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Reducing Distress,Building ResilienceA Review of Kooth Face-to-Face Services
02 REDUCING DIS TRESS , BUILDING RESILIENCE
I love the sessions with Jen I have changed in the sessions and outside of them it’s just really nice to have somebody to talk to I didn’t feel I could open up before but I do now I will miss the sessions.
Kooth F2F Service User
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 03
ContentsGlossary of Acronyms
Introduction
2018/19 Headlines
Service Users and Referrals
Service Use
Outcomes
Endings
Conclusion
References
04
06
08
12
16
20
24
26
29
04 REDUCING DIS TRESS , BUILDING RESILIENCE
BAME Black, Asian and Minority Ethnic
CAMHS Children and Adolescent Mental Health Services
CORE-YP Refers to Young Person’s Version of CORE Outcome Measure
CYP-IAPT Children and Young People – Improving Access to Psychological Therapies
GP General Practitioner
Kooth F2F Kooth Face-to-Face
YP Young Person
Glossary of Acronyms
0 5A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19
0 6 REDUCING DIS TRESS , BUILDING RESILIENCE
Kooth is best known for its online presence,
with over 100,000 young people registering with
the digital service annually. Kooth facilitates the
whole-school approach, engaging with a joined up
model of care in all commissioned areas, building
close relationships with local face-to-face services,
including the local CAMHS providers.
In seven areas the joined up approach goes
further with Kooth delivering a blended model
combining an online contract with a face-to-face
(Kooth F2F) counselling service.
In 2018/19, 2,275 users aged 10-21 years old
were referred to Kooth F2F which span from
Cornwall to Warrington. Though there are
nuances between the services, we have seen
consistent high rates of clinical or reliable
improvement for those who attend the service.
With a focus on access, these services offer
flexibility through offering sessions at preferred
locations at convenient times for users. The
service provision makes use of the CYP-IAPT1
recommended goal-based outcome measure, and
psychometric questionnaires (CORE-YP), to
measure the impact of our interventions. This
enables us to be person-centred and responsive
to any current difficulties.
This report offers insights from this service,
as operated in 2018/19, exploring the service
users journey from referral to intervention end.
A number of key papers have been referenced
throughout the report due to the comprehensive
data, insight and expertise they provide of similar
services. Of note are the 2017/18 report from the
Welsh Government offering transparency of data
for their nation-wide school based counselling
services, the work of Professor Mick Cooper
who as led on a range of research studies of
school-based counselling, as well as the evaluation
of reliable improvement rates in depression and
anxiety as experienced by young people, a paper
by Julian Edbrooke-Childs and others.
Comparison with similar services demonstrates
similarities in types of presenting issues,
demography of service users, and prevalence of
need, as will be presented in the following pages.
Charlotte Mindel
Research and
Evaluation Lead.
With thanks to contributions from Cristina
Gascón García and Crystal Oppong for their
support with the data collection and analysis.
Introduction
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 07
0 8 REDUCING DIS TRESS , BUILDING RESILIENCE
Top Presenting Issues
1 2
Anxiety/Stress Family Relationships
2018/19 Headlines
3
Confidence
4 5
Self-Worth Friendships
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 0 9
1 Building and Strengthening Support Network
2 Breathing exercises
3 Mindfulness and Specific Skills (e.g. Dialectic Behavioural Therapy)
referrals2,275
56%
53.5%
4%Top coping strategies developed
65.8%of service users
demonstrate clinical recovery or reliable
change
Average goal movement
8.6points
users 13-15 years old
referrals from schools (pastoral, teacher, head of year)
from BAME backgrounds
10 REDUCING DIS TRESS , BUILDING RESILIENCE
Cornwall1 x Senior Practitioner, 2 x Counsellors, 14 x Associate Counsellors
Halton3 x Counsellors, 2 x Associate Counsellors Knowsley1 x Counsellor, 2 x Associate Counsellors, 3 x Counsellors in Training
Nottingham City 1 x Senior Practitioner, 2 x Counsellors, 5 x Associate Counsellors, 2 x Counsellors in training
Powys 7 x Counsellors, 8 x Associate Counsellors, 1 x Art Psychotherapist in Training, 5 x Bank staff
Wakefield 5 x Counsellors, 2 x Associate Counsellors
Warrington1 x Senior Practitioner, 3 x Counsellor, 2 x Associate Counsellors, 2 x Counsellors in Training
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 1 1
All my friends have said how much more confident and happier I have been since starting F2F
Kooth F2F Service User
The counsellor was very kind and helpful to get me over my anxiety. I know that I can speak to her about anything
Kooth F2F Service User
12 REDUCING DIS TRESS , BUILDING RESILIENCE
As we see with other school-based counselling
services, such as those across Wales, the
majority of referral sources are pastoral leads
within schools.2 This demonstrates the value to
schools of such services, and the necessity of being
an integral part of a whole-school approach for
mental health.
