Technology Matters: Using apps to address loneliness in adolescents and young adults – leveraging tech engagement among digital natives

With COVID-19, loneliness has been catapulted into a phenomenon of international stature (Smith & Lim, 2020). Young people are disproportionately affected; loneliness has increased among younger adults, and worldwide, young people are more lonely than all other age groups through the lockdowns (Groarke et al., 2020). The science of having meaningful social connection tells us that loneliness in young people can be addressed both by targeting environmental factors, such as the opportunity to connect socially (e.g., participating in shared interest groups), and addressing the cognitions associated with social connections (Eccles & Qualter, 2020). For digital native youth and young adults, smartphone applications (apps) provide a unique opportunity to deliver skills that can buffer against both environmental and cognitive risk factors. Using apps to address loneliness presents a dilemma because it relies on the use of technology which many people blame for causing the problem it is aiming to address. The effectiveness of apps to reduce loneliness ultimately relies upon the user putting down the app to connect with others in a different way. It requires app developers to make technology that is engaging enough to interest those who may be most vulnerable to loneliness, on a potentially addictive medium already embedded in their lives, while simultaneously nudging them out into the real world. This is no small feat. A number of promising international efforts have used apps to combat loneliness among young people, and their unique features try to address the challenges above.


Introduction
With COVID-19, loneliness has been catapulted into a phenomenon of international stature (Smith & Lim, 2020). Young people are disproportionately affected; loneliness has increased among younger adults, and worldwide, young people are more lonely than all other age groups through the lockdowns (Groarke et al., 2020).
The science of having meaningful social connection tells us that loneliness in young people can be addressed both by targeting environmental factors, such as the opportunity to connect socially (e.g., participating in shared interest groups), and addressing the cognitions associated with social connections (Eccles & Qualter, 2020). For digital native youth and young adults, smartphone applications (apps) provide a unique opportunity to deliver skills that can buffer against both environmental and cognitive risk factors.
Using apps to address loneliness presents a dilemma because it relies on the use of technology which many people blame for causing the problem it is aiming to address. The effectiveness of apps to reduce loneliness ultimately relies upon the user putting down the app to connect with others in a different way. It requires app developers to make technology that is engaging enough to interest those who may be most vulnerable to loneliness, on a potentially addictive medium already embedded in their lives, while simultaneously nudging them out into the real world. This is no small feat. A number of promising international efforts have used apps to combat loneliness among young people, and their unique features try to address the challenges above.

Case study: Nod
Nod is a mobile app co-developed by Grit Digital Health and Hopelab, designed to prevent loneliness in early young-adulthood during the transition to college. Based in positive psychology, mindfulness-based self-compassion, and cognitive-behavioral coping skills, Nod has three key features: (1) social challenges-suggested ideas for reaching out to others and taking action to build social connections; (2) reflections-short in-app exercises that help students process social experiences and reduce self-criticism; and (3) written student testimonials that encourage a growth mindset toward social connection building. Nod has been adapted for use by college students who are on campus, virtual, or both by offering options for challenges that include both virtual and safe in-person connections.
In 2019, a randomized trial evaluated the effectiveness of Nod with 221 students entering their first year of college (Bruehlman-Senecal et al., 2020). At the start of the year, students were randomly assigned either to use Nod as they desired for 4 weeks, or to a waitlist control condition. At 4 weeks, loneliness and related mental health, social, and physical correlates were examined. Among students in the control group, those who had started the year with existing symptoms of depression showed heightened levels of loneliness, depression, and poor sleep quality, yet there was no such relationship between baseline depression and later loneliness in the group that received Nod. Nod also showed a similar buffering effect against decreased perceived social support and campus belonging-and users reported a stronger intention to return to campus in the upcoming school yearcompared to their peers who did not receive Nod.
Participants provided open-ended feedback about the utility of Nod: Nod allows me to think of ways to interact with people that I probably wouldn't have thought of on my own. It opens more opportunities for me I think it is beneficial to have the app as a freshman because you can use it to change how you approach situations and it helps to give you a new perspective These results suggest that Nod use buffered students from increased loneliness and related problems adjusting to college. While not tested in the trial, Nod's RCT performance flags it as a promising tool to support students in a virtual college environment, when the risk of loneliness and inability to make social connections is presumably more acute.
Case study: +Connect +Connect is a 6-week smartphone intervention that uses a strength-based positive psychology framework targeting loneliness severity in young people. It is gamified and engaging, delivering daily videos and posts that convey evidence-based concepts known to strengthen relationships and increase social connections. Over a two-year development cycle (2015-2017), young people aged 18 to 25 participated in a series of focus groups to inform the design and delivery of +Connect and was initially trialed in young people with psychosis (Lim, Penn, Thomas, & Gleeson, 2020).
A pilot-mixed methods study assessed the feasibility, acceptability, and safety of +Connect among lonely young people, with and without social anxiety disorder (Lim et al., 2019) The app met threshold criteria for feasibility-measured by uptake and app completion-across both groups, but acceptability findings varied. Participants with social anxiety disorder demonstrated twice the attrition rate as those without, and while qualitative data showed that both groups reported no negative outcomes, those with social anxiety disorder reported less acceptable ratings on outcomes. Qualitative data suggested that the positive psychology framework underlying the app design was effective; participants noted that positive outcomes from use of +Connect were driven by the processes of reflection, learning, and real-life application.
The pilot demonstrated that +Connect is a safe and feasible tool that may benefit lonely young people, but that those with social anxiety disorder in particular may require more tailored support. The findings support further modification and testing of a second iterative version, renamed Peer Tree, with a pilot randomized controlled trial.

