Psychological

What is it? Psychological interventions are a variety of talking therapies and mindfulness practices that help a student to explore difficult feelings, thoughts and behaviours, typically with a trained professional.

Evidence? There is robust research on the impact of certain types of psychological interventions on student mental health outcomes, including Cognitive Behavioural Therapy (CBT) and mindfulness. However, more research is needed on other types of psychological interventions, and from a UK context, that measures both mental health and student outcomes.

What is this intervention?

Interventions under this category are typically therapies that provide a safe and confidential space for a person to explore their feelings, thoughts and behaviours with a trained professional. A psychological intervention can include talking therapies and counselling, of which there are many kinds such as Cognitive Behavioural Therapy (CBT), Acceptance and Commitment Therapy (ACT) or psychotherapy. A psychological intervention may also take the form of mindfulness (a practice characterised by control of attention, awareness of the present moment and non-judgemental thoughts), attention training or stress management.

A psychological intervention can be tailored to the needs of the client or targeted group. It can be appropriate for people living with a wide range of experiences and mental health difficulties. This sort of intervention can be universal or targeted towards specific demographics.

Psychological interventions tend to be delivered on a one-to-one basis but may also be delivered in small groups. It is usually led by trained professionals who help the client to develop a better understanding of themselves and the world around them in order to help them to bring about the changes that they want to make. Many services offer time-limited interventions, though some individual therapies can be ongoing, at the client and therapist’s discretion.

Many services can be run online, either via online conference platforms or specialist apps and websites. Online therapeutic platforms may not involve direct contact with a trained professional though they are usually designed and moderated by trained professionals.

This intervention can be integrated within student support services or be outsourced to specialist organisations. Funding requirements and referral structures will depend on which departments or organisations are delivering the intervention as well as the level of training required.

How effective is it?

CBT, Mindfulness and ACT

There is a large body of evidence demonstrating the effectiveness of both CBT and mindfulness in supporting the mental health of students. Worsley, Pennington, and Corcoran (2020) conducted a systematic review of review-level evidence (systematic reviews and meta-analyses), finding a number of reviews which focused on the effectiveness of CBT to support student mental health. One such review (Huang et al., 2018) included randomised controlled trials (RCTs) only and therefore provides causal evidence for CBT. The authors found that CBT is effective at reducing symptoms of both anxiety and depression in students, with some evidence to suggest this can be sustained over time at six months and 18 months post-intervention.

Huang et al. examined the evidence on mindfulness as part of the same review of RCTs and found it to be effective in reducing depression, anxiety and stress in students, however, CBT led to greater reductions and there is less evidence that the effects of mindfulness are sustained over time. Regular, supervised practice appears key to its success. In a separate review, Halladay et al. (2019) found interventions which combined elements of both CBT and mindfulness to be especially effective, such as Mindfulness-based Cognitive Therapy.

There is less evidence on the effectiveness of other psychological interventions in supporting student mental health. Worsley, Pennington and Corcoran (2020) identify a single review of evidence on ACT. ACT derives from CBT, and, as the name suggests, focuses on the accepting (rather than avoiding) of negative emotions and committing to changes in behaviour. In their systematic review, Howell and Passmore (2018) include five RCTs, with four of these demonstrating a small positive effect of ACT on wellbeing, depression and anxiety in students. However, one study showed no difference in outcomes between the treatment and control groups, and all studies had a small sample size which limits the validity of findings.

Online CBT and mindfulness interventions

Worsley, Pennington and Corcoran (2020) also evaluate the evidence for online psychological interventions as part of their review, concluding that online versions of CBT and mindfulness are not as effective as face-to-face delivery but can successfully reduce depression, anxiety and stress in students. A study conducted at the University of Bristol (Morris et al., 2016) evaluated the effectiveness of an unguided internet-based CBT (i-CBT) intervention in treating anxiety and insomnia in students feeling stressed during the exam period. Students that signed up were randomised to receive either an ‘anxiety relief’ or ‘insomnia relief’ i-CBT programme for six weeks, or to a control group who were able to access the programme six weeks later (a ‘waitlist control’ design). Anxiety, sleep quality and depression were measured before and after the intervention using validated scales. The ‘anxiety relief’ and ‘insomnia relief’ groups reported significantly less anxiety and significantly higher sleep quality respectively post-intervention. Though a small sample size, this study demonstrates a universal treatment for students during a stressful period.