In 2018/19 we delivered two CAMHS specific
services, supporting those on waiting lists;
CAMHS are a significant referral source into
Kooth F2F across all areas. Other referrals
include GP, parents, youth workers and social
workers among others.
Service Users and Referrals
63.28% 56.36% 59.57%74.19% 59.70% 72.17%62.30% 62.50% 62.80%
36.72% 43.64% 40.43%25.81% 40.30% 27.83%37.70% 37.50%
Cornwall
Cornwall
CornwallCAMHS
CornwallCAMHS
Halton
Halton
Knowsley
Knowsley
Nottingham
Nottingham
Powys
Powys
Wakefield
Wakefield
WarringtonCAMHS
WarringtonCAMHS
Grand Total
Grand Total
37.20%
Percentage of Female and Male Service Users Across each Kooth F2F Service
Males
Females
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 13
June, October, and January are the peak months for referral
August is the lowest month for referrals from schools but highest month from CAMHS
62.8%Females
43%Referrals fromPastoral staff
in schools
37.2%Males
1,065 cases closed in 2018/19 with users identified
as spanning the different thresholds of need as
measured by the CORE-YP. The majority of those
referred in the same period who did not complete
a Kooth F2F intervention either did not want
counselling, were signposted to more appropriate
services, or were not contactable. Older age groups
of 16-18 years typically present to the service with
a greater variety of ‘presenting issues’ than younger
peers; this could be due to having had more lived
experience, or as a result of being more willing to
open up to a counsellor.
These transitional years for young people are
commonly challenging, with mental health
symptomatology increasing within these age
groups.3 Top presenting issues across Kooth
F2F are reflective of similar services nationally,
with the same top issues occurring in a review of
Welsh school-based counselling in both 2011 and
2018/19.1,4,5 This demonstrates that even with a
7 year difference the types of issues young people
are facing are remarkably similar, and could suggest
that more could be done systematically to support
young people with these areas of their lives.
14 REDUCING DIS TRESS , BUILDING RESILIENCE
40
35
30
25
20
5
10
5
0
40
35
30
25
20
5
10
5
0
These scores represent a lower threshold of
clinical need than the Kooth online service,
where 25.57 was the average onset score in
2018/19. However it does reflect what was seen
during a Youth Access study on school-based
counselling where 20.7 was the average CORE-
YP score, which creeps just above the moderate
threshold into moderate severe.6
Presenting issues prevalent for young people
with severe clinical distress include anger,
bereavement, depression or low mood, and
family relationships.
“Powys is the largest county in Wales, often YP live in
rural isolation and may not see another young person
outside of school. If they are really lucky they may have
WiFi and a signal where they may be able to connect
digitally. Kooth F2F counselling is a truly unique
service, particularly within Wales because it provides
young people an intimately safe space to connect with
another person face to face. It’s the connection which
matters, the relationship and the physicality where
all senses can be experienced between counsellor and
the young person. That’s the nuance of person-centred
counselling and magic happens, there is a real sense
of privilege for both people in the room within that
moment of time and space.”
Liz Quester, Powys Kooth F2F Practitioner
Core-YP at 1st Session
Severe 23.48%
22.73%
17.32%
23.27%
19.34
11.69%1.51%
Moderate Severe
Mild Low Level
Moderate
Average CORE-YP Score at 1st Session
Low Level
Healthy
Cor
e-YP
Sco
re
40
35
30
25
20
10
5
0
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 15
Top presenting issues
1 Anxiety/Stress
2 Family Relationships
3 Confidence
4 Self-worth
5 Friendships
6 Anger
7 Depression
We aim to address the challenges young people face early but also offer a service to those young people with more complex needs that are not being met in the additional services across Cornwall.
Covering the far corners of the county, seeing young people as quickly as possible and managing vulnerable young people’s needs requires the service to be responsive, flexible and dynamic but steady on its feet.
Louise Turvey Cornwall Kooth F2F Senior Practitioner
16 REDUCING DIS TRESS , BUILDING RESILIENCE
Kooth F2F service users attend a mean of
8 sessions, with quite a bit of variance across
the country. This fluctuates across the different
localities where Kooth F2F deliver, with the
two services that support CAMHS waiting lists
delivering an average of 11.6 sessions, over three
sessions higher than the services average. Average
attendance is higher than session attendance
figures from both Welsh school-based counselling
in 17/18 and the YIACS 15//16 data, which were
5.2 and 5.4 sessions on average, respectively.
