School-and community-based counselling services for children and young people aged 7– 18 in the UK: A rapid review of effectiveness, implementation and acceptability

Introduction: Provision of school-and community-based counselling services differs in terms of funding, implementation and eligibility criteria across the UK. The existing evidence of the effectiveness of counselling services is mixed, with little consideration of service context, implementation or acceptability. This rapid


| INTRODUC TI ON
Within the UK, the mental health and well-being of children and young people is a significant public health issue (Gunnell & Kidger, 2018).Almost 20% of learners aged 11-16 years report high rates of symptoms associated with poor mental health (Page et al., 2021).The COVID-19 pandemic exacerbated problems, with 27% of 10-to 11-year-olds reporting emotional difficulties in 2021, compared with 17% in 2019 (Moore et al., 2022).These findings have been reflected globally with a reported increase in depression, anxiety and psychological distress (Kauhanen et al., 2023).Poor mental health potentiates the risk of a range of adverse outcomes, including lower levels of academic attainment (Finning et al., 2020;Lereya et al., 2019;Parker et al., 2019) and being "not in education, employment or training" (NEET).It has been found that 62% of children and young people feel that there is a lack of mental health support available to them in school (Mind, 2021).
Governments across the UK nations provide guidance on the provision of school-and community-based counselling services to support the mental health and well-being of children and young people (Department for Education, 2016; Education Authority, 2020; Scottish Government, 2020;Welsh Government, 2013).Counselling is defined as the professional delivery of therapeutic services by a qualified practitioner (Psychotherapy, 2023).However, there is notable variation in approach to the funding, implementation and eligibility criteria (Department for Education, 2016; Scottish Government, 2020;Welsh Government, 2013).Following the COVID-19 pandemic, variation in provision has potentially increased (Psychotherapy BAfCa, 2022).Demand for counselling has been high since the pandemic, with 12,522 children or young people receiving counselling services in 2021/2022 in Wales, the highest number since this data collection in 2015 (Welsh Goverment, 2023).
In turn, waiting lists can be problematic, and service capacity is often overstretched (British Association for Counselling and Psychotherapy, 2022) leading to potential variation in the implementation of the service.
There is mixed and somewhat equivocal evidence on the effectiveness of school-and community-based counselling in the UK context.A number of studies have demonstrated short-term positive impacts on mental health outcomes, but these are not sustained longer term (Cooper et al., 2010;Cooper, Stafford, et al., 2021;McArdle et al., 2002;McArthur et al., 2013;Pearce et al., 2017;Pybis et al., 2015).Mixed impacts have been found for a number of more robust studies (Beecham et al., 2019;Cooper, Stafford, et al., 2021).
These include the ETHOS study (Cooper, Stafford, et al., 2021), where evaluation through randomised controlled trial found positive effects for the Young Persons Clinical Outcomes in Routine Evaluation (0.25, 0.03-0.47),but not for anxiety and depression (0.92, −1.53 to 3.38).This is in contrast with the evidence base that comes from the United States (US), which finds large effects sizes for school counselling (Gerler et al., 1985;Pattison & Harris, 2006;Prout & Prout, 1998).However, school counselling within the US tends to take a cognitive behavioural therapy (CBT) approach and has a focus on educational attainment compared with school counselling in the UK (Jenkins, 2009).The US approach is similar to what is offered globally in terms of being more directive and with a focus on educational attainment (Hui, 2002).Therefore, it is important to understand the unique school-and community-based counselling that is offered within the UK.
Systematic and literature reviews (Cooper, Pybis, et al., 2013;Lalor et al., 2006;Pattison & Harris, 2006) have aimed to synthesise the evidence base on counselling; however, they tend to be limited by a focus on effectiveness, rather than focussing on intervention context, implementation or stakeholder acceptability.This reflects a wider issue in the counselling literature, namely that it has been slow health and well-being, rapid review, school-and community-based counselling

Implications for practice and policy
• A complex system approach should be taken to understand the features of the system that counselling services need to adapt to in order to become embedded in a sustainable way (Gunnell & Kidger, 2018;Page et al., 2021).For example, an appropriate and confidential space for counselling should be provided.Ideally, the space should have a concealed entrance, be a private space where no one will overhear and be a nicely furnished room with a comfortable chair.
• Counselling should also be easily accessible with multiple and clear referral pathways.Learners should be able to self-refer, and any other referral should be made with the involvement of the learner.
• Research has indicated the importance of involving children in decisions and processes about their own mental health (Finning et al., 2020).Counselling should also be tailored to the needs of children (Lereya et al., 2019;Parker et al., 2019).Without this, the counselling process can be disrupted and learners unmotivated to engage in the process (Everall & Paulson, 2002).
• Finally, in terms of policy, the wider system in which counselling is delivered should be considered.For example, high-quality relationships between stakeholders and reducing stigma around mental health should be prioritised.These relationships will increase awareness of other organisations and services in the system.
to incorporate a complex system lens to service development and evaluation (Jacobson et al., 2019;Langellier et al., 2019).Complex system approaches recognise that intervention effectiveness is contingent on the contextual conditions in which it is implemented and evaluated.As such, to understand whether effective approaches can be scaled, it is important to understand the original delivery setting.Recently, this approach has become more prevalent in systematic reviews, especially within health, and is an important approach that should be applied within the counselling literature (Booth et al., 2019;Petticrew et al., 2019).In addition, the Medical Research Council (MRC) process evaluation guidance emphasises the relations between implementation, mechanisms and context.Therefore, it is important to understand how the intervention will be affected by its existing context and how the intervention may also change aspects of the context in which it is delivered (Moore et al., 2015).Therefore, a review is required that examines effectiveness and process data and addresses the extant gaps and limitations in existing reviews.This approach explores the context, implementation and acceptability in order to understand the intervention functioning and outcomes.This rapid review addressed the following research aims: 1. to explore the effectiveness of school-and community-based counselling services in the UK; 2. to understand how school-and community-based counselling services are implemented within the UK; and 3. to explore the acceptability of school-and community-based counselling services in the UK.

