The Effectiveness and Cost-effectiveness Trial of Humanistic Counselling in Schools (ETHOS)

Context & Background

Levels of mental health problems in children and young people are increasing (WHO, 2006). One in ten children in Britain have been identified as experiencing a diagnosable mental health disorder (Green et al., 2004). Britain is also falling behind in promoting well-being in children (UNICEF, 2010), and there are high levels of distress, low self-esteem, and self-harm in this population (Hawton & James, 2005). A study conducted by the Prince’s Trust (2012) reported that 30% of young people aged between 16 and 25 reported ‘always’ or ‘often’ feeling ‘down’ or ‘depressed’, and 21% felt that they did not receive the support they needed from school. Investing in support for young people with behavioural and emotional difficulties can help them achieve academically and improve longer-term outcomes such as employment and health.

One potential intervention that may alleviate psychological distress is school-based humanistic counselling (SBHC).  This is an established, standardized form of school-based counselling and its humanistic orientation reflects the predominantly person-centred/humanistic style of British school-based counsellors. SBHC is based in evidence-based competences for humanistic therapies (Roth et al., 2009) and a competency framework for those delivering humanistic counselling to 11-18 year olds has now been developed (Hill, Roth & Cooper, 2014). Data from four pilot trials suggest that SBHC may be clinically effective and reducing levels of psychological distress. However, a fully powered randomised controlled trial (RCT) is needed to provide a robust test of its effectiveness, to assess its cost-effectiveness, and to determine the underlying process of change.

For further reading, see ‘Resources’.

Overview of Trial

The ETHOS trial is a two-arm, parallel-group, tester-blind RCT comparing the clinical and cost-effectiveness of SBHC with pastoral care as usual (PCAU) in a school setting, and recruited participants between September 2016 and February 2018. Key eligibility criteria, which was assessed at baseline, included:

  • Aged between 13 and 16 years of age
  • Experiencing moderate to severe levels of emotional distress as assessed by a score of ≥5 on the Strengths and Difficulties Questionnaire Emotional Symptoms (SDQ-ES) Scale (Goodman, 2001).

Participants were randomised to receive either SBHC or PCAU. SBHC was delivered in up to 10 weekly, individual sessions in school, with a qualified, experienced counsellor who had also received training using a published clinical practice manual (see ‘Resources’). Adherence to the SBHC model was assessed by a sub-team of auditors and in clinical supervision. PCAU consisted of the schools’ pre-existing systems for supporting the emotional health and well-being of students. Those in PCAU were also offered counselling 6-9 months later.

The primary outcomes were psychological distress measured using the Young Person’s Clinical Outcomes in Routine Evaluation (YP-CORE; Twigg et al., 2009) and costs evaluated using the Client Service Receipt Inventory (CSRI; Beecham & Knapp, 2001). Secondary outcomes include psychological difficulties, levels of depression, anxiety and self-esteem, well-being, school engagement, educational outcomes and achievement of personal goals. Data was collected at 6-weeks, 12-weeks and 24-weeks post-baseline assessment. Researchers administering the measures were blind to allocation. The trial required n = 306 participants (n = 153 in each group), with 90% power to detect a standardised mean difference (SMD) of 0.5. Qualitative interviews with participants, parents and school staff were also conducted and sought to identify the mechanisms of change in SBHC.

Full details of the trial design can be found in the published protocol, see ‘Publications’.

The ETHOS trial is registered with the International Standard Randomised Controlled Trial Number (ISRCTN) Registry. ID: ISRCTN10460622.

The project was funded by the Economic and Social Research Council (ESRC) grant award for three years from April 2016 to April 2019. The trial team would also like to acknowledge the additional funding the study received from the University of Roehampton and the British Association for Counselling and Psychotherapy.


The ETHOS study is the first RCT powered to detect clinically meaningful differences, investigating the clinical and cost-effectiveness of SBHC compared to PCAU. The study will make a significant contribution to the evidence base for mental health provision for young people. Determining the clinical and cost-effectiveness of SBHC is important for all stakeholders, including policy-makers, statutory advisory bodies for child welfare, head teachers, children and young people practitioners, child welfare and parenting organisations, and young people themselves.

Trial Team

The trial is led by Professor Mick Cooper from the University of Roehampton.  The Project Manager, Megan Stafford, and Project Administrator, Tiffany Rameswari, are also based at the University of Roehampton.

