JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast, and I'm so glad you've joined us today. In this episode, Spencer speaks with Jessica Schleider about turning points in mental health and recovery, and testing single session interventions.

SPENCER: Jessica, welcome.

JESSICA: Thank you so much, excited to be here.

SPENCER: Is it possible to change someone's life with a really short intervention?

JESSICA: Well, that is the premise of the book I wrote, [laughs] so I do think it's possible. I don't think it's a given. I don't think it's always going to happen 100% of the time. But if we're talking about the possibility for somebody's life to change in a moment, I think it can.

SPENCER: How brief are we talking about here?

JESSICA: It depends on who you ask. For the book that I wrote, I actually got to interview almost 100 people with experiences of turning points, so to speak, in their mental health journeys. For some people, those turning points were a few seconds — something that somebody else said, something that they saw, a realization that they came to — that just shifted gears for them, allowing them to move in a different direction. And some single session approaches that are more structured can be 20 minutes, half an hour. But I definitely think it's possible for a brief moment or experience to have a lasting impact. And I think that shows up in all sorts of ways.

SPENCER: One thing I wonder about, maybe it takes only a few seconds to change, but could that actually have been building for months or years? So it seems like a few seconds, but really, you needed all that other background stuff to make that few seconds possible.

JESSICA: I think that's absolutely right. I think nothing happens in a vacuum. So your ability to take in a moment, of course, depends on your experiences up until that point. In my own life, I've definitely had these sorts of turning points. And the one that I talk about in the book that I've been open about before, is a turning point in my own recovery from mental illness. In middle school or so, I started really struggling with anorexia and was in and out of all sorts of levels of treatment for about 15 years. And it wasn't until graduate school when I self-enrolled in yet another intensive treatment program that somebody said something to me in that program that caused me to completely rethink every approach to treatment that I had had the opportunity to engage with so far. And that moment made a massive difference, even though it was a few seconds. But I don't think it could have happened without my treatment experiences up until then. So yes, the moment stood alone as something that I'll never forget, a moment that mattered for me. But of course, it was building on a lifetime of experience and struggle.

SPENCER: So what was that moment? You have me in suspense.

JESSICA: Basically, I had been through treatment for all these years in all these settings. It was not effective, not very helpful, just focused on weight gain or goals that weren't helpful or allowed me to sustain anything that I had done. When I got to this intensive outpatient program, it consisted of two group therapy sessions and a structured supervised meal every day so it was three hours of treatment a day. And right after one of the meals, at which I had had what my fellow patient knew to be a fear food of mine (something that I really struggled with eating), they kind of casually turned to me after the meal and asked me what made me try my fear food that day. And I said, "You know, I was never going to feel ready, so I just kind of did it." And that's the whole story. And she said back to me, "Have you ever thought that that might be the whole thing? All there is to recovery is just doing it? What if you just woke up every day and decided to do something that felt impossible, and then just kept doing that over and over again?" And when she first said this to me, I was kind of irritated [chuckles] because it seemed to be massively oversimplifying a decades-long problem that I had struggled with in every way imaginable for me. But as I reflected on what she said — I completely focused on her comment, I couldn't pay attention in any group therapy at all — I started to wonder what would happen if I did do that. And that led to all these other thoughts about, "Am I just scared of who I am without an eating disorder? Have I not tried this because it's just been easier to see myself as somebody who's sick and who can't do this kind of thing, who can't take scary steps by herself?" And it spurred me into action of trying to do exactly what she said. That was the moment that allowed me to engage in recovery in a different way. It wasn't responsible for the entirety of my being able to stay well. It wasn't responsible for every success I had after. But it did really matter. So I think meaningful moments can make a difference. I think single interactions or experiences can have a lasting impact. But I don't think they're operating in a vacuum.

SPENCER: Did you then use that as something of a mantra, that idea that you'll never be ready, you just have to do it?

JESSICA: Yeah, I basically let myself off the hook for having to feel ready, which is something that I had assumed would have to come first. And the fact that it didn't, wasn't something that had to hold me back. And I just hadn't thought about it in that order, which was really freeing and exciting and scary all at once, but it absolutely helped.

SPENCER: I find that a really interesting example, because it suggests something very specific to you about why that was so unlocking, because there was something in your mind about like, well, I can't do this till I'm ready. And then you suddenly had this realization, "Oh, I don't have to be ready. I just do it actually." That unlocked it for you. But I wonder, for someone else, maybe that would have no effect and they would need some completely other barrier to be unlocked.

JESSICA: 100%. And I think the moments that matter for different people vary so widely for exactly that reason. But I also think there are themes that tie them together that I think are common across these different kinds of moments based on the conversations I got to have with people.

SPENCER: What are some of the themes that you think are common to these sudden turning points?

JESSICA: I took a scientific approach to this because I don't know how to take other approaches to things. [laughs] I did these interviews with folks. I put out a call on social media, first of all, that asked, "Anyone who's had a turning point in their mental health history or trajectory or coping towards recovery, I want to talk to you. I want to learn about what it was, because I've had one of these, and I want to know if other people have had them, too." Turns out a whole lot of people have had them. And I got to talk to them and, after recording these interviews, I went back and did a thematic analysis of what were the commonalities across people's turning points? Is there a method to all of this and it really seemed to me like there was. And some of the big themes that emerged were surprising yourself. People, when they observe themselves, that moment of observing themselves doing something they never in a million years thought they could do, unlocked something for them and allowed them to engage in their recovery, in their coping differently. It allowed them to orient to themselves differently and believe about their competencies and abilities in a different way. Another big one was feeling validated or seen, and that probably isn't shocking. Everyone experiences or enjoys feeling understood by others. But for something like mental illness, which is often so stigmatized and can feel so isolating and lonely, there aren't necessarily built-in opportunities for you to feel like other people know what you're experiencing, where you're coming from. And the moment where, often for the first time, people felt like there was at least one other person in the world who 1,000% understood their suffering, their worries, their fears, that was a revelation for a lot of people. And that feeling of 'I'm not alone,' and this person is doing well in their life, so maybe I can, too, that was huge for a large number of people.