| ME THODS
The research team conducted a rapid evidence review (Varker et al., 2015).This approach was chosen as the aim of the review was to inform government policy (Garritty et al., 2021;Hamel et al., 2021).The rapid review was reported with reference to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist (Appendix B; Liberati et al., 2009).

| Study eligibility criteria
The eligibility criteria were prescribed in accordance with the PICO framework (Appendix F): • Population: participants were children and young people aged 7-18 years.
• Intervention: counselling was defined as: • a professional therapeutic support delivered face-to-face, online or via telephone; • delivered by a professional counsellor or by a child or young person in the role of peer counsellor, with a counsellor who provided support and guidance; • any type of therapeutic approach; and • a minimum of one component had to have been delivered via an educational setting (e.g., school, home school and pupil referral unit) or within a community setting (e.g., youth club, youth centre and community hall).
• Comparator: outcome evaluations did not have to have included a comparator.Where a comparator was specified, it could have included usual care or an alternative provision.
• Outcome: intervention had targets: mental health and wellbeing; intimate partner violence; bullying; and domestic violence.
Outcomes had to have been reported at the level of the child or young person.
• Study design: studies had to have reported data on effectiveness, implementation, acceptability or context.
• Limiters: date of publication was restricted to 1999-current; English and Welsh languages; countries of study conduct were restricted to the UK and Ireland.

| Searches and information sources
A search strategy was developed in Ovid MEDLINE (Appendix C) and adapted to the functionality of each database and website.
Five electronic bibliographic databases were searched: Medline; PsycINFO; Scopus; ERIC; and Social Policy and Practice.Grey literature searches were conducted in 23 national government and third-sector organisational websites (Appendix D).Websites were identified by the research team based on previous experience of related reviews.This ensured that the review could provide suitable evidence to inform government policy.Additional papers were sought from contract from the Welsh government and the research team.Databases and websites were searched from 1999, which marked the transfer of powers to the Welsh Assembly (now known as the Welsh Parliament).Searches were conducted in December 2020 and again in late May 2022.Where Welsh language reports were retrieved, an English language version was also sought for inclusion in the review.

| Screening and selection of studies
Retrieved studies were screened by title and abstract by one reviewer.Studies that were excluded as ineligible were checked by a second reviewer.Following this, the full texts of remaining studies were screened by one reviewer and verified by a second.
Discrepancies were resolved through discussion and recourse to a third reviewer.All papers were downloaded, stored and managed within Endnote.

| Data extraction
A data extraction form was developed and piloted with a subset of studies.The standardised data extraction from (Appendix E)

| Risk of bias
Methodologically appropriate quality appraisal tools were used to assess the quality of each study.Randomised control trials (RCTs), quasi-experimental, cross-sectional, cohort, case and qualitative studies were all checked using the Joanna Briggs Institute Checklist appropriate to the study type (Joanna Briggs Institute, 2017).Preand poststudies were checked with the National Heart, Lung and Blood Institute Quality Assessment Tool for Before-After (Pre-Post) Studies With No-Control Group (National Heart L, and Blood Institute, 2019).For mixed method studies where a methodology was only reported for an outcome evaluation, with a brief reference to qualitative data in the findings, only the outcome evaluation component was appraised.For mixed method studies where a methodology was presented for each composite method, each method was appraised separately (e.g., qualitative component appraised with qualitative methodological tool and outcome evaluation component appraised with RCT methodological tool).
Quality appraisal tools were not used to determine study eligibility.Quality appraisal was conducted by one reviewer independently and checked by a second.Discrepancies in extraction were resolved through discussion, sometimes with recourse to a third reviewer.

| Data synthesis
A narrative synthesis was undertaken, with separate narrative summaries constructed for the research aims on intervention effectiveness, implementation and acceptability.These were accompanied by a descriptive table reporting study characteristics and key findings.

| Study characteristics
Database searches identified 1,530 study reports, with an additional five study reports identified via grey literature searches.Following the removal of duplicates, titles and abstracts of 1,274 study reports were assessed.A total of 1,044 studies were excluded at this stage.
The full texts of the remaining 227 study reports were screened.On completion of screening, 66 study reports were eligible for inclusion in the review.These were linked to 54 different evaluations of counselling provision.The process of study retrieval is reported in the PRISMA flow diagram (Figure 1 and Appendix A).

