In recent years, there has been growing interest from national government in exploring the opportunities provided by new technology to increase access to mental health services for children and young people. The devolved nature of health commissioning has, however, meant that progress in introducing such services is driven at a local level and has remained highly variable.
Online provision of mental health support
Existing literature provides insight into some of the benefits associated with online provision of mental health services as well as some of the challenges it presents.
Studies show that young people value the anonymity and confidentiality afforded by online counselling1 and are more likely to open up online. Young people have also been found to appreciate the control they have over the online interface, such as the ability to log-off or to delete a draft response. The accessibility of online services outside of the working day was also seen as beneficial.
Some of the challenges of online counselling include: misunderstandings caused by the lack of non-verbal communication methods, the anonymity of the counsellor and the time delay of sending messages online. However, these challenges were generally not considered to be insurmountable and counsellors and their clients were still able to develop a high level of trust in the online relationship. Moreover, in many services, such as Kooth, counsellors are not anonymous and recent improvements in technology have reduced some of these identified concerns, such as time delay.
Meta-analyses of existing research point to the potential of increasing access to support using online counselling but also the need for a blended approach with face-to-face support offered alongside online provision.
Online provision of mental health support: The Kooth Model
Kooth is an online counselling and emotional wellbeing platform for children and young people, provided by XenZone. It is provided free at the point of use for young people living in more than 70 Clinical Commissioning Group areas where the service is commissioned.
The Education Policy Institute has analysed data provided by XenZone to understand more about the use of online counselling services. The median age of a Kooth service user is 15, which reflects the pattern of emergence of mental health problems in young people aged between 14 and 17. Nearly one in five (18 per cent) of the new registrations in 2016-17 were for those aged between 10 and 12, showing that online provision of mental health support is popular with pre-teenage children as well as teenagers.
71 per cent of Kooth clients are girls or young women, compared to 52 per cent of child and adolescent mental health service (CAMHS) clients overall. This could indicate that girls and young women are more likely to ask for help, as young people refer themselves to Kooth. However, comparison with the gender breakdown of Kooth’s face-to-face counselling services shows that a slightly higher proportion of boys were accessing the face-to-face services, which also operate on a self-referral basis. Teenage girls are more likely to engage in social media than boys and this could also be a reason why girls are more attracted to using a service like Kooth which is similar in style to social media, with live forums as well as online counselling conversations.
Boys are slightly more likely to use the service at a younger age than girls. 8.5 per cent of the boys using Kooth were aged 11, compared to 4.6 per cent of the girls. 5.7 per cent of the girls were aged 18, compared to 4.2 per cent of the boys. This may indicate that older teenage boys are less likely to engage with mental health support or to engage with such support online.
Around 1 per cent of those responding to the question about their gender chose the category ‘Agender’ or ‘Gender Fluid’, compared to the 0.02 per cent of clients in traditional CAMHS services who were recorded as having a gender listed as ‘other’. This could indicate that young people are more willing to be open about gender fluidity online.
When compared to the general population in the local authority areas where it is commissioned, Kooth attracts a higher proportion of people from different ethnic minority backgrounds (17.6 per cent compared to 10 per cent). This was a benefit of the service which was mentioned in our interviews with commissioners in Hertfordshire and in Plymouth. There is also evidence from the literature that this is a potential benefit of online counselling.
Although Kooth is busiest in the immediate hours after school, the data shows that young people use the service late into the night, including after professional counselling support closes at 10pm. Some young people also use it during school hours. Seven out of 10 (69.1 per cent) log-ins occurred outside of the traditional working week (9am to 5pm Monday to Friday). This indicates that young people are more likely to want to access mental health support outside of traditional clinic opening hours, which poses challenges for the way in which child and adolescent mental health services are currently structured.
Young people engage with Kooth in a variety of ways. In our sample, 27 per cent accessed the self-help articles; 36 per cent engaged with the forums. 25 per cent communicated with counselling via live chat and 26 per cent used the asynchronous messaging option.
The most common reason cited for young people accessing Kooth was stress and anxiety. Other common reasons included problems with friendships or family relationships, bullying, self-harm and lack of self-worth.
Early indications from goals set by young people themselves on what they want to achieve from treatment is that these are being met, with 46.5 per cent of goals fully met.
Feedback from young people using the service shows that Kooth clients seem to be able to build strong relationships with their counsellors and to respond well to counselling sessions.
The Education Policy Institute also used a questionnaire to elicit feedback from Kooth clients about their experiences of the site. 39.7 per cent said that online counselling was their preferred method of support, compared to 14.7 per cent who preferred face-to-face counselling. A quarter of respondents (24.5 per cent) preferred a mixture of both types of support. A significant minority (12.4 per cent) said that the online articles were the element of the site that they appreciated most and 8.7 per cent selected the online forums. This shows the benefit of self-help and enabling young people to support each other in addition to offering professional counselling support.
Young people were asked the top reasons why they chose online counselling. The main reasons were associated with the anonymity involved. Young people also appreciated the convenience of being able to access online counselling from their own home and out of hours. Additionally, Kooth clients appreciated being able to express themselves clearly through sending online messages.
The questionnaire also asked young people who hadn’t chosen to use online counselling the reasons why they did not want to use it. The main reasons were a fear of having their comments read and uncertainty about talking to a counsellor via the internet rather than face-to-face. This demonstrates the importance of offering a blended approach so that young people can choose the type of counselling which suits them best.
Online support in practice
The Education Policy Institute conducted interviews and further analysed local data from three Kooth services in Hertfordshire, Plymouth and Halton.
The themes raised in these interviews reflected the findings in existing research. For example, in all three areas young people appreciated the anonymity, confidentiality, accessibility and control offered by online counselling.
The local commissioners also appreciated the availability of high quality data about service use, which has allowed them to respond to trends in presenting issues by putting in place relevant support offers. Another benefit was that the service could reach groups that were not always accessing traditional services.
Despite all these benefits, the commissioners all acknowledged the need for a blended approach so that face-to-face support was available for those young people who did not want to receive counselling online.
In all three areas, it was difficult to assess the impact of introducing the service on referral rates. One key challenge was that the anonymity of the service meant that data collection on individual patterns of service use was difficult. In addition, measuring the impact of the introduction of Kooth was difficult because it was hard to disentangle this from other changes to local provision.
In all three areas, providers and clinicians had had some concerns before the introduction of the service about safeguarding young people and appropriate governance procedures. It was difficult to assess how far this was related to the fact it was an online counselling service or to what extent the misgivings were related to Kooth being offered by a non-NHS provider. In all three cases these concerns had been allayed after the service was introduced and the partner providers had been reassured about its governance models. The benefits of partnership working with a non-NHS provider were raised by two commissioners. For example, they felt that this enabled staff to embrace a different working culture and the use of new technology.
This project has identified emerging findings about the nature of online provision of mental health support for children and young people. It is not intended to be an evaluation of the Kooth model nor of the impact of the introduction of the service. A stated aim of the project, however, was to identify what further research is needed to understand more about the impact of commissioning online counselling. The final section of the report makes recommendations about ways in which an effective evaluation programme could be undertaken.
In particular, sufficient time would be needed for a pilot to be established and to allow for robust data to be collected and evaluated. Clinical Commissioning Groups involved would need to have access to relevant benchmarking data. The research would need to control for potential confounding factors to enable a full assessment of the impact of the service.