1 INTRODUCTION

Adolescence is a critical period for biological, psychological and social change, and reflects the constant evolution of one's environment and experiences (Blakemore, 2019). Whilst this transition into adulthood is a universal—yet unique—experience, this gives rise to vulnerability to mental health difficulties (Kessler et al., 2005). Within the UK, one in twelve 5- to 19-year-olds are diagnosed with an emotional disorder, with children and young people from lower-income backgrounds presenting with the highest rates (Sadler et al., 2017). The long-term implications of mental health difficulties among young people tend to persist into adulthood and are associated with the onset of physical health problems later in life (Goodwin et al., 2009; Kessler et al., 2005). In addition, mental health difficulties are found to reciprocally correlate with socio-economic status (Pickett & Wilkinson, 2018; Platt et al., 2017; Reiss, 2013); negatively impact one's quality of life and educational success (Chen et al., 2006; Colman et al., 2009); and pose as a risk factor for engaging in health-risk and self-harm behaviours (Fergusson & Woodward, 2002). Addressing mental health problems among young people has therefore become a public health priority, particularly individuals from disadvantaged backgrounds (e.g. low income, ethnic minority; Kieling et al., 2011).

For some young people, statutory Child and Adolescent Mental Health Services (CAMHS) may be experienced as stigmatising (Iskra et al., 2018; Radez et al., 2020). Moreover, they may lack consideration for individual differences due to emphasising a medicalised approach (Callaghan et al., 2016). They have also been found to be difficult to access due to underinvestment (England & Mughal, 2019), which has led to long waiting times and a general lack of availability, particularly for those from low socio-economic backgrounds (Hansen et al., 2021; Roberts et al., 2016). However, in recent years, the UK Government has attempted to expand the delivery of mental health services within schools (Department of Education, 2016; Department of Health and Social Care & Department for Education, 2017).

Whilst school-based counselling is a confidential service and does not require parental and carer involvement or consent, parents and carers are considered an important referral route (BACP, 2015). They are likely to take on a significant responsibility for managing mental health difficulties in adolescents and may, therefore, influence intervention acceptability and adherence (Nock & Ferriter, 2005; Stiffman et al., 2004). This is demonstrated by young people's engagement and their outcomes being influenced by parents' and carers' perceptions of interventions (Logan & King, 2001; Schlimm et al., 2021). It is estimated that between a half and two-thirds of parents and carers are aware of their child attending counselling (Cooper, 2009). The experiences and perceptions of parents and carers are therefore an important area of consideration for developing and evaluating school-based counselling, as well as gaining further insight into its wider impact (Stapley, Midgley, et al., 2016; Stapley, Sharples, et al., 2016).

Despite this, there is limited literature on the perceptions of parents and carers towards school-based counselling (Cooper, 2013). Existing literature has, instead, focused on parents' and carers' perceptions—and experiences—of specialised mental health services for young people (e.g. CAMHS; Bone et al., 2014; Coyne et al., 2015; Crouch et al., 2019; Stapley, Midgley, et al., 2016; Stapley, Sharples, et al., 2016; Teggart & Linden, 2007). Such studies have, for instance, explored parents' and carers' perceptions of access to—and involvement in—interventions, and examined moderators for parents' and carers' satisfaction using self-report measures (Barber et al., 2006; Bjorngaard et al., 2008; Blader, 2007; Haine-Schlagel & Walsh, 2015; McNicholas et al., 2016; Vaishnavi & Kumar, 2018). The one exception to this is Hill et al.'s (2011) survey of parents' and carers' attitudes to secondary school-based counselling in Wales. The parents and carers predominantly viewed school-based services positively. The study, however, did not elicit the meaning and context behind the parents' and carers' responses.

The aim of this present study was to conduct the first in-depth examination of parents' and carers' perceptions and expectations of the impact of school-based counselling. The study sought to identify perceptions of school-based counselling prior to, during and after receiving this intervention, by providing parents and carers with the opportunity to reflect upon the therapeutic process and their child's experiences. In doing so, the paper aims to contribute to a more comprehensive understanding of the outcomes and process of school-based counselling, thereby contributing to its future development and dissemination.