As you can see from the graph on page 17, over
50% of service users will have attended 7 sessions
or less, however there is a significant number
of users who will go on to have a much greater
number of sessions (15+) which increases the
average of session attendance. Typically, the users
who are having a greater number of sessions have
been referred through services supporting CAMHS
waiting lists, which could suggest they’re working
with young people with complex needs who
require longer term support.
Service Use
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%Powys
11.26%
17.75%
28.14%
23.81%
18.61%
10.90%
19.87%
26.28%
21.79%
20.51%
13.79%
3.45%
17.24%
25.00%
21.55%
18.97%
4.76%
26.98%
17.46%
23.81%
12.70%
14.29%
11.17%
12.29%
17.32%
26.82%
30.17%
6.67%
21.11%
20.00%
20.00%
32.22%
4.76%
4.76%
33.33%
14.29%
42.86%
7.35%
22.06%
23.53%
17.65%
27.94%
11.69%
17.32%
23.27%
22.73%
23.48%
Cornwall Nottingham Wakefield Knowsley Halton WarringtonCAMHS
CornwallCAMHS
OverallAverage
CORE-YP Thresholds for Service Users (2018/19 closed cases) at First Session
% o
f Tot
al U
sers
Level First Session (group)
Healthy
Low Level
Mild
Moderate
Moderate
Severe
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 17
As is typical within mental health services,
there can be a waiting time between
assessment and the start of counselling. Across
Kooth F2F this time was slightly higher for those
with Mild or Moderate need (average = 40 days),
than those with Moderate, Moderate Severe, or
Severe thresholds of need (average = 36 days).
Those who met the top of the severe threshold of
need, scoring 35-40 points, waited an average of
24 days for counselling from assessment.
Once in attendance young people are met by
practitioners with varying modality experience,
usually working from a person-centred,
psychodynamic or integrative approach depending
on training. Where appropriate other techniques
will be used incorporating creative arts, sand tray
therapy and CBT techniques to meet the young
person’s preferences and needs.
Service UseNumber of Sessions Attended by Service Users in 2018/19
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16-20 20-30 30-40
171.58%
353.26%
423.91%
444.09%
625.77%
817.53%
989.12%
22921.3%
1029.49% 94
8.74%
534.93% 50
4.65%40
3.72% 333.07%
131.21%
181.67%
403.72%
191.77%
50.47%
240
220
200
180
160
140
120
100
80
60
40
20
0
18 REDUCING DIS TRESS , BUILDING RESILIENCE
Zara is a fifteen year old female referred to
Kooth F2F by her head of year at school who
had noticed Zara becoming increasingly withdrawn
during lessons and anxious about her school grades.
Zara’s friends had also expressed concerns to the
head of year, as had noticed self-harm marks on
Zara’s wrists.
An assessment session with a Kooth F2F
practitioner identified that Zara was finding it
challenging to manage the stress of maintaining
high grades at school, and was using self-harm as a
coping mechanism. During the risk assessment Zara
shared that she had no intentions of ending her life
and did feel able to keep herself safe. From here
the practitioner was able to focus the work in the
sessions to finding more healthy ways to manage
the feelings surrounding Zara’s school work.
Using a person-centred approach, Zara was
supported in exploring her difficult thoughts and
feelings around the pressures she felt at school,
coming up with strategies together to help manage
these on a day-to-day basis. Sessions also included
discussion of distraction techniques for self-harm,
and psychoeducation around anxiety including
techniques for managing anxiety such as
grounding exercises.
Zara created goals during the sessions such as
“Write coping strategies flashcards” and “Speak to
Mum when feeling anxious”. Zara achieved all of
the goals she set over her 6 sessions. Zara’s CORE-
YP score was 28 at the start of her sessions which
improved to 14 at session six. Zara reported to be
feeling “more able to cope with the urges” and
“less worried about her future exams”
Composite Case Study Representing a Kooth F2F User
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 19
Zara became withdrawnand anxious during lessons
Session identifiedZara was stressedabout her grades and self-harmed as a coping mechanism
Zara created Goalssuch as “Writing
coping strategies flashcards” and
“Speak to Mum when feeling anxious”
Zara reported to be feeling more able to cope with urges and less
worried about her future
Practitioner explored healthier
ways to manageZara’s feelings
surrounding herschool work
Zara achieved all of the goals she set overher 6 sessions
These includedistraction techniques and groundingexercises
Zara’s CORE-YP score was 28 at the start of her
sessions, which is now improved
to 14 at session 6
Zara’s friends noticed self-harm marks and inform head of year
Assessment session with a Kooth F2F practitioner
20 REDUCING DIS TRESS , BUILDING RESILIENCE
OutcomesOutcomes are measured within Kooth F2F
using CORE-YP, goals, and practitioner and
service user observation. Goals are a key measure
of therapeutic distance travelled by a young person.