SPENCER: What do you think that unlocked for them? Was it something about seeing that someone else was able to do what they were struggling with who's in a similar situation, or something else?

JESSICA: Well, that's what it came down to, for a lot of folks. One man that I interviewed talked about being in an inpatient unit when he was struggling with substance abuse and serious mental illness. And the facilitator for his group therapy session was a peer specialist, which means they were a person with lived experience of everything that he was going through. And he'd never met someone who both had his set of experiences, and wasn't the one locked in an inpatient unit, as in they were leading the group, not a member of the group. And that for him was huge, because he couldn't possibly envision another future for himself before that moment. And feeling like somebody got where he was coming from, that they could really see him, and that they were in a different place than he ever imagined he could be in, was really important.

SPENCER: So part of that seems to be about saying this is possible, and you know it's possible because you can see an example in front of you. Whereas, maybe a moment ago, it didn't seem like it could actually be achieved.

JESSICA: Precisely. But specifically, I think relating to somebody else who's been through that experience, I think, makes a big difference. Something I think back a lot to is this theory in social psychology called self-determination theory. Self-determination theory is a framework for understanding how and why people change their behavior. And it boils down to the idea that all human people have three basic psychological needs. Those needs are for a feeling of competence, like I have the skills to do stuff, of autonomy, like what I do will matter for my future, and relatedness as in, I want to feel connected to others and be seen by others. And I tend to think that turning points or single session interventions that make a dent for people tend to be fulfilling one or multiple of those basic needs. So they tend to be helping people feel a little more autonomous, a little more competent, or a little more related. And when those needs are fulfilled, something's unlocked so that behavior change becomes possible where it wasn't before.

SPENCER: I think I get how seeing someone who succeeded, who's similar to you, can make things seem possible and therefore get you to do something you never thought you could do. But I think I don't understand the relatedness point more generally, of how just feeling related to someone unlocks us for people. Could you explain that a bit more?

JESSICA: Loneliness can be incredibly paralyzing. If you feel like you're the only person on the planet with a specific experience, it can feel like there's nowhere to go with that, can feel like there's no point in trying, because there's no way that your view of the world, your experience of the world, your approach to relating to it will ever make sense. So feeling as though there's a place for you, feeling as though somebody understands you and you understand them, that can help undo the paralysis that loneliness can create. And without that sense of 'I belong here, there's a place for me,' it's really hard to get yourself going in any other direction.

SPENCER: Do you think there might also be an element of feeling defective, and then when you realize that there are others like you, maybe you feel like, "Oh, maybe I'm not defective. Maybe I'm just a certain way"?

JESSICA: Absolutely. I think the loneliness piece, and the isolation piece often comes from a place of 'maybe I'm broken, maybe I'm just incorrect as a person, something's fundamentally wrong with me.' And seeing somebody else who's had the same struggles, who you wouldn't say that about at all, is a really important moment for a lot of people as they're struggling to make sense of their mental health difficulties and how to overcome them.

SPENCER: You mentioned two different themes that tie together these turning points people have: one, observing yourself doing something you thought you never could do, and the second, feeling validated or seen. What are some of the other turning points that you saw in your research?

JESSICA: Another turning point was something that I ended up calling 'reclaiming your narrative.' A lot of people described taking a step in a direction that felt markedly different from the direction they felt like they were headed in before, and taking back the ownership over their own future. Across a bunch of different types of mental health difficulties, hopelessness — a feeling that your future is not in your control — is pretty pervasive, and can really keep your symptoms going and keep the difficulties going and prevent any progress from happening. But when people talked about consciously making a decision to do something different, to step towards a future that they want for themselves, and to actually define for themselves what that future looks like... Like 'I want to graduate college,' for example; whereas before, it was incredibly difficult to go to class, to even get up in the morning, to motivate myself to do anything, taking that first step to attend a course that you hadn't been able to for the past two weeks, for some people, that was a turning point. For others, it was more around figuring out what they wanted to do career-wise and taking a step towards making that happen. Or how they wanted their relationships to go and taking a step towards strengthening one that really mattered to them. The common theme was, they figured out what they wanted for themselves, and did something to make that future a little more possible.

SPENCER: One thing I wonder about is, how much of these sudden changes people experience have to do with their sense of identity changing? And to just give an example of that, I heard about this book for smoking cessation, where the basic premise of the book is it just tells you you're no longer a smoker. It just tries to convince you of that. 'Yup, you're no longer a smoker.' Some people don't find this helpful at all, but some people just stop smoking when they read this and never smoke again, which is kind of crazy.

JESSICA: Yeah, that's so interesting. I think identity is a huge piece of this. But I often hear about — and in our research, what we often find — is that undoing an identity of being a person with permanent depression, or a person for whom anxiety is just a permanent part of yourself, that is difficult to get past. And one of the interventions that my lab has developed explicitly helps people understand how depression and anxiety aren't fixed traits. They're experiences that, through coping and through responding differently to certain kinds of stressors, you can actually help yourself and train your brain to react differently, taking away that sense of identity attached to a certain symptom or a certain disorder, or helping people break through that. That can often be quite helpful.

SPENCER: That's interesting. So identity can work both ways.

JESSICA: Exactly, either creating an identity that's helpful for people, or supporting people and moving away from an identity that isn't necessarily helpful.

SPENCER: That intervention you mentioned where you're teaching people anxiety and depression aren't fixed traits, it's almost giving people hope that change is possible without necessarily giving them a way to change. But it's kind of opening up the doors to change. Is that right?