2 METHODS 2.1 Study design

This study used a qualitative research design and was conducted as part of the wider effectiveness and cost-effectiveness trial of school-based humanistic counselling (ETHOS), a two-arm, parallel-group, individually randomised controlled trial (RCT). The aim of the ETHOS study was to evaluate the effectiveness and cost-effectiveness of SBHC for psychological distress in young people (typical age range 11–18 years) compared to access to a school's usual pastoral care provision, using a representative sample of 18 secondary schools across Greater London, UK (Cooper et al., 2021). All schools in the ETHOS study were state funded: 11 academies, six community schools and one foundation school. Five of the schools were faith schools (Church of England), and five were single sex schools (three all-female, two all-male). Seven (39%) of the schools were in the most deprived Index of Multiple Deprivation quintile. The mean percentage of children from Black and ethnic minorities in the schools was 47%.

2.2 Participants

Parents and carers of young people who had participated in the main ETHOS study were invited to take part in semi-structured interviews following the conclusion of counselling. Parents and carers were selected from a sub-sample of six participating schools from the ETHOS study according to a range of variables, including school type (local-authority-maintained or academy schools), Ofsted rating, student population, and same-sex and mixed-sex student base. Details of 39 parents and carers were obtained following contact with pastoral care staff from participating schools.

A total of 19 participants agreed to be interviewed. During the analysis, two interviews were omitted due to inadequate sound quality and/or content being outside of the scope of the research question. This resulted in 17 interviews being included in the final analysis: 16 female participants and one male participant.

2.3 Procedure

Interviews were conducted by telephone and lasted an average of 25–30 min.

To explore parents' and carers' perceptions and experiences, an interview guide was created to elicit reflections and opinions, including their perceptions of their child's experiences. Parents and carers were asked for their perspective on any noticeable changes in their child during and after counselling. The semi-structured interview guide shown in Table 1 was used flexibly and consisted of questions regarding: (a) their background information (relationship with the child, their child's previous experiences of mental health support), (b) their perception of the counselling (their expectations and goals, experience compared to expectation), and (c) the perceived impact of the counselling (its influence on the child and family relationships). During the interviews, further probing questions were asked about each discussion topic to elicit deeper responses. Interviews were carried out by researchers who were specially trained in working with and listening to young people and parents and carers. The interviews were digitally recorded and transcribed verbatim for analysis.

TABLE 1. Semi-structured interview guide questions Questions Had you talked to your child about mental health in general or their issues before the counselling? What do you think they felt about the counselling in school? Did they talk about the counsellor at all? What were your expectations of the counselling before it started? How did these experiences compare to your expectations? What effect, if any, has the counselling had on [your child] during their sessions and since it finished? 2.4 Ethical considerations

The study consisted of a two-step consent process aimed to ensure that participating parents and carers were fully informed. The first step involved obtaining written consent from parents and carers, and assent from their children, to participate in the ETHOS study, which included information on the possibility of being contacted for interviews. The second step included obtaining written and verbal consent for participation in the interview prior to the start of the phone interview. Ethical approval for the study was obtained under procedures agreed by the University Ethics Committee of the University of Roehampton (reference PSYC 16/227).

2.5 Data analysis

The transcribed text was analysed using thematic analysis following the six steps detailed by Braun and Clarke (2006), shown in Table 2. As the data focussed upon individual experiences, an inductive form of thematic analysis was conducted to identify and report patterns (or themes) of meaning within data. The data review process consisted of analysing data using NVivo 12 (QSR International Pty Ltd, 2018) and data were coded into levels of themes and sub-themes.

