Chat with Headstrong to strengthen adolescent mental wellbeing

If you search online for “health and fitness” apps, you are likely to be overwhelmed, with over 200,000 commercially available digital tools. The quality, safety and evidence behind these apps can vary enormously. It can be quite daunting to discern the good from the bad or the ugly. A recent review found that just over 6 per cent of apps are evidence based. Some have compared it to the “Wild West”, and there have been calls for regulations, or at least guidelines for consumers and clinicians on how to choose trusted tools.

In a previous article (see “Mental health”, New Zealand Doctor, 12 October 2022), we outlined the various apps designed in, and for, Aotearoa New Zealand. We argued for the importance of culturally responsive apps and for clinicians to support young people who want to use digital tools.

Here, we provide more information about Headstrong (headstrong.org.nz), one of the newest digital tools designed specifically to support the mental wellbeing of rangatahi (young people). Since 2022, Headstrong has been supported by Te Whatu Ora, and it is listed on the Access and Choice website (wellbeingsupport.health.nz) alongside other inperson and digital initiatives.

Headstrong is a free app available to all in Aotearoa. It emerged out of A Better Start: E Tipu e Rea National Science Challenge as one of the home-grown innovations to support youth mental health and resilience. We carried out consultation and co-design with rangatahi, who told us they would like to access trusted information in a way that is familiar to them – like a simple instant chat with a friend or a trusted support. This led us to create a flexible chatbot-like system to deliver content in a way that resembles instant chat (eg, WhatsApp or similar message platforms) and “feels” conversational.

If the word chatbot concerns you, you’re not alone. We have recently seen the emergence of powerful artificial intelligence chatbot systems, such as ChatGPT. These are designed to simulate human conversation and use natural language processing to analyse and interpret the messages and generate appropriate responses. They also use machine learning to become more responsive to user input over time.

However, chatbots can also operate more simply, by following rule-based systems, and Headstrong fits into this category. This means it follows a set of predefined rules and scripts to provide an appropriate response. When a user sends a message to the chatbot, the system analyses the message to see if it matches any of the rules. If it finds a match, the chatbot replies to the user with a predefined response. The resulting “chat” is simple and has some limitations, but nevertheless, mimics a conversational exchange. Headstrong also uses quick replies (ie, options of words or emojis as ready-made user input) as a key tool to guide the user through the conversation.

Currently, Headstrong offers three courses for young people to choose from (and more are coming soon):

Foundations is a course designed to introduce key mental health and coping skills to support healthy thinking and positive behaviours to enhance mood. Content is based on principles of cognitive behavioural therapy (CBT), interpersonal therapy, mindfulness, positive psychology and harm-minimisation strategies. Users are invited to try various skills, such as spotting negative thoughts, structured problem solving, relaxation (through recorded tracks and written instructions), conflict resolution and more.

Stress Detox helps young people cope with stress and anxiety in their day-to-day lives. There are 21 skills or strategies to learn, grouped into feelings, thoughts and actions in line with the CBT model. Young people can find out more about “good” and “bad” stress and the different types of anxiety, and learn various mindfulness and meditation skills, as well as how to combat anxious thoughts and avoidance behaviours. The course has been evaluated in a sample of young adults and shown to improve stress and wellbeing. Users also liked the conversational interface and the ease of use.

Kia Haumanu is a new and exciting upgrade of the Aroha programme (which was created in response to the stress associated with COVID-19 and public health restrictions in 2020). As of April 2023, the course has been revitalised to support rangatahi whaiora. Mātauranga Māori (Māori knowledge) and te reo Māori are at the centre of the app, while CBT and positive psychology are more in the supporting role. The idea is that this is a tool to reconnect with whānau, with tikanga and with te reo Māori through traditional approaches (eg, engaging in traditional waiata and pūrakau). It can also serve as a tuakana–teina support tool so that whānau can learn how to support their rangatahi who may be distressed.

Adolescents can access support and advice discreetly and at any time, even outside of traditional office hours

Young people value choice and autonomy. Thus, Headstrong is designed to give users a variety of options in how they engage with the app. For example, users can pick the guide they interact (or chat) with from a range of diverse avatars. Rangatahi can choose one course, or do all at once. They are encouraged to return regularly (daily notifications at a time chosen by the user can be set up to create a regular check-in), or they can explore as much of the app as they wish in their first session. Users are rewarded with badges for learning new skills, and they can also “favourite” their preferred content and access it from the app menu.

Headstrong is designed with ease in mind. The daily chats are short (about five minutes or less per skill) and the language is youth friendly. Emojis are used frequently, and there is humour, inspirational quotes, illustrations and even mini-games to engage the user.

The many benefits of digital tools have been well proven. Accessibility is a key advantage – apps can be downloaded onto smartphones or other devices, making them convenient and easy to use. Adolescents can access support and advice discreetly and at any time, even outside of traditional office hours. For those who may feel uncomfortable or stigmatised seeking help in person, mental health apps can provide a safe and confidential space for support.

There are several quality digital health tools already “on the market” in Aotearoa, and they serve different needs and purposes. Unlike some of the other digital interventions, Headstrong is not intended as a treatment for existing distress or disorder, but rather as a universal programme of proven skills and strategies to strengthen mental wellbeing and resilience. It has been designed specifically for young people, in contrast to the majority of commercial apps that are intended to appeal to adult users.

The basis of Headstrong and other similar apps is that they become a catalyst for learning positive behaviours that enhance mood and resilience. Young people can build self-awareness and develop healthy coping skills through education and self-care practices. Headstrong offers a familiar chat-like interaction to deliver its content, but it doesn’t allow conversation to sway outside of pre-scripted logic. Ultimately, it remains focused on delivering prescribed messages to strengthen the young person’s mental wellbeing.

One of the criticisms of digital mental health tools is that too few people “finish” them for them to be effective. There is a temptation to download an app, take a look and never go back to it. This is like having a gym membership and never stepping foot inside the fitness studio, but there are ways to help your motivation, such as joining group classes, having a buddy or even getting a personal trainer. We believe clinicians (counsellors, nurses, health improvement practitioners, GPs) can be a source of motivation to encourage young people and their whānau to get the most out of digital tools. We would like to challenge you to the following:

• Get to know the digital tools yourself. You’re not too old for Headstrong or other teen-specific mental health apps!
• Talk with your young patients about digital tools, and find out which one(s) they (or their friends) use already.
• Family and whānau might also need to get on board. Excessive screen time is a valid concern, so it’s important to explain to whānau how mental health apps differ from games or social media and what they can offer instead.
• Consider how you might leverage off the digital tool in your clinical practice. For example, suggest patients listen to relaxation tracks or use digital mood monitoring to measure progress.
• Digital tools work best when there is a human touch. It is important to encourage, support, troubleshoot and be there for the young person.
• At the heart of digital technology is choice – there is no one tool for everyone. Keep trying different tools until you find the one that fits!
• Share digital tools that work well for your patients with other clinicians.

Karolina Stasiak, Naomi Davies, Sarah Hopkins and Tania Cargo are involved in the national implementation of Headstrong through their professional roles at the University of Auckland