| Population and setting
Eleven studies were conducted in primary educational settings, and 36 were undertaken in secondary educational settings.Two studies were conducted in specialist educational settings for learners with additional needs.One study was conducted in a college.Three studies were undertaken in community services, for example, via youth services.Nine studies were conducted through a combination of primary, secondary, specialist and community settings.Two studies were conducted through a counselling service.Two studies did not specify a setting (Appendix F).

| Study design
There were 32 studies that conducted an evaluation on effectiveness, 27 studies reported implementation and 34 studies addressed acceptability.Some studies reported more than one type of evaluation design and data.

| Mental health and well-being outcomes and outcome measurements
Of the studies that measured changes in student mental health and well-being after they received counselling, two validated measures were commonly used.Nine studies employed the Young Persons Clinical Outcomes in Routine Evaluation (YP-CORE) measure.The YP-CORE is a 10-item self-report measure of emotional well-being for 11-to 16-year-olds, which covers domains of well-being, problems and symptoms, functioning and risk.Nine studies used the Strengths and Difficulties Questionnaire (SDQ).The SDQ is a brief behavioural screening instrument, which includes emotional symptoms, conduct problems, hyperactivity/inattention, peer relationships and prosocial behaviour.For the SDQ, child and young person, teacher and parent versions were used.

| Study quality appraisal
For a number of designs, there were issues with small sample sizes, a lack of clear description of the counselling services delivered and the study participants, and only a single measure of the outcome at a single time point.There were a number of further issues identified for each study design.For RCTs, there were baseline imbalances across arms, and there was contamination across intervention and control groups.For nonrandomised controlled trials, it was unclear whether the comparison group received counselling or a similar service.With pre-and postevaluation designs, there were reported issues with treatment integrity.Qualitative studies were limited by limited reporting on the perspectives and background of the researcher(s) (Appendix G).

| Effectiveness of school-and community-based counselling services
In total, 33 studies reported on the effectiveness of school-and community-based counselling.This section will provide evidence from the following: primary school settings; secondary school settings; specialist educational settings; and community settings.
Within the findings for each type of setting, data will be presented starting from the most scientifically robust evaluation method.
Overall, the evidence base is mixed, and the limited quality of the evaluations means that it is unclear which approaches might be effective.There is no clear evidence of effectiveness for the robust student designs; however, there is some tentative evidence for positive impacts within the weaker study designs.Additionally, due to the wide variety of approaches being evaluated, it is not possible to say which therapeutic approach is most suitable for the school and community setting.
Ten evaluations were conducted with learners in primary schools (Cooper, Stafford, et al., 2021;Cooper, Stewart, et al., 2013;Daniunaite et al., 2015;Economics PB, 2018;Finning et al., 2021;Lee et al., 2009;McArdle et al., 2002;Sherr et al., 1999;Sherr & Sterne, 1999).The one RCT conducted with learners primarily in primary school found that, after 12 weeks, learners participating in both group therapy and curriculum studies groups reported reduced problem behaviours (McArdle et al., 2002).The group therapy was, therefore, not seen to be more effective than the curriculum study approach.The feasibility cluster randomised design did not show a significant improvement in the SDQ measurements (Cooper, Duncan, et al., 2021).Both of the nonrandomised controlled evaluations (Finning et al., 2021;Sherr & Sterne, 1999) and four of the pre-and poststudy designs (Daniunaite et al., 2015;Economics PB, 2018;Lee et al., 2009;Sherr et al., 1999) related to school counselling provided by the charity organisation Place2Be.All of the studies found an improvement in mental health using either parent or teacher reporting (Finning et al., 2021), learner reporting (Sherr & Sterne, 1999), counsellor reporting (Sherr et al., 1999) or the SDQ measurement (Daniunaite et al., 2015;Economics PB, 2018;Lee et al., 2009).In addition, a study evaluating a variety of counselling approaches found that there were large reductions in psychological distress for learners (Cooper, Stewart, et al., 2013).However, it has also been found that learners who received one-to-one counselling reported better outcomes than those who received group counselling, but these were not sustained six months after receiving counselling (Lee et al., 2009).
Eighteen studies reported evaluations in secondary schools (Beecham et al., 2019;Churchman et al., 2020Churchman et al., , 2021;;Churchman, Mansell, Al-Nufoury, & Tai, 2019;Churchman, Mansell, & Tai, 2019;Cooper et al., 2010Cooper et al., , 2014Cooper et al., , 2019;;Cooper, Duncan, et al., 2021; F I G U R E 1 PRISMA 2020 flow diagram for new systematic reviews that included searches of databases, registers and other sources.Cooper, Pybis, et al., 2013;Fox & Butler, 2007, 2009;Hanley et al., 2011;McArthur et al., 2013;McElearney et al., 2013;Pearce et al., 2017;Pybis et al., 2015;Stafford et al., 2018).One of the most robust evaluations to date is the ETHOS trial, which assessed the impact of a 10-week school-based humanistic counselling programme on psychological distress (Cooper, Duncan, et al., 2021;Stafford et al., 2018).Using the YP-CORE, the intervention was found to have a small positive effect 12 weeks after young people received the counselling provision, and the impact was sustained 24 weeks after the intervention.Some improvements were also seen in measures for young people's goal attainment, self-esteem, well-being and psychological difficulties.However, a positive impact was not found for young people's anxiety and depression, externalised difficulties, engagement with school, school outcomes or educational outcomes.
A further five studies reported on four small pilot RCTs that looked at the same counselling approach.These studies reported mixed results (Aithal et al., 2021;Beecham et al., 2019;Cooper et al., 2010;McArthur et al., 2013;Pearce et al., 2017;Pybis et al., 2015).After 12 weeks, McArthur et al. (2013) found that those who received school-based humanistic counselling had made significant improvements on the YP-CORE compared with those who did not receive the intervention.Pearce et al. (2017) and Pybis et al. (2015) found that counselling was initially effective as rated on the YP-CORE; however, the impact was not sustained at further follow-ups.Furthermore, Cooper et al. (2010) found no significant effect six weeks after attending counselling when measured on the SDQ.Eight evaluations of secondary school-based counselling that used a pre-and postdesign were reported (Churchman et al., 2020;Churchman, Mansell, & Tai, 2019;Cooper et al., 2014Cooper et al., , 2019;;Cooper, Pybis, et al., 2013;Fox & Butler, 2009;Hanley et al., 2011;McElearney et al., 2013).Overall, it was found that school-based counselling had a positive impact on learners' psychological well-being.
Looking at other settings, one study reported an evaluation of counselling in a specialist education setting (Cobbett, 2016).This nonrandomised study (Cobbett, 2016) delivered arts therapies coupled with person-centred counselling.There were significant differences in ratings of the SDQ between learners who received the intervention and those who did not.Within the community, two preand poststudies (Duncan et al., 2020;Wilkinson et al., 2018) were conducted.Duncan et al. (2020) collected data from young people who accessed Youth Information, Advice and Counselling Services (YIACS).The YP-CORE results suggested that counselling had a positive impact on their mental health.The final study (Wilkinson et al., 2018) investigated the effectiveness of interpersonal counselling (IPC) provided by an Early Help Team.This study again found improvements in mental health, with a reduction on the Revised Child Depression and Anxiety Scale (RCADS) for all participants.
Overall, the evidence base was mixed, with no clear evidence of effectiveness within the robust designs but some tentative evidence of positive impacts on children and young people's mental health and well-being within the weaker designs.Equally, no studies found counselling provision to be harmful, or to have any unintended impacts.

