Understanding the experiences of young people, parents, caregivers, school staff and practitioners engaged in ECHOES: a school-based intervention for distressing voices

Hearing voices is a relatively common experience among school age children but can be very distressing. In the UK, voice hearing is often a stigmatised experience, and there are recognised connections between voice hearing and risks to wellbeing and self-harm. Despite this, there are no established psychological interventions specifically designed to support young people who hear distressing voices, and many experience long waits for specialist support from child and adolescent mental health services. The ECHOES study explored the feasibility and acceptability of delivering a brief school-based psychoeducation and coping strategies intervention for young people who hear voices. Within an uncontrolled feasibility study conducted in secondary schools in Southeast England, the ECHOES intervention was delivered by Mental Health Support Teams (MHST). Qualitative accounts were gathered from 96 participants across the four participant groups: school students, Plus-1s (parents/caregivers), school staff, and MHST practitioners. Data were collected throughout the study via interviews, focus groups, feedback forms, and reflective accounts, and analysed using the Framework Method to explore acceptability, perceived impact, and implementation experiences across stakeholder groups. Young people described the ECHOES intervention as meaningful and supportive, particularly in helping them understand their voice hearing experiences, develop coping strategies, and regaining a sense of control. Psychoeducation acted as a catalyst for meaning making and narrative change, with some participants reporting shifts in how they related to their voices. Engagement required emotional investment, and acceptability was shaped by the school context, including academic pressures, concerns about visibility and stigma. Across participant groups, flexibility, autonomy, and relational delivery were identified as key facilitators of engagement, but a perceived rigid structure and abrupt endings limited benefit for some. ECHOES is a feasible and broadly acceptable early intervention for young people who hear distressing voices when delivered flexibly within school settings. Refinement is needed to enhance individualisation, to ensure the therapeutic materials are age appropriate for a wide range of developmental stages, to support practitioners in their delivery of the ECHOES intervention, and to improve the pacing of endings and follow-up. Further evaluation through a randomised controlled trial is warranted to assess effectiveness and sustainability. Trial registration ISRCTN16395888