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Counselling services for young peopleIntroduction

Promoting the mental health and emotional well-being ofchildren and young people in the UK is a key aim of thecurrent national policy agenda. In recent years, this has beenmarked by an increased interest in the use of psychologicaltherapies and in how to improve access to suchinterventions.

Psychological therapies are known to be effective fortreating many mental health conditions and are preferableto drug treatments for people under the age of 18.1

They cover many different ways of working includingpsychodynamic, art-based, drama-based, group analysis andsystemic approaches.2

Counselling, which can fall within any one of theseapproaches, is recognised by the Department of Health(DH) as a form of psychological therapy, and accepted as atherapeutic approach in the range of interventions forchildren and adolescents. With evidence of its effectivenesswith anxiety and depression, the Department’s reportTreatment Choices in Psychological Therapies andCounselling gives the following definition:

‘a form of psychological therapy that gives individuals anopportunity to explore, discover and clarify ways of livingmore resourcefully, with a greater sense of well-being.Counsellors practice within the… therapeutic approaches…(for example) CBT, humanistic, art therapy, existential,drama therapy, personal construct and interpersonaltherapy…’.3

A further definition, given by Youth Access specifically inrelation to counselling for young people, is as follows:

‘an activity voluntarily entered into by a young person whowants to explore and understand issues in their lives, whichmay be causing difficulty, pain and/or confusion. Theboundaries of the relationship are identified and an explicitcontract agreed between the young person and thecounsellor. The aim is to assist the young person to achievea greater understanding of themselves… to create a greaterawareness of their personal resources and of their ability toaffect and cope with their life’.4

Alongside the recognition of the importance ofpsychological therapies, it is apparent that the availability ofthis provision is limited on the NHS, with wait times of overa year being commonplace.1

The costs of not offering appropriate and timely mentalhealth interventions are considerable both for the

individual, in terms of prolonged ill health and poor adultoutcomes, and for society in terms of costs related to healthservices, social care and the criminal justice system.1,5 Foryoung people in particular, mental well-being affects botheducational attainment and stability in relationships withothers, both of which are essential foundations for a healthyand happy adult life. Costs to society were the central themeof a report by Layard in 2004, which described mentalhealth as ‘Britain’s biggest social problem’ and called for asignificant expansion in provision of psychologicaltherapies, noting that:

‘Patients’ biggest complaint of the service is the lack ofpsychological therapy, and partly for this reason there ismore discontent about mental health services than almostany other aspect of the NHS’.6

Policy context

The current policy context is supportive of the developmentof counselling services for young people. In England, suchpolicy includes: Youth Matters, the youth green paper,7

Youth Matters Next Steps8 and guidance for thedevelopment of Targeted Youth Support,9 all of which areclosely connected to the cross-governmental children’sservices strategy, Every Child Matters (ECM), and indeedcan be seen as vehicles through which the five outcomes ofthe ECM programme will be delivered.10

Cross-cutting these, is the National Service Framework(NSF) for Children, Young People and Maternity Services11

and in the education arena, policy initiatives such asNational Healthy Schools, extended schools and theTargeted Mental Health in Schools project (TMHS).12 Theseinitiatives provide a clear platform for extending anddeveloping the range of support interventions, includingcounselling, to be offered to young people in education.

The commissioning of counselling provision is alsocongruent with various commissioning frameworks thathave been issued recently by the DH. These include the JointPlanning and Commissioning Framework for Children,Young People and Maternity Services,13 which emphasisesjoined up provision, early intervention and prevention. Thework of the DH’s Third Sector Partnership Team and theThird Sector Commissioning Task Force add furthersupport. The ‘third sector’ can be described as the range oforganisations that sit between the State and the privatesector including small local community and voluntary

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groups, small and large charities, and a growing number ofsocial enterprises and cooperatives.

Specifically in the field of mental health services for youngpeople, the planning framework Improvement, Expansionand Reform14 gave considerable impetus to the developmentof new services. This set out the expectation that so called‘comprehensive’ Child and Adolescent Mental HealthServices (CAMHS) would be available in all areas of thecountry by 2006. It was acknowledged that this did notmean that all services would be in their final configurationor available in every locality by that date. However, wherelocal provision is:

‘not appropriate or possible, commissioners will need to setout the collaborative arrangements that will ensure thatthere is an agreed pathway to meet the specific needs froman alternative service; i.e. a clear and comprehensivenetwork of services’.15

Voluntary and youth sector counselling services for youngpeople can play a crucial role in ensuring a continuum ofservices from the community primary care level through tomore specialist mental health services, and with an emphasison acceptability, availability and easy access.

