Teen Helpline Motivational Interviewing Study (MI)

This study will examine the feasibility and acceptability of using an implementation strategy, performance feedback and facilitated practice, to train teen helpers in Motivational Interviewing (MI) within a helpline setting. MI will be delivered with the goal of increasing help-seeking in real life among helpline users. The study will take place within Teen Talk App, a text-based teen-to-teen helpline. The study will use human centered design principles to engage stakeholders in developing and refining the MI training and implementation strategy (performance feedback and facilitated practice).

First, teen peer helpers and their supervisors/leaders will be engaged to adapt and co-design an MI training that will be responsive to the helpline context. This will include adapting MI to brief, text-based exchanges. As part of the Discover stage in human-centered design, focus groups will be conducted with Teen Talk App teen helpers (3 focus groups, n=4 each) and supervisors/ leaders (2 focus groups, n=5 each), along with individual interviews with users (n=12), to explore how to adapt MI for use within an online, text-based teen peer delivered helpline context. Focus groups and interviews will explore stakeholders' perceptions of the role of Teen Talk App in supporting IRL help-seeking and solicit feedback on how MI strategies can be adapted for use within Teen Talk App. Results from the preliminary work conducted by the current research team will be presented to describe current MI skill use among Teen Talk App helpers. Teen helpers will be asked to provide feedback on how MI strategies can be adapted for the diverse brief, text-based exchanges they encounter on the application. Supervisors/ leaders will be asked to provide feedback on how MI may fit within their existing protocols and trainings. Based on the feedback provided in the Discover stage, a rapid prototype MI workshop will be designed for training Teen Talk App peer helpers. An iterative process of presenting and refining the workshop will occur based on stakeholder input across three workshops (n=4 each). First, the workshop will be presented to teen helper stakeholders. Workshops will be co-facilitated by the PI, a Clinical Psychology PhD student, and a Teen Talk App supervisor/ leader. Each workshop will be followed by individual cognitive interviews with the stakeholder teen helpers. Participants from the interviews will be invited to a follow up focus group where results from the interviews will be presented to them for further feedback. Supervisors/ leaders will be interviewed to process the workshop and their impressions of helpers' reactions. Findings from these focus groups will be integrated to refine the workshop prototype. While three iterations are proposed, focus groups participants will determine whether further iterations are needed.

The study will then engage teen peer helpers and their supervisors/ leaders to co-design a performance feedback interface, using MI adherence metrics provided by an Artificial Intelligence derived tool (Lyssn) and the structure of facilitated practice sessions. As part of the Discover stage, teen peer helpers (3 focus groups, n=4 each) and supervisors/ leaders (2 focus groups, n=5 each) will be invited to two rounds of focus groups to discuss their perspectives about the acceptability of AI-derived PF or FP. At the beginning of each focus group, they will receive a general overview of PF or FP. Teen helpers will be asked to provide feedback on how to promote motivation and receptivity of the training feedback. Supervisors/leaders will be asked similar questions, along with suggestions for how to integrate the implementation strategy into existing workflows. Users will not be engaged in this study aim given the focus on developing a provider-facing implementation strategy. Based on the feedback provided in the Discover stage, two rapid prototypes (performance feedback and facilitated practice; PF and FP) will be designed for training Teen Talk App peer helpers. Separate iterative processes of presenting and refining the prototypes will occur based on helper (n=12) and supervisor/ leader (n=10) input across at least three cycles for each PF and FP. At the end of an iteration cycle, focus groups participants will determine whether further iterations are needed. The PF prototype will be developed by the research team to integrate MI adherence metrics provided by Lyssn, with the goal of displaying metrics in an age-appropriate manner that promotes motivation, openness, and encourages teen helpers to continue towards adherent delivery of MI. An iteration cycle will begin by individually presenting stakeholders with a prototype report as part of a cognitive interview. They will be provided a general overview of PF and MI. The prototype will provide example metrics on individual adherence to MI strategies, suggesting areas for improvement. Participants will be instructed to pretend the feedback was based on their individual use of MI.They will then be asked provide their perspectives about the tool's effectiveness, acceptability, and appeal, and suggestions for improvement (e.g., in content wording and display). Participants from the interviews will be invited to a focus group where results from the interviews will be presented to them for further feedback.

