Clara Faria: Welcome to Mind the Kids, a podcast series dedicated to exploring the latest advancements in child and adolescent mental health research and practice. As a junior doctor and child and adolescent psychiatrists in training, I'm passionate about understanding and addressing the diverse mental health challenges that are faced by young people globally today. And in this series, I will be joined by renowned researchers and clinicians from around the world to discuss their cutting edge in research, interventions, and best practices in child and adolescent mental health. Through these conversations, we really want to highlight the importance of global collaboration, cultural sensitivity, a topic we'll be exploring today as well, and evidence-based approaches in improving mental health outcomes for young people worldwide. Whether you are a researcher, a clinician, or you're just someone that is interested in mental health, this podcast series is designed to have something for everyone and today I'm super excited because we have the pleasure of receiving Professor Maria Lodis from the University of Bath Department of Psychology. Maria is a clinical psychologist and a leading researcher and she focuses on enabling adolescents to access effective treatments for their emerging mental health problems. Thank you so much, Maria, for being here today with us. Professor Maria Loades: Thanks Clara, thanks for the invite. Clara Faria: So there's lots for us to talk about, but I think the main program of research you're focusing on today is single session interventions. And you just published many interesting papers about it, which we're going to go into detail a little later. But I wanted you to tell us if possible, what are single session interventions and what is the needs gap they are feeling? Professor Maria Loades: Sure, I mean, Clara, no, most psychological therapies have been designed to be multiple sessions. And what I mean by that is that we tend to assume that someone's going to come for treatment, if it's a therapist delivered treatment or to use something like an app over and over and over again, and that the benefits of that therapy accrue over time so that that user has to attend multiple times, use multiple times in order to get what we think is the full dose or the course of treatment. Yet the reality when we look at apps, face-to-face therapy provision, any age group, any presenting problem is that many people don't and can't keep using the therapy or the app. So single session interventions are intentionally designed to be one-off or standalone. So they make the most of the time that the user or client has in this moment to help them overcome their struggles without assuming that they're going to come back to this space again. Now, that doesn't mean they can't come back to use that again, but we haven't assumed that we will necessarily meet again or that they will use the product again. So essentially, we're flipping on its head the way we normally approach psychological therapy and saying, let's package each key message to standalone. So we might say this single session intervention is about this certain key message or is to achieve this certain aim. And we do that within that standalone session. Clara Faria: That's very interesting. I had the pleasure of watching you very recently in a fantastic lecture Maria gave to our research group, the Child and Adolescent Resilience and Mental Health Research Group here in the University of Cambridge. You made a very compelling case for single-session interventions. Considering the current landscape of mental health in the UK today and the growing need we have for more specialists, what do you think is the problem that single-session interventions are helping solve? Professor Maria Loades: Essentially, we know that many young people, as many as one in four, struggle with things like depression symptoms at any one point in time. We know that there are things that we can do that can help them to overcome those struggles. And also that even when they aren't yet at full diagnostic level, so maybe it's just early symptoms of depression, they do get in the way of functioning for young people. So we really need to get them access to those things that work. Yet there are a number of different barriers to accessing help for young people. So from the young people's perspective as individuals, things that might get in the way of them accessing help include some of the practicalities of how we traditionally provide mental health help. Right? Have these clinics that are mainly open between nine and five, Monday to Friday, which is when young people are also at school or college. So the practicalities don't necessarily work. But in addition to that, even though things have improved, there is still a stigma about seeking help for mental health problems that does get in the way for young people. Also young people fundamentally are at that stage in their lives. And I think we all remember being there of, you wanting to become more independent. That's what adolescence is about is developing into an independent adult. So you don't necessarily want to rely on other people. You don't necessarily feel able to reach out and rely on other people. You might feel like you want to rely on yourself more. And that's very normal. So needing to then go through asking adults to access help doesn't necessarily fit well with the normal developmental trajectory for young people. So that's what might get in the way, Clara, for the individuals themselves. But then there are also things in terms of our system for providing mental health help that also are barriers. So one of those things is that we lack trained therapists. We don't have enough to meet the needs. And I don't see single sessions as replacing anything else that we already do, but I do see them as something we could provide at scale without needing to have bottlenecks or to gatekeep in the way that we traditionally have to do for trained therapists, which is a limited resource. So what we see in services that are delivered by therapists is that they have waiting