Single Session Interventions: Expanding Current Provision and Improving Early Access

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In this Papers Podcast, Dr. Maria Loades discusses her co-authored Child and Adolescent Mental Health (CAMH) journal paper ‘Technology Matters: Online, self-help single session interventions could expand current provision, improving early access to help for young people with depression symptoms, including minority groups‘ (https://doi.org/10.1111/camh.12659).

There is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include:

  • How do single session interventions work and what they entail.
  • The drop-out rate among young people for repeat attendance interventions.
  • The groups of young people that are more likely to drop-out of repeat attendance interventions.
  • Why young people often disengage from the repeat attendance model of care.
  • The advantages of single session interventions.
  • Effectiveness of single session interventions on depression symptoms.
  • Single session interventions as an expansion, rather than a replacement, of current provisions.
  • Implications of findings for child and adolescent mental health professionals.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.

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Maria Loades
Dr. Maria Loades

Dr. Maria Loades is a Senior Lecturer/Clinical Tutor for the Doctorate in Clinical Psychology programme at the University of Bath. She is a qualified Clinical Psychologist, working in a variety of mental health settings, including adult mental health, a children’s inpatient unit, and various community CAMHS. She has a post-graduate diploma in CBT for children, young people and families from the Anna Freud Centre/University College London, and a Postgraduate Certificate in the Supervision of Applied Psychology Practice at the University of Oxford. She secured an NIHR doctoral research fellowship in 2016 to further her research into depression in paediatric Chronic Fatigue Syndrome at the University of Bristol, and the Paediatric CFS team at the Royal United Hospital in Bath. Her research interests include: developing and delivering CBT for children and young people with depression, including those with chronic illnesses, therapist competence in delivering CBT, particularly in the field of child and adolescent mental health, and CBT supervision.

Follow on Twitter @MariaLoades

Other resources

Transcript

[00:00:06.870] Jo Carlowe: Hello, welcome to the Papers 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. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.

Today, I’m interviewing Dr. Maria Loades, Clinical Psychologist and Clinical Tutor at the Department of Psychology at the University of Bath. Maria is the joint author of the paper, “Online, Self-Help Single Sessions Interventions Could Expand Current Provision, Improving Early Access to Help for Adolescents with Depression Symptoms, Including Minority Groups,” recently published in CAMH. This paper will be the focus of today’s podcast.

If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.

Maria, welcome, thank you for joining me. Can you start with an introduction about who you are what you do?

[00:01:13.990] Dr. Maria Loades: Hi, Jo, it’s lovely to talk to you. I’m Maria Loades, and by background I’m a Clinical Psychologist and I worked, for a number of years, in Child and Adolescent Mental Health Services before I took up a job here at the University of Bath. And, primarily here, my main role is to train Clinical Psychologists of the future, but, in addition to that, I have been conducting an increasing amount of research, over the last few years, really to focus on young people with problems with their mood and how we can get them help as early as possible. So, that’s what my focus area is on at the moment.

[00:01:58.100] Jo Carlowe: Great, thank you, and today, we’re going to focus on your paper on single session interventions. Before we go into the detail of the paper, can you describe how single session interventions work and what they typically entail?

[00:02:11.300] Dr. Maria Loades: Well, single session interventions are nothing new actually, but they are really what they sound like, which is that they are a one-off session, either with a Therapist or a self-help, so on one’s own, and they are single session in that there isn’t an expectation that someone will have a second session or further follow-up sessions. That is an option, if people want or need it, it doesn’t preclude that, but they are designed to be used as a standalone source of help.

[00:02:49.390] Jo Carlowe: And current mental health service provision for young people is typically designed on the assumption of repeat attendance rather than this single session intervention model. As we’re going to discover from your paper, there is a high dropout rate amongst young people for repeat attendance. What is the dropout rate? And I’m wondering whether some groups are more likely to drop out than others and why do young people so often disengage from this model of care?

[00:03:15.690] Dr. Maria Loades: Yeah, you’re exactly right. The traditional model of mental health services is very much one where there is repeated attendance over time expected. And what we see when we look at the data, both in trials, but also in routinely-collected datasets like the very large-scale Child Outcomes Research Consortium, CORC, datasets is that young people do tend to dropout over time and particularly young people from minority backgrounds. So, young people from more economically disadvantaged backgrounds, young people from ethnic minority backgrounds, young people who are LGBQT+.

Could well be that our services are not serving them very well and so it is important that we think about how we can improve engagement over time in services rather than just assuming that dropout means that they only want or are able to attend once. That said, what we see across the world, and it’s really interesting no matter what age group you look at, it applies to young people, but it also applies to adults, is that there are a proportion of people who seek help who only come or use the help once.

