How the science of “supportive accountability” could transform mentoring

By Jean Rhodes

If you own a smartphone, you have probably downloaded at least one application that has promised some form of self-improvement—from losing a few pounds to mastering mindfulness. On its own, your app may not seem particularly consequential but, collectively, smartphone apps and other technology-delivered interventions are quietly revolutionizing education and mental health services. What’s more, they might just transform youth mentoring. Mental health apps (MHapps), for example, can successfully address a range of common mental health concerns. Apps can also be used to help youth achieve a range of academic and career goals, from applying to college to discovering new career paths. When technology-delivered interventions are blended with coaching and support, they can produce outcomes that rival those of face-to-face interventions, often at little or no cost and in ways that are more geographically, financially, and socially acceptable to youth and their caregivers.

Despite this promise, youth and adults alike struggle to remain engaged in self-administered apps and web-based platforms, and as many as three-quarters don’t complete the recommended number of sessions. Compared to self-guided apps, those that incorporate some form of coaching to help users remain actively engaged are far more effective. So, in a nutshell, we have targeted, evidence-based apps that work best for youth when they are supported by lay coaches; and we have mentoring programs that are in need of targeted, evidence-based interventions.

This may just be a match made in heaven. Here’s why.

First, the ubiquity of smartphones and the development of mobile mental health, health, and wellness apps have made evidence-based care accessible in ways that could shift the mentoring landscape. Many incorporate engaging, intrinsically motivating interactive lessons, quizzes, games, and virtual rewards, and 95 percent of young people already have access to smartphones and are in the habit of checking them many times a day. Youth also appreciate the autonomy and reduced stigma that MHapps can afford, and many prefer to handle their issues on their own.

Additionally, the best MHapps are digital applications of cognitive behavioral therapy principles, including methods to cope with stress, and techniques such as journaling or tracking thoughts, feelings, and behaviors. This sort of self-monitoring can also help young people recognize, label, and ultimately better regulate their emotions.

A new tool, MentorHub, has incorporated coaching dashboards that enable mentors to easily track, encourage, nudge, and reward mentees’ engagement. These dashboards can also facilitate program staff’s efforts to monitor matches. It incorporates sophisticated data collection techniques (e.g., time sampling youth’s moods, conducting randomized assessments, automatic scoring, and visualization of data) which, aided by machine learning, can simplify, expedite and improve the capacity of programs to monitor and evaluate their efforts. Increasing the frequency, accuracy, and efficiency of data collection and analysis has potentially far-reaching effects (e.g., enabling early detection of problems and more targeted support as well as reducing the need for costly program evaluations). Apps are also able to address the needs of underserved and marginalized groups, who tend to rely on their smartphones even more heavily than do their more privileged counterparts and have less access to in-person programs. Some evidence-based apps have been adopted for use across racial and ethnic groups, helping to spread linguistically and culturally acceptable interventions while reducing waitlists in overburdened mental health systems. Likewise, many app-based interventions can be completed in a matter of months or even weeks, potentially releasing volunteers from the traditional one-year mentoring commitment so they can work with additional youth. Mentees on waitlists may also benefit. Frontline staff can draw on youth’s intake data to recommend targeted, evidence-based apps for waitlisted youth to work on with family members or other caring adults.

In addition to improving access to care, apps have reduced financial barriers. Although some require fees and subscriptions, a growing number of federally funded mental health apps (MHapps) are publicly available at little or no cost. Built on years of research and evaluation, they can also readily incorporate new research and practice updates as their fields advance. For example, Northwestern University’s Center for Behavioral Intervention Technologies offers an array of health and mental health apps, including Intellicare, that cover depression and anxiety, thoughts and feelings, activities and emotions, social support, and more. When paired with coaching, these apps have produced significant improvements in health and anxiety in as little as eight weeks.  Along similar lines, mindfulness and meditation apps like HeadSpace have shown positive effects on users’ depressive symptoms and school adjustment, irritability, mood, and stress management. Some MHapps are being developed and adopted with youth programs in mind since the marginal costs of scaling to new users and/or reusing the training again and again are trivial. For example, SuperBetter was designed to “help youth-focused organizations increase resilience, promote social and emotional learning, and reduce student anxiety and depression,” and has shown impressive effects on youth depression levels (0.67 to 1.07).Apps are poised to extend the reach of evidence-based care to more youth.