Cook, Mostazir and Watkins (2019) compared the effects of a guided and unguided rumination focused i-CBT intervention with a waitlist control group. Participants were UK university students experiencing elevated worry and rumination. The i-CBT was split into six one-hour modules with key strategies including coaching participants to spot warning signs for rumination and worry, and developing and practising techniques in response. The guided version had written support from a qualified therapist at the end of each module with participants only able to access the next module when feedback was received. The unguided version had the same content that participant’s could access at any time, with automatic conditional feedback addressing common challenges. Though only tested on a small sample, both the guided and unguided versions of the i-CBT reduced the risk of experiencing a major depressive episode relative to the control group, as measured via a semi-structured diagnostic interview completed 15 months after the intervention had been completed. There was also a reduction in rumination, worry, and symptoms of depression at three- and six-months relative to the control group, though this was not sustained at the 15-month follow-up.

Other recent causal studies, conducted in Iran, have demonstrated the effectiveness of online-delivered CBT at reducing anxiety and increasing resilience in students during the COVID-19 pandemic (Shabahang, Aruguete and McCutcheon, 2021; Toosang, Pasha and Safarzadeh, 2021).

Simonsson et al. (2021) also looked at the effectiveness of an online intervention at supporting students during the COVID-19 pandemic, evaluating an eight-week online mindfulness course. Students attending the University of Oxford were invited to participate and randomised to start the mindfulness course immediately or three months later . Anxiety and depression scores were measured before and after the course took place, with results showing a significantly greater reduction in anxiety, but not depression, over time in those in the intervention group.

Other evidence on online psychological interventions comes from those administered through mobile apps. Two RCTs provide causal evidence on different CBT-based mobile apps used across UK universities. The apps incorporate modules covering areas such as thought challenging, mood tracking and relaxation techniques. One study evaluated the ‘Feel stress free’ app, showing a reduction in depression and anxiety symptoms after six weeks of use (McCloud et al., 2020). Another RCT evaluated the ‘Biobase’ app which includes a wearable device to track physical symptoms and sleep quality alongside the CBT modules. The intervention group had significantly reduced anxiety and increased wellbeing compared to the waitlist control, and this was sustained at a two-week follow-up (Ponzo et al., 2020).

Attention Training and Stress Management

There is a small amount of evidence on the effectiveness of attention training to support student mental health difficulties. Attention Training Technique (ATT) was developed based on the theory that those suffering from anxiety and depression have biases in their processing which means they prioritise threats and negative situations, causing higher levels of stress and anxiety. ATT aims to increase attention flexibility and involves focusing one’s attention on different sounds in the environment and rapidly shifting between those sounds (for instance, bird song, clock ticking). Callinan, Johnson and Wells (2015) recruited students on Social Sciences courses to participate in a RCT if they had had a stressful life event recently (such as a car accident or death of a family member) and were experiencing intrusive thoughts on the event. Participants were randomised to either the intervention group, who received two sessions of ATT, or the control group, who took part in an attention filler task. Both groups were exposed to a pre-recorded narrative of their stressful life event before and after the intervention and asked to complete surveys on intrusive thoughts and positive and negative affect at both timepoints. Analysis showed that the intervention group had a significant reduction in intrusive thoughts and negative affect compared to the control group.The previous evidence on ATT is from a clinical population, and therefore this study supports the effectiveness of the intervention, at least in the short term, in a non-clinical student population that have experienced trauma or stressful life events. The effects have been replicated in a more recent RCT conducted on university students in Norway with self-reported symptoms of depression, anxiety, or stress, with the effects maintained at six-month follow up (Haukaas et al., 2018).