| Implementation of school-and community-based counselling
In total, 24 studies reported findings on the implementation of counselling in school-and community-based settings.Six key implementation factors were reported: a flexible and inclusive approach; service awareness; access; the location of counselling, including atmosphere and location; the relationship between counsellors and children and young people; and the relationship between counsellors and schools.Overall, it was found that factors needed to enhance provision include an inclusive approach that meets diverse needs, service awareness and knowledge, ease of access, sufficient resources, improvement in perceptions of the service and highquality stakeholder relationships.
The first aspect of implementation was the delivery approach used, and the importance of a flexible and inclusive range of techniques.This was reported in primary school, secondary school and community settings (Pattison, 2010;Warr, 2010).Pattison (2010) reported results from an evaluation of the inclusivity of school counselling services for learners who have learning disabilities.
Several counselling approaches were considered to be inclusive, including integrative, humanistic, person-centred or psychodynamic (Pattison, 2010;Westergaard, 2012Westergaard, , 2013)).In terms of mode of delivery, counsellors reported that engaging a range of modalities could be beneficial (Hennigan & Goss, 2016).In terms of service awareness, studies identified that there was a need to ensure high levels of service awareness across staff, learners and parents/caregivers (Fox & Butler, 2007;Le Surf & Lynch, 1999).
Within the community, awareness of counselling services was considered problematic, and young people suggested greater publicity of the counselling service was necessary (Le Surf & Lynch, 1999).
Although in some cases awareness was high, learners were unsure about how to access counselling, who the counsellors were and the range of issues that counsellors could help with (Fox & Butler, 2007).Negative perceptions of counselling among children and young people were also an issue, as although they were aware of the service, they had misunderstandings about the service and what it means to ask for help.They were concerned about being stigmatised/teased or exacerbating existing situations involving bullying (Fox & Butler, 2007;Le Surf & Lynch, 1999;Parsons & Dubrow-Marshall, 2018, 2019;Prior, 2012a).In particular, young men who accessed counselling in the community were concerned about how they would be perceived by their peers if they asked for help (Le Surf & Lynch, 1999).
Studies found that secondary school learners considered it positive that they could access counselling during the school day (Duffy et al., 2021;McArthur et al., 2016) and suggested that having the option to drop-in to the service before deciding to have counselling could support their understanding and decision-making process (Le Surf & Lynch, 1999).However, learners also felt there could be negative impacts on educational outcomes if sessions were held at the same time each week (Duffy et al., 2021).It was identified that even if the school created an accessible environment for counselling, there was still a key issue with waiting lists due to lack of counselling staff and therefore a delay in learners accessing necessary support (Government W, 2011a(Government W, , 2011b;;Hamilton-Roberts, 2012;Parsons & Dubrow-Marshall, 2018).In some instances, it was reported that professionals were discouraged from making referrals to services due to waiting lists (Le Surf & Lynch, 1999).
In terms of the atmosphere created by the environment, it was important that a relaxing space was created to deliver counselling, which could improve the counselling experience (Churchman, Mansell, & Tai, 2019;Westergaard, 2012Westergaard, , 2013)).Farr et al. (2021) reported that within the community, the space should be easily accessible from home and school, and the venue should have an appropriate space in which users would not encounter others who they might find intimidating.It was also imperative that counselling was delivered in a confidential environment.Learners were concerned about how confidentiality would be approached in a school setting and whether it would be maintained by counsellors (Fox & Butler, 2007;Le Surf & Lynch, 1999;McArthur et al., 2016;Prior, 2012b).Learners identified that they were concerned about the privacy of the counselling location and that this should be discrete but easily accessible (Duffy et al., 2021;Fox & Butler, 2007;Le Surf & Lynch, 1999;Parsons & Dubrow-Marshall, 2018).
Establishing a trusting and empathetic relationship with the counsellor was also a key aspect (Verasammy & Cooper, 2021;Westergaard, 2012Westergaard, , 2013)), and learners expressed that knowing the counsellor was independent from the school facilitated this (McArthur et al., 2016;Prior, 2012b).They also identified that having a choice of counsellor was important to accommodate any preferences they may have (i.e., gender or ethnicity; Fox & Butler, 2007).Ensuring a good ending to therapy and reflecting on barriers and facilitators to change was also important (Bamford & Akhurst, 2014).
Examining the relationship between counsellors and schools, it was important that counsellors were integrated within the school (Prior, 2012b).Counsellors wanted school staff to support their role and suggested that greater awareness of counselling practices could improve relationships (Hamilton-Roberts, 2012).Tensions could arise in the relationship between counsellors and school staff due to differing perceptions of issues raised by learners and understanding of appropriate outcomes from counselling (Hamilton-Roberts, 2012).In an evaluation of counselling in primary schools, counsellors reported the need to invest time into establishing good relationships with school staff and adequately explaining the service (Wilson et al., 2003).