TABLE 2. Thematic analysis process based on the procedures outlined by Braun and Clarke () Phase Process Author involvement Phase 1: Data familiarisation Transcribing data, reading and re-reading the data, noting down initial ideas. This familiarisation facilitates an enriched account of the data. JE, ALE, SS Phase 2: Generating initial codes Coding prominent features of the data in a systematic fashion across the entire data set, collating data relevant to each code. Coding can be made at both semantic and latent levels. JE, ALE, SS Phase 3: Searching for themes Collating similar or related codes into potential themes, gathering all data relevant to potential themes. JE, ALE, SS Phase 4: Reviewing and refining themes Reviewing if the themes work in relation to coded extracts (phase 1), as well as the entire data set (phase 2). Themes are reworked until a final set of themes are produced and effectively illustrate the data. ALE, SS Phase 5: Defining and naming themes Themes are refined and developed through finalising names and written definitions, producing an overall ‘story’. PL, ALE, SS, CD, MC Phase 6: Producing the report Producing the report further acts as the final opportunity for analysis. This includes further refinement of themes, by selecting vivid, compelling extract examples which relate the analysis to the research question and literature. PL, ALE, SS, CD, MC 3 RESULTS

Two superordinate themes were identified: (a) the context of the counselling, and (b) the content of the counselling. The context of the counselling was the backdrop to the child's involvement in the school-based counselling, which included home environment and school environment. The content of the counselling related to the different stages of the process, which included before, during and after the counselling, as well as the outcomes.

3.1 The context of the counselling 3.1.1 Home environment

The majority of parents and carers felt that they had an open relationship with their child. They would discuss a range of issues with them, including problems related to life, mental health and managing or processing feelings. As one parent stated: ‘we have quite an open relationship. I know she keeps her feelings quite guarded, but we have an open relationship, and she talks to me about anything’. Some parents and carers, on the other hand, stated that the openness had its limits and that their child would not share everything with them: ‘open and teenagers don't necessarily go together’.

Although most parents and carers felt they already had an open relationship with their child prior to the counselling, they were generally supportive of the child accepting the school-based counselling offer. The offer was seen as an opportunity to talk to someone outside the family who could offer a different kind of support: ‘it was something that I personally as a father wanted him to do, that an opportunity to come along, that was great, so I absolutely snapped it’.

Despite descriptions of having an open relationship, most of the parents and carers experienced an unwillingness from their child to discuss their counselling. For instance, ‘she never ever discussed it at all with me, I'll be honest’, ‘no, she didn't really say much at all’, ‘she didn't really talk a lot about it, she just sort of shrugs, you know? Typical teenager!’ The parents and carers generally accepted the privacy of the counselling and did not delve further into the precise content or how their child experienced it.

3.1.2 School environment

Universally, parents and carers felt glad that the counselling was taking place in the school environment, as they thought it was good to have the counselling in a familiar setting. Moreover, they felt that this accommodated fitting it in around their daily routines: ‘it was kind of more acceptable because it was at school, it wasn't anything special or anything different that she had to make any additional effort for because it was part of the school day’. However, some parents and carers also described how going back to class immediately after counselling may have been distressing for their child.

Parents and carers were generally not concerned about missed lessons and thought that emotional well-being of the child was more important. However, some experienced a degree of anxiety from their children: ‘she had to miss lessons to have the counselling, and then she had to catch up on what she missed’.

Communication was emphasised by parents and carers when it came to the school environment. Many felt they had not received adequate information from the school regarding the counselling. The parents and carers voiced a degree of frustration due to a perceived lack of engagement and, therefore, exclusion. One participant, for instance, said, ‘I had nothing from the school at all. No support, no back-up, no feedback, nothing. That was all down to whether or not I wanted to… I had to contact them, basically’.

3.2 The content of counselling 3.2.1 Before counselling: high hopes and expectations

Most parents and carers were introduced to the school-based counselling study through a letter provided by the school or information provided by their child. Those who had only received a letter appeared to feel less informed about what the study entailed. However, a few parents and carers had received additional information from school staff via face-to-face meetings or over the telephone. These parents and carers reported greater satisfaction regarding the way they were introduced to the study: ‘[the teacher] actually discussed them with me, would I be interested in them doing that? Just to see if it would help them get a bit off their chest and how they feel, and things like that’.

All parents and carers interviewed in this study had consulted their child about receiving counselling. In most cases, the decision to participate was shared and mutual: ‘she was very much for it, and because she was very much for it then that was the decision for me’. Although such participation was mutually agreed, it appeared that the child was provided the autonomy to have the final say on whether or not to join the study.