lists, they have thresholds for accessing help, and there are normally a series of different processes that a young person has to go through to get access to them, including asking often multiple different people in the system, people like GPs, and then having an assessment to see if you meet the criteria, maybe being sent to another service. So what we can potentially do with single session interventions is particularly when they're self-help, provide them on demand anonymously at the point of need and at a time and place that suits a young person without them having to go through these hoops of asking for help from other people and without them having to meet any particular criteria for accessing them. That's probably true of many self-help digital mental health interventions. But most of the existing ones, like some very good apps out there, for instance, get back into this problem of assuming that the young person is going to keep using them over time. And the reality is that especially self-help, young people just don't keep using them over time. So what we can do with these self-help single session interventions is deliver a key message in something we've designed to stand alone. but is anonymous on demand and available without barriers to access. Clara Faria: Yeah, I think that's a key point you mentioned that the barriers to access, thinking about, I was reading a paper the other day about networks of care in the modern adolescent that was published in Psychological Medicine. And it was really interesting because they took data from the Oxford Student Survey and they modelled helpfulness of CAMHS. But the bit that like struck me the most is that they looked also at people who didn't find their parents helpful because most young people would find their parents and closest, you know, family helpful. But for the young people, for example, that don't have that family support or are looked after children, for example, I mean, we know that these young people have the worst mental health outcomes because for them it's super hard to access services. And it is really interesting, the, you know, the possibility that single session interventions offer indeed that it can be, it's free at the point of access is evidence-based and you can access it on your own terms anytime. I wanted to ask you, because I know you've worked for many years as a clinical psychologist and like where did the inspiration, where did the idea to, you know, test and implement this huge program in the UK came from and if you were inspired by your experiences as a clinical psychologist as well? Professor Maria Loades: It's been a real journey for me, Clara. So initially I worked after I qualified as clinical psychologist full-time in the National Health Service in England, mainly in child and adolescent mental health services. And I guess what I particularly felt as a jobbing practitioner was a frustration around how many young people were coming to see us in clinics and saying how hard it had been to get access to help, how long they'd had to wait to see us and how they'd had to get worse in order to meet the criteria. So how they tried to get help at an earlier stage, but that they hadn't yet been sufficiently depressed or anxious to meet the criteria for help. And that all just seemed really back to front to me. But also, you know, particularly in the space of adolescent depression, as compared to say, anxiety. As a clinician, I would look at the evidence base to see what might be the best approach to use to help a particular young person. And the evidence base was really lacking. You know, there was very little in the space of adolescent depression that really helpfully told us what would work for whom. That's still a problem now, although things have improved. But really, I guess that set me off on the mission of thinking, I need to improve access to help, and particularly for adolescent depression symptoms. Really, initially, when I set off on that mission, necessarily see single session interventions as the answer. I've done a lot of other work in looking at how we can train up lower intensity therapists and provide briefer treatments with less trained people, task shifting, work around school-based interventions. But I guess as I did that, and also during the pandemic, when it became really apparent how much the scale of the problem was growing. You we were seeing more and more young people with mental health problems, emerging mental health problems, struggling with their emotions. We were seeing longer and longer waiting lists in camps and part of that was due to the pandemic. Part of that was happening anyway, even before the pandemic. But really it was in that context where I then heard a podcast by Jessica Schleider about these single session intervention approaches and a penny kind of dropped for me of like, yeah, no matter what we've tried to do in providing, easier access to support without all these barriers, we just haven't got there yet. And an extension on what we've already got, an addition to what we've already got that could really enable that immediacy of access and anonymous access, which is particularly important for those young people who might come from minoritized groups already, you mentioned young people who've had experiences of being in care, but also young people who've maybe identified as a sexual or gender minority or young people from ethnic minority who we know particularly struggle to access traditional clinic-based services. This could be a really important extra source of help that they can get an access and the work in the States has really indicated that first of all, these interventions can be effective in reducing depression symptoms for young people at three to nine months later, which for a single session self-help intervention that is so scalable is really rather impressive. But also the work in the States has indicated that we see much better uptake from those minority groups. For these kind of interventions, then we see of our traditional clinic based services. So we see much more population representative proportions