| Acceptability
In total, 31 studies reported on the acceptability of school and community counselling.This section explores the perspectives and experiences of those involved in receiving or delivery counselling services, notably children and young people, parents/carers, school staff and counsellors.It was found that, overall, school-and community-based counselling services demonstrate high levels of acceptability.There are particular approaches and principles to counselling that are experienced positively, notably services that offer choice and encourage young people to be involved in decisionmaking about sessions.Online services have potential and were considered as a useful supplement to in-person provision.There were some aspects that were not positively experienced, which may be addressed in any future counselling service.
Overall, counselling was perceived as acceptable to learners across all settings.Five studies reported on the acceptability of counselling within primary school settings (Government Three qualitative evaluations reported on the acceptability of counselling within specialist school settings (Cobbett, 2016;Pattison & Harris, 2006;Warr, 2010).Three evaluations reported on the acceptability of counselling within community settings (Duncan et al., 2020;Lalor et al., 2006;Wilkinson et al., 2018).However, there were some learners who reported issues around counselling acceptability.
Learners across primary and secondary school settings reported a number of positive and negative experiences and per-  Lynass et al., 2012).Learners perceived that techniques they had learnt in counselling would be useful in future, such as coping strategies, how to talk about their emotions, self-relaxation and anger management (Kernaghan & Stewart, 2016;McArthur et al., 2016).
Although learners liked accessing counselling at school, some learners found missing lessons and going back to the classroom challenging.Additionally, some learners felt uncomfortable discussing their emotional experiences (Wilson et al., 2003), and within secondary school, some learners perceived seeing a counsellor as demonstrating weakness (Prior, 2012a).
Learners in primary school liked the therapeutic play approach (Kernaghan & Stewart, 2016) However, some learners found it difficult to share their personal experiences in a group setting.Dance Movement Psychotherapy group was delivered to learners with special educational needs and those experiencing social and emotional difficulties (Parsons & Dubrow-Marshall, 2018, 2019).Learners reported positive emotions due to the therapy, which included enjoyment, self-confidence and feeling empowered (Longhurst et al., 2022).Young people reported that interpersonal counselling helped them recognise their own depressive symptoms and understand what steps they could take to help themselves (Government W, 2011a(Government W, , 2011b)).It was also noted that some young people found talking about their problems difficult and the end of counselling could present difficulties (Wilkinson et al., 2018).
Within specialist school settings, learners reported that arts therapy was beneficial in a number of ways, which included using a preexisting skill, regulating emotions, experiencing positive emotions and expressing themselves through non-verbal methods of communication.Learners also reported a preference for arts therapy rather than therapy from Child and Adolescent Mental Health Services (CAHMS), which they felt could lead to stigma (Cobbett, 2016).
In terms of mode of delivery, studies explored avatar-based counselling (Cooper et al., 2019;van Rijn et al., 2018) and online therapy (Hanley et al., 2017).Learners reported high levels of satisfaction with avatar-based counselling, with male learners being more satisfied than female learners (Cooper et al., 2019).In a qualitative evaluation of avatar-based counselling, learners reported that counselling was helpful.Some learners felt that the avatar software helped them to express their feelings; however, others found the software acted as a barrier to talking to the counsellor.All learners who reported that the software was not helpful were female learners, and the majority were from Black, Asian and minority ethnic backgrounds (van Rijn et al., 2018).In addition, online counselling may be an appropriate supplementary service to face-to-face counselling for learners (Hanley et al., 2011).
Parents also viewed counselling as beneficial.They reported improvements in emotional competence; better relationships with family, peers and school; and coping with parental separation (Wilson et al., 2003).However, some reported that their child found counselling boring, troubling or disappointing.Some parents also reported that learners were unsettled by the counselling and had negative emotional experiences such as anger or decreased selfconfidence (Wilson et al., 2003).In addition, cultural aspects impacted the acceptability of counselling for parents.In one orthodox Jewish school, poor perceptions were attributed to facing stigma in the community, asking for advice or permission from a rabbi, and the desire for counsellors to be compatible with the cultural and religious beliefs of the school community (Sharman & Jinks, 2019).
School staff also valued the counselling service, and it was seen to be sensitive to the needs of different communities (Government W, 2011a(Government W, , 2011b)).Loynd et al. (2005) found that teachers were positive about counselling being available within the school.Secondary school staff considered counselling as a key service in addressing self-harm issues for learners (Evans et al., 2019).However, 27% of teachers reported concerns about counselling taking place within the school and thought learners might take advantage of the service in order to avoid lessons (Loynd et al., 2005).Further to this, in the evaluation of home-school support workers (Vulliamy & Webb, 2003), some teachers felt that this approach conflicted with schools' values, as it potentially compromised a disciplinary approach to managing challenging learner behaviour.However, counsellors believed that school counselling services were valuable due to the person-centred nature of counselling and the ability to be independent from the school community (Hamilton-Roberts, 2012).

