Effectiveness and cost-effectiveness Trial of Humanistic cOunselling in Schools: Individual RCT (ETHOS)

Lead Research Organisation: Roehampton University
Department Name: Psychology


There is a current crisis in mental health care for young people, and the UK government is trying to find ways of addressing it. Currently, approximately one in ten young people in the UK experience significant problems with their emotions or their behaviour. Schools may be a particularly good place to tackle this problem because they are somewhere that nearly all young people go to. Indeed, evidence suggests that young people are as much as ten times more likely to attend a school-based service than a non-school-based one.

Certain psychological treatments, such as cognitive behavioural therapy (CBT), can help young people address specific mental health disorders like generalised anxiety. However, the kind of psychological problems that many young people experience do not fit into such diagnostic categories. Rather, they are responses to particular life problems, such as family difficulties, bereavements and bullying. Although these difficulties may not be at a severe level, addressing them early on may be very important in helping to ensure that they do not develop into more chronic problems in later life.

In the UK, one of the most common ways to try and help young people through these problems is school-based 'counselling.' This can take a variety of forms but, in contrast to CBT, focuses mainly on providing young people with a space to talk through their problems, get things off their chest, and work things out for themselves in a supportive, confidential and understanding relationship. Initial evidence suggests that counselling is very popular with young people and their teachers, and there is some scientific evidence -- including PhD work funded through the ESRC -- that a standardised form of school-based counselling (school-based humanistic counselling) reduces psychological distress and improvements in self-esteem. However, to properly inform government decision-making, better evidence is needed to test whether it really is of help.

To provide this evidence, we will conduct a study in 18 English secondary schools. We will provide some young people (aged 13-16) who are experiencing psychological difficulties with up to 10 weeks of school-based humanistic counselling while others will receive their school's usual pastoral care. Decisions about who gets what will be made on a random basis, as this gives us the best chance of working out if the therapy really works. After six weeks, three and six months, we will look at whether those young people who received the counselling are experiencing less psychological distress than those who did not. We will also look at whether the benefits of providing the counselling service justify the costs. This is important as there might be better ways of spending the money to improve well being in schools. In addition, we will look at whether the counselling helps young people improve their resilience, self-esteem and engagement with education; and what they -- and their teachers and parents/carers -- think is helpful and unhelpful about counselling.

This research is important because school counselling may be able to make a major contribution to improving the psychological wellbeing of young people in the UK. The project team have extensive experience of conducting studies like this, and the current design has been tested and shown to work. The costs of the trial cover the work of the project team along with involvement from a specialist trials unit at Manchester University. Members of the project team have also been closely involved in recent policy initiatives regarding children's mental health.

The safety of young people is a major concern. We will not include any young person who is at risk of harm to self or other, but refer them to specialist support. We will assess young people in the study and arrange for appropriate support for them if we become concerned about them. We will also ensure the highest levels of anonymity and confidentiality for participants.

Planned Impact

In 2014, Norman Lamb, the UK Minister for Care and Support, along with the All-Party Parliamentary Committee for Health, acknowledged the urgent need for new evidence-based studies to develop and improve the provision of mental health support for children and young people with behavioural and emotional difficulties.

As a fully-powered effectiveness and qualitative study of the successfully piloted School-based Humanistic Counselling (SBHC) intervention, the ETHOS study has the potential to make a major contribution at national level in the development of services to support young people's mental health. Both the Department of Health (DoH) and Department for Education (DfE) are currently considering the roll-out of school-based counselling in England, but decision making is hampered by a lack of sufficiently reliable evidence. By combining an RCT with an economic analysis, ETHOS research will provide data and analysis with the potential to validate a scaling up of SBHC to all secondary schools in England and Scotland. Already, results from pilot studies of SBHC, led by CI (Cooper), have been cited in evaluation reports underpinning the decision by the Welsh Government to require local authorities to provide an independent counselling service for young people in their area.

At present around 65% of schools in England and Scotland claim to provide young people with access to counselling, with around 60,000 young people attending counselling in England each year (Cooper, 2013). However, delivery is patchy and inconsistent, and the kind of counselling being provided is unclear and, in most cases, untested. Findings from the ETHOS trial may therefore support a wider and more consistent dissemination of this intervention. It can also help to ensure that the kind of school-based counselling being provided is evidence-based: of a form that has been shown to significantly reduce levels of psychological distress in young people.

In addition to impacting national policy-making, ETHOS research can provide an evidence-base to support decision making at local level by local authority commissioners, headteachers and directors of children's services in relation to mental health interventions in schools.

As an early intervention evaluation, ETHOS research may also provide DoH analysts with data to identify an opportunity to relieve pressure on specialist outpatient and inpatient CAMHS.

A key instrument in the ETHOS study will be the newly-developed competency framework for humanistic counselling with young people, from which a new manual and adherence scale for 11-18 year olds will be tested and developed. The SBHC manual will set new benchmarks for the practice of counselling interventions and will be made available via the British Association for Counselling and Psychotherapy (BACP) to counsellors and psychotherapists working with young people (CYP). The manual will also form the basis for the development of a training curriculum and other (DVD format) training material for counsellors working with young people.

Ultimately, the impact of the ETHOS study will be on the wellbeing of young people, themselves, and the families, schools and communities within which they are embedded. Research suggests that around 45% of young people who participate in school-based counselling will move from clinical levels of psychological distress to non-clinical levels. Qualitative reports from teachers also suggest that approximately 80% of young people who participate in SBHC will experience improvements in their capacities to engage with studying and learning, particularly in terms of being able to concentrate more in class. If SBHC can be shown, through a fully-powered trial, to causally determine these effects, and if it is rolled out across England and Scotland, then hundreds of thousands of young people -- over the coming years -- will be able to accrue the benefits of this intervention.
Description Through our randomised controlled trial, we have established evidence on the effectiveness of adding school-based humanistic counselling to pastoral care as usual, for young people who are experiencing psychological distress. This is the first time that definitive evidence of the impact of this intervention has been assessed. This finding is of importance as the issue of young people's mental health is of major concern at the present time, and there is a need to find effective ways of addressing this problem. School-based humanistic counselling is one of the most widespread interventions for young people's mental health at the present time--both in the UK and internationally--but to this point it is not clear whether or not, on average, it actually helps young people.