JESSICA: That's exactly right. And we find that hope is actually the mechanism of change for that intervention. We can measure it in clinical trials... We've tested this particular program in thousands of teens across the US, and we find pretty consistently that short-term changes in teens' sense of agency, and teens' hope for the future are the predictors of whether they respond to the intervention months later. And we do see exactly what you're saying, that hope is the mechanism there, or hope is one of the mechanisms by which that change is happening for folks after the single session program.

SPENCER: Can you tell us a bit about the experimental design? Are you randomizing some people to get the intervention and others to a control?

JESSICA: That's right. I can tell you a little more about what the control is. This is a randomized clinical trial and this is a fully digital intervention. I can tell you about our most recent large-scale study of this. This was during the pandemic; we were really lucky to get a grant from the National Institute of Mental Health and we were able to recruit a national sample of 2452 teenagers struggling with depression across all 50 states in the US. Really exciting. We recruited entirely through social media, which is where teens are, so we thought that would be a good place to go. And teens were randomized on their phones — because that's where they were doing the study — to one of three different conditions. Either this 'people can change' intervention, which we call project personality, another single session intervention that targets behavioral activation or the idea that what you do can shape how you feel, or a third single session condition, which was a placebo, and that program was basically designed to sound like therapy, but not be particularly helpful. And what that condition told people was that sharing your feelings is good, and you should do it. So kind of therapy speak-ish, didn't give away that it was the control group, but still the same length as the other single session programs, had the same level of interactivity and things like that.

SPENCER: And what was the length?

JESSICA: About 15 to 20 minutes per condition.

SPENCER: That's so short, it's just mind blowing.

JESSICA: That is so short, and yet one of the biggest comments we get from people is, 'make it shorter.' [laughs] But I'll get back to that.

SPENCER: Is that a Gen Z thing perhaps? [laughs]

JESSICA: I've been doing this research for a while, and I guess it always has been with Gen Z. But in any case, what we found was that from before to right after the single session intervention, we found that teens who got either of the active single session interventions showed significant improvements in hope for the future and in their sense of agency, their sense of ability to solve problems in their lives. And then we followed up three months later — which is a long time when you think about a 15 to 20- minute intervention — and we found that, on average, teens who received project personality or the ABC project showed significantly lower depression symptoms than teens assigned to the control. And teens assigned to project personality also showed lower anxiety symptoms and lower traumatic stress due to COVID, as well as lower restrictive eating behaviors compared to the control. So there were cross-problem outcomes that were really exciting for project personality which suggests that simply teaching somebody that change is possible — unlocking that hope through a brief experience — can actually have a lasting effect.

SPENCER: What about the behavioral activation intervention? How did that fare against the control?

JESSICA: The behavioral activation also significantly reduced depression compared to the control in the teens, but it worked pretty much identically well to project personality. So we then followed up to see, could we have matched people to the best-fit single session intervention, knowing as you said before, that different people are going to respond to different things? But we found that they both operated by increasing hope, actually. So there wasn't really a way to match people to the best-fit SSI because how they worked was essentially the same. On that note, we're basically at this point just saying it's probably best to give teens the choice of which one they think is more relevant to them, and give them the opportunity to exert that agency and decision than to try to pick for them.

[promo]

SPENCER: That was such a short intervention, my prior would be that the effect sizes will be pretty small. That doesn't mean they're not worthwhile, right? In 15 or 20 minutes, it can be incredibly valuable, even to have a small effect size, but I just wanted to get a sense; how much change are we talking about here?

JESSICA: You're absolutely right; it is an overall small effect. In the land of effect sizes in clinical psychology, we use standardized effect size called Cohen's d. A Cohen's d of 0.2 is a small effect, 0.5 is medium, and 0.8 is large. So both interventions compared to the control had a Cohen's d effect size of 0.18, so definitely, solidly, a small effect. But when we look at the within-group effects — just looking at the control group participants, for example — we see that people in the control group actually did get a little better. The within-group effect size for the control was around 0.3; whereas, the within-group effect size for project personality and behavioral activation was closer to 0.5 or 0.6. So part of the reason we're seeing that small effect when we look across groups, is because the control wasn't doing nothing. That to us is helpful in knowing, not only is this better than nothing, but it's better than a credible something, which is important, because you can't always assume that something is better than nothing.

SPENCER: There's always a question with control groups getting a big boost of, is it a placebo effect? Is it because you accidentally included an act of intervention to your control? Maybe actually learning that it's good to express your emotions actually helps people? Or is it some other effect that's neither of those? Could it be a regression to the mean? For example, a lot of times when there's a study recruiting for depression or anxiety, the people who are near the peak of their depression or anxiety might be more likely to enroll and so you might get a strong regression to the mean effect. I'm just curious how you think about — obviously, it's tough to tell — but how you think about trying to disambiguate these different explanations for why the control got such a boost.

JESSICA: It's a great question. And we've used the same control in a number of studies so we have some perspective on what might be happening. And with depression and anxiety, since we are recruiting high-symptom teens, I think regression to the mean is probably the most likely one because people do experience these symptoms in a cyclical manner. I also think that, even with a regression to the mean, we probably wouldn't have seen as large an effect as we did in the control group alone. So my guess is that feeling like you've done something that you expect to be helpful is probably playing a role. Because also in our studies, we asked people to guess whether they were in the control group or not. And so we have a sense of how credible the control group actually is, and people guess pretty much at chance as to whether the actual control group is the control group. So I suspect there's a pretty strong expectation effect for people thinking, 'I got something that's supposed to help me and therefore I'm feeling a little better,' plus regression to the mean. So I think the fact that the active programs — the project personality and ABC — are outperforming both of those things is pretty compelling.

