental psychopathology and youth cognition such as perceived control. How do these factors inform the design of interventions for children and young people?
Dr. Jessica Schleider: Every single session intervention that our lab develops we try to target one construct. One theoretically important target or mechanism that may impact on depression and anxiety in youth or at least relevant mechanisms to those outcomes. There are of course very wide variety of things we could target in a single session intervention and what to target is a big question, but what we’ve landed on is that targeting modifiable beliefs and cognitions may be the best bet for these, what these interventions are capable of doing.
So for example, the belief that you are capable of change. The belief that treatment can be helpful. A sense of hope about your future. A sense of perceived control. These are the types of things that we design our interventions to be able to move just a little bit so they are perceptible to the individual and we try to move those targets both in parents and in adolescents in our interventions that we’ve developed so far.
We target parents for a few different reasons. One of course parents’ attitudes towards treatment often affect whether kids will receive it. The Parent is very motivated to seek out interventions or think they can be helpful for their children’s mental health difficulties. They’re more likely to get that treatment for their child. They’re often as the gatekeepers to youth mental health care.
One of our interventions that we tested in the past specifically is designed to alter parents belief that therapy can be effective by teaching about the brain and neuroplasticity and the fact that because of how our minds and brains are built and how they work all of us are capable of changing our emotions and our responses to stressors, and we found in an online randomised trial that teaching this idea to parents in a one session, eight to 15 minute programme improved their likelihood of saying that therapy could be effective both for themselves and for their children.
In our interventions for adolescents we more directly target their own sense of perceived control over their own emotions and behaviours by using a lot of concepts from neuroscience to teach them how and why they can, to some degree, have larger degree than they believe control their skills and reactions to stressful situations either by exerting more self-compassion, by engaging in more valuable and high-value activities to improve their mood or simply by practicing new ways.
What we find across all of our interventions that from before to after teens consistently report that they feel more hopeful and more in control of their outcomes than they did before taking the programmes.
Interviewer: You mentioned earlier that the impact of single session interventions does start to wear off. So I’m wondering how long does the impact last and is there a need for some kind of booster session at a later stage?
Dr. Jessica Schleider: Absolutely, and I think the need for continued attention to mental health concerns is true and important to attend to regardless of what kind of treatment a person is receiving. So even for longer-term psychotherapies effects are not permanent. I mentioned earlier that we don’t see any kind of treatment including single session interventions as a silver bullet or a vaccine of any kind or an inoculation against future difficulties.
We do you see it as a potentially helpful way of addressing a current problem in a very streamlined targeted way. We fully expect that individuals may benefit from and seek out multiple single sessions if and when they need them for different types of problems that emerge and that’s one of the reasons were so interested in this question of which single session intervention is best for whom and at what point in time, so that we can better match people to specific interventions that may meet their needs in the moment where they’ll be most helpful.
Interviewer: Your research tests novel approaches to dissemination in non-traditional settings. So beyond brick-and-mortar clinics. Can you give some examples of this?
Dr. Jessica Schleider: In one project which is being funded by the Klingenstein Generation Foundation we’ve partnered with primary care paediatric clinics affiliated with Stony Brook University in New York and there are nine different clinics that we’re working with. A couple of years ago the American Academy of Paediatrics emphasised the importance of screening for depression symptoms in early adolescence presenting for regular medical check-ups.
This is a wonderful thing because it will improve the detection of mental health problems, specifically depression, which is associated with a lot of negative outcomes, but the problem with this call for more screening is that there weren’t more services to address the increased detection. Often kids would be left with a list of referrals to call only to be met with wait lists that last month’s and they would be unable ultimately to access care even after being screened or identified.
Nutritionists often don’t have anywhere to refer their clients who screen elevated on these problems. So we have partnered and are testing the effects of pairing this depression symptom screening in paediatric primary care clinics with immediate access to free online single session interventions for parents and for teenagers, and our goal in this project is to see whether offering these interventions right at the time of screening can improve outcomes, both symptom wise and in terms of likelihood of following up with longer-term care in the future.
