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The evidence behind Bubble

Melon’s approach to improving Teen Mental Health has developed over nine years delivering evidence-based digital therapeutics combining the latest research in neuroscience, psychology, behavior change and human centered design. Bubble is our product evolution, the culmination of evidence and experience delivered in an engaging and supported manner to improve teen mental health.

Here we will share the scientific research supporting the foundations Bubble is built on and the therapeutic approach we have taken. It will give an overview of our therapeutic framework, how it will be delivered, and evidence of efficacy.

Our Therapeutic Framework

Whilst Bubble is not classified as a therapy it draws on therapeutic frameworks and strategies proven to be effective health interventions. Cognitive Behavioral Therapy and Relational psychotherapy frameworks which have been effectively used across our products for the past nine years.

Cognitive Behavioral Therapy (CBT)

CBT is often used as the umbrella term for behavior therapies that focus on how thoughts, feelings and behaviors are connected. It is widely accepted that these provide an effective framework to support mental health difficulties (Mayo Clinic, 2019). It has been found to be particularly effective in the treatment of anxiety disorders in adolescents (Yin et al, 2021).

Three differing CBT based approaches are (Hayes and Hofman, 2017):

Cognitive Behavioral Therapy. Helping people challenge and change destructive thought and behavioral patterns.
Dialectical Behavior Therapy (DBT). DBT focuses primarily on improving emotional regulation, distress tolerance and mindfulness.
Acceptance and Commitment Therapy (ACT). Considered a ‘third wave’ psychological therapy, ACT encourages people to embrace difficult thoughts and feelings, whilst focusing on workability and psychological flexibility.

There are overlaps in many of these therapeutic frameworks. Therapists often use different strategies as the situation requires and encourage clients to experiment with what works, all of the skills are transferable to different challenges and assist with a resilience mindset.

Relational psychotherapy

Relational psychotherapy is founded on the concept of relationships with others being an essential aspect of emotional well-being. Individuals who find it difficult to maintain supportive and healthy relationships may experience a sense of disconnection in addition to feelings of diminished self-worth and general distress, and their sense of emotional well-being may be negatively affected. Evidence shows that improving relationships and family functioning improves youth mental health outcomes (Berk et al. 2020).

The practice of relational psychotherapy adheres to the following principles:

It is important for a person to maintain fulfilling and satisfying relationships with those around them in order to maintain emotional health.
Stress and emotional upheaval are often the results of past relational experiences, and these concerns may inhibit the present self from full expression.
Relational psychotherapy provides an atmosphere of empathy and attentiveness in order to elicit full disclosure of the experiences and events affecting the person seeking treatment, as well as the effects they have had both relationally and socially.
The people engaging in understanding these foundations, work together to forge a strong, collaborative, and secure relationship that can serve as a model for future relationships the person wishes to develop. Other relationships can be measured against this supportive one to determine if they are constructive or destructive.

Melon’s therapeutic heritage

Melon has been delivering digital therapeutics, based in CBT and relational psychotherapy, to support people to manage their physical and mental health since 2012. Over this time Melon has proven an approach focused on the following elements to be particularly effective:

Connection - tech enabled human connection connecting people with others on a similar journey in a private, anonymous social network
Personalized Engagement - personal goals, nudges, reminders and positive reinforcement
Education - through video, audio, visual and written mediums
Self-awareness - using a health journal to passively or manually track activity and behaviors (sleep, pain, mood, physical activity, work hours, food diary etc)
Coaching - to help if extra support is needed

CDC Diabetes Prevention Program (USA)

Melon is a fully recognised provider of the US Govt funded Diabetes Prevention Program (DPP). Over a 2 year CDC reporting period the CDC Diabetes Prevention Program had validated clinical data that showed a successful reduction in weight and HbA1C for users. As a result of this, Melon received full recognition in September 2020.

Emotional Wellness Program

The Melon 12 week Emotional Wellness programme draws from CBT, DBT and ACT. It was evaluated over a 2 year period and was found to have very promising outcomes through improved GAD, PHQ9, and K10 scores.

“Melon appears to be demonstrating levels of effectiveness at least as high as the effectiveness of the Managing Mood group therapy. This is demonstrated by the large change in assessment scores across the GAD, PHQ9 and K10.” Independent report Synergia for Comprehensive Care, Primary Health Organization 2018.

Audits/Scores/Awards

Over our history, Melon has received a range of high scores and awards from independent auditors and health related organizations, demonstrating our effective approach.

Mayo Clinic, USA

Melon was one of three companies in the US selected by Mayo Clinic in 2015 as an innovation partner which included a residence at Mayo in Rochester, Minnesota working with a range of clinical specialists providing feedback on our programmes and approach.