of ethnic minority and actually over representation of sexual and gender minority young people in the existing studies in the USA. And from our pilot studies here in the UK, we're seeing the same trends. So this might help young people to get early access to help, including some who might never feel able to access any other kind of help that we already have. And so that really was what cemented my commitment to pursuing this in the UK context as a program of work and really thinking carefully about how do we bring those interventions that have been developed and well tested in the States to the UK and adapt and implement them here in ways that fit with our context and the young people and their lives here. Clara Faria: That's actually the perfect hook because my next question was going to be about implementation. We spent the first half of the podcast discussing about the rationale and the promise of single-session interventions. You and your team recently published a very nice paper on the BMC psychology. I was just wondering if you could share with us the main findings of it. Professor Maria Loades: Absolutely. No, for me, Clara, what felt really important to do as a first piece of work before we just ran these single session interventions here in the UK is to find out what young people here thought of the idea. know, young people are key stakeholders. So for this to work, we've got to understand their views of this. What is we first recruited a team of young co-researchers. So in our group, we've already for quite a long time had a young persons advisory group and they've been involved in our studies in different ways, including helping us to design study documentation and think about our research priorities and dissemination. But we've never previously actually involved young people as co-researchers in collecting data and then analysing that. So in this study, we really wanted to do that. And there were a couple of reasons for that. One is what we were trying to do in the study was to find out what young people in the UK think about single session interventions and about online mental health resources and information. And we felt that having a young co-researcher in the interviews where we're exploring this with our participants would help those young people to feel more at ease and more open to sharing. But also we really felt that they brought a unique perspective to then both the interviews and collecting the data, but also to the data analysis. So we recruited this team of four young co-researchers. They were all 16 to 18 year olds and we trained them in qualitative interviewing and safeguarding and confidentiality. And then they co-interviewed the 24 participants. So they were all online interviews. so each online interview had a research team member plus a young co-researcher interviewing the participant and the young co-researcher had bits of the topic guide that they used to guide what they asked the young people about. The researcher had other bits and they worked together as a pair and they always met just beforehand to discuss how they were going to do things and debrief together afterwards as well. And really that led to, I think, a really nice output in terms of us understanding how young people viewed these single session interventions. And the key thing was young people were hopeful about the promise of single session interventions. We described what a single session intervention was and asked them their thoughts on it. They were hopeful, but also sceptical, Clara. That's perfectly appropriate. I feel a bit like that too. Is this too good to be true? So they saw potential benefits, but did also doubt whether a single session was enough and could be meaningful. They did really confirm for us what we expected the benefits to be. So they talked about the advantages they could see in single session interventions of the anonymous easy access and the ability to seek help without formally disclosing anything to anyone. But, I think this was the key thing that really got me thinking more was our participants really shared with us their concerns about how we would logistically implement these single session interventions in the UK. So they were thinking about things like age-appropriate content. Like is something that's appropriate for a 13-year-old also appropriate for an 18-year-old? And how can you make sure that your content is appropriate for the age range you're targeting, for instance? How can you share signposts to these interventions and let people know about them in ways that they will know that it's something trustworthy? You know, in this space where there's so many things being promoted to us all the time, how does a young person know that this is something that is evidence-based and has been developed following scientific principles and so on and so forth versus something that's a commercial product for sale? They talked to us a lot about, and we were very interested to explore with them further also, so that was something we specifically asked about, but they talked to us a lot about what places we could share the information about these things being available to reach those people before they come to ask other people. It's really public health level. It's how can we get the message out there that there is this free, accessible, easy to use resource. How can we get that out there to the places that young people are already spending time and they're already maybe looking or finding out about help and information? So yeah, it felt like a really important study from a number of different points of view, but really gave us a lot of insight into what we might need to think more about in order to really make this fit in the UK context. Clara Faria: Yeah, in your answer, you just raised a key point for me. And I think for all researchers that work with science communication, basically, especially, I think in the realm, in the space of digital interventions, there is so much out there. There are so many apps, some amazing apps, some not as amazing apps that like are not evidence-based, but that are out there talking