Cognitive Bias Training is a similar intervention to ATT, which aims to combat biases in emotional processing, such as having a higher sensitivity to negative affect (negative emotions such as anger and sadness). One study from the UK sought to train students to overcome such biases. Penton-Voak et al. (2012) recruited students with moderate depressive symptoms via advertisements around a university campus. In a RCT, 80 students, majority female, were randomised to either the intervention or control condition. Training was delivered over four days to both groups, which involved participants being shown happy, sad or ambiguous faces. At the baseline phase, participants judged whether each face was either sad or happy to establish the balance point at which their perception shifted from happiness to sadness. During the training phase, participants were again shown the faces and given feedback as to whether they were ‘correct’ or ‘incorrect’ in their judgement; those in the intervention condition were trained to judge expressions near the balance point (ambiguous faces) as happy, whereas the control group were given feedback to encourage the same judgement as their original balance point. At the test phase, the balance point was calculated again. The results showed that the training had worked on the intervention group – during the test phase they were more likely to judge ambiguous faces as happy rather than sad. At two-week follow-up the intervention group had significantly higher positive affect scores (demonstrating positive emotions such as joy), however, though their depression and negative affect scores were lower, they were not significantly different from the control group.

Some studies have sought to design and evaluate stress management interventions; these are more tailored to the predictors of poor mental health in students, typically focusing on time management and problem-based learning, cognitive reappraisal of potential stressors, and stress management strategies to promote more effective coping. Delaney et al. (2016) designed a stress management intervention (NURSE – Nurture nurse, Use resources, foster Resilience, Stress and Environment management) specifically for nursing students attending a university in the USA. The intervention focused on developing self-awareness with regard to stressors, and teaching communication and behaviours to aid nursing students in a simulated stressful environment. The authors conducted a pilot RCT with a small sample to understand the feasibility and efficacy of the intervention. Qualitative interviews were also conducted with trial participants and although students gave positive feedback on the intervention, there was no significant difference between those that received the intervention and the control group in perceived stress, resilience and their grade point average (GPA).

Dyrbye et al. (2017) evaluated a stress management and resilience training intervention for two cohorts of first year medical students attending a university in the USA. The intervention took the form of a course running throughout the year and incorporated elements of mindfulness to aid in stress reduction, as well as modules around attention, gratitude and acceptance. Participants completed questionnaires at the start and end of their first year to measure stress, burnout, quality of life and happiness. Analysis showed that self-reported quality of life and happiness declined over the time period, and stress increased. This implies a negative effect of the intervention, however no comparator group was included in the study so it is unclear whether the intervention was the cause of the poorer outcomes.

The vast majority of the evidence looks at the impact of interventions on students on a particular course, or else students in general. Petersen (2013) however, evaluated the impact of a stress management intervention on ‘first-generation’ students – those that come from families where neither of their parents attended HE. In a pilot RCT with a small sample size, first year students randomised to the intervention group participated in a seven week mind/body stress management intervention which involved practising with a support group. Outcomes measures were captured before and after, and the intervention group reported significantly lower distress and impaired functioning, and significantly greater social support compared to the control group. This may indicate the importance of the support group element in the intervention effectiveness for first generation students. Attainment, as measured by GPA, did not differ between the two groups post-intervention. Kim et al (2018) focused on male students in particular, evaluating a brief stress management intervention that incorporated elements of CBT at a university in South Korea. The authors found that the intervention had sustained effects (at three-month follow-up) for self-reported depression and anxiety when compared to the control group, though the sample size was, again, small.

Rackoff et al. (2022) evaluated the effectiveness of an online stress management intervention to support university students in the USA experiencing moderate to high stress during the COVID-19 pandemic. The intervention included self-guided modules on building resilience and moving forward, alongside modules more specific to the pandemic, such as ‘dealing with challenging times’ and ‘grief and loss’. Over 500 students participated in the study and were either randomised to the intervention group or a control group that were emailed information on other available support services. Participants receiving the online self-help treatment had significantly larger reductions in stress and depression from pre-treatment to post-treatment and this was sustained at three-month follow-up. However, there was no difference in anxiety levels between the two groups. Whilst the intervention was designed to treat pandemic-specific student mental health difficulties, the study provides evidence for an online, accessible treatment to reduce symptoms of stress and depression.

How secure is the evidence?