When we’ve offered this free service to families who’ve, you know, been deemed eligible for our study we’ve been met with a lot of excitement that something was offered to them and available right away. So I think a lot of families are very accustomed to having to wait many weeks or months before receiving any support. We certainly have seen over and over again the gratitude for being able to get something right away.
Interviewer: When families do wait and wait and wait and become disheartened do they often just drop out of the system entirely?
Dr. Jessica Schleider: That’s exactly right. Unfortunately that is a reality that tends to recur and that just speaks to the importance of offering services when they’re needed, and single session interventions I think are very well positioned to help fill that gap. Another programme we just published a pilot trial on was actually designed for individuals who were waiting for psychotherapy. So who had been put on wait list for out-patient services and were given one of our single session interventions in the interim to prevent clinical deterioration while they were waiting for future services, which happens quite frequently.
And we did find with the one session programme we developed reduced internalising distress over two weeks. When typically we would expect to see an increase or a stabilisation of symptoms.
Interviewer: Jessica, what is Project YES and who is that aimed at?
Dr. Jessica Schleider: So Project YES is our response to demand for greater access to our single session online interventions. Before we had developed Project YES we had spent a couple of years testing out these online single session interventions and have been finding positive, promising effects as far as four to nine months out for some of our online single session programs for teenagers. A couple of news outlets here in the US took interest in our work.
So the Atlantic and Vox wrote articles about our research and that was very exciting, but what it led to was a massive influx in parents and caregivers calling our lab at Stony Brook University asking if their teenagers could have immediate access to our interventions and at the time we just weren’t set up to do that. We considered making them open access or publicly available at that scale, but the number of contacts we had received led me to believe that it was necessary ethically to make these things publicly available so that others could access the more broadly.
They wanted to try them out, particularly if their other option for their teenagers was nothing at all, which is quite common. So we developed Project YES which stands for Youth Empowerment and Support as an online, ongoing programme evaluation that includes three of the single session online interventions for teenagers that we’ve developed.
These interventions can be accessed by anyone in the world at any time at no cost and anonymously. We collect anonymous data pre and post intervention on Project YES intervention outcomes, so that we can see at least in the very short term how teenagers are responding to and potentially benefitting from each of our programmes that we have online, and recently we came out with a paper in Journal of Medical Internet Research for mental health reporting preliminary findings of YES, and we found that across all interventions almost 200 teenagers who completed YES anonymously said they benefited from our interventions.
Reported significant reductions in hopelessness. Increases imperceived control and increases a sense of urgency over their own behaviours. We also found that the vast majority of youth taking part in Project YES we’re from under-represented backgrounds or marginalised backgrounds and in groups that systematically have had less access to mental health services. So LGBTQ identifying youths, racial and ethnic minority youths is for an over represented portion of our Project YES sample, which we saw is very promising as a potential way of reaching kids who may not otherwise get care.
Interviewer: Do you have the website that you can share with us?
Dr. Jessica Schlieder: Yes, it is schleiderlab.org/yes
Interviewer: Okay, and can you spell Schleider for our listeners.
Dr. Jessica Schleider: I can. S-c-h-l-e-i-d-e-r-l-a-b all one word .org/yes.
Interviewer: Brilliant. Thank you. Jessica, what else is in the pipeline that you’d like to mention?
Dr. Jessica Schleider: Yeah, so we actually just launched a trial and we’re currently recruiting and folks can participate if they would like testing a new single session intervention for parents, teaching skills to help parents build bravery and reduce anxiety in their young children ages four to ten. There has been a lot of interest from parents of younger children than teenagers in, you know, what can we do for kids who are maybe at risk at a younger, earlier stage in development in a brief period of time so.
This is our first attempts at trying to target parents of younger children and hope of being able to make a change there and create interventions for those younger kids who need them. Another project that’s ongoing is funded by the National Institute of Health here in the US and we are calling it Track to Treat and this is our attempts to approach the question of how do you personalise the provision of single session interventions depending on personal clinical needs.