about mental health and how do you promote to promote your mental health. And, and, and I, and I think in this space, that is already like, I wouldn't say saturated, but that is already, you know, very big, like how to signpost young people that it is trustworthy, you know, and that actually this intervention and this help app is different than, you know, an app that was developed for commercial use and that you need to pay a fee to access and that not necessarily is going to be evidence-based. Is your team exploring this further in other studies? Is there any like preliminary findings you can share? Professor Maria Loades: What we already did in that Can We Connect study, which is where we asked the young people what they thought of single session interventions. We also asked them to share with us where they look for information and support around mental health, particularly online. We asked them to screen share with us and show us how they would navigate to look for help if they were struggling with their mental health. And when then a Google search page came up, we asked them to click on things that they would be interested in and what they thought of those things when they looked at them. And that really helped us to think about what do young people think of what's out there and what do they think of what they find and how do they judge credibility and trustworthiness. And so there is a separate paper that we published in Psychology and Psychotherapy, Theory, Research and Practice that specifically looks at that and includes actually co-produced guidelines that we drew up with our young co-researchers around what to share, where to share, how to share mental health information with young people online. But in particular around the credibility and trustworthiness piece, we found young people were incredibly savvy, Clara, about how they judged trustworthiness and credibility. They looked for things like logos of like particularly the NHS, if something had the NHS logo, they thought it was really trustworthy. If it had a university logo, they would trust it more than if it was just like some kind of product placement, as it were. They also talked to us about how they knew that social media probably had quite a lot of doubtful information on it. They liked it because it felt validating to look and to spend time in the space of social media. They felt that that was where they could hear other people's stories and get validation for their own. But in terms of what they found out about in social media, they were like, I would check it out. Maybe I would Google it as well. I'm not sure if I would take on things that were recommended in that space where things that were recommended on websites, especially if a couple of websites agreed and if they were websites of trusted organizations or if they were things that they'd also heard about somewhere else. Like they'd also heard about it at school or they'd also heard about it from their parents or from their friends. you know, kind of using this almost triangulation of like, okay, if I've heard about it in a couple of places and from people I trust or places I trust, if it's got a logo, then maybe it's more indication of it being trustworthy and credible. They also like, you know, they're really prioritized and this for me was a real learning point. They're really prioritized how professional resources looked. And I'm not by nature a very creative person. I don't think very visually. And some of our study adverts in the past have been fairly basic. And actually, it really made me appreciate how much we need to invest time in thinking about how we make things look and feel to really make them trustworthy and credible, but also appealing and engaging to young people and tools like Canva are really helping us to do that. But actually what we've done in our own program of work is really worked on a whole other program of co-design with young people. We've had over 25 young people involved in helping us to then design the website that will post our single session interventions and the materials that will be on that to enable young people to find out more about what these single sessions are and how to access them and also to signpost them to other sources of support if that's not enough for them to do the single session or if they want something different, not one size fits all, this isn't for everyone, but really co-designing how we then let people know about these in ways that help them to judge that piece around, I trust this? And is there something that is safe to click the link to? Is this something that is evidence-based? Is there something that's been developed with young people in mind? Those things are all really key. Clara Faria: Absolutely. So you've just mentioned that actually in the end of your answer, but one key point I think that you constantly highlight and I think it's super important is that it's the message more help is available if needed. I think the key thing as you've said, to make sure that it's self-containing and if, you know, if that's your one-off, you know, help you deliver then that there's something useful there as opposed to, know, 12 sessions, CPT program as we're more traditionally used to. And I think that's fantastic. But I'm just thinking, so for example, a huge asset of single session interventions is the anonymity and you can access it at any point. And I'm wondering, you will be reaching a very wide range of young people and some of these young people might just have like mild difficulties and the single session intervention will be fantastic and that's all they're going to need. I'm now thinking about young people who might be struggling more, like young people who are maybe experiencing suicidal thoughts. And I'm wondering, is it possible to embed signposting and like safeguarding flags within those single session interventions? How does that aspect work? Professor Maria Loades: Yeah, absolutely. you know, it's something we've kind of learned about as we've gone along to what was already done in all the studies in the States so far on these single session