The NSF,11 published in 2004, is a ten-year programme forimprovement in children’s health and well-being. Its key aimis to achieve a situation where:

‘multi-agency services, working in partnership, promote themental health of all children and young people, provideearly intervention and also meet the needs of children andyoung people with established or complex problems’.15

The NSF links to, or can be seen as sitting within, the ECMprogramme. This endorses multi-agency and collaborativeapproaches and calls for the improvement and integration ofuniversal services. It also promotes the reconfiguration ofservices around the child, young person and family in oneplace (i.e. the ‘one-stop’ model) and a shift fromintervention to prevention.

Thirty Public Service Agreements (PSAs) were published aspart of the government’s Comprehensive Spending Review2007. PSA 12, to improve the health and well-being ofchildren and young people, sets out the government’s visionfor improving the physical, mental and emotional health ofall children for the next three years. One of the keyindicators on which progress towards the vision will bemonitored is improving emotional health and well-being,and CAMHS.

Counselling provision for young people - anoverview

Voluntary sector provision is a key component in theprovision of counselling services for young people, withvoluntary organisations increasingly involved in providingin-school services (for example Place2Be) as well asoperating from their own community-based premises, wherethey typically focus on a slightly older age range.16

Youth Information, Advice, Counselling and SupportServices (YIACS) are the largest provider of young people’scounselling services across the UK. Often operating fromhigh street-based premises, and based on the ‘under oneroof’ or ‘one-stop’ model, these services provide freecounselling via many different routes for young people aged13 to 25 years.

Findings from a survey commissioned by Youth Access in2005 as part of the a2c Project provide a comprehensivepicture of the counselling offered by YIACS.17 (a2c, Accessto Counselling, is a DH funded project which aimed toimprove young people’s access to mental health services byenabling voluntary and community sector counsellingorganisations to be integrated into the strategic planningand commissioning of local services). The currentlimitations in counselling provision were highlighted – insome parts of the country, YIACS are working effectively ona partnership basis with CAMHS, whilst in othersrelationships are either non-existent or very limited. Fiftythree per cent of the survey respondents reported that there were:

‘young people in their area not able to access counsellingservices either because no provision is available or becauseof factors such as location, opening times, counsellorcapacity, lack of outreach, funding boundaries’.

The survey revealed considerable variations in the size andstructure of YIACS counselling services:

• over two thirds of the counsellors work as volunteers/onan unpaid basis

• supervision and training is offered internally in some,whereas in others, this is provided by external agencies

• 87 per cent of counsellors are trained at certificate,diploma, masters or other level; the remainder aretypically final year students on diploma and otherrecognised counselling courses

• the length of time counselling is offered varies fromperiods of six weeks to over a year and in most services,follows an initial assessment session

• 69 per cent use some form of counselling outcomes tool(for example, the Clinical Outcomes Routine Evaluationtool (CORE), Teen CORE and YPs CORE or the Healthof the Nation Outcome Scale for Children andAdolescents (HoNOSCA))

• user feedback is one of the frequently used tools formeasuring the effectiveness of counsellor’s practice.

Self-referral and referral by GPs are the most commonroutes into these counselling services. However, referrals onto, and from CAMHS appear to be growing. With regard topartnership working with CAMHS and other agencies, thesurvey findings revealed a very mixed picture ofdevelopment. Just under 14 per cent of YIACS reportedsome form of contractual arrangement with their local

CAMHS – with an established or contractual relationshipbeing seen to benefit young people’s access to counsellingand other mental health services – and 22.8 per centreported receiving some funding from CAMHS to providecounselling. However, 39 per cent reported no or a limitedrelationship with CAMHS and cited factors such as a lackof time and resources, and a more widespread lack ofvoluntary sector involvement, as barriers to thedevelopment of a working relationship with CAMHS.