Goals are set collaboratively with the practitioner
and reviewed sessionally or as appropriate with
the young person to mark progress out of 10.
In 2018/19, 83% of the 2,973 goals set across the
year were moved, with an average goal movement
of 8.6. This movement is very positive with a
‘3 point’ movement considered reliable change,
and soon to be trialled by the NHS nationally as
recognised “measurable change”.7
Top 10 Goals Created
Emotional 24%
Anxiety 16.5%
Personal Growth 10.2%
Further Support 9.9%
Family 6.4%
Wellbeing 6.3%
Friendships 4.6%
School/Work 4.4%
Relationships 3.5%
Relating to others 3.3%
Example GoalsFurther SupportTo attend the Dialectic Behavioural
Therapy Group.
Emotional goalUse distraction techniques discussed
in the session when OCD is triggered.
Anxiety goalWrite down feelings and emotions
when struggling with sleep as a result
of anxious thoughts.
Personal growth goalChallenge negative thoughts about self when
they occur rather than listening to them.
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 21
Over half of all set goals fell into three main categories; ‘emotional’, ‘anxiety’ and ‘personal growth’ with the remaining goals split sparsely across many other categories.
5 Goals with Greatest Movement
Goal Category
Further Support
Anxiety
Friendships
Emotional
Family
Average Goal Movement
9.6*
8.67
8.32
8.32
8.31
*Goals are moved between 0 and 10 to mark progression
2 2 REDUCING DIS TRESS , BUILDING RESILIENCE
A longside goals which are used as a
personalisable tool for demonstrating
distance travelled, CORE-YP is utilised
as a psychometric assessment throughout
interventions. Within CORE-YP, reliable change
is that which exceeds change which could occur
as a result of chance or measurement error,
with clinically significant change defining those
whose movement has taken them from the
clinical to the non-clinical population.
65.8% of service users demonstrate clinical
recovery or reliable change, with an additional
25% experiencing improvement in score but
not meeting the threshold for reliable change.
This is hugely significant when contextualised
by the evaluation of treatment for adolescents
of depression and anxiety, whereby the highest
rate of reliable improvement which was seen
for those with anxiety was 53%.8
experiencing improvement in score but not meeting the threshold for reliable
change
additional
25%
65.8%of service users
demonstrate clinical recovery or reliable
change
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 2 3
As we would expect to see, there is a
correlation between those entering the
service with at a higher clinical threshold
experiencing a greater movement in score
improvement – up to 17.9 points movement
compared to an average movement of 7 points.
In terms of service activity, we found that young
people referred from professional services such
as CAMHS or the GP received a higher than average number of sessions than
those referred from other sources such as
pastoral leads in schools.
24 REDUCING DIS TRESS , BUILDING RESILIENCE
EndingsW hen it came to ending interventions, the
majority of endings were as planned (82%);
70% of these endings were due to a completed
intervention and recorded positive change for the
service user. Other planned endings occur due to
disengagement with the service, or the additional
needs of a young person where they are referred
or signposted to alternative services.
Amongst the planned endings, the majority of
service users were ready to end their intervention
(80%) after engaging in a particular number of
sessions. The most prevalent reason for being
ready to end was due to affective change (26%)
which encompassed changes in mood, feelings
and attitudes.
A number of service users displayed behavioural
change (14%) which was noted as the reduction
of maladaptive behaviours such as self harming.
An additional 14% of those who were ‘ready to end’
recorded that their primary take-away from the
intervention was having developed new coping
strategies, enabling them to end counselling.
Other reasons included; improvement in
communication, confidence, understanding
of self and reduced anxiety.
There was a small number of service users of those
who planned to end whose experiences prevented
them from receiving the same outcomes as those
outlined above. These experiences included
difficulties within counselling, a need for more
support/referral or they experienced no change.
“YP feels he is able to manage his emotions,and attached thoughts much better.”
“YP is feeling happier and more able to talk about her feelings with others.”
When reviewing the end of intervention
assessments as filled out by the practitioner we
identified that 81% of those recorded as being at
risk of self-harm were female (this is 4% of total
‘closed case’ population compared to 2% of the
total male population). These statistics are in
alignment with The Good Childhood Report9
2018 which reports that females are twice as
likely than boys to self harm.