The current evidence base for CBT and mindfulness in supporting student mental health is strong. There are a large number of RCTs that have been conducted with student populations which provide causal evidence on these interventions, through comparison of a treatment group that receives the intervention and a control group that does not (or does so only after a set time period – a waitlist control). However, the evidence for other psychological interventions such as ACT, ATT, and stress management is less secure with only a small number of causal studies.

In addition, there are only a small number of causal studies from the UK with the majority, including those referenced in Worsley Pennington, and Corcoran’s review of reviews, being from the USA. More research is needed in a UK context to draw reliable conclusions that are accurate for UK HE providers.

Furthermore, much of the evidence captures mental health outcomes immediately or soon after the intervention has been received, and therefore further research is needed to ascertain whether effects can be sustained in the long-term. In addition, there are only a few studies which focus on student outcomes, such as attainment and continuation. It is important to understand whether interventions improve student mental health but also that they contribute to success on-course.

The majority of the research studies on psychological interventions recruit students through poster and email campaigns, which results in an overrepresentation of females compared to males in the evidence because female students are more likely to seek help and to use mental health services than males (Eisenberg, Golberstein, and Gollust, 2007). This makes the evidence for psychological interventions less secure for male students. Some of the evidence focuses on students on a specific course such as Medicine or Nursing; these students are functioning in a different environment in which they are exposed to work-based stressors quite unlike other HE courses. In other studies, students are encouraged to participate through offering credits needed as part of Social Science courses. This evidence should therefore be treated with caution as it may not be generalisable to students on different courses.

How do I evaluate this intervention?

As the evidence base is strong for CBT and mindfulness, there is less need to evaluate these interventions for the student population in general. However, as noted in previous sections, the quality of the evidence can vary based on how studies have recruited students as well as the courses being studied therefore it is still important to evaluate specific programmes in a particular context. The current evidence also does not consider the impact of these interventions on different subgroups of students, for instance, any variation by age, gender, sexuality and ethnicity. It is likely that interventions may work better for some people than others; as referenced in the section above, therapies may not be meeting the needs of students from different ethnic backgrounds in particular. There are examples of CBT being adapted for specific groups, for instance Hall et al. (2019) who designed a CBT-based intervention to reduce depression among LGBTQ+ young people, though these have not been evaluated robustly. Any adaptations or new interventions should be grounded in a strong Theory of Change to break down the causal mechanisms as to why an activity will lead to a desired outcome.

RCTs are one of the most robust ways to measure interventions as they allow comparison of two groups that have either received or haven’t received the intervention, whilst controlling for observable and unobservable differences between the two groups. These trials should take place outside of lab settings to test whether, and how, interventions translate and perform in the ‘real world’.

There are many examples in the literature on using a wait-list control design, for instance, McCloud et al. (2020) and Ponzo at al. (2020) that evaluated the effectiveness of mobile apps on student mental health. The key benefit of this design is that the control group is still able to receive the intervention, just at a later date once outcomes have been measured in both groups. Outcomes should be measured in both treatment and control groups using validated scales before and after the intervention has been received. As we are lacking evidence on the longer-term effects of interventions, measuring outcomes at multiple time points (e.g. three-, six- and twelve-month follow-ups) is important, rather than only immediately after. We also have a paucity of evidence that measures the impact of psychological interventions on student outcomes such as attainment, retention and progression and providers should seek to embed these into evaluation plans.

See our evaluation guidance for more support.

Where can I find more information and guidance?

For guidance from the Mental Health Charter, please follow the links below:

Most psychological interventions fall under the following themes:

• Support services
• Risk
• External partnerships and pathways 
• Proactive interventions and a mentally healthy environment
• Research, innovation and dissemination

Where does the evidence come from?

The evidence in the Toolkit was gathered via an evidence review undertaken as part of the Student Mental Health Project. For full details of this review, please see our Methodology document.

It is important to note that our review, and therefore this Toolkit, only relates to student mental health. The review did not cover other populations (e.g. school children, other adult populations) or non-HE settings. The review was also subject to other inclusion/exclusion criteria, outlined in the Methodology document. However, we have flagged some additional links to the wider literature where appropriate and included them under ‘other references’ below.