Learnings from our work
Loneliness is a uniquely challenging problem to address with technology. The cognitive-behavioral cycle of loneliness means that as young people become more lonely, they are more apt to attribute these feelings to flawed personal characteristics, which serves to justify a retreat into fewer social activities, creating a self-fulfilling cycle that perpetuates loneliness. Technology can provide an opportunity to develop behavioral and cognitive social connection skills, yet may also serve as another excuse to be buried in phones rather than out in the real world. The design for this must be purposeful and considered.
Both of the case studies described above chose to use a mobile app over social media to engage with young people around social connection. Advantages of apps include control over privacy and the design of meaningful skill-building. That said, a key challenge with apps versus social media lies in keeping users engaged longterm. A supplemental clinical interaction can support continued use and maximize long-term benefit. Social media tools, by default, favor a large number of brief social interactions, and may carry a risk of alienation or cyberbullying, which can contribute to more loneliness. Designing supportive interventions on social media platforms requires a careful consideration of the risks. There may be opportunities to build on the strengths of both modalities (apps and social platforms) with intentionality and thoughtful consideration of fit for the particular health and population challenge being designed for.
Finally, the COVID-19 pandemic provides an interesting opportunity to address loneliness in young people via mobile technology. The worldwide response to COVID-19 has allowed the experience of isolation and loneliness to shed some of its stigma. No longer is loneliness a flawed characteristic of oneself, but a natural byproduct of social distancing-of doing what we need to do to protect our communities. Technology can facilitate messages of support and unity; rather than feeling isolated and alone, young people can connect over the shared experience of loneliness. Preliminarily, Nod has responded to the pandemic by teaching strategies that can promote the development of meaningful social connection in the virtual world. Being digital, the products discussed here can be easily modified to meet changing needs in changing times.

Implications for practitioners
In the wake of COVID-19, mental health practitioners are likely to see an unprecedented need to support young people and to address loneliness specifically. The following are some recommendations for practitioners and providers in using apps for loneliness.
We suggest centering loneliness in formulations and interventions, for example, adding loneliness into the assessment process, case conceptualizations, and outcomes assessed as part of routine mental health practice. Second, we recommend adequately vetting apps that you recommend to clients. As myriad apps and other digital tools are likely to respond to the call to action of COVID-19, those that are evaluated for clinical efficacy and enduser engagement are most likely to provide a safe and effective supplement to your care. Resources such as the non-profit PsyberGuide (https://onemindpsyberguide. org/) and the app evaluation model from the American Psychiatric Association (Torous et al., 2018) provide critical analysis to inform the choice of a specific app and can be recommended to clients and families. Finally, the choice to use an app also carries a responsibility to discuss strategies to best engage, while also supporting clients in their practice of the necessary skills to support social connection offline. With teens especially, there is a need to discuss how technology can enhance and facilitate our lives, but requires boundaries on when and how often it should be used.
There has never been a moment of greater responsibility to find creative ways to leverage the promise of technology to support a connected but lonely generation.