Digital Mental Health Innovation Award

Melon was selected by PsychCongress (the largest education event and community for mental health professionals since 1987) as the inaugural winner of the Digital Mental Health Innovation Award in 2017.

Melon Manual

Melon’s CBT based Mental Wellness resources for youth and caregivers is utilized by over half of New Zealand’s schools through Melon Manual’s downloadable resources and videos. The CBT based animations alone have been accessed by over 2 million New Zealanders.

2021 HPA Audit.

The 2021 HAP “Aotearoa New Zealand Digital Tools for Mental Health and Wellbeing” audit highlighted Melon’s programs include significant evidence-based content.

DMHAS score

The Digital Mental Health and Addiction Services Framework Audit (NZ) awarded Melon a score of 97.9%

Our Therapeutic Approach

Extending therapeutic support

The Covid-19 pandemic has disproportionately impacted Youth Mental Health through immediate and longer-term factors which affect young people such as social isolation and a loss of structured occupations (school, work, training) (Power, Hughes, Cotter, & Cannon, 2020). As a result, there are adverse mental health conditions such as anxiety and depression in youth (Octavius, et al. 2020).

The loss of routine, an important coping mechanism for youth with mental health issues, is associated with a decline in youth mental health (Lee, 2020). Evidence also points to the lack of access to traditional therapeutic services as being a factor (Power, et al. 2020). Because of this, there are now strong calls to increase access to support for youth through the extension of digital support mechanisms (Guessoum, et.al, 2020; Power, et.al, 2020; Singh, et. al, 2020).

Digital delivery of CBT

While there is ample evidence of the efficacy of CBT approaches (American Psychological Association, 2017; Yin et. al, 2021) the question may be asked if the digital delivery of CBT is also effective. Meta-analyses have shown superiority of this form of CBT to wait-list control groups, and randomized controlled trials have shown it to have approximately equivalent efficacy compared to face-to-face CBT (Andrews et al., 2018; Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018). Taken together, these meta-analyses suggest that digital CBT is a safe and effective method to decrease barriers of access to CBT (Wilhelm, Weingarden, Ladis, Braddick, Shin, & Jacobson, 2020).

Bio/neurofeedback

Biofeedback/neurofeedback will be a prominent feature of Bubble (eg. heart rate and heart rate variability). These model physiological and emotional reactions and feed the information back to the user. White et al. (2017) found that neurofeedback therapy, when combined with breathing slowly (Heart Rate Variability training) was effective in reducing symptoms of both anxiety and depression. Facilitating awareness of our own physiology (such as brain activity or cardiac function) can enhance therapeutic approaches for anxiety disorder, depression, obsessive-compulsive disorder (OCD) and schizophrenia) via self-regulation. Biofeedback has also been shown to improve impulse control difficulties, and attentional difficulties in bulimia nervosa and attention deficit hyperactivity disorder,as well as symptoms of stress, anxiety and anger. The focus on physiological data in the psychotherapeutic context is gaining traction and has strong theoretical underpinnings (Edwards and Kemp, 2020).

Parental lay support

Digital interventions for mental health disorders have been widely developed and have had promising results (Anderson, et.al, 2009; Baumeister, Richer, Munzinger, & Lin, 2014; Johansson & Andersson, 2012). The most effective digital interventions involve support of another person, which may be an issue with an understaffed sector. Alternative methods of support, such as using lay supporters and parents have been proposed to address this.

Arjadi et al. (2018), looked at the efficacy of an internet-based behavioral intervention with lay counselor support rather than professional mental health counselors. They found that participants with a lay counselor had significant reductions in PHQ-9 scores (depressive symptoms), and a 50% higher remission from a depressive episode compared to those undertaking psychoeducation alone. Christiana and Setiwan (2018) argue findings like these “support the potential use of the internet to increase access to mental health treatment and potential task shifting from health professionals to trained lay counselors for treating depression” (p.688).

More recent research has looked more specifically into the use of CBT with parents as the supporters. Yin et. al (2021) conducted a meta-analysis on parent-only CBT and concluded that “current evidence indicates that parent-only CBT can be an alternative and acceptable intervention for treating children and adolescents with anxiety disorder” (p.2).

Ensuring Engagement

Ensuring good engagement with a program is important for its efficacy. Digital CBT interventions should incorporate features which encourage engagement and bring users back to the intervention (Willhelm et. al, 2020).