In addition, a number highlighted a reliance on short-termand one-off funding as hampering their ability to fullydevelop their services. Similarly, limitations in theiradministrative infrastructure had restricted their analysisand use of outcomes data, although this was beingaddressed, with the available data indicating positiveoutcomes.

Different approaches in voluntary sector counselling services

The wide range of provision, the different therapeuticinterventions offered, and the flexibility in the ways voluntarysector counselling services for young people are delivered, isevident in a number of recent reports. In CommissioningCounselling Services for Young People,16 a series of case studiesdescribes the array of provision, which includes:

• extended opening hours including evening and weekendopening

• emergency counselling, brief/short-term counselling and longer-term support

• satellite and mobile services

• training and support for volunteers in listening skills, in peercounselling, anger management, management of self-harm and in dealing with bullying

• groups and individual work in local schools and otheragencies such as Connexions, youth centres, YMCAs andcommunity drug and alcohol services

• advice and advocacy, sexual health advice, work with familyand relationship issues, work with bereavement, substancemisuse advice and treatment

• group-based post-counselling support

• telephone and text-messaging support

• fast tracking arrangements into CAMHS

• Primary Care Trust (PCT) and/or local CAMHScommissioned provision including psychotherapy and worktargeted on meeting the needs of young people from blackand minority ethnic communities.

A similar diversity of provision is revealed in the report Listenup! Person-centred approaches to help young peopleexperiencing mental health and emotional problems. 18 Bothreports demonstrate how such provision, with a focus on

flexibility, providing a holistic and diverse range of interventions,and with a commitment to giving young people a choice, cansuccessfully work alongside and complement CAMHS andother public services for young people. It can also play a vitalrole in engaging with young people who may not choose toapproach formal mental health services, and can improvegeographic access through the development of satellite servicesor the delivery of provision in other settings typically used byyoung people.

Conclusion

The provision of counselling services for young people canmake an important contribution to the policy agenda toimprove the mental health and emotional well-being ofchildren and young people. Hard ‘evidence’ in terms ofoutcomes data specific to counselling for young people islimited, but growing. Overall, there is an increasingrecognition of the importance of psychological therapies, andimproving access to these therapies is a current DH initiative.

The ways in which these services are delivered appears to bea particularly important part of their success. Defining ‘goodpractice’ in service provision is a complex task and definitionsabound. Maxwell, in a much cited work,19 suggested that thequality of care could be measured by six dimensions: access toservices; relevance to need (for the whole community);effectiveness (for the individual); equity; social acceptability;and efficiency and economy.

Further support comes from the growing literature aboutwhat works in supporting children and young people withmental health and emotional problems, and in promotingwell-being. This encompasses both the perspective of whichtreatment options bring positive individual clinical outcomes20

and increasingly, the perspective of young service usersthemselves in terms of what services they find acceptable andare therefore more likely to use.21,22,23 Much of thisinformation highlights the importance of the style of deliveryof services. Young people want ready access and are easilydeterred by long wait times and complicated professionalreferral routes. Furthermore, it lends considerable support tothe ‘one-stop’ or ‘under-one-roof’ model - and the use ofinformal, non-medical settings that are the trademark ofmany voluntary sector services including YIACS.3,24

Support to develop voluntary sector counselling services fitsespecially well with the national policy agenda of addressingthe needs of young people in the transition between childhoodand adulthood since many services, most notably YIACS,span the 13-25 age range. This is known to be a time whenserious mental health problems can emerge and variousreports, in the main focused on the 16-25 age range, havehighlighted the considerable barriers to support that can facethis age group. These include Breaking Down the Barriers,4

Sidelined,25 Turned Upside Down26 and the report by theSocial Exclusion Unit Transitions: Young Adults withComplex Needs.27 The latter makes particular reference to the‘wide consensus amongst service providers’ as to the

Counselling services for young people

for Children, Young People and Maternity Services. London:DfES.

14. Department of Health (2002) Improvement, Expansion andReform. London: DH.

15. Department of Health (2004) Report on the Implementation ofStandard 9 of the National Service Framework for Children,Young People and Maternity Services. London: DH.

16. Street, C (2007) Commissioning Counselling Services forYoung People: A guide for commissioners. London: YouthAccess.

17. Young, K (2006) Youth Access to Counselling (a2c)YIACS/CAMHS Survey. Quorn: Harrington YoungOrganisation Development Consultants.

