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


Levels of mental health problems in children and young people are on the increase, with as many as one in eight now experiencing a diagnosable mental health disorder.

One potential approach to addressing this problem is school-based humanistic counselling (SBHC).  This is an established, standardized form of school counselling, and its humanistic orientation reflects the predominantly person-centred/humanistic style of British school-based counsellors. SBHC is based on core competencies for work with children and young people, and has been found to be effective in reducing psychological distress across four pilot trials. However, an adequately-powered trial of SBHC, with a full economic evaluation, has been necessary to provide a more rigorous test of this intervention. 

Overview of Trial

The ETHOS trial was 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. It recruited participants between September 2016 and February 2018. Key eligibility criteria, which were 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) and costs evaluated using the Client Service Receipt Inventory (CSRI). Secondary outcomes include psychological difficulties (SDQ), levels of depression, anxiety and self-esteem (RCADS), well-being (WEMWBS), school engagement (SES-BE), educational outcomes, and achievement of personal goals (GBO Tools). Data were 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 to identify the processes of change in SBHC.

Full details of the trial design can be found in the published protocol here.

The ETHOS trial was 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 adequately powered RCT of SBHC, and also the first to conduct a comprehensive and robust cost-effectiveness analysis. Through doing so, 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 was led by Mick Cooper from the University of Roehampton.  The Project Manager, Megan Stafford, and Project Administrator, Tiffany Rameswari, were also based at the University of Roehampton.

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

The study was 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) was established and chaired by Professor Derek Bolton. Other members of the TSC, outside of the core research team, included a counselling academic, a statistician, an economist, and members of the YPAG.

The role of the TSC was 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) was also set up to review accruing trial data and to assess whether there were any safety issues that should be brought to the participants’ attention. The DMEC was independent of the core trial team and was chaired by Professor Jason Madan. Other members included an independent statistician and independent health economist. 

Trial Update

Recruitment was completed in February 2018 and data collection was completed in July 2018. Our hope is that the main findings from the trial will be published in Spring 2020.

Publications to Date

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.

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©


Manuals, Protocols, and Plans

Adherence measures


Forms and Measures


See a video of Professor Mick Cooper’s inaugural lecture, at the commencement of the ETHOS trial.

Press Releases

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

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


We are planning to hold a dissemination conference for the findings of the study in 2020, to coincide with publication of our results. 

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:

School-Based Humanistic Counselling (SBHC)

SBHC, as delivered in ETHOS, was based on competences for humanistic counselling with children and young people and followed a clinical practice manual. The therapy assumes 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 ETHOS trial were asked to complete the Outcome Rating Scale sessional measure. The PCEPS-YP-S measure was also used, in supervision, to explore counsellors' adherence to SBHC practice.

A brief example of school-based humanistic practice is presented below.

Brief demonstration of school-based humanistic counselling: Jasmine



A more extended example of SBHC, followed by reflections by counsellor and client, is presented below.

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