SPENCER: Yeah, just to unpack regression to the mean a little bit for our listeners — because it can be a pretty subtle thing — imagine that you're enrolling people into your study, and just by chance on that day, one participant is just feeling really good, better than normal. Normally, they feel depressed, but they just happen to be feeling good. They may not enroll in the study, because they're like, "Oh, I'm actually not depressed. I don't fit the criteria." Whereas on that same day, someone else happens to be feeling much worse than their average. Maybe they normally feel mildly depressed and today they feel really depressed. They might be more likely to enroll. And so you can get either a self-selected effect or, due to formal study criteria — we're saying you have to be above this score on this intake measure to get into the study — you get people who are just above that cut-off end up in the study and those just below don't, just by chance alone. And then you find that people kind of move down as soon as they enter.

JESSICA: Exactly. You're getting people at their worst so they're likely to get a little bit better as time goes on.

SPENCER: Right. And then there's also the expectancy effect, which is, if you feel like you might be improved by an intervention, maybe that actually helps you in a variety of ways. Maybe that makes you more motivated. Maybe it gives you more hope. Maybe it's just a placebo benefit where, because you expect to feel better, you do feel better. So yeah, lots of complicated things there. You mentioned behavioral activation intervention. It sounds like that also had an effect. Could you tell us a bit about what that teaches, and what you think is useful from that?

JESSICA: Sure. That actually goes back to the turning point that I had, because a lot of the content from this intervention is similar to what was helpful for me. The behavioral activation intervention teaches this idea that what you do can shape how you feel, and that you don't have to feel good before taking action that's aligned with your values. So people who do this program, which is freely available... Anyone can actually try it and project personality on our lab's website. Once we find that things are effective, we make them free. People in the ABC project first are told that what you do and how you feel are totally linked to each other. So let's try out an example. People are asked first to rate their mood right now on a scale from zero/awful, to ten/great. They are then asked, okay, pick one of these three funny or adorable or inspiring videos to watch, YouTube videos or TikToks. And people pick whichever one they want. There's one of a porcupine making very cute noises. There's one of a ridiculously amazing basketball shot. And there's one of a very cute little mini pig walking downstairs and jumping into a pile of oatmeal. They're all great, very well tested for being positive mood-inducing. And then after they watch the video, we ask them to rate their mood again. Almost inevitably, their mood goes up by at least a point because these videos are just imminently delightful. And what we then are able to message to them is, "Wow, in just 30 seconds of watching this random video that has nothing to do with you or your life or your values, you noticed a change in your emotions. Imagine if you were to plan out five minutes a day where you did something that's just for you, did something to connect with someone who makes you feel good, and did one thing to reach or get a step closer to a goal that matters to you." And we walk them through making an action plan for doing exactly that. And at the end of the single session intervention, they have a concrete plan for engaging in values-aligned activities that they can use moving forward, and they're asked to screenshot it, and they can take it with them afterwards. So that's pretty much what the intervention is. And we find that it's just as helpful as project personality in helping people break down the idea that they can't change to open up that hope and possibility.

SPENCER: Are there other single session interventions you've studied that you've found to be effective?

JESSICA: There are. We have all of them on our lab website if anyone wants to scroll through.

SPENCER: We'll link to it in the show notes so people can check it out.

JESSICA: Awesome. Yeah, we have a bunch of different single session approaches, and they target difficulties from body image difficulties to self-harming behaviors to social anxiety, as well as one that's actually not a digital program. It's a human delivered program. That one's designed to be problem-agnostic, as in, it doesn't matter what problem you're coming in with, we can help you take a step in a direction that's going to help you feel a little bit better, like you're moving towards a goal that's important. That intervention is called a single session consultation and it's something that you can actually train anybody to do. You don't have to be a mental health professional to deliver it or learn how to do it, and those materials are also free.

SPENCER: What does the person who's delivering this actually do during that session?

JESSICA: The person who's delivering the single session consultation first introduces the session. They frame explicitly, 'This is a single session support.' And that's important because expectation setting is a big part of helping people get the most out of each experience or each encounter. So first, the clinician says, "This is a particular special form of support. It's called the single session consultation. I'm not going to be your long-term provider or support person, but I am going to work as hard as I can today to make sure you're leaving here in a better place than you came in. So this is going to be a super goal-directed session. Are you ready to do something like that together and work really hard for the next hour to make it happen?" After the person opts in, the provider asks them to identify their top problem that led them to seek support today. After they do that, they then flip it and say, "Okay, what is your top hope for this conversation? What would tell you by the end of this conversation that it was important, that it did something helpful for you?" Once they get that top hope, the provider asks, "Imagine that a miracle happens overnight. You don't know that this miracle has happened because you were sleeping. [laughs] It was overnight. But when you wake up, your top problem is totally gone. It has evaporated from existence, and your top hope is totally achieved. Walk me through your morning and tell me what would tip you off to the fact that this miracle had occurred. What would you do differently? How would you interact with people differently? What would you think or feel that was different?" That gets the person thinking about this other future that they might not have imagined before, where their top problem is totally gone. The provider then asks them, "All right, if you could rate on a scale from one to ten, how close you are right at this moment to your miracle day being real, where would you be?" Most people say they're between a three and a six. And then the rest of the session is geared towards helping people make a three-point action plan to get one point higher on their miracle day scale, so to get from a three to a four. Not to a ten, that would be unfair and unrealistic. It's unreasonable to think that anybody could even be at a ten consistently for any problem, but you can get to a four. There are a few other exercises, but the overall goal of this intervention is to help people feel like there is a path that is clearly feasible for them. And to help them feel more autonomous and more self-efficacy, so that the next step towards a problem that may have seemed insurmountable suddenly feels in reach. And that's exactly what we see in the intervention: people's hope increases, people's agency increases, and their symptoms actually decrease, even in some of our studies, while they're waiting on months-long waiting lists for therapy,

SPENCER: How does creating the three-point action plan work? Is there a certain process that they go through?