18. Garcia, I, Vasiliou, C and Penketh, K (2007) Listen Up? Person-centred approaches to help young people experiencingmental health and emotional problems. London: MentalHealth Foundation.

19. Maxwell, RJ (1984) ‘Quality assessment in health’, BritishMedical Journal, 288, 6428, 1470-1.

20. Fonagy, P and others (2002) What Works for Whom? A criticalreview of treatments for children and adolescents. London:Guilford Press.

21. Street, C and Herts, B (2005) Putting Participaton intoPractice: A guide for practitioners working in services topromote the mental health and well-being of children andyoung people. London: Young Minds.

22. Kurtz, Z (2005) Minority Voices: A guide to good practice inplanning and providing services for the mental health of blackand minority ethnic young people. London: Young Minds.

23. Mumby, C (2001) Building User Involvement: A step-by-stepguide to involving users in youth information, advice,counselling and support services. London: Youth Access.

24. National Children’s Bureau (2005) Children and YoungPeople’s Views on Health and Health Services: A review of theevidence. London: NCB.

25. Howarth, C and Street, C (2000) Sidelined: Young adults’access to services. London: New Policy Institute.

26. Smith, K and Leon, L (2001) Turned Upside Down:Developing community-based crisis services for 16-25-yearolds experiencing a mental health crisis. London: MentalHealth Foundation.

27. Office of the Deputy Prime Minister (2005) Transitions: Youngadults with complex needs. London: ODPM.

28. National Institute for Health and Clinical Excellence (2005)Depression in Children and Young People: Identification andmanagement in primary, community and secondary care.Clinical guideline 28. London: NICE.

highlight no. 239Highlight No. 239 © National Children’s Bureau 2008. ISSN: 1365-9081. Highlights maybe reproduced by NCB members for non-commercial circulation within their ownorganisation, subject to acknowledgement of source. Contact the Library for furtherinformation. National Children’s Bureau, 8 Wakley Street, London EC1V 7QE. Tel: 020 7843 6000. Fax: 020 7278 9512. www.ncb.org.uk

beneficial effects of counselling for young people. It also notesthat the evidence that young adults benefit from counsellingwhen they receive it, is supported by National Institute forHealth and Clinical Excellence (NICE) guidance on thetreatment and management of depression.28

There is clearly recognition of the importance of counsellingon a wide range of fronts. However, it is apparent thatsignificant and more stable investment is needed if currentgeographic variations and service limitations are to beaddressed. Additionally, as the report We Need to Talk notes,1

more rigorous research, alongside the development ofinspection and audit structures, is needed if a situation is to bereached where much more is known about what works fordifferent groups of children, which will in turn support amore strategic commissioning of counselling services foryoung people.

Dr Cathy StreetMarch 2008

References

1. Bird, A (2007) We Need to Talk: The case for psychologicaltherapy on the NHS. London: Mental Health Foundation.

2. Department of Health (2004) Organising and DeliveringPsychological Therapies. London: DH.

3. Department of Health (2001) Treatment Choice inPsychological Therapies and Counselling. London: DH.

4. Wilson, C (2002) Breaking Down the Barriers. A strategy indevelopment. London: Youth Access.

5. Scott, S and others (2001) ‘Financial cost of social exclusion:follow-up study of antisocial children into adulthood’, BritishMedical Journal, 323, 7306, 191-3.

6. Layard, R (2005) Mental Health: Britain’s biggest socialproblem?http://cep.lse.ac.uk/textonly/research/mentalhealth/RL414d.pdf

7. Department for Education and Skills (2005) Youth Matters.London: TSO.

8. Department for Education and Skills (2006) Youth Matters:Next steps. London: DfES.

9. Department for Education and Skills (2007)Targeted YouthSupport. London: DfES.

10. www.everychildmatters.gov.uk

11. Department of Health (2004) National Service Framework forChildren, Young People and Maternity Services. London: DH.

12. Department for Children, Schools and Families (2008)Targeted Mental Health in Schools Project.http://www.dcsf.gov.uk/pns/DisplayPN.cgi?pn_id=2008_0016

13. Department for Education and Skills and Department ofHealth (2006) Joint Planning and Commissioning Framework