In terms of the expectations parents and carers had prior to counselling, having someone to speak to (thus having greater access to support) and improved overall well-being were the two most hoped for outcomes. One participant said they wanted their daughter to disclose ‘her feelings, and hopefully, rather than bottle them up, talk to someone and hopefully release any anger or upset that she had there, because she obviously wasn't doing it to us’. Other parents and carers mentioned improved relationships and confidence as outcomes they hoped for, including improved academic performance. However, three parents and carers indicated no expectations: ‘no, no expectations at all. As I say, the trials and research, you just have to take it as it comes, really. I had no expectations at all’.

3.2.2 During counselling: balancing confidentiality with openness Confidentiality of the counselling, and how it led the child to trust the counsellor, was pertinent among parents and carers:

It takes a hell of a lot for him to trust somebody, so he must trust this counsellor a lot because of all of the stuff that he's obviously spoken to them about, he knows it's not going to be going any further.

Parents and carers felt it was positive that the counsellor was independent from the school, as they saw this as enabling their child to speak to somebody who was unaware of social and academic issues. Moreover, parents and carers perceived their child as opening up to their counsellor for other reasons. Participants, for instance, said, ‘she clearly felt comfortable to open and discuss issues that were quite sensitive for her’, ‘I think she just liked to be given the opportunity to get her feelings off her chest, because she does it at home quite regularly, but she does like other people knowing her business!’ Parents and carers also described how the process of trusting the counsellor and opening up led to the child feeling relief during counselling: ‘she said it's good to talk to somebody—especially, the first couple of sessions, you could see that she just seemed a bit more happier, she'd probably unburdened some of her feelings. You could see that’.

Concerns regarding the counselling were, however, expressed by some parents and carers. Some adolescents were reported to come home upset after counselling, thus raising concerns as to whether the counselling period was long enough. Despite this, parents and carers experienced the positive effect of their child receiving vouchers as an incentive for participating in the ETHOS study—a practice which made an impression: ‘he gets excited when he gets his gift vouchers, I promise you that!’.

3.2.3 Outcomes of counselling: cautiously positive Increased confidence and overall well-being were the most positive outcomes perceived by parents and carers. Parents and carers reported that their children had become more confident, as evidenced by them becoming more open and independent, and dressing and behaving differently:

It probably exceeded my expectations because I didn't really think that we would get very far, you know? I didn't really think it was going to make much of a difference, but as I said, she does seem to have more confidence now, and she's doing what it is that she wants to do.

In relation to overall well-being, a majority of parents and carers described how the positive effect of counselling had been sustained for their child: ‘she does seem much happier and not as—we haven't had the phone calls from the school, let's put it like that, for a little while!’ Increased happiness was most commonly reported by parents and carers when asked about the outcomes of the counselling. Other outcomes for adolescents included improved relationships, better academic performance, and an enhanced understanding of oneself. Improved relationships included those inside and outside the family, and were often tied to improved confidence:

I'm actually getting people saying she's like a different person. She's smiling, she's engaging in conversations with other people, not just immediate family and younger family members. She's engaging with the adults, she's engaging with the older teens and things, and she's more confident in herself.

Parents and carers also perceived their child to have improved academic performance, and they connected this to improvements in confidence, well-being and relationships: ‘[it's changed] her attitude towards learning. She's done peer mediation for some of the younger children. She's on the school council. Yes, she's just been putting herself out there’.

Whilst positive outcomes were perceived by most parents and carers, some also described more mixed or negative outcomes. For instance, some felt that counselling had no effect on their child: ‘he hasn't changed, he's still the normal child he was before he started the counselling, so his behaviour hasn't changed or anything like that, he's still a little shit!’ Others felt that the initial positive impact of counselling had lessened over time: ‘she seems to be back to her old self now’. In the minority of cases where negative outcomes were perceived, parents/carers felt it was mainly in relation to overall well-being. Some were concerned this was linked to the form or duration of the counselling: ‘I don't know whether they just touched on things that just opened up more and made her think a bit more deeply, I'm not sure, but she's just definitely worse’. In addition, some parents and carers felt it was too early to say what the outcomes were and whether they were positive or negative: ‘I couldn't say. It's probably a bit too early. I think as they're growing up he will probably get a better understanding of it’.