JESSICA: Within the single session consultation, the provider is actually trained to use a solution- focused approach. A solution-focused approach is a little bit different than a lot of what you think of when you think of therapy because a lot of therapy assumes that the person seeking support doesn't have skills; they lack skills, they lack abilities, and therefore they need to be taught different coping skills in order to function better. Solution-focused therapy takes the opposite assumption. This theory assumes that everybody, no matter what their past experiences or current struggles, has inherent strengths and skills, because otherwise, how would they have gotten this far in life? So assuming that you have skills already, that you have things that you've done that have worked for you in the past, the goal isn't to teach you new skills. The goal is to help you realize what your current skills are, and help you use them more effectively right now. The provider essentially asks a series of questions to the person seeking help to help them identify exceptions to their current top problem. When was the top problem a little less bad? When were they doing a little bit better? And what were the circumstances surrounding that situation? And that helps the person remember what they were doing, or who they were with, or what kinds of circumstances they were in, that allowed them to be in a better place with their top problem. And that line of questioning usually helps people self-identify what skills they can already draw from to get one point higher on their action plan, rather than being taught new skills, which is really tough to do. You're talking about multiple skills in just one session of support.

SPENCER: That's really cool. And have you run a randomized control trial on the single session support as well?

JESSICA: Solution-focused brief therapy, which is the backbone of the single session consultation, has a lot of evidence behind it. That modality of treatment, which sometimes is one session, but can also be multiple, has been through RCTs. And it's definitely an evidence-based treatment for a wide variety of problems. The single session consultation, because we often work with real-world clinics in delivering it, nobody wants to do an RCT [laughs] because all of the clinics we work with just want to give the intervention to everybody. Because when these clinics have month-long waiting lists, they want a solution to that. So they're more interested in learning to deliver the SSC and giving it to everybody on their waiting list than randomizing some people to still get nothing. So as a result, we've run open trials. And in those open trials, we can benchmark what we would deem to be clinically significant change. So there are standardized measures of things like depression and anxiety. And evidence has shown that if you have a significant point reduction in those validated measures, then you can consider that change to be clinically meaningful or clinically significant. So while we haven't run randomized control trials, we have been able to show that there's a clinically meaningful drop in depression symptoms and anxiety symptoms, while people are waiting for therapy, when they get the single session consultation. And the unfortunate reality is that waiting lists have actually been shown to be harmful. So there have been some comparisons in research showing that not being on a waiting list — as in not seeking treatment at all — is better for your mental health than being on a waiting list. [laughs] So the fact that we're seeing clinically meaningful reductions in symptoms after the SSC compared to what we expect to see on waiting lists — which is things getting worse — is definitely promising.

SPENCER: One thing you've mentioned in some of these studies is that increasing hope and increasing agency seems to happen right after the interventions. And then if you study that, that seems to be linked to the benefits people get. And I'm wondering, to what extent do you see hope and agency still raised at the end of (let's say) three months when you follow up or has it returned to baseline? Do people still feel more hope and agency?

JESSICA: We do see sustained improvements, especially in hope, at three-month follow-ups, nine-month follow ups. In one of our studies, we saw improvements in hope at three months. In another study, we saw improvements in perceived control at nine-month follow-up. So those seem to be longer-lasting. But because of the nature of how we can measure things like hope and agency — we can ask people, "How hopeful are you about your future right now? — it's easier to measure immediate change in those things than something like depression. With depression, every validated measure asks, "How have you been doing in the past two weeks?" and from before to after a 20-minute activity, it is not possible for that to change. [laughs] So as a result, we look for change in things that have some chance of moving from before to after a session. But we do see sustained impacts there as well.

SPENCER: You also mentioned that you have done nine-month follow-ups. What does the effect size look like then? You mentioned that it was about 0.18 standardized effect size at three months; do you see it come down when you go all the way to nine months? I imagine you would.

JESSICA: Well, we have one study out to nine months. And I want to preface this by saying this was a much smaller sample. The first ever randomized trial that I conducted on project personality had a nine-month follow-up. This was for my dissertation. About 96 teens with depression and anxiety were in that study and, believe it or not, we actually saw an increase in the effect size from three to nine months. And the effect size at nine months was, depending on if you were going by teens' report or parents' report, between 0.3 and 0.6. There were pretty decent-sized effects in that study. But I tend to trust the larger studies more just because you get a more accurate, precise picture of what the effect size truly is. So I hope we get to do another study with 1000s of teens with a nine-month follow up. We're currently finishing up a trial with several 100 teens with a two-year follow-up for these interventions. So hopefully I'll have more data to report back pretty soon.

SPENCER: Do you think that increasing hope and agency is sort of the fundamental thing that's going on with these interventions? Or do you think that there's active ingredients beyond that?

JESSICA: I think there have to be active ingredients beyond that because the answer is never that simple. [laughs] There is no one answer, no one way that these interventions help. But I do think that shifts in hope and agency matter. I think in reality there is no one mechanism to any kind of therapy. So my take is that doing more interview-based research, doing more qualitative research and listening to people's stories like I got to do for my book, we should also do it in research. I think that will help us understand better what people are experiencing as the reasons these things work. We've historically, as a field in intervention research, been pretty bad at collecting non-numeric data points and trusting people's lived experiences and stories as scientifically sound information. But I really think we're going to have to in order to really understand what's going on for people. One of my lab's postdocs, Benji Kaveladze, did a really interesting study where he asked people to report if they had an aha moment during an online single session intervention and he's currently in the process of coding people's responses from his study. But he's finding that more than half of the time, people are reporting that they do have aha moments during single session interventions, and his study is going to take their written responses to figure out what are those made of. I think that kind of work will help us a lot in figuring out what the mechanisms of change are, despite our historical reliance on these Likert-type scales.