And particularly, when we also start to look at the digital mental health intervention space, we all know this with apps that we download, and this is not just related to mental health, but, broader I would say, is we all have an inclination to download something or to try something that looks like a good idea and not to go back to it a second time. I’ve got so many apps on my phone that have never really been opened, since I first installed them.

So, there does appear, consistently across the world really, to be this pattern that around about a third of young people might only attend for a couple of sessions or might only use something for a couple of sessions. It depends a little bit on what that something is and who the young people are as to the exact figures, but we do see a significant proportion of people only using something once. And if we’ve designed those things, be it an app, be it a in-person intervention, be it a telephone intervention, be it a Internet-based therapy, if we’ve designed those things, assuming that someone is going to come back, then potentially, what is happening is that those people who are only using it once are not getting the full dose of whatever we’re assuming to be helpful.

If we’ve designed it thinking they’ll come ten times, then we’ve spaced out the important things probably across those ten sessions. So what we’re doing here is rather saying, “Okay, well, if we assume that someone only attends once, how can we make sure that they get whatever is our assumed active ingredient or the thing that makes the difference, within that single sitting?” Yes, they could come back again, there’s nothing stopping them from coming back again to use the same intervention again or a different one, and that’s great if they want to do that, but let’s assume that they’re only coming this one time and how can we make the most of that one chance we’ve got.

[00:06:39.820] Jo Carlowe: So, let’s focus more on the detail of your paper. So, this is, “Online, Self-Help Single Sessions Interventions Could Expand Current Provision, Improving Early Access to Help for Adolescents with Depression Symptoms, Including Minority Groups,” recently published in CAMH. Maria, can you give us an overview of the paper to set the scene? So what did you look at and what did you find?

[00:07:01.620] Dr. Maria Loades: So, what this paper is, is one of the Tech Matters pieces for Child and Adolescent Mental Health, which was a really great opportunity to summarise what the field has learned so far and where we need to go as well in terms of thinking of how we really capitalise on these online, single session sources of help for young people, and how we expand upon, not replace anything we’ve already got, but expand upon what we’ve already got, through really using this different, kind of, way of delivering help. And the starting point for me really was finding out, from an ACAMH podcast a couple of year ago, about the work that’s been done on these online, single session interventions by a group who’ve been working out of Stony Brook University in the United States, led by Assistant Professor Jessica Schleider. And Jessica has really taken this idea of single sessions and applied them as online, self-help specifically designed for youth mental health. And she’s now got a series of different single-session interventions, which she’s shown in a number of clinical trials to be helpful to young people in terms of reducing depression, even at up to nine months’ follow-up.

So, from a one-off, 20-30 minute intervention that a young person does all by themselves without contact with a trained provider, to have differences that are visible in terms of depression symptoms in the longer-term, I think is very impressive, given that it’s a very scalable treatment. So, if we’re able to use that to really help a much bigger range of young people and a much bigger number of young people much earlier on in their journey, then I think that is a really potentially important thing to look at.

So, for me, that was the starting point. And what is also really, I think, key from what Jessica’s found is the young people who’ve used these online, single session interventions have been a much broader range of young people that we see our services reaching. So, we know that services, again, across the world, in terms of child and adolescent mental health, are disproportionately accessed by the majority ethnic groups and disproportionately not accessed by minority groups like LGBQT+ and like ethnic minority young people.

Yet, when Jessica’s done work in the USA, what she’s found, in terms of uptake and reach for these single session interventions, is that there’s been much better reach into those kind of communities and populations than we see in our traditional services. Indeed, in her largest trial that she did during the pandemic, recruited around 2,500 teenagers, there was approximately what you would expect in terms of ethnic minority young people compared to the population of the USA, and actually she found an over-representation of LGBQT+ young people.

Now, generally those are people who disproportionately don’t use services. So for that to be over‑represented is really neat, actually. It’s really great that this is something that is clearly proving to be more accessible to those young people than our traditional services are.

[00:11:00.350] Jo Carlowe: And you’ve talked about scalability and reach, were there any other advantages of single session interventions that you would like to highlight?

[00:11:08.580] Dr. Maria Loades: What is important to highlight with these interventions is that a young person can access them anonymously. And we know that another massive barrier for young people in getting help and getting evidence-based help is that of stigma and of feeling reluctant or unable to actually ask people for help. So, what these online, self-help options do is they remove, or at least very much reduce, the need for asking someone else in order to get the help.

We need to find ways, here in the UK, to ensure that we can research these online single session interventions in a way that removes the need for parental consent. And I’ve actually got a funded programme of work where this is something I’m going to be looking at quite extensively to ensure that we can still monitor outcomes over time with young people consenting for themselves to the research components. But in terms of a clinical service, what this enables is a young person to access something that’s helpful, without necessarily needing to go and ask a gatekeeper, be that a parent, be that a GP, be that a Teacher.