3.2.4 After counselling: a need for support and re-direction It was common among parents and carers to express regret over counselling not lasting longer: ‘I think the counselling is fantastic and it's a shame that it's not continued’. This reflected previous concerns regarding the duration of counselling as not being long enough for some adolescents involved, and there was concern about what would successively happen: ‘she's going to a different college, so where does she pick up next? Where does she access that support?’ On the other hand, this perception motivated some parents and carers to explore other avenues for continuing support:

It made her and I realise that she needs some more. She needs somebody to talk to. Before, I thought, ‘No, maybe not, they seem to be okay’, but I think after those sessions, we've both realised that she does need to have somebody to chat to.

Several parents and carers mentioned seeking CAMHS support following school-based counselling, but the waiting times for CAMHS were seen as a key problem. Parents and carers also described exploring alternative supportive avenues themselves: ‘it's led to a lot of other stuff we've got to go and seek help somewhere else. I’m going to go to a support group. I need to deal with some of it myself’.

4 DISCUSSION

Managing adolescent mental health difficulties remains a public health priority and requires rigorous and comprehensive research in order to continuously develop and provide effective interventions (Department of Health and Social Care & Department for Education, 2017). Whilst school-based counselling is widely delivered in the UK, research that examines parents' and carers' perceptions remains limited. Broadly speaking, our findings triangulate with evidence for the effectiveness of humanistic counselling (Cooper et al., 2021), with parents and carers seeing it as enhancing their child's sense of self (e.g. increased self-knowledge, self-confidence and willingness to be open), and improved academic performance and relationships (Brännlund et al., 2017; Durlak et al., 2011; Timulak & Creaner, 2010; Wells et al., 2003). By considering the context and content of counselling, our findings have identified potential factors which inform counselling outcomes (e.g. improved self-confidence) within a school setting.

Most pertinently, our findings support schools as a positive setting for providing access to mental health support (Kavanagh et al., 2009; Pearce et al., 2017; Wells et al., 2003). This is imperative to the on-going development of school-based interventions, which can serve to address young people experiencing barriers to accessing support and unmet service needs (i.e. extensive waiting times; Costello et al., 2014; Department of Health and Social Care & Department for Education, 2017; Shanley et al., 2008). Our findings identify factors which both support and contextualise service users perceiving school-based counselling as improving access to support (Griffiths, 2013; Hanley et al., 2012; Lynass et al., 2012). The context of school-based counselling was found to provide young people with the opportunity to independently speak to someone in a familiar, non-judgemental and confidential environment. By providing a self-referral service, this supports the development of a greater sense of autonomy and privacy among young people (Dunne et al., 2000; Lynass et al., 2012). Accordingly, parents and carers perceived that receiving external support provided their child the opportunity to express themselves privately and to emotionally engage with the process. On this note, parents and carers perceived confidentiality as an important aspect of the service, in line with young people viewing confidentiality as an important helpful factor in school-based counselling (Cooper, 2006).

Our findings, however, also identify factors in which the context of school-based counselling may negatively affect outcomes. For instance, parents and carers reported experiences of receiving inadequate information on the school-based counselling service. These findings accord with parents' and carers' experiences of specialised mental health services (i.e. CAMHS; Bone et al., 2014; Coyne et al., 2015; Crouch et al., 2019; Teggart & Linden, 2007), young people's perspectives of counselling (Griffiths, 2013) and evaluations for school-based counselling (Cooper, 2009; Hill et al., 2011). Given teachers' and counsellors' role in providing information and support, our findings suggest that effective communication will enhance perceived supportive input, as well as service access, satisfaction and outcomes (Cooper et al., 2016; Coyne et al., 2015; Holmboe et al., 2011). For instance, effective communication is found to reduce anxiety, and/or reluctance, among parents and carers and young people, particularly if this is their first experience of accessing mental health-related support (Coyne et al., 2015). However, it is important to note that increased communication around school-based counselling to parents and carers should not compromise the confidentiality between a young person and their counsellor.

