Post by Phoebe Barnett, PhD student and Research Assistant. You can follow Phoebe on Twitter.

Reading time: ~3 mins

Clinicians delivering psychotherapeutic treatments to students may choose to adapt their interventions, to try and account for their unique context. In this post, Phoebe Barnett outlines the findings from her recent systemic review, which investigated whether current adaptations to treatments for students are working.

Student counselling services have reported considerable increases in the number of students accessing care. Alongside this, they report that their clients are presenting with more severe mental illnesses. While this is likely to be at least partly caused by widening access to university, recent reports have highlighted that student-specific concerns, such as academic pressure, financial distress, substance misuse and family upset are rising ^1,2.

Many of the current psychological therapies delivered to students were originally designed for the general population, and may therefore miss important factors related to student distress. One possible way in which student mental healthcare could be improved is by designing specialised treatments for students; for example, by targeting the prevention of suicide and self-harm ^3,4. As students are easy to recruit, previous research has often included them in their samples. However, the research rarely aims to establish what works best for them specifically. It is important to understand how to support mental health needs in this specific population, and how we can further adapt evidence-based treatment so students feel the support available to them is relevant to the difficulties they are facing. 

I therefore systematically reviewed the evidence from randomised-controlled trials of psychological therapy conducted in student populations. In doing this I aimed to establish if a specific focus on adaptation would work better than generic approaches.

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Our findings

In general, psychological treatments are effective in reducing students’ symptoms of depression, anxiety disorders and eating disorders. This result, although unsurprising, is important because depression and anxiety disorders are the most common in students. There is also overrepresentation of eating disorders in students, compared with non-students. Unfortunately, few investigations into treatments for PTSD in students have been conducted, and, despite recent reports of suicide rates in students increasing^5,6, we did not find any studies which focussed on either self-harm or suicidal ideation.

Only a small number of studies, 13 out of 84, specifically adapted their intervention for students. When we compared  studies looking at adapted and non-adapted treatments, adapted interventions did not lead to better outcomes or greater adherence to treatment. Those who received adapted treatments actually fared worse in most cases.

Those who received adapted interventions actually fared worse in most cases. Concerns about students dropping out would be better addressed with interventions focused on motivation, rather than reducing treatment length.

These results seemed counterintuitive at first, however when we looked into this in more detail, some of the adaptations did not fully encompass what students may need from mental health support. For example, a common assumption was that students lack the motivation to attend longer treatment programmes (although this point is disputed and contradicts some recent qualitative research I have conducted). Three studies sought to achieve better outcomes by reducing the treatment intensity: one delivered web-based sessions, one reduced the total number of sessions and the final study provided a single session of low-intensity treatment. But our review found no evidence that reducing treatment intensity in this way benefitted patients in terms of symptom reduction and treatment tolerability. It was not clear whether the shortening of previously evidence-based treatment models removed key “ingredients” which, in turn, hindered the effectiveness. We suggest that concerns about students dropping out would be better addressed by focussing on motivation, rather than potentially sacrificing important elements of therapy by reducing treatment length.

Positive effects were seen in two studies who provided more sessions alongside evidence-based adaptations, suggesting a potential avenue for further research.

Conclusion

In sum, psychological treatments can be beneficial for students, but so far they have not been fully optimised for them. There remains a lot of uncertainty over how we can provide interventions to students in a way that suits them best. A greater understanding of context-specific causes of mental health problems and distress could lead to more promising treatments for students.

References

1. Doerr, J. M., Ditzen, B., Strahler, J., Linnemann, A., Ziemek, J., Skoluda, N., Nater, U. M. (2015). Reciprocal relationship between acute stress and acute fatigue in everyday life in a sample of  university students. Biological Psychology, 110, 42–49.back
2. Murray, A. L., McKenzie, K., Murray, K. R., & Richelieu, M. (2015). An analysis of the effectiveness of university counselling services. British Journal of Guidance & Counselling, 44, 1309139.back
3. Gawrysiak, M., Nicholas, C., Hopko, D.R., 2009. Behavioral activation for moderately depressed university students: randomized controlled trial. Journal of Counseling Psychology 56 (3), 468-475back
4. McIndoo, C., File, A., Preddy, T., Clark, C., Hopko, D., 2016. Mindfulness-based therapy and behavioral activation: A randomized controlled trial with depressed college students. Behaviour Research and Therapy, 77 118–128. https://doi.org/10.1016/j. brat.2015.12.012.back
5. Horgan, A., Kelly, P., Goodwin, J., Behan, L., 2018. Depressive symptoms and suicidal ideation among Irish undergraduate college students. Issues in mental health nursing 39 (7), 575–584.back
6. Read, J.P., Griffin, M.J., Wardell, J.D., Ouimette, P., 2014. Coping, PTSD symptoms, and alcohol involvement in trauma-exposed college students in the first three years of college. Psychology of addictive behaviours 28 (4), 1052. back

Post by Dr Chloe Campbell, Deputy Director of the UCL Psychoanalysis Unit

Reading time: ~ 6 mins

The remote therapy experiment brought about by the pandemic has had a silver lining, as therapy has become more accessible to many people. Keeping some form of online therapy is desirable for this reason, but it does raise new challenges for communication. Chloe Campbell reflects on how a psychological understanding of trust can help us understand online communication better.