Accountability

Willhelm et.al (2020) highlight the significance of a user’s need to feel accountable and cared for. While traditionally this may have been accountability to a therapist, they argue that “lay coaches with some training may be just as effective for keeping users engaged” (p.6). A sense of connection and accountability has been a core feature to many Melon features for years.

Interactive experiences and game theory

Using game theory and interactive gaming elements to increase engagement is commonly used to increase user engagement. This is no different in mental health, and calls for an increase in ‘gamification’ techniques are often made (Cheng, 2020). Importantly, research into applying game theory to digital mental health interventions also point towards their effectiveness to increase therapeutic change. Fleming et al. (2017) demonstrate “that it is feasible to translate traditional evidence-based interventions into computer gaming formats and to exploit features of computer games for therapeutic change” and that “applied games have considerable potential for increasing the impact of online interventions for mental health”(p.1).

Improving relationships

The need for supportive relationships

There is an increasing body of evidence stressing the importance of psychosocial support for improved youth mental health outcomes. In fact, the National Scientific Council on the Developing Child (2015) states “Science shows that children who do well despite serious hardship have had at least one stable and committed relationship with a supportive adult. These relationships buffer children from developmental disruption and help them develop ‘resilience,’ or the set of skills needed to respond to adversity and thrive.“

The involvement of loved ones in supporting a young person has been found to have many positive benefits such as reduced suicidality (Brent, 2016; Pineda and Dadds, 2013) and risk taking behavior (Qu, Fuligni, Galvin, & Telzer, 2015). More recently, Guessoum et al (2020) found an important factor of youth mental health outcomes in times of crisis, such as the Covid-19 pandemic, are familial coping abilities. They state that as adolescents are often vulnerable, they need careful consideration by caregivers during these times.

It is not surprising, therefore, that the World Health Organization does not only promote socioemotional skill development for improved youth mental health outcomes (World Health Organization, 2021a; World Health Organization, 2021). They also specifically call for programs which help strengthen the ties between adolescents and their families. Similarly, the U.S. Surgeon General’s 2021 ‘Protecting Youth Mental Health’ advisory states that “Families and caregivers play a critical role in providing the safe, stable, and nurturing environments and relationships young people need to thrive.” As a result, the advisory’s recommendations focus heavily on developing supportive relationships between a young person and a trusted adult.

Parental support in therapeutic interventions

Many studies have shown that behavior problems improve the best with Parental Management Training/Cognitive Behavior Therapy as opposed to interventions which do not involve parents (Texas Children's Hospital, 2012). Lebowitz et.al (2020) found parent-based treatments for anxious childhood emotions effective and Yin et.al (2021) highlight findings that parent-led CBT is effective.The Texas Children’s Hospital CBT handout (2012) states this is because parents not only learn the skills needed to respond effectively, but it enables them to teach children skills to handle negative emotions and teach the whole family skills to communicate better or solve problems effectively.

Summary

As has been demonstrated in the preceding sections, there is strong empirical evidence for the effectiveness of CBT, its extension of its therapeutic benefits digitally, and how a parent can offer effective support in its provision. The provision of CBT by itself, however, is not all that is needed. Heading the findings and calls from experts in youth mental health, youth also need the support of a loved one to achieve the best health outcomes possible.

Digital therapeutic extension

Based on almost a decade of experience in delivering digital health interventions, and empirical evidence, Bubble’s digital CBT based interventions improve the socioemotional skills needed for better mental health outcomes.

The socioemotional skills initially focused on in Bubble will help both parent and teen improve their executive functioning in order to react more beneficially both individually and towards each other. Both teen and parent receive the training needed to thrive in difficult times. Importantly, these initial skills taught lay a foundation of a relationship in which to build upon.

Relational improvement

Bubble is a shared experience between a teen and a parent. This is a fundamental guiding principle of the product and therapeutic design. Bubble helps build the teen-parent relationship through features specifically targeted at improving empathy and understanding, a shared language, frequency of interactions, communication and connectedness, and other aspects of relationship building.

Lay support and training

The connected nature of Bubble allows for upskilling of the parent into the role of the lay supporter,highlighted in the academic research. Once the foundational relationship skills have been practiced and potentially mastered, the parent and teen experiences diverge. While the teen will develop their coping strategies for difficult times, the parent will learn the support skills required to provide the best support possible to the teen. They learn how to respond to their teen in ways that promote more positive behaviors and less negative behaviors and improve parent-teen relationships.

Engagement

Melon’s experience in game theory and its use in designing Bubble will help to incorporate many of the proven strategies (mastery loops, implicit rewards etc) which increase engagement. Along with this comes the inherently motivating factors of feeling accountable to the other member of a user’s bubble and the sense of feeling connected and cared for.

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