SPENCER: I've found in my own work, the mix of qualitative and quantitative to be incredibly powerful. I find that if I just limit myself to quantitative, I can make measurements, but I often don't know for sure what I'm measuring; I don't fully understand what I'm measuring and also I can miss important hypotheses. Whereas if I just do qualitative, then it's hard to measure anything. So I might have lots of cool ideas, but I don't really know what's so. I find that the two research techniques complement each other beautifully and yet, I find that in the world of research, they're often split; it's different people doing quantitative versus qualitative where, to me, they're these complementary tools, that doing them both together is the most powerful of all.

JESSICA: I totally agree, and it's really unfortunate. There is often an aversion to qualitative research in a lot of psychology departments because it's historically been framed as less scientific or less rigorous. But I think doing quantitative research in the isolation of any qualitative information, that seems unscientific to me, and it seems like a really unfortunate piece of the puzzle to have missed in so much of treatment research to date. So I'm definitely supporting my lab in increasing the mixed methods approach in the work we're doing on single session supports, moving forward. But hopefully, it'll be more of a field-wide shift in making sure we really know what people's experiences are, not just what the numbers say.

[promo]

SPENCER: We've had some shocking results in our work where, once we did the qualitative piece, we realized that the quantitative made no sense. An example of this is, there was a scale that others had developed that was supposed to measure everyday delusional beliefs, and they claim that ordinary people have lots of delusional beliefs. And we did a replication of it; we found the same effects they found largely. But then we asked people to explain their answers to these questions. And so there are questions like: Do you believe that the television is talking to you, specifically to you? Do you feel like insects are crawling over your skin? And so when we asked people to explain their beliefs, they're like, "Yeah, because I watch TV online and it has hyper targeting just to me," and we're like, "Oh, yeah, that's pretty reasonable." "Oh, and yeah, I got lice from my children and so I have lice all over me," and we're like, "Yeah, that's also pretty reasonable." [laughs] So yes, these (quote unquote) 'delusional beliefs,' nobody bothered to check if they're actually delusional or not. They just assumed they were.

JESSICA: Yeah, that's not great. It's an excellent example of why you really have to talk to people, or the numbers aren't necessarily telling you what you assume they are.

SPENCER: I wanted to add something about effect size. You mentioned that you were seeing effect sizes around 0.18. I just wanted to give some context to the listener. What does that mean? And so a couple of ways to think about that: one is that, imagine there's a disorder where 50% of people recovered without treatment. If you added effect size about that big, then that would mean 60% instead of 50% recover with the treatment. So that gives you some context. Or if you're imagining a pill that can make you taller, that effect size is about equivalent to growing 0.6 inches for people in the US. Or if you had a weight loss intervention for people in the US, that would be like a weight loss intervention that caused you to lose six pounds. That just gives you some kind of intuitive feeling for what we're talking about here.

JESSICA: Yeah, that's a good point. And I'll also say that effect sizes and studies refer to the on-average effect of the intervention. But there's a lot of variability; some people had a much larger effect if you look at their individual data, and some people had no effect at all. So I think the next step for us — and we haven't been super successful in this so far because it's really complicated — is figuring out how we can tell who's going to benefit from these. So far, it's been mostly no results, as in we haven't found any differences based on demographics or symptom levels or any of the other things we measure, but hopefully, as we are able to use more advanced methods, we'll be able to pinpoint: Are there profiles for certain people where we can predict with some accuracy, yeah, you're in a really good place to benefit from this? But that's for the future, we hope.

SPENCER: Yeah, that would be amazing. One thing that I've found to be the case is that it's really hard to even make something that works on average. And it's so much harder still to then predict what will work and then give people the right thing. Obviously, you can do it using common sense-based things, like you can say, "Well, maybe if someone has an issue, or they're closing themselves off to a lot of positive activities, maybe the intervention involving opening yourself up to positive activities might help," so you can use common sense things like that. But to actually collect the data and build a predictive model, it's just that much additional work on top of everything and I think it's very rarely been achieved.

JESSICA: Absolutely. I think that the most advanced machine learning models have yet to really help us in moving towards precision psychiatry, or precision mental health care. We tried that in one paper. We actually built an algorithm, or really, this was led by my graduate student, Isaac Ahuvia. So shout out to him for doing this incredibly challenging work. We tried to build an algorithm that would predict whether a teenager would respond better to project personality or the behavioral activation project ABC. And what we found is that the predictors were just so similar across the two interventions that there was no way to match people to the right treatment, which is great from a public health standpoint — just make them both available and teens can choose — but not great from a precision mental health care standpoint. So I tend to think that maybe it doesn't matter what the intervention is, so much as when it's delivered. I say that because we've done some work in our lab with a really wonderful nonprofit called Koko. And Koko is a digital mental health nonprofit that works with social media companies to embed mental health supports based on people's search terms into social media platforms. So for example, when somebody searches for 'suicide,' Koko pops up and offers them resources beyond just a crisis helpline. And in the past couple of years, my lab has worked with Koko to embed all of our single session interventions into their service so that, when people indicate through their search terms or activity on social media that they may be experiencing a mental health crisis, they're offered some of our programs. And in that context, we see the same magnitude of effects as we do in our clinical trials, when the single session interventions are offered to people in that realm, and sometimes we even see larger effect sizes and higher completion rates than we do in naturalistic studies. So I think something about delivering a just-in-time intervention, getting at somebody right when they're seeking help or right when they want support or need it, or they're perceiving a need, I think that probably matters more than tailoring the content to a person's individual characteristics.

SPENCER: That's really interesting. Have you ever developed an intervention that bombed in the research where you're like, "It just doesn't seem to work"?