Unfortunately, the potential to do so, particularly for MHapps, has been limited by low engagement, improper use, and high rates of noncompletion in the absence of coaching and support.[13] Engaging youth in mental health services has always been a challenge, and self-administered MHapps are no exception. Compared to the rates of other health and wellness apps, MHapps have the lowest use after one month, even when mental health care providers recommended them.[14] The most common solution to these difficulties has been to provide users with coaches who can help boost engagement through what behavioral scientists refer to as “supportive accountability”—that is, regular check-ins, monitoring, troubleshooting, and other interactions. Supportive accountability seeks to isolate and efficiently address common difficulties or “failure points” that are open encountered in app-based interventions. These include usability (design flaws in the app), user engagement (a lack of motivation), fit (the app does not address the user’s specific needs), knowledge (incorrectly using the app), and implementation (insufficient incorporation of new skills into the user’s daily life).[15] Supportive accountability coaches seek to identify the failure points and maintain engagement with the app, not deliver the actual intervention.

Several studies and systematic reviews have highlighted the positive associations between supportive accountability and users’ engagement, number of logins, use of interactive tools, and outcomes.[16] These studies have shown that, with guidance, effect sizes of apps and other technology-delivered interventions are comparable to those obtained in face-to-face interventions, whereas entirely self-guided programs have yielded relatively few benefits.[17] A recent large-scale meta-analysis, for example, showed that students whose use of technology-delivered interventions was supported by coaches, either in person or through online contact, showed more gains than those who self-administered their interventions.[18] In fact, supported interventions produced nearly double the effects of self-administered interventions (0.55 versus 0.28). As the researchers noted, “support from paraprofessionals or even peers might enhance participant goal setting, expectations, and motivation, and thus improve intervention engagement, adherence, and outcomes.”[19]

In a recent meta-analysis of sixty-six randomized control trials of MHapp interventions, researchers found that studies that offered guidance (e.g., regular supportive text messages, phone calls, and personalized feedback) and engagement reminders yielded effects that were more than double those of studies in which no such support was provided (e.g., 0.51 versus 0.21 for anxiety; 0.48 versus 0.23 for depression). Even simple reminders dramatically increased the effects of app-based interventions (0.15 versus 0.39 for anxiety; 0.18 versus 0.32 for depression).

In our lab, we recently surveyed many meta-analyses, isolating the effects of interventions with and without coaching and support.

Importantly, this coaching and support need not be delivered by highly trained professionals. Previous studies have found no difference in technology-delivered engagement or outcomes when youth were supported by clinicians versus nonprofessionals.[20] Supportive accountability need not be delivered in person and requires relatively little time on the part of the coach or mentor. Clearly, there is a role for mentors in providing such reminders and guidance.

The science of supportive accountability is still new and needs testing and refinement with youth mentors.[21] Careful prospective studies on the effects of supplementing mentoring relationships with MHapps, for example, are needed to understand their effects and to ensure that any potential benefits are not offset by unintended consequences. We will need to study their feasibility across different geographical, socioeconomic, age, and racial/ethnic groups. Other issues, including cultural sensitivity, intergenerational technology gaps, privacy, and ethical concerns, will need to be resolved as targeted, technology-delivered interventions are blended with mentoring practice.[22]

Mentor training will also need to be updated to incorporate the lessons of supportive accountability. FAnd finally, a focus on incorporating effective intervention models in no way diminishes the importance of good working relationships, which provide the necessary motivation and support for youth’s engagement and learning. But when the relationship is leveraged in this way, it has the potential to provide young people with the tools they need to thrive.