| DISCUSS ION
The present rapid review draws together the current evidence base on the effectiveness, implementation and acceptability of schooland community-based counselling services for children and young people aged 7-18 in the UK.This review recognises implementation and acceptability, which have previously not been focussed on, as important aspects that should be considered during intervention development and evaluation (Skivington et al., 2021).In addition, previous effectiveness results have not been understood through a complex system approach, which may account for the mixed findings within the area.This review has explored the context, implementation and acceptability in order to understand the intervention functioning and outcomes.These findings contribute to an understanding of how school-and community-based counselling services meet the needs of the target population and interact with the organisation (Skivington et al., 2021).
It is difficult to draw conclusions as to whether school-and community-based counselling services in the UK are effective, in part due to the limited evidence base and because a limited range of therapeutic approaches have been tested.Many of the 33 evaluations do not specify which therapeutic approach was evaluated, and those that do tend to draw upon a limited range of therapeutic approaches.They tended to only use a person-centred/humanistic, or integrative orientated intervention.Therefore, it is unknown whether other therapeutic approaches might be more effective.
Evidence from outside UK schools suggests that CBT and interpersonal therapy might be effective, but this has not been tested within the UK (Cooper, Stafford, et al., 2021;Pattison & Harris, 2006).
However, it must be noted that these approaches are more structured with specific goals, which could lead to easier measurement.
The focus of school counselling outside the UK tends to also be on academic attainment, and career guidance therefore has different potential outcomes (Foster-Fishman et al., 2007;Hui, 2002;Jenkins, 2009).Further to this, the evidence base across primary and secondary schools cannot be pooled together as they use very different approaches due to the younger age group.Due to the number of limitations within the included studies, the results from this review should be interpreted with caution.
Overall, the evidence for effectiveness is limited and mixed.
Where robust study designs are used, there is no clear evidence of effectiveness.For weaker study designs, there is some tentative evidence that counselling may have positive impacts across different settings.Within the different settings, there are more robust evaluations in secondary schools, which have shown mixed effects.
However, there is a poor evidence base in both primary school and community settings.Taking this into account, there is some tentative indication that counselling might positively impact young people's mental health and well-being, but again, more research is needed.
Importantly, there is no evidence of harm.In addition to this, there was evidence from the acceptability data that learners, teachers and parents felt that counselling improved mental health.There were also key learning points in terms of areas for improvement that could inform future interventions and the counselling service.
One of the key issues identified was that counselling has been implemented as a discrete intervention and has not taken into account the complex school context and the wider education system.
Few of the interventions identified were designed and delivered in a way that took account of the education system and therefore did not have a priori system-thinking lens approach.This meant that the non-linear relationships, feedback loops and dynamic interacting elements of a system approach were not considered during the planning, implementation or reporting of the counselling service (Hawe et al., 2009).Therefore, the data within this paper have identified what an ideal service should look like and barriers and facilitators to this.In addition, this paper found that there are limited data on the wider system, which would have allowed for an understanding of the underlying operational mechanisms (Allender et al., 2015).In order to understand further how the counselling service is interacting with the education system, focus should be given to system norms, financial resources, human resources, social resources, regulations and operations (Foster-Fishman et al., 2007).
However, the acceptability and implementation data are helpful in explaining the mixed effectiveness findings within this review.There were several implementation issues identified that could have affected the overall effectiveness outcomes.Many of the participants did not know about the service or had misconceptions about the service, which inhibited access (Duffy et al., 2021;Fox & Butler, 2007;Government W, 2011aGovernment W, , 2011b;;Hamilton-Roberts, 2012;Hennigan & Goss, 2016;Lalor et al., 2006;Le Surf & Lynch, 1999;McArthur et al., 2016;Parsons & Dubrow-Marshall, 2018;Pattison, 2010;Prior, 2012aPrior, , 2012b;;Spratt et al., 2007).In addition, there were issues with the counselling space and its location leading to concerns about confidentiality (Duffy et al., 2021;Fox & Butler, 2007;Le Surf & Lynch, 1999;Parsons & Dubrow-Marshall, 2018).It was also found that it is important to tailor the therapeutic approach for the age range and the needs of the child receiving counselling.According to the NICE guidance for mild depression, there are a number of therapeutic approaches that could be considered and adapted to the developmental needs of the child as required (The National Institute for Health and Care Excellence, 2019).Finally, problems with how counsellors were integrated within the school (Prior, 2012b) were identified, which impacted the support that counselling received from the school staff (Hamilton-Roberts, 2012).This may explain some of the mixed effectiveness finding, as without sufficient integration and awareness of the service, there may be limited impact the service can have.Although there were implementation issues, there is a volume of evidence within the acceptability data that the counselling service is highly valued by learners, teachers and parents (Evans et al., 2019;Government W, 2011aGovernment W, , 2011b;;Loynd et al., 2005;Wilkinson et al., 2018).Therefore, despite the implementation issues and whether counselling is viewed as a discrete intervention, it is seen as an important service within the school and community settings.Overall, these findings provide some key insights into how counselling interventions could be improved going forward, which could lead to changes in effectivities findings.