JESSICA: We've developed a couple that have short-term effects and no long-term effects. And the one that comes to mind is the one that we put together for self-harming behaviors in teenagers. So we publish null results as often as we do, not as often, but pretty often, whenever we get them. And in this particular study, we were attempting to shift rates of self-harm, and we shifted intentions to self-harm and self-hate in the short term.

SPENCER: 'Short term' meaning right after they've completed the intervention?

JESSICA: Yep, right after they complete the intervention, people said they had more intentions to stop self-harming and that they hated themselves less, which is great. In the lifespan of a suicidal thought or a self-harming, self-injurious thought, that matters because they really do change moment to moment. But when we followed up three months later, we saw no on-average effects on actual self-harming behaviors, which isn't exactly unusual. There are actually no real evidence-based treatments for self-harming behaviors in adolescents. My wonderful colleague and friend, Kathryn Fox, did an amazing meta analysis on all treatments for self-harming behaviors and suicidal ideation and behaviors, and found that there was really no evidence for any evidence-based treatment on either front. So our intervention flopped, just as much as most interventions for that particular problem flopped. [laughs] Other times we've seen no results, have mostly been in samples of non-treatment seeking people, so the general population, for example, people who don't have specific mental health problems. And so my thinking on that just reinforces this idea that the real time that single session interventions can help are when people are seeking out care or perceive some kind of need. When you're trying to use them as a prevention tool for people who aren't struggling and don't see a need, they're probably not going to work.

SPENCER: My understanding is there have been big challenges in research on prevention. And I suspect part of that might be, let's say you're trying to build a preventative measure and you give it to a bunch of people, well, only a very small percentage of the people would have developed (let's say) depression or anxiety in the period you're studying anyway. So you're already talking about a really small group of people that you could even impact. And so it's gonna be pretty hard to detect an effect there. And I think people have raised big questions about some of the widespread resiliency interventions that have been rolled out, whether they really work. So I'm curious if you have thoughts on that.

JESSICA: Absolutely. I think you're right. First of all, I think we don't have the right measures. We don't have the right tools to measure outcomes in prevention trials because measuring symptom reductions in a prevention trial doesn't really make sense. If you don't expect most people to have symptoms to start with, then you're not going to see movement in that outcome at follow-up. But the bigger issue, I think, goes back to this idea of choosing to do something or not, when you think about the school assembly approach to preventing mental health problems — like teach all kids coping skills at once, and hope that it helps prevent stuff in the future — that's targeting a whole bunch of people who have no motivation or reason to care about the intervention that you're trying to deliver. And motivation is important. There are many interventions out there that are purely targeted to motivation for engaging in something therapeutic. And if you see no need for content, you're probably not going to pay attention to it or remember it, or pocket it for future use. So I do tend to think that, in terms of prevention, we're probably better off creating flexible systems that can respond to people when problems arise, rather than trying to — although this is much easier — teach everybody resiliency skills at once. I tend to think people are more likely to learn better when they have some need so the information is relevant to them, rather than when they just happen to be at third period.

SPENCER: Now, one question that might be hovering over this whole conversation is, why single session interventions? Why not make longer treatments?

JESSICA: Great question. Because we have a whole lot of those. So the premise of why I got started on studying single session interventions was, while I was training to be a traditional therapist delivering cognitive behavioral therapy to children and families, longer-term treatment, multi-session... They're great in theory, and they'd be wonderful if everybody could access them and complete them. But they can't. Most of the families that I treated in the real world were unable to come back after a few sessions, or even one session in many cases. And if you zoom out, you see the statistics that about 80% of youth with significant mental health problems access no treatment at all. That's about 50% for adults who need mental health support, access nothing. Among those who do, as it turns out, the most common number of interactions folks have with any kind of specialty mental health service is one. Meanwhile, we've spent 50 years building 16 to 20-session interventions that in no way correspond to how people are actually able to access care. It's due to financial barriers, logistical barriers, stigma; there are endless reasons why people can't access treatment. So single session interventions definitely aren't a replacement for longer-term therapy. People will still need longer-term therapy, and many will still want it. But I do think they can bridge these gaps in mental health systems that it's become completely clear that traditional longer-term treatments are never going to be able to fill. And so I think single session interventions are a totally critical part of a broader mental health ecosystem that actually takes public health seriously, that makes sure that something is available to everybody, and that that something is systematically better than nothing. That's the short version of why my whole lab focuses on single session supports, and why I think they matter.

SPENCER: You mentioned earlier that it's hard to predict which intervention to give which person. But a cool thing is that people with short interventions can just try multiple of them, right? If the first one is not helpful to them, they can go try another one. And so it actually is more useful if it's not correlated who benefits from each one. If they were very correlated, it wouldn't be that helpful having lots of these interventions. I'm wondering, do we know anything about whether benefiting from one means you're more or less likely to benefit from another one?

JESSICA: That's a great question. And we don't know the answer to that yet. My lab is about five and a half years old now. And we've spent the first five-ish years establishing proof of concept. Do these work? Can these work? What are the conditions under which they work? What are the components of single session programs that can be helpful? Now that we have proof of concept, we're getting more creative with the questions we can ask and exploring things like implementation and naturalistic use and uptake patterns of single session interventions, and integration of single sessions into broader health systems, and outside of broader health systems. So that's one of the several questions we're working on. We ultimately don't know outside the context of clinical trials, whether and to what degree people actually interface with multiple single sessions if they have the chance. So these are all questions that we're learning, mostly by observation at this point. And hopefully, I'll have more coherent data to share with you soon but it's definitely a next step for us.

SPENCER: It sounds like most or maybe all of the work you mentioned is on adolescents. And I'm wondering, how do you think about the difference between building single session interventions for adolescents versus if you were going to build it for older adults?