[1] L. Marsch, S. Lord, and J. Dallery, Behavioral Healthcare and Technology: Using Science-Based Innovations to Transform Practice ( Oxford University Press, 2014); J. Firth et al., “The Efficacy of Smartphone-Based Mental Health Interventions for Depressive Symptoms: A Meta-analysis of Randomized Controlled Trials,” World Psychiatry 16, no. 3 (2017): 287–298, https://doi.org/10.1002/wps.20472.

[2] A. E. Kazdin and S. L. Blase, “Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness,” Perspectives on Psychological Science 6, no. 1 (2011): 21–37.

[3] J. Torous et al., “Clinical Review of User Engagement with Mental Health Smartphone Apps: Evidence, Theory and Improvements,” Evidence-Based Mental Health 21, no. 3 (2018): 116–119.

[4] G. Andersson and P. Cuijpers, “Internet-Based and Other Computerized Psychological Treatments for Adult Depression: A Meta-analysis,” Cognitive Behaviour Therapy 38, no. 4 (2009): 196–205; S. Perini, N. Titov, and G. Andrews, “Clinician-Assisted Internet-Based Treatment Is Effective for Depression: Randomized Controlled Trial,” Australian and New Zealand Journal of Psychiatry 43, no. 6 (2009): 571–578.

[5] M. Anderson and J. Jiang, “Teens, Social Media & Technology 2018,” Pew Research Center, May 31, 2018, https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/.

[6] R. Mojtabai et al., “Barriers to Mental Health Treatment: Results from the National Comorbidity Survey Replication,” Psychological Medicine 41, no. 8 (2011): 1751–1761.

[7] D. Bakker et al., “Mental Health Smartphone Apps: Review and Evidence-Based Recommendations for Future Developments,” JMIR Mental Health 3, no. 1 (March 2016): e7, https://doi.org/10.2196/mental.4984.

[8] Bakker et al., “Mental Health Smartphone Apps”; J. Nicholas et al., “Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality,” Journal of Medical Internet Research 17, no. 8 (2015): e198.

[9] R. F. Muñoz, “Using Evidence-Based Internet Interventions to Reduce Health Disparities Worldwide,” Journal of Medical Internet Research 12, no. 5 (2010): e60.

[10] D. Mohr, P. Cuijpers, and K. Lehman, “Supportive Accountability: A Model for Providing Human Support to Enhance Adherence to eHealth Interventions,” Journal of Medical Internet Research 13, no. 1 (2011): e30.

[11] J. A. M. Flett et al., “Mobile Mindfulness Meditation: A Randomised Controlled Trial of the Effect of Two Popular Apps on Mental Health,” Mindfulness 10, no. 5 (2019): 863–876, https://doi.org/10.1007/s12671-018-1050-9; M. Economides et al., “Improvements in Stress, Affect, and Irritability Following Brief Use of a Mindfulness-Based Smartphone App: A Randomized Controlled Trial,” Mindfulness 9, no. 5 (2018): 1584–1593.

[12] A. M. Roepke et al., “Randomized Controlled Trial of SuperBetter, a Smartphone-Based / Internet-Based Self-Help Tool to Reduce Depressive Symptoms,” Games for Health Journal 4, no. 3 (2015): 235–246.

[13] Bakker et al., “Mental Health Smartphone Apps.”

[14] C. Stiles-Shields et al., “What Might Get in the Way: Barriers to the Use of Apps for Depression,” Digital Health 3 (2017), https://doi.org/10.1177/2055207617713827; E. G. Lattie et al., “Uptake and Usage of IntelliCare: A Publicly Available Suite of Mental Health and Well-Being Apps,” Internet Interventions 4 (2016): 152–158, https://doi.org/10.1016/J.INVENT.2016.06.003.

[15] S. M. Schueller, K. N. Tomasino, and D. C. Mohr, “Integrating Human Support into Behavioral Intervention Technologies: The Efficiency Model of Support,” Clinical Psychology: Science and Practice 24, no. 1 (2017): 27–45, https://doi.org/10.1111/cpsp.12173.