Co-investigators for the trial include: Karen Cromarty (Consultant), Peter Pearce (Metanoia Institute), Charlie Duncan (British Association for Counselling and Psychotherapy), Professor Michael Barkham and Dave Saxton (University of Sheffield), Professor Peter Bower (University of Manchester), Professor Jeni Beecham (London School of Economics), Dr Stephanie Smith and Dr Gayle Munro (National Children’s Bureau), and Dr Cathy Street (Consultant).

The study is supported by the Manchester-based UKCRC registered Clinical Trials Unit (MAHSC-CTU).


Members of the ETHOS team celebrating end of data collection in July 2018.

Involvement of the Public

A young persons’ advisory group (YPAG) and a family research advisory group (FRAG) have been established which provide a link between the study and its participants and their parents/carers. The YPAG and FRAG are both made up of people who have received training from the National Children’s Bureau Research Centre in a range of research skills and have been involved in various ways throughout the study, including attending the Trial Steering Committee meetings (see below).

ETHOS Young Advisors

Three of the four members of the advisory group are pictured at their first meeting in May 2016.

Trial Governance

A Trial Steering Committee (TSC) has been established and is chaired by Professor Derek Bolton. Other members of the TSC, outside of the core research team, include a counselling academic, a statistician, an economist, the YPAG and FRAG, a representative educationalist, and a representative from the ESRC.

The role of the TSC is to monitor the scientific integrity of the trial and assess trial quality and conduct (in accordance with the principles of good clinical and research practice (as per the British Association of Counselling and Psychotherapy, Social Research Association, and ESRC guidelines)).

A Data Monitoring and Ethics Committee (DMEC) has also been organized to review accruing trial data and to assess whether there are any safety issues that should be brought to the participants’ attention. The DMEC is independent of the core trial team and is chaired by Professor Jason Madan. Other members include an independent statistician and independent health economist. 

Trial Update

18 schools were recruited into the trial between September 2016 and February 2018, with 330 participants recruited following 596 assessments. Participants were allocated to either SBHC (N = 167) or PCAU (N = 163). Recruitment was completed in February 2018 and data collection was completed in July 2018. 84% of counselling sessions were attended and data completion rates across each time point ranged from 98.4%-100%. 


The results of the study are expected to be published in 2019.


Trial Protocol

Stafford, M. R., Cooper, M., Barkham, M., Beecham, J., Bower, P., Cromarty, K., Fugard, A. J. B., Jackson, C., Pearce, P., Ryder, R., & Street, C. (2018). Effectiveness and cost-effectiveness of humanistic counselling in schools for young people with emotional distress (ETHOS): study protocol for a randomised controlled trial. Trials, 19, 175.

The protocol for the trial was developed by Megan Stafford (Project Manager) and Professor Mick Cooper (Chief Investigator) along with a team of leading practitioners and specialists. The protocol was published in March 2018 in Trials and sets out the protocol for an RCT in a school setting to determine the clinical and cost-effectiveness of SBHC compared to PCAU. It is available for free download:

Children, Young People and Families

Karen Cromarty (School Coordinator) published an article explaining the importance of the study and is available for free download here. This article first appeared in the September 2018 issue of BACP Children, Young People & Families, published by the British Association for Counselling & Psychotherapy. 2018©

Forthcoming Papers

We intend to publish several papers from the project, including a main outcome paper. Further details will be published here.


See a video of Professor Mick Cooper’s inaugural lecture on the ETHOS trial and download the slides.

Press Releases

A press release (March, 2016) regarding announcement of the trial can be read here.

A press release (March, 2018) regarding publication of the trial protocol can be read here.


2019 conference details coming soon.