| Review strengths and limitations
There are a number of strengths to this rapid review.The review involved policy stakeholders in the research by ensuring they were consulted during the development and implementation of the search strategy.The research team included an information specialist with expertise in systematic reviewing who was involved throughout the review process.The review also employed systematic processes, such as following the PRISMA checklist.Finally, the review used standardised critical appraisal tools to check the quality of all included studies.
There are, however, some limitations to the rapid review as the rapid methodology means the search may not have been fully comprehensive.Further databases and grey literature could have been searched.Searches were also restricted to the UK and Ireland, which limits the applicability of the review findings to other countries as a result of the specific education settings and policies within the UK and Ireland.In addition to this, the review team did not perform screening independently in duplicate.However, the team did mitigate this by a second reviewer completing checks.Similarly, data extraction and quality appraisal were conducted by one reviewer and checked by a second.Therefore, some bias could have been introduced to the screening, extraction and appraisal processes.In addition to this, the grey literature was selected by the research team, which could have introduced section bias.However, the nature of the grey literature was to provide policy context to the review as required by the government funder to ensure the review was fit for purpose to inform future government policy.

| Implications for future research, policy and practice
Future research should concentrate on building the evidence base for counselling across secondary, primary and community provision.
During development, counselling interventions need to attend to context, implementation and acceptability.As per the MRC framework for complex interventions, this review has found that contextual factors need to be considered from development through to evaluation (Skivington et al., 2021).In terms of evaluation, researchers need to conduct robust studies through RCTs and qualitative process evaluations with a system-focussed perspective, to capture intervention implementation and acceptability (McGill et al., 2020;Moore et al., 2015).It is important to build an evidence base that can be used to better inform public health decision-makers.By using the complex system approach, evidence can be developed that takes account of real-world complexity (McGill et al., 2020).Future research should start by trying to understand the complex education system in its current state and then to understand how the system undergoes change as part of the implementation of the counselling intervention (McGill et al., 2020).Future RCTs should also ensure that they are able to capture what works, for whom and under what circumstances (Fletcher et al., 2016).This evidence base will contribute to longer term sustainability and ensure that mental health support within schools takes a stepped care model (most effective, yet least resource-intensive treatment).In addition, it is important in terms of reporting that it is clear what is being tested and there should be better reporting of the context.
In terms of implications for policy and practice, a complex system approach should be taken to understand the features of the system that counselling services need to adapt to in order to become embedded in a sustainable way (Hawe et al., 2009;Moore et al., 2015).For example, an appropriate and confidential space for counselling should be provided.Ideally, the space should have a concealed entrance, be a private space where no one will overhear and be a nicely furnished room with a comfortable chair.However, the extent to which counselling within schools can be guaranteed to be confidential has been questioned.Learners are likely to know each other, to have classes together, to be aware of others attending counselling sessions and to see the school counsellor interacting with pupils and staff around the school (Clifford-Poston, 2000).
Counselling should be embedded into the whole education system (Hawe et al., 2009).Awareness of the service and how the service can be accessed should be improved (Fox & Butler, 2007).
Counselling should also be easily accessible with multiple and clear referral pathways.Learners should be able to self-refer, and any other referral should be made with the involvement of the learner.
Finally, research among young people has indicated the importance of involving them in decisions and processes about their own mental health (Health Do, 2012).Counselling should also be tailored to the needs of children (Cooper et al., 2010;Westergaard, 2012).Without this, the counselling process can be disrupted and learners are unmotivated to engage in the process (Everall & Paulson, 2002).
Finally, in terms of policy, it is recommended that the wider system in which counselling is delivered should be taken into consideration.For example, high-quality relationships between stakeholders and reducing stigma around mental health should be prioritised.
These relationships will increase awareness of other organisations and services in the system (Hewitt et al., 2022).In addition, conversations about mental health and well-being and help-seeking will aid in normalising counselling (Pattison, 2010).Staff should also be trained to understand counselling and in skills to support children and young people with their well-being.In addition to this, there should be an evaluation infrastructure that is put in place to monitor the implementation of the service to ensure a high-quality, sustainable counselling service is delivered.This could potentially follow the Accountability Bridge Model (Coker et al., 2004), which aids school counsellors in the planning, delivery and assessment of the effectiveness and impact of their services.