[16] Andersson and Cuijpers, “Internet-Based and Other Computerized Psychological Treatments for Adult Depression”; Mohr, Cuijpers, and Lehman, “Supportive Accountability”; V. Spek et al., “Internet-Based Cognitive Behaviour Therapy for Symptoms of Depression and Anxiety: A Meta-analysis,” Psychological Medicine 37, no. 3 (2007): 319–328; M. G. Newman et al., “A Review of Technology-Assisted Self-Help and Minimal Contact Therapies for Anxiety and Depression: Is Human Contact Necessary for Therapeutic Efficacy?,” Clinical Psychology Review 31, no. 1 (2011): 89–103.

[17] N. Titov et al., “Transdiagnostic Internet Treatment for Anxiety and Depression: A Randomised Controlled Trial,” Behaviour Research and Therapy 49, no. 8 (2011): 441–452.

[18] C. Conley, J. Durlak, and A. Kirsch, “A Meta-analysis of Universal Mental Health Prevention Programs for Higher Education Students,” Prevention Science 16, no. 4 (2015): 487–507, https://doi.org/10.1007/s11121-015-0543-1.

[19] Conley, Durlak, and Kirsch, “A Meta-analysis of Universal Mental Health Prevention Programs for Higher Education Students.”

[20] N. Titov et al., “Internet Treatment for Depression: A Randomized Controlled Trial Comparing Clinician vs. Technician Assistance,” PloS One 5, no. 6 (2010): e10939.

[21] Mohr, Cuijpers, and Lehman, “Supportive Accountability.”

[22] G. Bernal, M. I. Jiménez-Chafey, and M. M. Domenech Rodríguez, “Cultural Adaptation of Treatments: A Resource for Considering Culture in Evidence-Based Practice,” Professional Psychology: Research and Practice 40, no. 4 (2009): 361; J. Torous et al., “Mental Health Mobile Phone App Usage, Concerns, and Benefits among Psychiatric Outpatients: Comparative Survey Study,” JMIR Mental Health 5, no. 4 (2018): e11715.

[23] N. Titov, “Internet-Delivered Psychotherapy for Depression in Adults,” Current Opinion in Psychiatry 24, no. 1 (2011): 18–23.

[24] Schueller, Tomasino, and Mohr, “Integrating Human Support into Behavioral Intervention Technologies.”

[25] Schueller, Tomasino, and Mohr, “Integrating Human Support into Behavioral Intervention Technologies.”

[26] A. Barak et al., “A Comprehensive Review and a Meta-analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions,” Journal of Technology in Human Services 26, no. 2–4 (2008): 109–160, https://doi.org/10.1080/15228830802094429; M. E. Larsen et al., “Using Science to Sell Apps: Evaluation of Mental Health App Store Quality Claims,” Nature Digital Medicine 2 (2019): 18.

[27] J. Linardon et al., “The Efficacy of App‐Supported Smartphone Interventions for Mental Health Problems: A Meta‐analysis of Randomized Controlled Trials,” World Psychiatry 18, no. 3 (2019): 325–336, https://doi.org/10.1002/wps.20673.

[28] Barak et al., “A Comprehensive Review and a Meta-analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions.”

[29] D. R. Singla et al., “Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries,” Annual Review of Clinical Psychology 13 (2017): 149–181, https://doi.org/13:149–81/10.1146/annurev.

[30] M. S. Karver et al., “Meta-analysis of the Prospective Relation between Alliance and Outcome in Child and Adolescent Psychotherapy,” Psychotherapy 55, no. 4 (2018): 341.

[31] S. A. Baldwin and Z. E. Imel, “Therapist Effects: Findings and Methods,” in Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, ed. M. J. Lambert, 6th ed. (New York: Wiley, 2013), 258–297.

[32] R. Spencer, “A Working Model of Mentors’ Contributions to Youth Mentoring Relationship Quality: Insights from Research on Psychotherapy,” LEARNing Landscapes 5 (2012): 295–312.