You know, the traditional model of mental health services generally depends on asking multiple people for help and telling your story multiple times. And we know that that’s a barrier and that gets in the way and it means that people don’t get help early, but also, that young people who feel particularly ashamed or embarrassed or come from communities where metal health problems might be still more stigmatised, might not be able to get help at all. So, this really opens up a door for those young people to have an option of getting something that might be helpful. And, indeed, it might encourage them to seek further help, you know, we’re – and that’s something I’ll be measuring, in my work on this here in the UK, is actually, does doing a single session intervention may be make you more likely to go and seek some more help sooner? And that would be a great outcome, I think.

[00:13:18.019] Jo Carlowe: But how do you envisage then young people accessing or getting signposted to these single session interventions, if you’re trying to remove the gatekeepers?

[00:13:27.589] Dr. Maria Loades: So, what’s worked incredibly well in the USA is letting young people know about these online interventions through social media. So, we know that Instagram, in particular, is a very much currently-favoured social media platform for young people. And advertising widely, providing a link or a QR code whereby a young person can link straight in, choose what they’d like to focus on. So, in the States they have a range of different options, it might be a self-kindness intervention or a growth-mindset intervention or a behavioural-activation intervention, a young person can choose which one they’d like to do and complete it by themselves, through any device that has a connection to the Internet, from anywhere in – in the USA or, indeed, potentially, in the world.

I think there was an interesting piece of work to do in finding out, though, and it is perhaps culturally specific, as to how young people could find out about these and how we could make sure we get the message out there. So, again, in my work here in the UK, over the next two years, I’m going to be working with young people to really co-design ways that we can advertise and essentially market these single session interventions to young people, so that we’re getting the message out there to them in ways that are relevant and credible to them, in the places they’re already looking for help.

So, I’m intending to really find out from young people, you know, where do they look and what do they think of what they find and how can we then build in strategies to let them know about things like online single-session self-help? But to be honest about other sources of help too, the ways they look and how they look can inform us about how we advertise and market our child and adolescent mental health services more broadly, too. So, there’s a wider ambition there.

But I think, you know, it’s really thinking how do we make this credible and relevant? We know that young people are accessing lots of information that might, indeed, be detrimental to their mental health on social media. How can we also put some information out there that is about things that we know are proven to be sources of help and sources of support for them in the same space because that is the space where they’re at?

[00:15:58.430] Jo Carlowe: I want to focus a bit more on the evidence around effectiveness. So, in your paper you describe this, in particular the work from the USA, and you mentioned Jessica earlier, but this seems to suggest that single session interventions are effective in reducing depression symptoms in adolescents. Can you elaborate a bit more on what is known?

[00:16:18.671] Dr. Maria Loades: Yeah, so in the States, they’ve done three randomised controlled trials now, which have shown, across those three trials and across a range of different young people, that these online single sessions and completing them can lead to improvements in the short-term. So in what we would call the proximal outcome, so the things that change right after you’ve done them on things like how much someone feels hopeful about the future, and on a sense of agency, so how much control they might have over their lives.

So, when we look from right before you do this to right after you do this, those are the kind of things we see changing. Then when we look over time, what we see changing is from before you do this to down the line, whether that’s three months, six months, nine months down the line, we see greater reductions of depression symptoms for the young people who’ve done these single session interventions as compared to active control or placebo single sessions. So single sessions that are built to be very similar, but don’t contain the active ingredients.

And that’s really persuasive because actually, it means that we’ve controlled, for young people’s attention and time spent doing activities and it is the specific activities. So the learning about growth mindset and doing activities related to growth mindset or learning about behaviour activation and doing activities related to that rather than just the time spent doing things on the Internet that’s making the difference.

[00:18:09.500] Jo Carlowe: Any other findings, Maria, that you would like to highlight from the paper?

[00:18:13.880] Dr. Maria Loades: What I think is really key, and this relates back to what I was talking about earlier, Jo, in terms of making sure we’ve got reach and uptake, is that across all the different trials that Jessica’s done, but also when she’s then subsequently looked at these single session interventions more in routine practice, so offering them free via her website and tracking people’s outcomes. But also, in a large project she did in partnership with, essentially, the equivalent of the Town Council in San Antonio in Texas, what we see is that these interventions seem to really work for all young people who access them.

So, there doesn’t seem to be big patterns of difference in terms of them being of benefit if you’re moderately depressed, but not if you’re severely depressed, or if you are younger, but not older, or if you live in a rural area or not. So, it seems like, from all the different analyses that have been done so far, that these work for anyone who uses them. Of course, there are individual differences and of course they’re not going to be right for some people. But what we know is that different things do work for different people and yet we are here managing to reach a broad segment of young people who we don’t normally reach very well, and I think that’s really important to highlight.

