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

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.

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.