Effectiveness and cost-effectiveness of humanistic counselling in schools for young people with emotional distress (ETHOS): study protocol for a randomised controlled trial

Background: One in ten children in Britain have been identified as experiencing a diagnosable mental health disorder. School-based humanistic counselling (SBHC) may help young people identify, address, and overcome psychological distress. Data from four pilot trials suggest that SBHC may be clinically effective. 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 process of change. Methods/design: The Effectiveness and Cost-effectiveness Trial of Humanistic Counselling in Schools (ETHOS) is a two-arm, parallel-group RCT comparing the clinical and cost-effectiveness of SBHC with Pastoral Care as Usual (PCAU) in school settings. Eligibility criteria for young people include being between 13 and 16 years of age and experiencing moderate to severe levels of emotional distress. Participants are randomised to receive either SBHC or PCAU. SBHC is delivered in up to 10 weekly, individual sessions in their school with a qualified, experienced counsellor who has also received training using a clinical practice manual. Adherence to the SBHC model is assessed by a sub-team of auditors and in clinical supervision. PCAU consists of the schools’ pre-existing systems for supporting the emotional health and well-being of students. The primary outcomes are 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, levels of depression, anxiety and self-esteem, well-being, school engagement, educational outcomes and achievement of personal goals. Qualitative interviews with participants, parents and school staff will look to identify the mechanisms of change in SBHC. Researchers administering the measures are blind to allocation. The trial requires n = 306 participants (n = 153 in each group), with 90% power to detect a standardised mean difference (SMD) of 0.5. An intention-to-treat analysis will be undertaken. Discussion: This RCT is powered to detect clinically meaningful differences, and will make a major contribution to the evidence base for mental health provision for adolescents. It will have implications 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. Trial registration: Controlled Trials International Standard Randomised Controlled Trial Number (ISRCTN) Registry, ID: ISRCTN10460622. Registered on 11 May 2016

Effectiveness and cost-effectiveness trial of humanistic counselling in schools for young people with emotional distress (ETHOS) 2016-2019

The ETHOS study (Effectiveness and Cost-effectiveness Trial of Humanistic Counselling in Schools) was a 'fully powered', two arm, parallel-group RCT which compared the clinical and cost-effectiveness of school-based humanistic counselling in addition to pastoral care as usual (SBHC) against pastoral care as usual alone (PCAU). Quantitative datasets are: (a) participants' demographic details, number of sessions (SBHC only), use of pastoral care, and adverse events; (b) outcomes at assessment, 6 weeks, 12 weeks, and 24 weeks (Young Person's CORE, Strengths and Difficulties Questionnaire, Revised Child Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, Warwick and Edinburgh Mental Well-Being Scale, Client Service Receipt Inventory, Goal-based Outcomes (and goal texts), and the Experience of Service Questionnaire); (c) process measures at six weeks: Barrett-Lennard Relationship Inventory, Working Alliance Inventory (SBHC only), and session-by-session Outcome Rating Scale; (d) educational outcomes (attendance, exclusion, predicted grades), (e) adherence ratings for counsellors and supervisors. Basic descriptive data are also available for schools, counsellors, and counsellors' supervisors. Qualitative datasets are semi-structured interviews with participants, parents/carers, and pastoral care staff regarding their experiences of, and views on, the school-based counselling.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.</p

Effectiveness and cost-effectiveness trial of humanistic counselling in schools for young people with emotional distress (ETHOS) 2016-2019

The ETHOS study (Effectiveness and Cost-effectiveness Trial of Humanistic Counselling in Schools) was a 'fully powered', two arm, parallel-group RCT which compared the clinical and cost-effectiveness of school-based humanistic counselling in addition to pastoral care as usual (SBHC) against pastoral care as usual alone (PCAU). Quantitative datasets are: (a) participants' demographic details, number of sessions (SBHC only), use of pastoral care, and adverse events; (b) outcomes at assessment, 6 weeks, 12 weeks, and 24 weeks (Young Person's CORE, Strengths and Difficulties Questionnaire, Revised Child Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, Warwick and Edinburgh Mental Well-Being Scale, Client Service Receipt Inventory, Goal-based Outcomes (and goal texts), and the Experience of Service Questionnaire); (c) process measures at six weeks: Barrett-Lennard Relationship Inventory, Working Alliance Inventory (SBHC only), and session-by-session Outcome Rating Scale; (d) educational outcomes (attendance, exclusion, predicted grades), (e) adherence ratings for counsellors and supervisors. Basic descriptive data are also available for schools, counsellors, and counsellors' supervisors. Qualitative datasets are semi-structured interviews with participants, parents/carers, and pastoral care staff regarding their experiences of, and views on, the school-based counselling.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.</p