Data Protection

Due to the new General Data Protection Regulation (GDPR, 2018) which we’re sure you’ve already heard about, we have recently updated our privacy notice. This explains what data we collect, why we collect it, how we use it, who we share it with and other information relating to the privacy of participants’ data. This statement applies to the ETHOS project and its related project, AGENCY. For more information about GDPR in relation to either project please contact:

ETHOS: Megan Stafford, Project Manager:
AGENCY: Charlie Duncan, PhD student:


School-Based Humanistic Counselling (SBHC)

SBHC is based on competences for humanistic counselling with young people aged 11–18 years, and follows a clinical practice manual developed for the trial (see Kirkbride, R. 2017, Counselling young people: A practitioner manual). It is based on the theory that distressed young people have the capacity to successfully address their difficulties if they can talk them through with an empathic, supportive, and qualified counsellor. School-based humanistic counsellors use a range of techniques to facilitate this process, including active listening, empathic reflections, inviting young people to access and express underlying emotions and needs, and helping clients to reflect on, and make sense of, their experiences and behaviours. Young people are also encouraged to consider the range of options that they are facing, and to make choices that are most likely to be helpful within their given circumstances. As part of the intervention, young people participating in the trial are asked to complete a sessional outcome measure in accordance with the recommendations outlined in the Children and Young People Practice Research Network (CYP PRN) report that highlights the clinical utility of employing a regular feedback tool in counselling. Our sessional measure is the Outcomes Rating Scale (ORS) which assesses the following areas of life functioning: personal well-being, family and close relationships, social relationships, and general well-being; and is integrated into the therapeutic dialogue. To ensure adherence to SBHC practice, the trial uses a version of the person-centred and experiential psychotherapy scale (PCEPS), adapted for use with young people.

SBHC Videos & Links with PCEPS

A brief example of school-based humanistic practice can be accessed here.

Brief demonstration of school-based humanistic counselling: Jasmine



A more extended example, followed by reflections by counsellor and client, is available here.

Extended demonstration of school-based humanistic counselling: Sophia



Further Reading

Please find a list of additional readings used in the study that you may find useful:

  • Baskin, T. W., Slaten, C. D., Crosby, N. R., Pufahl, T., Schneller, C. L., & Ladell, M. (2010). Efficacy of counseling and psychotherapy in schools: A meta-analytic review of treatment outcome studies. The Counseling Psychologist, 38(7), 878-903.
  • Beecham, J., & Pearce, P. (2015). The ALIGN Trial: service use and costs for students using school-based counselling. Personal Social Services Research Unit Discussion Paper 2883, University of Kent.
  • Cooper, M. (2009). Counselling in UK secondary schools: A comprehensive review of audit and evaluation studies. Counselling and Psychotherapy Research, 9(3), 137-150.
  • Cooper, M. (2013). School-based counselling in UK Secondary schools: A review and critical evaluation. Lutterworth: BACP/Counselling MindEd. [Online] Available at:
  • Cooper, M., Rowland, N., McArthur, K., Pattison, S., Cromarty, K., & Richards, K. (2010). Randomised controlled trial of school-based humanistic counselling for emotional distress in young people: Feasibility study and preliminary indications of efficacy. Child and Adolescent Psychiatry and Mental Health, 4(1), 1-12.
  • Cooper, M., Stewart, D., Sparks, J., & Bunting, L. (2013). School-based counselling using systematic feedback: a cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23(4), 474-488.
  • Hill, A., Cooper, M., Pybis, J., Cromarty, K., Pattison, S., Spong, S., & Couchman, A. (2011). Evaluation of the Welsh School-based counselling strategy. Cardiff: Welsh Government Social Research.
  • McArthur, K., Cooper, M., & Berdondini, L. (2013). School-based humanistic counseling for psychological distress in young people: Pilot randomized controlled trial. Psychotherapy Research, 23(3), 355-365.
  • Pearce, P., Sewell, R., Cooper, M., Osman, S., Fugard, A.J.B., & Pybis, J. (2017). Effectiveness of school-based humanistic counselling for psychological distress in young people: Pilot randomized controlled trial with follow-up in an ethnically diverse sample. Psychology and Psychotherapy: Theory, Research and Practice, 90, 138-155.
  • Pybis, J., Cooper, M., Hill, A., Cromarty, K., Levesley, R., Murdoch, J., & Turner, N. (2014). Pilot randomised controlled trial of school-based humanistic counselling for psychological distress in young people: Outcomes and methodological reflections. Counselling and Psychotherapy Research, 15(4), 241-250.
  • Rupani, P., Cooper, M., McArthur, K., Pybis, J., Cromarty, K., Hill, A., & Turner, N. (2013). The goals of young people in school-based counselling and their achievement of these goals. Counselling and Psychotherapy Research, 14(4), 306-314.

ETHOS partners