Findings from these focus groups will be integrated to refine the PF prototype as part of the next iteration cycle.

To refine the FP strategy, new and former participants will be invited to one of three facilitation groups with the goal of practicing MI skills (initial prototype). FP groups will be led by the PI, a trained Clinical Psychology PhD student, and a Teen Talk App supervisor/ leader. Each group will have two breakout rooms that will each provide targeted practice of specific MI strategies. Participants will be asked to use the mockup PF tool to determine the breakout room in which they should participate. To enhance rapid feasibility of this iterative prototyping stage, only two MI strategies will be selected for prototyping at this stage. Practice will involve the use of role plays, behavioral shaping, and positive reinforcement strategies delivered by an MI trainer. Helper participants will be asked to provide feedback on this process through individual cognitive interviews and focus groups, following the same process described above for the iteration of PF strategies. Cofacilitator Teen Talk App supervisors/ leaders will be interviewed about their impressions of the FP groups and helpers' reactions.

Finally, the study will test the feasibility of integrating the adapted MI into a helpline with the support of the implementation strategy (PF-FP). All Teen Talk App helpers will have the opportunity to be trained in MI. Initial MI training will occur over two meetings, comprised of a workshop and online practice session. To maximize training reach, three cohorts will be trained across consecutive months. To align with routine workflows, MI training will be offered during regularly scheduled monthly Teen Talk App continuing education (CE) online meetings. Following completion of the MI workshop and online practice, teen helpers who enroll in the research study (N=50) will be randomized to receive either online training as usual (i.e., monthly CEs) or online enhanced training (i.e., monthly PF-FP) for 6 months. Participants in the enhanced training condition will receive monthly PF reports that include their Lyssn metrics on MI skill use based on their Teen Talk exchanges. FP sessions will offer targeted practice exercises to promote specific MI skills indicated as low on each helpers' PF report. Participants will be placed in a breakout room that corresponds to the targeted MI skill areas indicated by their PF reports. MI training and enhanced training will be delivered by the PI and a PhD student who has obtained MI certification. TAU will be delivered by Teen Talk App staff. Teen helpers will participate in study assessments at baseline prior to the MI workshop, immediately after the MI training, and after 4 and 7 months of ongoing training (TAU or enhanced with PF-FP). They will be compensated $25 per survey and $50 for completing a qualitative interview at the end of the trial. During the trial, supervisors/ leaders (n=5), and helpers (n=5) will be invited to participate in monthly periodic reflections to support ongoing PF-FP iteration. Participants will be compensated $50 for each reflection. To measure the effect of the implementation strategy on clinical outcomes, Teen Talk users will also be recruited into the study. Users who are acutely suicidal (designated a "high risk" flag based on Teen Talk App algorithm) will not be recruited to avoid interrupting Teen Talk App's emergency workflow. Users who are actively engaged with Teen Talk App helpers (i.e., a minimum of 6 back-and-forth text exchanges, established in our preliminary study) will be invited to participate in the current study. During the study enrollment period, all users who meet study criteria will receive a pop-up notification on the Teen Talk App application inviting them to participate in a brief, de-identified survey where no sensitive information will be collected. User participants (N=100) will be asked to complete very brief follow-up surveys 1 week, 4 weeks, 3 months, and 6 months after their baseline measures (see Table 5). A small subset of user participants (n=15) will complete a qualitative interview to examine acceptability of MI strategies in Teen Talk and the intended objective of promoting IRL help-seeking. Users will receive $10 per survey (i.e., 5-10 minutes) and $50 for the interview.