[00:19:48.330] Jo Carlowe: Very much so. I know you mentioned earlier that single session interventions aren’t meant to be about replacing what already exists. But is there a danger that your findings could be used to justify reducing resources for more intensive, long-term interventions?

[00:20:04.919] Dr. Maria Loades: I think there’s very much that danger and that’s why I’m so keen to emphasise that I see this as an expansion on current provision and not an instead of anything else. I do think there’s absolutely the need for longer-term interventions and for interventions delivered by Therapists, including highly-trained Therapists, bottom line, that is what I am myself, I’m trained to deliver interventions over time, and I absolutely do believe that that is, and will always continue to be, a very important part of what we offer.

But what we know is that the need is so much greater than what we are ever going to be able to scale in terms of the numbers of Psychologists we can train, the numbers of professionals we can train, and the amount of interventions we can provide. So, I think, as an addition that we can add into the system, that we might well be able to usefully offer to people whilst they wait for something else, or when they’re first considering whether it’s right for them to do something more as, kind of, almost a taster session.

So, as I was saying earlier, you know, it might well be that actually, offering this means someone’s more likely to come and ask for more help sooner, and we need to then ensure that those other sources of help are in place for those people, too. But for some young people, this might be enough as a standalone and might indeed be all they can or are able to access, and I would really love to see that vision realised. It’s been realised, to a large degree in the States now, but we need to think about how we bring that to other places in the world and really capitalise on it in a way that makes sense for young people in the UK and beyond.

[00:21:55.510] Jo Carlowe: And what are the implications of your findings for CAMH professionals who may be listening today?

[00:22:01.580] Dr. Maria Loades: I think as a CAMH professional, the first and very important thing is to think that not everyone is going to be able to access more than one session. So, when we’re working with young people, be it whether we’re recommending a self-help approach or be it that we’re working with them in person, I think it’s always worth asking ourselves the question, how can I make sure that this one meeting has been useful? How can I make sure that the young person has something to take away from today? You know, traditionally, our model is assess and then treat. But we all know that actually an assessment, you do try to do things that are helpful and just how can we make sure that there’s something even in that first meeting that they takeaway that’s helpful, should they never be able to come back again? So, I think that single session model is helpful.

But, secondly, is thinking there are these sources of support out there that young people can access. Right now, indeed, a young person from anywhere in the world can go and access Jessica Schleider’s single session interventions, as they’ve been designed for the States via her website. So, knowing about those sources of support as CAMH professionals and knowing that we can recommend them, that they are evidence-based, I think is really helpful, too.

[00:23:20.140] Jo Carlowe: Are there any further recommendations that emerge from your research?

[00:23:24.270] Dr. Maria Loades: I think we have to be really cautious in asking some of those questions that I’ve highlighted today about how do we let young people know about these? How do we make sure that they can access them, but also, how do we then make sure they’re not harmful for any young people? You know, I think in anything we offer, we’ve always got to ask ourselves, are we really following through on not doing any harm? And so, I think in my work, I’m really planning to work with young people and with practitioners to ensure that we find a way to offer these to those people for whom they can be helpful, in ways that they can be helpful, but also, to make sure that they are not potentially harmful in any ways. So, just really thinking about what the unintended consequences might be and ensuring that we guard against those.

[00:24:16.710] Jo Carlowe: And what follow-up research are you planning or is there anything else in the pipeline that you would like to share with us?

[00:24:22.480] Dr. Maria Loades: Yeah, so, funnily, there is an extensive programme of work I’ll be doing in my Spotlight on Adolescent Mood Problems Group at Bath over the next five years, which is NIHR funded. So that’s National Institute for Health Research funded, where we’ll really be trying to answer some of these questions about how we can bring the single session interventions to the UK and test whether they work as well as they’ve done in the United States. So, watch this space really, there’s going to be lots on this from me in the next few years.

But I think what’s critical is that we all start thinking how do we ensure that help is available early for young people? And, for me, that’s my real mission and the mission of my group. We hear from young people so often that they get help after such a long journey to help-seeking, and I really think that, for me, the space I’m in, but what we all need to do is to make sure we’re paying attention to that space and thinking how can we get young people help that works as early as possible before things get too bad?

[00:25:37.730] Jo Carlowe: Finally, Maria, what is your take home message for our listeners?

[00:25:41.250] Dr. Maria Loades: The journey to learning about single session interventions has really made me think differently about how we plan our work therapeutically and how we make sure that what we’re offering in a moment is useful, that one-at-a-time approach. And I think, for me, that would be the take home message, is really think, “If I only have this one meeting, if this is my only chance to make a difference, how can I put as much value into that as possible?” So, for me, that’s been the real learning point and that would be the take home, is “How can I make this meeting count?”

[00:26:20.880] Jo Carlowe: Wonderful. Maria, thank you ever so much. For more details on Dr. Maria Loades, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A‑C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or review, and do share with friends and colleagues.

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