Please also note that this Toolkit page only includes Type 3 (causal) studies which have been rated as providing medium/high-quality evidence according to our evidence strength ratings. These studies are outlined in the page above and referenced below. A full list of studies collated via our evidence review, including Type 1/Type 2 studies, and those rated as providing weak/emerging evidence, can be found in our Evidence Review Spreadsheet. A breakdown of these studies by type and strength of evidence is available to download.

Main references

Systematic reviews and meta-analyses

Conley, C.S., Durlak, J.A., Shapiro, J.B., Kirsch, A.C., & Zahniser, E. (2016) A meta-analysis of the impact of universal and indicated preventive technology-delivered interventions for higher education students. Prevention Science, 17, 659-678. doi: 10.1007/s11121-016-0662-3

Farrer, L., Gulliver, A., Chan, J., Batterham, P.J., Reynolds, J., Calear, A., Tait, R., Bennett, K., & Griffiths, K.M. (2013) Technology-based interventions for mental health in tertiary students: A systematic review. Journal of Medical Internet Research, 15(5), 1-14. doi:10.2196/jmir.2639

Halladay, J.E., Dawdy, J.L., McNamara, I.F., Chen, A.J., Vitoroulis, I., McInnes, N., & Munn, C. (2019) Mindfulness for the mental health and well-being of post-secondary students: A systematic review and meta-analysis. Mindfulness, 10, 397-414. doi:10.1007/s12671-018-0979-z

Howell, A.J., & Passmore, H. (2018) Acceptance and Commitment Training (ACT) as a positive psychological intervention: A systematic review and initial meta-analysis regarding ACT’s role in well-being promotion among students. Journal of Happiness, 20(6), 1995-2010. doi:10.1007/s10902-018-0027-7

Huang, J., Nigatu, Y.T., Smail-Crevier, R., Zhang, X., & Wang, J. (2018) Interventions for common mental health problems among university and college students: A systematic review and meta-analysis of randomized controlled trials. Journal of Psychiatric Research, 107, 1-10. doi:10.1016/j.jpsychires.2018.09.018

Worsley, J., Pennington, A., & Corcoran, R. (2020) What interventions improve college and university students’ mental health and wellbeing? A review of review-level evidence. https://whatworkswellbeing.org/wp-content/uploads/2020/03/Student-mental-health-full-review.pdf

Causal studies

Callinan, S., Johnson, D., & Wells, A. (2015) A randomised controlled study of the effects of the attention training technique on traumatic stress symptoms, emotional attention set shifting and flexibility. Cognitive Therapy and Research, 39(1), 4–13. doi:10.1007/s10608-014-9634-8

Cook, L., Mostazir, M. and Watkins, E. (2019) Reducing stress and preventing depression (RESPOND): Randomized controlled trial of web-based rumination-focused cognitive behavioral therapy for high-ruminating university students. Journal of medical Internet research, 21(5), p.e11349. doi:10.2196/11349

Delaney, C., Barrere, C., Robertson, S., Zahourek, R., Diaz, D. and Lachapelle, L. (2016) Pilot testing of the NURSE stress management intervention. Journal of Holistic Nursing, 34(4), pp.369-389. doi:10.1177/0898010115622295

Kim, S., Kim, H., Lee, H., Lee, H., & Noh, D. (2018) Effectiveness of a brief stress management intervention in male college students. Perspectives in Psychiatric Care, 54(1), 88-94. doi:10.1007/s10964-018-0909-3 

Haukaas, R.B., Gjerde, I.B., Varting, G., Hallan, H.E. and Solem, S. (2018) A randomized controlled trial comparing the attention training technique and mindful self-compassion for students with symptoms of depression and anxiety. Frontiers in psychology, 9, p.827. doi:10.3389/fpsyg.2018.00827

McCloud, T., Jones, R., Lewis, G., Bell, V. and Tsakanikos, E. (2020) Effectiveness of a mobile app intervention for anxiety and depression symptoms in university students: randomized controlled trial. JMIR mHealth and uHealth, 8(7), p.e15418. doi:10.2196/15418