JESSICA: That's a great question. One of the interventions I mentioned, the single session consultation, the one that's delivered by humans, that one is mainly tested in adults, actually. That one is, I think, flexible. We've successfully delivered it to both teens and adults with pretty limited adaptation because it's a pretty flexible program. Recently, we've begun adapting a lot of our single session programs for adult populations. And in reality, the adaptations are much less complicated than I expected them to be. And when we share our single session interventions that are explicitly for teens for free on the internet, we do ask people, 'Are you a teenager or are you an adult?' when they take them, and it's about half and half. Adults take the adolescent ones pretty frequently, and tell us that they feel that they're helpful. So the main differences aren't that there are totally different skills that are helpful for teenagers or adults. Frankly, behavioral activation helps people of many ages. It's more of the stories and the personal testimonials and narratives that we include in the interventions that differ. So in all of our digital programs, we include a series of lived experience narratives, that share stories from real people who we interview for the programs, and who donate their stories of how they use the information in this program to help them in difficult situations through depression, through anxiety or through whatever the problem is that we're addressing. So we find that the main thing we have to adapt for different populations — including adults, but also including different cultures, different languages — are those stories. So we're still working on and working through how different populations might need different kinds of adaptations. But as it turns out, the skills that are helpful for teenagers don't resonate all that differently with the ideas and skills that are helpful for adults. Hope is ageless; everyone needs more of it.

SPENCER: And you don't have to teach them at a more sophisticated level for adults? Do the same kind of explanations work?

JESSICA: There are some cases where we have slightly more complicated explanations. But that even depends on what population of adults we're targeting. If we're targeting a general population of adults, for all comers, that's very different than targeting Oxford University students, who tell us that they want references and they want citations in the single session interventions we build for them. But we don't get similar feedback when we're not targeting highly educated subsamples. I tend to think — and maybe this is my bias as a child therapist — I tend to think adults appreciate simplicity and structure. And you don't age out of appreciating simplicity and structure so we don't find that there are too many differences that have to be made for those pieces, no.

SPENCER: Before we wrap up, I want to see what we can pull out that our audience might find useful in their own lives. We've talked about a bunch of different interventions. Besides doing the interventions on your website, what are some things that people can think about doing that may have a big impact on their own challenges?

JESSICA: One suggestion actually came from somebody that I interviewed for my book. That person, I asked them, "Do you think everybody has turning points or do you think that certain people are more prone to them?" And they had a really interesting response; they said, "I think everyone probably has them, but not everybody notices them." And I think stepping back and allowing yourself to reflect on what turning points in your life you might have experienced but missed because you weren't paying attention, or you weren't looking for them at the time, I think that can be a pretty powerful exercise. And using the themes in the book — such as times where you felt really seen, or you saw someone else that you felt inspired by, or times where you took a hold of your future in a different way and took a step towards making it possible, or times when you surprised yourself and did something you didn't think you could — reflecting on those, giving yourself a chance to maybe journal a little bit about them, or even talking about them with a friend, I think that can help shift perspectives on what's possible for your next steps. And I think it can also help you appreciate how turning points have shown up in your own life, and allow you to be a little bit more attuned to them in the future.

SPENCER: Any other parting advice from what you've learned from doing all these interventions and doing all these interviews?

JESSICA: Change really can happen at any moment, and dominant narratives of how therapy works, how treatment works, tell us that change happens over long periods of time, and therapy is a lifelong journey. And although that might be true in some cases, it is also the case at the same time that change is constant, and any moment can be a turning point. I think that's a pretty uplifting thought to have in the back of your mind when you're struggling. At least it is for me.

SPENCER: We'll put the interventions up on our website. And if you're interested in more about Jessica's work, check out her new book, "Little Treatments, Big Effects." Jessica, thanks so much for coming on today. I really appreciate it.

JESSICA: My pleasure. Thanks for a good conversation.

[outro]

JOSH: A listener asks: "When the Fed raises interest rates, it does so to combat inflation, although this also often causes lots of people to lose their jobs. Is that trade-off worth it?"

SPENCER: So I'm not an economist, but I'll tell you what I think about this. So basically, if there's lots of inflation, it means prices for goods keep going up. Or another way to put it is that the dollar or whatever currency gets worth less and less. As we know, looking at different societies across time, sometimes this can spiral completely out of control, or you can get into hyperinflation, which can be really, really bad. Even if you don't get into hyperinflation, inflation can be really problematic because it kind of erodes people's savings. If you have a bunch of money saved in US dollars and then the dollar has a lot of inflation, you essentially lose your savings. So it can be really bad for individuals to have a lot of inflation. So the Fed, they'll raise interest rates to help combat this. And by raising interest rates, essentially what they're doing is they're making it more expensive to borrow money. When they make it more expensive to borrow money, people borrow less money and therefore do less economic activity. So companies, when it's more expensive to borrow money, they'll borrow less and they'll therefore start fewer new projects and so on. When it's more expensive for individuals to borrow money, they'll take on less debt and do less spending. And so this kind of cools off the economy to try to reduce prices. Because if people are doing less economic activity, that tends to mean that prices will fall because there's kind of less demand for goods. And so basically, the Fed, by raising interest rates, it can reduce inflation, the theory goes. Now, as pointed out by the listener, the flip side of this is that when you raise interest rates, because there's less economic activity, that means there could be less employment as well. Because if with fewer projects going on, fewer goods being bought, there are fewer jobs to go around. This is really fundamentally a trade-off. Whether it's worth it really depends on a lot of factors, but preventing inflation from spiraling out of control is really, really clearly a good thing. So being willing to sacrifice some employment to help keep inflation under control could well be worth it. But really, when you think about it, the Fed is trying to balance these two things, right? They care both about employment and about inflation. And they're trying to achieve a reasonably strong level of employment while preventing inflation from getting out of control. And so it's really a balancing act.