Parents and carers also perceived challenging elements in the content of school-based counselling. Parents and carers reported anxiety regarding the structure of counselling—specifically, expressing concerns over limited counselling sessions, including its discontinuation. In effect, some perceived the service to provide an inadequate number of sessions for the level of support they felt was required. Our findings of wanting more support can, however, be contextualised by identified challenges of school-based services and the research itself, including: (a) being required to work in line with term times and school holidays, (b) being predominantly short-term, and (c) inadequate funding—interrupting the development, and consistency, of supportive outcomes (Broglia et al., 2017; Mair, 2016). These findings accord with previous accounts of parents' and carers' expectations for receiving adequate (or ‘realistic’) support from mental health services (Harden, 2005), as well as young people wanting further counselling (Cooper, 2006; McArthur, 2013).

On this note, the literature has suggested that young people and parents and carers attend to differing positive aspects when evaluating satisfaction with mental health services (Garland et al., 2003, 2007; Yeh & Weisz, 2011). For instance, young people are found to focus on the relational aspects of an intervention, whilst parents and carers hold greater emphasis on service consistency and perceived coordination (Aarons et al., 2010). Our findings, however, reflect a consensus between parents' and carers' and young people's perceptions and expectations of mental health services. Parents, carers and young people were found to mutually value a good therapeutic rapport, which leads to increased self-confidence and levels of trust (Aarons et al., 2010; Garland et al., 2007; Griffiths, 2013). School-based counselling may facilitate this by ensuring the development of a ‘productive therapeutic relationship [and] therapist empathy’ as part of providing the necessary conditions for ‘therapeutic change’ (Angus et al., 2015, p. 336; Hill et al., 2013; Shirk et al., 2011). This is also respective to the emotion-filled and self-discovering process of humanistic counselling—a perceived ‘helpful’ factor of counselling among young people (Dunne et al., 2000; Patterson & Joseph, 2007). Moreover, parents and carers and young people both perceived receiving a ‘different’ or ‘new’ perspective from the counsellor as a factor for promoting positive emotional (e.g. confidence), interpersonal (e.g. improved relationships), and behavioural (e.g. improved academic performance) outcomes (Dunne et al., 2000; Lynass et al., 2012).

4.1 Limitations and future direction

This study has provided qualitative insight from a representative population on school-based counselling, which was manualised and adherence-checked. This, in effect, means that we know specifically what the young person, and therefore their parents and carers, were responding to. However, our method of recruitment may not have given a representative perception of school-based counselling, as parents and carers who volunteered in this study may have been more motivated, engaged and/or compliant than the average parent or carer. Moreover, value added in terms of the extent to which certain behaviours (e.g. academic improvement) are seen may be used as a proxy for counselling outcomes.

Our interviews were conducted via telephone which, although provides logistical convenience and practical advantages (e.g. enhanced access to interviewees), may have impacted establishing a rapport and a potential loss of contextual data (e.g. absence of visual cues, data distortion or loss). Parents' and carers' reports of the impact of counselling are also ‘second hand’, in that they are based on perceived effects rather than felt effects, per se. Additionally, as with all interview studies, reports may be subjective or reflect demand biases. Parents' and carers' perceptions were also not analysed in relation to specific cases.

This study suggests a variety of avenues for future research. Future studies should explore perceptions of parents and carers by collecting data from a more naturalistic setting (e.g. a self-referral service) and/or a service absent of incentivisation. Further, the sample of this study was focused on six schools in one demographic region within the UK, with relatively high levels of social deprivation and ethnic diversity. This, in turn, introduces area-level variations and may, therefore, limit the wider transferability of findings to differing socio-demographic backgrounds. This may be reflected in ETHOS's relatively small intervention effects, which may be indicative of the sample's high levels of poverty and chronicity of distress (Cooper et al., 2021). It is therefore suggested that parents' and carers' perceptions require further investigation for a deeper understanding of multiple experiences, particularly among a wider and diverse sample with differing backgrounds and experiences.