interventions is, yeah, absolutely embed signposts, reinforce the message throughout the interventions that there is more help available if necessary, here are sources of support. So we've done similar in the UK. you know, the beginning of the intervention throughout the intervention at the end, there are various different places where we signpost here, extra sources of support, and we've got a list of sources of support, which are also including ones that are accessible anonymously and on demand, things like the Shout text and Helpline, for instance. So I think it feels very important that this is linked in to all the other great supports that are out there, that there's encouragement in it to support young people to ask for more help if they need it. And actually one of the things our young people's advisory group said to me is that they think that one of the ways that single session interventions might help some people is that they give, doing the single session intervention gives them a language and the words with which to go and talk to other people in their lives about their difficulties. You know, if they were not sure about doing that, doing the single session, not sure how to do that, doing the single session might then help them to be able to go and do that. So we do think maybe, you know, for some young people actually these interventions work because they are a pathway to getting further help, informal from those people around you in your lives or formal from mental health service providers or maybe both for some young people. I've thought carefully, Clara, as well about whether young people who are really severely affected by depression symptoms might not benefit from this and whether we should keep it for those people who are more at the mild to moderate end of their struggles. But I am reluctant to introduce extra barriers. And what the work in the States has found is that even young people who got quite severe depression symptoms seem to benefit from these interventions. We'll keep monitoring that. If we see any cause for concern around safety for participants around particular patterns, like let's say we picked up a trend that those young people who were more severely depressed at the beginning of the intervention were less likely to benefit, then we would certainly look to think about how we then positioned it more carefully for those people. All the evidence we've got to date is that this is helpful, irrespective of whether you are severely impacted or not by the depression, irrespective of your age or gender or minority status. you know, I'm quite encouraged from what we've seen already that these are safe and effective across the board. Clara Faria: That's really good to hear. And your work is really well backed by many studies and also many focus groups you've conducted with young people. think you really seem to be covered on all bases. And one thing that I think is also key and that your team also explored still on the implementation front, you mentioned one of the points young people in your advisory groups raised was the age-appropriateness of the intervention and how it's important to think that, you know, maybe an intervention for a 13, 14 year old should look different than an intervention for a 16 to 17 year old. And then that got me thinking about the study you've published, assessing Gillick competency in under 16s, I think, if I'm not mistaken. And it would be great if you could tell us a little bit more about that, because I think this study is huge and has implications for everyone really working with young people that are under 16 in the digital, you know, mental health realm. Professor Maria Loades: Absolutely. yeah, this is an absolutely key part of us ensuring that the interventions are barrier free. essentially, different countries have different laws around consent. So that's the very first thing that's important to say. Here in the UK, if you're under 16, you are not presumed to be competent to consent for yourself to treatment or research. Indeed, you have to either demonstrate your competence, your Gillick competence. So that means to show that you can understand why a study is being done, what it involves, what the risks and benefits are of taking part. And if you can show that you understand those things for this decision you're making, then you're considered to be Gillick competence and able to consent for yourself. The alternative is that if you can't demonstrate that, then you can get your parent or your caregiver to consent for you on your behalf. Now, we do recognise, as we were talking about earlier, that some young people, and especially those who might be particularly vulnerable to struggling with their mental health, might not feel able to ask their parents for consent. So in planning how to evaluate these single session interventions here in the UK, we recognised that we needed to find a way within these self-help anonymous interventions to allow these young people who are not yet 16, to demonstrate that they can consent so that they can access the intervention and to be part of our evaluation without that barrier. reality is this principle is used all the time in clinical settings, let's say in school counselling, young people who are not yet 16 will be provided with counselling without their parents necessarily knowing about it, although counsellors mainly do encourage them to talk to their parents, but don't necessarily mandate it, and if a young person understands what's being offered, then they can consent for themselves. out with our young people advisors and with various of the different experts who helped us with this programme of work. And what we found was that there had been work in actually Australia already where they'd used multiple choice questions after the information about a study and before the consent form to check that a young person understood these kind of aspects of Gillick competence and if they did then they could consent for themselves. And so we worked with our young people advisors to develop a series of multiple choice questions to really enable young