About XenZone:

XenZone is an innovator in digital mental health.  Established over 16 years ago, we have delivered over 110,000 hours of online counselling and support to children, young people (CYP) and adults. Our CYP service, Kooth, is commissioned in over 1 in 3 Clinical Commissioning Group (CCG) areas across the country. Kooth Student is aimed at University students. For over 18s, Qwell helps meet the requirements of the Preventative Agenda.  These services complement existing face-to-face provision, with accessible support till 10pm seven days a week, and clear pathways for referral into other services.  Staff are constantly supervised and work within a strong culture of clinical governance and safeguarding.  Our ethos for service provision is person centric.  Practitioners are trained in a variety of evidence based techniques including CBT, DBT and a range of psychotherapy approaches. 

We are submitting this response based on the wealth of professional experience we have accumulated since we established the UK’s first online counselling service in 2004. We are keen to shine a light on the role that online therapy can play in supporting children and young people’s mental health as they navigate social media, and how we make such services as appealing, accessible and effective as possible.

Summary:

  1. Children and young people are comfortable online and happy to share their problems and worries in that environment. We must remember though that online behaviours will reflect young people’s vulnerabilities and that these can be magnified online. If we want to support their mental health effectively, we need to meet them there
  2. Such services must have a proactive community management strategy, monitoring use and over-reliance and ensuring safeguarding practices are a key priority
  3. Online mental health and emotional wellbeing support services need to be exemplars in providing a ‘safe space’ where they can discuss issues affecting their mental health without judgement. Giving young people easy access to such a service increases the likelihood of being able to intervene early and prevent escalation
  4. Anonymity is critical, particularly for young people finding it hard to admit they’re struggling, and for some hard-to-reach communities for whom discussing mental health issues is taboo. As stated above, adhering to safeguarding practices and having clear community management policies are critical

 

What evidence there is on the effects of social media and screen-use on young people’s physical and mental well-being — for better and for worse — and any gaps in the evidence

  1. In this response, we are viewing the Kooth online counselling and emotional wellbeing support service as a ‘social media’ site. It incorporates elements commonly found on social media, such as peer-to-peer forums and the ability to ‘chat’ via live text (to a professional counsellor). The difference is that as well as being focused on mental health, the site is secure and monitored and represents a ‘safe space’ for children and young people.
  2. It’s also worth noting that exposure to risk is necessary to build resilience. Some individuals and groups of young people require more support to navigate risk, but trusted adults (parents, teachers, counsellors, etc) can extend conversations around risk to reduce harm.

Building an evidence base

  1. If we accept that anonymity is key to early intervention and that young people are and will continue to look online for mental health support, we need to see more creative methodologies to accurately measure outcomes and impact. These should take account of the complex ways people interact with online services.
  2. Such methodologies will also need to take account of the pace of technological change so that they are not redundant by the time findings are available.
  3. According to research paper ‘Examining the complexities of measuring effectiveness of online counselling for young people using routine evaluation data’ published in the journal Pastoral Care in Education, “…the online service, when compared with equivalent face-to-face data, attracts a wide range of needs and levels of distress, with a high proportion of complex needs presented. Such findings may also reflect the complex nature of the support needs for the client group in question. Capturing appropriately rich data using a range of qualitative and quantitative measures that account for the complex online environment and client group needs to be carefully considered.”

Evidencing the therapeutic alliance

  1. Chat session feedback questionnaires are used to capture the effectiveness of the therapeutic alliance on Kooth. Of the 11,711 responses in 2017, 85% felt they had been “heard, understood and respected” a lot. 95% would recommend Kooth to a friend.

Appeal

  1. If we were to measure the impact of online counselling through the level of self-referrals – in other words, the appeal or popularity of the service – we would see a significant impact as registrations and log-ins increase year on year. As well as being the result of more commissions in CCG areas, this is also testament to the motivation of children and young people to log in and get help.
  2. During 2017 over 56,500 children and young people (an average of 4,711 every month) signed up to Kooth; Kooth counsellors held more than 28,000 one to one online therapy sessions.

The areas that should be the focus of any further research needed, and why;

  1. Online counselling for children and young people, as explained in the previous response, warrants research which helps shape an approach to measuring outcomes and impacts fairly and accurately.

The well-being benefits from social media usage, including for example any apps that provide mental-health benefits to users

  1. While we are aware that social media can be detrimental to young people’s mental health, we believe that online counselling sites - if safe, secure and moderated, with robust community management policies – can be a force for good.
  2. Services can offer many benefits using a ‘social media’-inspired medium. We see positive outcomes from children and young people who choose to use Kooth. Significant numbers set their own therapeutic goals, for example.

Goal setting

  1. Each goal is scored out of ten depending on how close it is to being achieved. The average goal movement score in 2017 was 5.9 (over 9,000 goals moved); many of these goals will still be active today.