Morris, J., Firkins, A., Millings, A., Mohr, C., Redford, P. and Rowe, A. (2016) Internet-delivered cognitive behavior therapy for anxiety and insomnia in a higher education context. Anxiety, Stress, & Coping, 29(4), 415-431. doi:10.1080/10615806.2015.1058924

Penton-Voak, I.S., Bate, H., Lewis, G. and Munafo, M.R. (2012) Effects of emotion perception training on mood in undergraduate students: randomised controlled trial. The British Journal of Psychiatry, 201(1), 71-72. doi: 10.1192/bjp.bp.111.107086

Petersen, T.J., (2013) Evaluation of a Stress Management Program for Newly Matriculated First-Generation College Students: A Randomized Controlled Trial. Ohio University. http://rave.ohiolink.edu/etdc/view?acc_num=ohiou1375377440

Ponzo, S., Morelli, D., Kawadler, J.M., Hemmings, N.R., Bird, G. and Plans, D. (2020) Efficacy of the digital therapeutic mobile app biobase to reduce stress and improve mental wellbeing among university students: randomized controlled trial. JMIR mHealth and uHealth, 8(4), p.e17767. doi:10.2196/17767

Rackoff, G.N., Fitzsimmons-Craft, E.E., Taylor, C.B., Eisenberg, D., Wilfley, D.E. and Newman, M.G. (2022) A randomized controlled trial of internet-based self-help for stress during the COVID-19 pandemic. Journal of Adolescent Health, 71(2), pp.157-163. doi:10.1016/j.jadohealth.2022.01.227

Shabahang, R., Aruguete, M. S., & McCutcheon, L. (2021) Video-based cognitive-behavioral intervention for COVID-19 anxiety: a randomized controlled trial. Trends in psychiatry and psychotherapy, 43, 141-150. doi:10.47626/2237-6089-2020-0056

Simonsson, O., Bazin, O., Fisher, S. D., & Goldberg, S. B. (2021) Effects of an eight-week, online mindfulness program on anxiety and depression in university students during COVID-19: A randomized controlled trial. Psychiatry research, 305, 114222. doi:10.1016/j.psychres.2021.114222

Toosang, M. A., Pasha, R., & Safarzadeh, S. (2021) The effect of cognitive-behavioral therapy training on resilience and psychological hardiness in students during COVID-19 pandemic situation. International Journal of School Health, 8(4), 247-256. doi:10.30476/intjsh.2021.93392.1191

Xu, Y.-Y., Wu, T., Yu, Y.-J. and Li, M. (2019) A randomized controlled trial of well-being therapy to promote adaptation and alleviate emotional distress among medical freshmen. BMC Medical Education, 19(1). doi:10.1186/s12909-019-1616-9

Other References

Akel, S. (2019) Insider-outsider: The role of race in shaping the experiences of black and minority ethnic students. Goldsmiths, University of London.

Dyrbye, L.N., Shanafelt, T.D., Werner, L., Sood, A., Satele, D. and Wolanskyj, A.P. (2017) The impact of a required longitudinal stress management and resilience training course for first-year medical students. Journal of general internal medicine, 32(12), 1309-1314. doi:10.1007/s11606-017-4171-2

Eisenberg, D., Golberstein, E. and Gollust, S.E. (2007) Help-seeking and access to mental health care in a university student population. Medical care, pp.594-601. Available at: https://www.jstor.org/stable/40221479

Hall, W.J., Rosado, B.R., and Chapman, M.V. (2019) Findings from a feasibility study of an adapted cognitive-behavioural therapy group intervention to reduce depression among LGBTQ young people. Journal of Clinical Medicine, 8(7), 949. doi:10.3390/jcm8070949

Kroenke, K., Spitzer, R.L. and Williams, J.B. (2001) The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), pp.606-613. doi:10.1046/j.1525-1497.2001.016009606.x

Wampold, B E. & Brown, G. S. (2005) “Estimating Variability in Outcomes Attributable to Therapists: A Naturalistic Study of Outcomes in Managed Care.” Journal of Consulting and Clinical Psychology, 73 (5), 914–23. doi:10.1037/0022-006X.73.5.914