Reasons for Service Users being ‘Ready to End’ Counselling
Affective Change 25.7%
Behaviour Change 13.9%
Coping Strategies Learnt 13.7%
Improved Communication 10.5%
Improved Understanding of Self 10.7%
Improved Confidence 13.3%
Reduced Anxiety 12.2%
A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19 2 5
of service users who responded to an end of counselling questionnaire would recommend the service to a peer.
Young people shared that they found the service approachable, non-judgement, helpful, safe and comfortable.
of users were both satisfied with the speed of contact from the service, and satisfied with the number of sessions offered to them over the course of their intervention.
Service User Satisfaction
85%
95%
Thank you for being trustworthy and understanding me
Kooth F2F Service User
26 REDUCING DIS TRESS , BUILDING RESILIENCE
ConclusionIt has been shown that humanistic person-centred
approaches to counselling for young people are
effective in reducing clinical need and distress,
along with additional outcomes such as those seen
here; improved coping skills, feelings of improved
confidence, understanding of self and reduced anxiety.
These outcomes are demonstrated through the
changes in CORE-YP scores for service users
over their time in service as well as their goal
achievements.
It could be suggested that a face-to-face approach
encompassing values of access, flexibility, and
person-centredness enable such improvements
for the users of this service, many of whom meet
high thresholds for clinical need and distress.
The spectrum of need identified across Kooth F2F
highlights the value of having a counselling service
available for young people in the UK. Choice of
support is both important to services users and can
enable more people in getting the right support for
them10, this is why each Kooth F2F service is part
of an integrated choice offer including the Kooth
online service.
Despite changes to the political landscape and
technological advancements young people today
face the same presenting issues as they did almost
10 years ago, and suggestively are in just as much
need to feel heard and valued by another human.
Kooth F2F continues to provide consistent,
accepting, confidential spaces for young people
to get that need met and support young people in
building resilience for use throughout their lives.
27A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19
All my friends have said how much more confident and happier I have been since starting F2F.
Kooth F2F Service User
28 REDUCING DIS TRESS , BUILDING RESILIENCE
29A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19
References1. British Association for Counselling &
Psychotherapy. (2013). Children and Young
People Practice Research Network (CYP
PRN): A toolkit for collecting routine outcome
measures. Leicestershire: British Association
for Counselling & Psychotherapy.
2. Welsh Government (2019). Counselling for
Children and Young People, 2017/18. [online]
Wales. Available at: https://gov.wales/sites
/default/files/statistics-and-research/2019-03
/counselling-for-children-and-young-
people-2017-18-494.pdf [Accessed 13 Dec. 2019].
3. Murphy, M. and Fonagy, P. (2012). Mental
Health Problems in Children and Young People.
Annual Report of the Chief Medical Officer
2012, Our Children Deserve Better: Prevention
Pays. [online] Available at: https://assets.
publishing.service.gov.uk/government
/uploads/system/uploads/attachment_data
/file/252660/33571_2901304_CMO_
Chapter_10.pdf [Accessed 10 Dec. 2019].
4. Cooper, M. (2013). School-based counselling
in UK secondary schools : a review and critical
evaluation. [online] Available at:
https://strathprints.strath.ac.uk/45319/
[Accessed 13 Dec. 2019].
5. Hill, A., Cooper, M., Smith, K., Maybanks,
N., Cromarty, K., & Pattison, S. et al. (2011).
Evaluation of the Welsh School based
Counselling Strategy: Stage One Report.
Welsh Government Social Research.
6. Rayment, B. (2016). Counselling for young
people and young adults in the voluntary
and community sector: outcomes and
demographics from a practice research
network. Presentation, British Association
for Counselling and Psychotherapy.
7. Jacob, J. (2019). Measuring what matters:
learning from goal-based outcomes data
analysis. Presentation, CORC Regional Seminar.
8. Edbrooke-Childs, J., Wolpert, M., Zamperoni,
V., Napoleone, E. and Bear, H. (2018).
Evaluation of reliable improvement rates in
depression and anxiety at the end of treatment
in adolescents. BJPsych Open, 4(4), pp.250-255.
9. The Children’s Society. (2018).
The Good Childhood Report.
London: The Children’s Society
10. Frith, E. (2017). Online Mental Health
Support for Young People. London:
Education Policy Institute.
30 REDUCING DIS TRESS , BUILDING RESILIENCE
Notes
3 1A RE VIEW OF KOOTH FACE-TO -FACE SERVICES 2018/ 19
The Practitioner was very kind and helpful to get me over my anxiety. I know that I can speak to her about anything.
Kooth F2F Service User
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