Online Forums

  1. Our online forums also benefit young people; peer to peer support is incredibly powerful. Conversations like the one below are typical:
  2. Kooth user 1

‘I have to go to the GP this week and I’m scared. I hate saying stuff face to face. I’m just really struggling. I hate being in school. I just can’t talk to anyone’.

Kooth user 2

‘I know a girl who so shy and won’t talk to anyone! It takes a long time to make eye contact but she’s great. You need to be comfortable in your own skin. You’re perfect as you are! Try writing down any compliments you get and totally forget anything negative!?!? Try it? It can only help’

Kooth user 1

That’s pretty cool- I’ll try that tomorrow in school. Thanks, this live forum thing is a really good idea. There’s many others that understand what you’re going through’.

Kooth user quotes

  1. Feedback to Kooth counsellors from young people shows how such services can be hugely beneficial:

"I haven’t been able to do anything with my life for years - now, I want to live it. You have got me through situations others didn't even know were happening. You kept me safe. You’ve kept me alive. Others couldn't do that."

"It's just great to talk to someone anonymously and not be judged"

"After our chat I feel a lot better. Last week was hard and I really didn't want to live anymore. But after reading your info it gave me some courage to be strong and to cope. I realise now there's lots of people who went through the same thing as me which is comforting. I’m now much better at coping."

 

The physical/mental harms from social media use and screen-use, including: safety online risks, the extent of any addictive behaviour, and aspects of social media/apps which magnify such addictive behaviour;

  1. Through our long history, we have seen how forums and postings can become addictive. We learned early on that a ‘reward system’ (likes) for posts could have detrimental effect, where young people were focused on seeking approval from peers (this feature was removed some years ago).

Online safety risks

  1. In terms of harm from social media, we regularly hear stories shared by young people on Kooth. Sometimes these issues are discussed in moderated forums.
  2. As an example, we heard from a young woman talking about Facebook being used to harass and abuse her by an ex-partner. She dealt with this by deactivating her account, which is a fairly typical response. Young people often re-join the site as there is pressure to be on Facebook and a feeling that they might be missing out on social interaction. There is then the possibility of being ‘found’ again and the cycle continues.
  3. She commented: “My ex is such a hassle. I have de-activated my old facebook and blocked him on my new one as he kept asking me to get back with him because I was 'the love of his life' despite cheating on me twice…”
  4. Another young person shared a story where she had joined a social media site where she entered in to an online relationship. Her online boyfriend became controlling and asked for inappropriate images, which this young person supplied out of fear. After ending the relationship, her boyfriend’s friend had messaged her to say he had tried to take his own life as a result. The girl began self-harming and the case eventually went to court; the ‘boyfriend’ was part of a child sex gang.
  5. She said: “I still find it hard to talk about this because after all this happened my relationship with my dad changed, know it’s time to open up and get help about my self harming. I wanted to share my story so maybe it could help others.”
  6. The value of the live moderated forums is that young people feel it is a safe space to share often very personal stories for the benefit of the community, or to seek reassurance. Being open and sharing stories is a positive first step to getting help. They might then ask for a one to one session with a Kooth counsellor or use the confidence gained through peer-to-peer support to speak to a trusted adult.

Resources for professionals

  1. Separately, and in response to feedback from young people who said that professionals working with them need a better understanding about online risks and resilience, we created an ‘online risk and resilience’ resource available through MindED. This is aimed at professionals working with children and young people. Such resources are vital in ensuring the right guidance reaches those with the ability to support children and young people.

Any measures being used, or needed, to mitigate any potential harmful effects of excessive screen-use — what solutions are being used?

  1. Online services and social media sites must have a proactive community management strategy. Online one-to-one counselling on Kooth, for example, is available up to 10pm and not beyond due partly to the detrimental impact of blue-screen wakefulness Children and young people cannot contact counsellors through social media, online forums are moderated and there is no ‘Kooth app’
  2. As part of our work to support children and young people’s wellbeing, we would, if necessary and as part of their therapy, talk about blue-screen wakefulness and encourage children and young people to take regular breaks from screens
  3. Our counsellors and clinical team oversee an individual’s use of the site and online counselling to ensure it doesn’t stray into addictive behaviour or over-reliance

 

The extent of awareness of any risks, and how awareness could be increased for particular groups — children, schools, social media companies, Government, etc;

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What monitoring is needed, and by whom;

  1. The British Association for Counselling and Psychotherapy (BACP) monitors accredited services and should be considered for a wider monitoring role to include services such as Kooth. NHS accreditation should also be accelerated so that people can be confident of using safe and professional services. Social network sites could develop a mental health and emotional wellbeing strategy for its members around usage, culture and behaviours.

What measures, controls or regulation are needed;

  1. Counselling is counselling, whether in a room or via a screen; regulation already in place should be applied to online counselling; the BACP and UK Council for Psychotherapy (UKCP) have written guidelines and policies around this.

Where responsibility and accountability should lie for such measures

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April 2018