| CON CLUS ION
Based on this rapid review, there is limited evidence from a UK context that school-or community-based counselling services improve mental health and well-being outcomes for those children and young people who attend.The few RCT studies suggest that there is no clear evidence of effectiveness due to the mixed findings across the outcomes and timelines.However, these studies looked only at a humanistic counselling approach, and further research needs to be conducted looking at other therapeutic approaches or a tailored counselling approach, which are being used outside the UK.
For weaker study designs, there is some tentative evidence that counselling may have positive impacts across different settings.In addition, there is a volume of evidence within the acceptability data that the counselling service is highly valued by learners, teachers and parents and is seen as an intervention that can improve wellbeing and support educational attainment.The main finding for the implementation data was that counselling is often seen as a discrete service that is not well-embedded within the education system.Due to the number of limitations within the included studies, the results from this review should be interpreted with caution.Future work is needed to improve the implementation of counselling services based on complex system thinking to ensure that we understand/ anticipate how the intervention works with the system and the system influences the intervention.In addition, key factors identified in this review, such as awareness raising, stakeholder relationships and improvements in confidentiality, and the complex implications of this when applying it to the education setting, should be considered for future interventions.

AUTH O R CO NTR I B UTI O N S
Lauren

ACK N O WLE D G E M ENTS
We express our gratitude to the study participants of all the included research papers.We also extend our thanks to members of the research team, Helen Morgan, Rohen Renold, Matt Davies, Peter Gee and Joan Roberts.

FU N D I N G I N FO R M ATI O N
The data used in this article are from a study commissioned by

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors have no conflict of interest in relation to the study undertaken for this paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
The Welsh government are the data controller for this study; however, as this is a rapid review, all data are available via the published papers included.

PATI E NT CO N S E NT S TATE M E NT
Not applicable.

PE R M I SS I O N TO R E PRO D U CE M ATE R I A L FRO M OTH E R S O U RCE S
Not applicable.

CLI N I C A L TR I A L R EG I S TR ATI O N
Not applicable.

A PPE N D I X A Characteristics of included study reports
Author, year

Checklist item
Within a community setting, young people suggested that developing telephone counselling services could improve the accessibility of services (Le Surf & Lynch, 1999).However, counsellors did identify barriers to the development of online counselling services such as lack of resources and training; issues around confidentiality; loss of quality in the therapeutic relationship; and concerns for learners in terms of the need for immediate support (Hennigan & Goss, 2016).

the
Welsh government in 2020 to conduct a review of schooland community-based counselling services, to support optimisation of existing services for 11-to 18-year-olds, and extension to younger primary school-aged children.The Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement (DECIPHer) is funded by the Welsh government through Health and Care Research Wales.The study was also supported by the Wolfson Centre for Young People's Mental Health, established with a grant from the Wolfson Foundation.

First
Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Quality Appraisal of Qualitative Study Designs 17461405, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License included the following: study details, intervention and comparator, participants, outcomes, findings, and strengths and limitations.Data were extracted by one reviewer and checked by a second.

Identification of studies via databases and registers Identification of studies via other methods Identificat-ion Screening Included
17461405, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Rapid evidence review search strategy Database: Ovid MEDLINE(R) ALL <1946 to November 17, 2020> Search Hits
Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 17461405, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 17461405, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 17461405, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License A P P E N D I X A (Continued)A P P E N D I X A (Continued)A P P E N D I X A (Continued)

D I X D Grey literature searches and study retrievals Website (date/initials) Total hits
Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/capr.12688 by Welsh Assembly Government, Wiley Online Library on [14/05/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License A PPE N D I X G