4.2 Clinical implications

While the scope of this study did not focus on efficacious mechanisms of school-based counselling, this study does, however, add to the extant literature by identifying its helpful and non-helpful aspects from parents' and carers' perspectives. Our findings therefore raise a number of important implications for school-based counselling. Most pertinently, parents and carers emphasised the importance of effective communication, raising the suggestion that professional staff (e.g. teachers, counsellors) should adequately inform parents and carers about the nature and function of school-based counselling services, without compromising client-counsellor confidentiality. Although access to school-based counselling may not require parental or carer consent (Hanley, 2012), it is important that parents and carers are able to access, and understand, service information. This would promote service-user engagement and informed choice (Coulter & Ellins, 2006).

Strategies for improving communications, referrals and access to support—where additional funding is available—may include having named point(s) of contact in specialist mental health services and schools. This may involve having a ‘mental health lead’ in every school, who ensures that school staff and practitioners are aware of any information on additional supportive services, including specialist mental health services (Department of Health, 2015). Furthermore, to encourage young people to initiate mental health support, schools should include a self-referral process or, if available, ‘drop-in’ services within a confidential, anonymous set up (Cooper, 2009; Hill et al., 2011). Self-referrals should, however, have the option to include parents and carers and to involve school staff in this process. Further, to ensure effective communication and awareness, schools should actively publicise the service, as well as encourage young people to attend appointments by utilising appointment slips or text reminders (Department of Health, 2015).

Our findings also raise concerns over whether effective support can be delivered within specific time restraints (Mair, 2016). Therefore, we suggest school-based services should consider providing an open-ended service and/or increasing counsellors' availability, wherever possible (Cooper, 2004, 2006). Furthermore, schools and counsellors should make joint decisions on how and when sessions are provided. For instance, providing appointments to pupils before or after school hours, or during breaks (e.g. lunchtime) may further prove as a time protecting strategy for improving access to support and communication between school staff, counsellors, pupils and parents/carers (Department of Health, 2015). On this note, school-based counselling may incorporate alternative support resources, such as online self-help support (Brown, 2016), as this may have the potential to increase outreach and reduce waiting times. This is particularly relevant for providing support outside of traditional school hours (e.g. during evenings, nights, weekends; Gatti et al., 2016), as this does not require regular face-to-face attendance. Moreover, given that parents and carers were found to seek post-intervention support, alternative support resources could be extended as a source of counselling ‘aftercare’. Lastly, given that some parents and carers sought further specialist services (e.g. CAMHS) following counselling, school-based counselling services should ensure close links with other mental health services for young people (e.g. CAMHS) and relevant professional staff (e.g. GPs; Cooper et al., 2006; Cromarty & Richards, 2009; McKenzie et al., 2010).

5 CONCLUSION

Our study has found that, in general, parents and carers have a positive perception of school-based counselling. This is consistent with previous research on young people's perceptions and experiences (Cooper, 2013; Griffiths, 2013). In general, our research found that the intervention was perceived as beneficial for young people, with positive changes in social and emotional well-being. It further supports schools as a promising setting for the provision of mental health support. It should also be acknowledged that schools serve as an excellent environment for high-quality research in mental health, due to being a universal point of access. This will be crucial for the coming years, given a potential decline in well-being among young people adversely affected by the COVID-19 pandemic, as well as the pre-existing, and ongoing, limited resources (Quilter-Pinner & Ambrose, 2020; Sadler et al., 2017; Vizard et al., 2020). It is therefore encouraged that future research includes young people, and their parents and carers, as part of the continuous development of mental health services (Hayes et al., 2019).

ACKNOWLEDGEMENTS

This work was supported by the Economic and Social Research Council [grant reference ES/M011933/1]. The Chief Investigator would also like to acknowledge additional funding to support the team from the University of Roehampton, the British Association for Counselling and Psychotherapy, and the Metanoia Institute. We would like to thank the parents and carers who participated in this study. We would also like to acknowledge the support and cooperation from Keith Clements and the Young People's Advisory Group and Parent and Carer Advisory Group, at NCB; and the school counselling coordinators at each participating school. Thanks to the following individuals for their support and guidance through the development and delivery of the ETHOS trial: Zainab Amir, Mark Donati, Andi Fugard, Adam Gibson, Chris Kelly, Rabia Khatun-Baksh, Rebecca Kirkbride, Susan McGinnis, Robert Elliott and Cathy Street.