So in this study we are first tracking individual adolescents’ symptom patterns over three weeks. So through an app on their smartphone they’re reporting their symptoms of depression multiple times a day for a few weeks, and in this study we’re going to be tracking whether their personal patterns of symptom trajectories and how their personal symptoms relate to each other can predict future response to certain single session interventions.
So for example, if for one adolescent certain symptoms of depression are just more important to their struggles and to their difficulties. So anhedonia or a lack of interest in activities, if that’s the most central symptom for them. It tends to come up the most we want to find out if that symptom pattern predicts response to an intervention that targets that symptom that’s most important to them.
So this is a five year study, funded by NIH and we’re very much looking forward to seeing if we can prospectively predict somebody’s odds of responding to a targeted single session intervention based on their personal symptom patterns.
Interviewer: I’m wondering how does one go about embedding an understanding of what science can contribute to central to the mental health policy agenda within the US and also in the UK or elsewhere?
Dr. Jessica Schleider: Sure. So policy wise I’m very much looking forward to having more conversations with folks in the policy world and the health policy world to essentially find cost effective and efficient ways to embed single session interventions into the mental health ecosystem. Currently we’re just at the very, very beginning of understanding what these brief targeted interventions can do and where they can be administered.
So I’m very interested in contributing ideally a few single session interventions to an expanded version of a stepped care approach to mental health treatment and mental health support. Whereby perhaps if, depending on our study results that we’re currently running, paediatric primary care clinics can automatically offer certain single session interventions to teenagers who screen high on depression symptoms. Perhaps school personnel can be equipped with access to single session interventions, so that they can provide them to students who present to them with needs.
This would be a way of standardising and ensuring that all folks who present for treatment just once get a tested evidence fact source of support that is optimally designed to help them and as a brief a period of time as possible.
Interviewer: I’m just wondering I recognise the need to make interventions accessible and scalable, but is there a danger of policy makers misusing it because it’s economically desirable, say at the expense of more long-term therapies or deeper work?
Dr. Jessica Schleider: Absolutely that’s a risk and this is why I say in every talk that I give and every workshop that I deliver this is not a replacement for what we already have. It is a means of filling in gaps that aren’t yet filled. There is no ethical reason to replace longer term therapy with a single session if that’s not clinically indicated for the individual. Certainly there is some subset of people who may benefit for whom a single session of the types that we develop may be just enough to address the concerns they’re presenting with, but that will inevitably not be true for everybody.
So I think the path forward is really to see where these interventions can be helpful within to complement and extend the system that already exists. Not to replace resources that are already there. You know that the current system is not suited to meet the needs that are out there. So the answer is not replacing what exists with what we’re developing. Its to use what we develop as an extension of the current system as a whole.
Interviewer: Finally Jessica, what is your takeaway message for those listening to our conversation?
Dr. Jessica Schleider: Well first I’ll speak from the perspective of mental health providers. I think that single session interventions have a lot of potential to be incorporated into all levels of mental health support for children and young people. Whether that involves administering or providing or offering single session interventions to folks who are waiting for treatment in your clinic or between sessions. I think there are so many creative ways to embed these supports to make our current system stronger and to maximise the chances that children will get something that helps them.
I think one message for providers is, the goal here is to use these supports creatively and flexibly among what you’re already doing and for youth I think a really important message is the one of the big reasons for creating these programmes is because teenagers, adolescents are often disempowered in their own process of seeking support and care. One of the main reasons we developed Project YES was so that adolescents could go directly to a free open source web site and try out things that may be helpful to them.
The empowerment part of YES, Youth Empowerment and Support is very much important to our team in that we want to give adolescents avenues to finding care for themselves, not just relying on a system to give it to them when they need it.
Interviewer: Jessica that’s great. Thank you ever so much. For more details on Doctor Jessica Schleider please visit the ACAMH website www.acamh.org and Twitter at acamh. Acamh is spelt acamh, and don’t forget to follow us on iTunes or your preferred streaming platform and let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.