We have also discovered evidence on whether school-based humanistic counselling is a cost effective intervention or not. This is an essential finding for policy makers and commissioners, who need to decide whether the benefits that this intervention might bring about are justified for its costs.

In addition to identifying whether or not school-based counselling is effective and cost-effective, we have also identified the specific pathways through which this intervention may be able to bring positive improvements about. This is through our analysis of interviews with approximately 50 young people who took part in the intervention. This is the largest study of this type: building on previous evidence in this area to establish a definitive understandings of the pathways through which school-based humanistic counselling may be able to bring about change.

We have also looked at the pathways that school-based humanistic counselling may bring about change by analysing, statistically, the relationship between the young people's levels of improvements and a wide range of variables: counsellors' characteristics (e.g., their years of experience), clients' characteristics (e.g., their gender), schools' characteristics (e.g., their roll), and therapy characteristics (e.g., the extent to which the young people experience the counsellor as empathic). In combination with the qualitative evidence, above, this will help us develop a much deeper understanding of what aspects of the counselling were helpful, and therefore how school-based counselling might be improved for the future.

We will shortly be submitting our key findings for publications, and once this has been released we will update this report to give specific details of the outcomes of this study.
Exploitation Route Our findings will provide critical information for commissioners (primarily school headteachers) on whether school-based counselling services should be (or should continue to be) funded. They will show whether this intervention is actually helping the young people, and then what the costs are for the amount of improvement expected to be attained.

Our findings will also provide very important information for the Department for Education, as well as other government bodies (e.g., NHS England), on the role that school-based counselling should play as part of a national strategy on children and young people's mental heath, informing both recommendations and policy.

Clinically, our findings will be able to inform developments in counselling interventions for children and young people. At an academic level, they will also help to inform theories of psychological change, and provide a basis for further research on counselling interventions with children and young people.

Most importantly, perhaps, these findings will be able to inform young people and parents about the potential benefits of school-based humanistic counselling, and help them make more informed decisions about whether or not this intervention is the right one for them.
Sectors Communities and Social Services/Policy,Education,Healthcare

Title Adverse Events Protocol 
Description A novel and detailed protocol for monitoring, assessing, and recording adverse events was developed as part of the ETHOS trial. 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? No  
Impact Elements of this protocol have been adopted by a large national trial of mental health interventions. Preliminary details of our adverse events protocol are available at in our protocol paper. We aim to publish a detailed paper detailing the development, and nature, of this protocol in 2020. The full protocol is available on request (please contact the Chief Investigator). 
URL https://doi.org/10.1186/s13063-018-2538-2
Title ETHOS Clinical Practice Manual 
Description The ETHOS Clinical Practice Manual was commissioned as part of the ETHOS trial, to provide guidance and a resource for the project. Its aim was to support training and the delivery of counselling within the trial. The Manual sets out the context and procedures of the ETHOS trial as well as the principles of humanistic counselling, the practice of humanistic therapy, and the range of interventions available to practitioners working with young people in schools. The purpose of the clinical practice manual was to provide a 'boundary around the intervention' that allowed practitioners to be appropriately responsive to each individual client. The ETHOS Clinical Practice Manual was first authored by Rebecca Kirkbride (University of Roehampton), and edited by Susan McGinnis (University of Strathclyde) and Mick Cooper (University of Roehampton). It was formatted by Tiffany Rameswari. The Manual draws on key material from the British Association for Counselling & Psychotherapy (BACP, 2014) 'Competences for humanistic counselling with young people (11-18 years)'. 
Type Of Material Improvements to research infrastructure 
Year Produced 2016 
Provided To Others? Yes  
Impact The manual formed the basis for the book, Kirkbride, R. (2017). Counselling young people: A practitioner manual. London: Sage. This text has been well-received and has been used in the training of counselling practitioners with young people. 
URL https://www.amazon.co.uk/Counselling-Young-People-Practitioner-Manual/dp/1473992125/ref=cm_cr_arp_d_...
Title ETHOS Supervision Adherence Scale 
Description We developed a three item scale to assess the appropriateness of supervisors' work in supporting school-based humanistic practice 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? Yes  
Impact Available on request from the chief investigator 
Title Person-Centred & Experiential Psychotherapy Scale - Young Person Supervision Version (PCEPS-YP-S) 
Description Along with the PCEPS-YP that was developed to rate audio segments of counselling sessions, we also developed a shortened, 4-item version, that could be used in supervision sessions. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact In development. 
Title Person-Centred and Experiential Psychotherapy Scale - Young Person Counselling Version 
Description Susan McGinnis and Robert Elliott (University of Strathclyde) were commissioned to adapt the Person-Centred and Experiential Psychotherapy Scale (PCEPS) so that it could be used with young people to assess the adherence of practice to person-centred/humanistic competences. The nine item PCEPS-YP measure which was created was used, in the ETHOS trial, to assess 20 minute segments of recording of counselling sessions. 
Type Of Material Improvements to research infrastructure 
Year Produced 2016 
Provided To Others? No  
Impact We aim to publish details of the PCEPS-YP, along with its psychometric properties, in 2020. The adult versions are available via the URL below. 
URL https://sites.google.com/site/pcepsresources/home/pceps-versions