Humanistic counselling plus pastoral care as usual versus pastoral care as usual for the treatment of psychological distress in adolescents in UK state schools (ETHOS): a randomised controlled trial

Mick Cooper, Megan Rose Stafford, Dave Saxon, Jeni Beecham, Eva-Marie Bonin, Michael Barkham, Peter Bower, Karen Cromarty, Charlie Duncan, Peter Pearce, Tiffany Rameswari, Gemma Ryan

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Background. About one in seven adolescents have a mental health disorder in England, UK. School counselling is one of the most common means of trying to address such a problem. We aimed to determine the effectiveness and costeffectiveness of school-based humanistic counselling (SBHC) for the treatment of psychological distress in young people in England, UK.
Methods. We did a two-arm, individually randomised trial in 18 secondary state-funded schools across the Greater London area of the UK. Participants were randomly assigned (1:1) using a centrally secure randomisation procedure with random permuted blocks to either SBHC plus schools’ pastoral care as usual (PCAU), or PCAU alone. Participants were pupils aged 13–16 years who had moderate-to-severe levels of emotional symptoms (measured by a score of ≥5 on the Strengths and Difficulties Questionnaire Emotional Symptoms scale) and were assessed as competent to consent to participate in the trial. Participants, providers, and assessors (who initially assessed and enrolled participants) were not masked but testers (who measured outcomes) were masked to treatment allocation. The primary outcome was psychological distress at 12 weeks (Young Person’s Clinical Outcomes in Routine Evaluation measure [YP-CORE];
range 0–40), analysed on an intention-to-treat basis (with missing data imputed). Costs were assessed at 24 weeks (Client Service Receipt Inventory and service logs). The trial was registered with ISRCTN, number ISRCTN10460622.
Findings. 329 participants were recruited between Sept 29, 2016, and Feb 8, 2018, with 167 (51%) randomly assigned to SBHC plus PCAU and 162 (49%) to PCAU. 315 (96%) of 329 participants provided data at 12 weeks and scores were
imputed for 14 participants (4%). At baseline, the mean YP-CORE scores were 20·86 (SD 6·38) for the SBHC plus PCAU group and 20·98 (6·41) for the PCAU group. Mean YP-CORE scores at 12 weeks were 16·41 (SD 7·59) for the
SBHC plus PCAU group and 18·34 (7·84) for the PCAU group (difference 1·87, 95% CI 0·37–3·36; p=0·015), with a small effect size (0·25, 0·03–0·47). Overall costs at 24 weeks were £995·20 (SD 769·86) per pupil for the SBHC plus PCAU group and £612·89 (1224·56) for the PCAU group (unadjusted difference £382·31, 95% CI £148·18–616·44; p=0·0015). The probability of SBHC being more cost-effective reached 80% at a willingness to pay of £390 for a 1-point improvement on the YP-CORE. Five serious adverse events occurred for four participants in the SBHC plus PCAU group, all involving suicidal intent. Two serious adverse events occurred for two participants in the PCAU group, one
involving suicidal intent.
Interpretation. The addition of SBHC to PCAU leads to small reductions in psychological distress, but at an additional economic cost. SBHC is a viable treatment option but there is a need for equally rigorous evaluation of alternative interventions.
Funding. This work was supported by the Economic and Social Research Council (grant reference ES/M011933/1).

© 2021, The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See
Original languageEnglish
Pages (from-to)178-189
JournalThe Lancet Child & Adolescent Health
Issue number3
Early online date20 Jan 2021
Publication statusE-pub ahead of print - 20 Jan 2021


  • adolescent health
  • mental health
  • academic settings
  • school counselling
  • randomised controlled trials
  • psychotherapeutic outcomes

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