Psychological therapy is not new or special: that is why it works. Humans beings have – for as long as we have had language – sought out other people’s minds, thoughts and perspectives in order to regulate their own state of mind.

Infants do it all the time and perhaps most obviously – a baby or young child is not only dependent on their caregivers for physical survival, but also to restore their sense of comfort, safety or to help them make sense of the world together.

This joining of minds, known as ‘joint intentionality’, is crucial to human development. Recent evolutionary thinking has suggested it underpins the sophisticated social cognitive skills that make the human species unique. It enables teaching and learning, sophisticated planning and collaboration – in essence it makes social cohesion and the development of culture possible. 

To be able to do all these complicated and demanding social cognitions, we need to be able to think about the mental states of other people and ourselves, an ability known as ‘mentalizing’. But mentalizing requires imagination – we cannot know for certain what is going on in other peoples’ minds, and even thinking about our own mental states is a highly abstract undertaking.

The human imagination allows us to do extraordinary things – from being able to think sensitively about someone else’s pain or distress, to being able to write and read great literature, to being able to make the abstract leaps in ideas that lead to ground-breaking scientific breakthroughs.

We all need to access to other people’s thoughts to help us manage our own – to moor our imaginations to something more  helpful for us, or indeed with reality

The flipside of our marvellous imaginative capacities is that sometimes our ability to think in such ways can, when unregulated, lead to intense psychological distress. Many forms of anxiety and depression can be understood as being, in some way, the product of our minds working away at great abstract capacity but with insufficient alignment with our social reality. 

This is where other people’s minds come in. We all need, at times, to access to other people’s thoughts to help us manage our own – to moor our imaginations to something more in line with what is helpful for us, or indeed with reality.

This is the power of joint intentionality and cooperative thinking. But a further complication in all this arises from another downside of human social complexity: not all humans can be trusted and opening up to the wrong person could leave you vulnerable.

As a result of this, we have also evolved the capacity to be highly sensitive to cues from other people that might suggest whether or not they (a) have something useful to say and (b) have our best interests at heart.

And it is here that the communication that is relevant to effective psychotherapy comes in. The kinds of cues that we are sensitive to are often highly interpersonal.

If we feel the other person is truly interested and capable of recognising us – even those parts of us that are hidden, perhaps even partly to ourselves – then that is a powerful cue that the other person is sufficiently invested in us for us to be able to think with them, to learn from them, and to use their mind to regulate our own.

Once we have had some practise accepting this in the therapeutic relationship, we can go on to build on what we have learnt in our daily lives. With a bit of luck, a virtuous circle might be activated – and treatment has become “effective”.

Of course, if the outside world does not support these developments, then it is much harder, and in some circumstances perhaps impossible, for the virtuous cycle to really keep rolling. After all, if we live in a hostile environment, where other people’s minds aren’t capable of investing benignly in each other’s, it would be a mistake to adopt such cooperative openness to others’ mental states.

So, where does this leave us with remote therapy?

The task of the remote practitioner is the same. Their work depends on their capacity to evoke in the client the same sense they have been recognised, that the practitioner is interested and invested in the client’s mental state, and is able to tolerate and accommodate the complexities this might involve.

Remote therapy can create particular challenges for this – but also perhaps offer some advantages.

Returning to an evolutionary perspective, the initial challenge arises from the fact that we adapted the capacity to read these signals in small, face-to-face social groups.

Working remotely creates challenges but more than ever it should focus us on the value of thinking together and communicating thoughtfully.

The role of signals such as eye contact, responding to body language and contingent responsiveness – the back and forth quality of shared conversation – are liable to be distorted in online communication. The person you are talking to may cut out for a minute and the conversational flow may be disrupted by time-lags and audio difficulties.

However, some individuals, including those who may feel others are not benign or well-intentioned towards them, may find another person’s attention overwhelming. For them, the buffer of online remoteness may provide some space to assess cues at a safe distance. The remote practitioner needs perhaps to work that bit harder to think about the cues, and to show that they have understood.

An example of this is the formulation, common at the beginning of therapy. We argue that the reason a skilfully done formulation is so important is that it is a thoughtful and explicit demonstration of the therapist’s interest in the client’s state.

In remote therapy, formulation is perhaps even more important given that other cues may be harder to convey remotely.

The need to work remotely creates challenges but perhaps more than ever it should focus us on the value of thinking together, of communicating thoughtfully and attempting to recognise and acknowledge mental states in all their complexity. And of course this includes the practitioners who themselves need to be appreciated and recognised for their efforts to connect with their clients, under conditions of such uncertainty.