people not yet 16 to demonstrate the capacity to consent. And we then to make sure that that was acceptable to parents of this age group, 13 to 15 year olds and to the 13 to 15 year olds themselves. We did a qualitative study to show young people of that age group, parents of young people of that age group, what we've developed and get their thoughts on it before we started using it in practice. And actually, again, we were really encouraged by what we found, Clara. Young people and parents both really saw this as a great way in a low risk study to enable and empower young people to make decisions for themselves and to work towards them being able to independently do that when they were older. You know, they recognise as to we that there isn't something magic that happens when you're 16 that you can suddenly make these decisions for yourself. Yes, that's the law says that's the point at which you can make decisions. But actually, things like this process, parents and young people saw as really empowering and enabling young people to develop their capacity to make decisions for themselves. And the reality is it's a fundamental human right and we know it's in things like the Children's Act is that children should be involved in decisions that them and so it felt really, really key for us to find a way to overcome the barrier, but also to give young people that opportunity. Clara Faria: That sounds wonderful. And we've talked about the rationale behind single-session interventions and then all of the wonderful work you and your group have been doing on implementation. to wrap up this podcast, looking to the future. So you've just mentioned this study around the Gillick competency was conducted with in a presuming low-risk mental health intervention. And do you think that in the future we could be developing targeted targeted interventions for targeted behaviours. So for example, I know that you are currently working on adapting one of the interventions that Jessica's team developed here in the UK. And I'm sure I'm really looking forward to reading that paper very soon. I suppose what I'm wondering is, do think you and your team in the future could be developing interventions, single session interventions? Professor Maria Loades: I think in the longer term, it would be wonderful and it's certainly where we're going and it's already what Jessica Schleider's team have done in the States very impressively, is it be wonderful to develop a whole library of these interventions so that young people with different problems and different preferences could choose which one might be best for them at that point. Yeah, I think, you know, the big picture for us is yes. We want to develop more of these. We've been working actually with partners at Rutgers University and also University of East Anglia, developing one of these single session interventions for sleep problems. So young people might be struggling with their sleep. know, again, we know lots of young people are struggling with their mental health struggle with their sleep. It's hard to get evidence-based help. So we've been working on Project Sleep as self-help single session that could help bridge that needs access gap. I think self-harm is interesting. Jessica's team did develop one single session intervention for young people who self-harm. And that was probably the one that's had the most mixed outcomes of all the interventions. And when you look generally in the space of brief interventions for self-harm and self-help interventions for self-harm, they do seem to be less consistently effective than things like, improving depression symptoms or improving problems with sleep, for instance. So I'm not sure if we will be able to develop something that works in the space of self-harm. There are some very good apps out there like Paul Stallard's app developed here at the University of Bath, which is called Blue Ice and Blue Ice is available on the app stores for free. And that's probably one of the best evidence self-help tools that I know about for young people with self-harm. I'm not entirely convinced yet that a self-help single session intervention meets the needs of young people who self-harm, but watch this space. I think we could and should develop lots of different ones of these to make sure that we offer young people as much choice as we can. Clara Faria: Thank you so much, Maria. It's been lovely to have this conversation with you. And my last question is, what is in the pipeline for you at the moment? I know you've been leading a huge amount of work around single-session interventions. What are you most excited about next? Professor Maria Loades: Gosh, I'm excited about so many things, but I'm going to keep it brief because I know I've talked a lot and I've already signposted a few things like absolutely developing a suite of interventions. I've got a few people in my group who are doing really important work. Natalia Kieke is a PhD student in our group and she's specifically working on developing a single session intervention for parents of young people struggling with depression symptoms around how they can support their teenage child with those symptoms. We've got two PhD students in our group, Sophie and Emma, who are each thinking specifically about how we can leverage these single session interventions for minority populations. So Emma's looking at LGBTQ+ plus young people and Sophie's looking at what she calls global majority young people, i.e. in the UK ethnic minority young people. We've also got work that's growing around how we can use these single session interventions for young adults and how we can adapt them for that age group. And then from there, we'll also look to think about how could we expand them out to different presenting problems and difficulties. Clara Faria: On that note, that sounds wonderful and I'm seeing you have a furry friend that requires your attention. Professor Maria Loades: A furry friend who's participating in the end of the podcast? This is Enzo, he's our team mascot! Clara Faria: It's really nice to meet you. He's adorable, Maria. Thank you so much.