reducing distress, building resilience...liz quester, powys kooth f2f practitioner core-yp at 1st...

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


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


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


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


All my friends have said how much more confident and happier I have been since starting F2F


The counsellor was very kind and helpful to get me over my anxiety. I know that I can speak to her about anything



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


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.


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


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


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


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


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


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


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.


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


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


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.


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%


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



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.


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.


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.


reducing distress, building resilience...liz quester, powys kooth f2f practitioner core-yp at 1st...

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