Written evidence submitted by the University of Roehampton (CYP0019)

This submission is a note on recent findings regarding the effectiveness and cost-effectiveness of counselling in UK secondary schools. This is with respect to the Committee’s question regarding the wider changes needed in the system for youth mental health care as a whole.

I am a Professor of Counselling Psychology based at the University of Roehampton, and Chief Investigator for the ETHOS trial. School-based counselling is one of the most prevalent intervention for young people’s mental health problems in the UK [1] and, therefore, an important area to address in any decisions regarding youth mental health policy. The Effectiveness and Cost-effectiveness Trial of School-based Humanistic Counselling (ETHOS) was the largest study, to date, of school counselling in the UK—supported by funding from the Economic and Social Research Council [grant reference ES/M011933/1]. Findings from the study were published in Lancet Child & Adolescent Health in January 2021 and are available here[1].

The ETHOS study was conducted in 18 state-funded secondary schools in London [2]. Recruitment was through the schools’ pastoral care teams who were briefed on the trial and asked to identify potentially eligible young people. If parental/carer consent was given, young people were then assessed by a member of the research team to see if they wanted—and assented—to participate; and to check that they had at least moderate levels of emotional symptoms. Eligible young people were then randomly assigned to one of two conditions: school-based humanistic counselling (along with access to the school’s usual pastoral care provision) (167 young people), or access to usual pastoral care alone (162 young people).

Counselling sessions were delivered on an individual, face-to-face basis, and lasted about 45 minutes. They were scheduled weekly over a period of up to 10 school weeks. The counselling was delivered by a team of 19 counsellors, all of whom were qualified to diploma level (at least two years, part time training). The counsellors received clinical supervision throughout the trial, and recordings of their practice was ‘audited’ to make sure they adhered to humanistic counselling competences.

Effectiveness

Our main finding was that, 12 weeks from assessment, those who had participated in counselling reported significantly less psychological distress than those who had not (see figure). These differences were still present 12 weeks later; and were not affected by factors such as clients’ gender, age, or ethnicity. However, the differences between the two groups was relatively modest: about two points on our ‘Young Person’s CORE (YP-CORE)’ measure of psychological distress, which ranges from 0 to 40 [3].

We also found that counselling brought about medium to large improvements on the clients’ individual goals (for instance, feeling more confident, improving their relationships with their parents/carers, or controlling their anger), and self-esteem across all time points; and small improvements in wellbeing and psychological difficulties at 12 weeks. However, the counselling had no significant effect on symptoms of anxiety and depression. It also had no effect on the young people’s willingness to engage with school; or on other educational outcomes, such as attendance and exclusion rates, number of disciplinary proceedings, and predicted grades. In addition, we found that the counselling did not bring about reductions in the use of other services, such as pastoral care support or GPs. Economically, then, the cost of the counselling was not offset by other service savings—at least not over the 24 week period.

Satisfaction

When asked to rate, overall, whether the counselling was good or not, around two-thirds said that this was ‘certainly true’, 30% said that it was ‘partly true’, and about 5% said it was ‘not true’. We found similar levels of satisfaction when we analysed data from our 50 post-counselling interviews. Around half of the clients were unequivocally positive, for instance, ‘I really loved it; I loved her, I thought she was amazing’. Another 20% were then generally positive, but described one or two elements that they found less helpful. Approximately 20% said that the counselling had not helped much, but could see some positive elements to it. Finally, two of the 50 clients (4%) described the counselling in almost wholly negative terms. One of these, for instance, dropped out after only one session: ‘Just didn’t think it helped. Nothing really happened, we didn’t even speak.’

Mechanisms of Change

A preliminary analysis of our interview data suggests four main ‘pathways of change’. First, for about three-quarters of the clients, counselling seemed to be of value because it helped them get things off their chests. ‘It was getting all the negativity out of me’ said one young person. Second, about two-thirds of the clients said that the counselling was helpful because of the advice that they had received. This was mainly with respect to relating to others (for instance, advice on ignoring bullies), or learning ways to deal with stress (for instance, making a timetable). This finding was of particular interest because, in humanistic counselling, there is a particular emphasis on not giving clients advice. Third, for about 60% of the clients, the counselling seemed to have been helpful because the ways they had developed of relating to the counsellor—in particular, trusting and opening up—were then generalised out to significant others in their lives. Finally, around 40% of the clients said that the counselling had helped them to develop insight into themselves and their situations, which then helped them identify, and choose, more effective ways of behaving. One client, for instance, said that they had discussed their ‘morning routine’ with their counsellor, and by doing so had found a less stressful way of starting the day.

Our interview data also suggests three aspects of the counselling that the young people did not like, or had impeded positive change. First, around 30% of the clients said that they found the silences in the counselling awkward or uncomfortable. One client said, ‘She [the counsellor] didn’t have a lot to say. She would just sit there and stare at me for sometimes three minutes at a time. Literally it was three minutes!’ Closely related to this, a similar proportion of clients said that they would have liked some more advice, guidance, or feedback from the counsellor—not just listening or reflecting their words. Third, around 20% of the clients acknowledged that they, themselves, found it difficult to trust people; and that this had made it hard for them to open up to the counsellor. Several of these clients went on to say that there was not much that the counsellor could do here. One client said, ‘I didn’t let the counselling change me.’

Summary

Our findings suggest that, on average, school-based humanistic counselling can help young people, with effects that persist for at least three months after the end of counselling. The counselling was most effective in helping young people improve their self-esteem and achieve personal goals; least effective at reducing mental health symptoms. In addition, it showed no effect on educational outcomes or reducing other service costs. Such averages, however, can mask differences in the way that young people responded to the counselling: around two-thirds seem to have found it wholly or mostly helpful, another 30% or so found it helped a bit; and then approximately 5% really did not like it. Although there is no clear evidence on who it was most helpful for, our interview data suggests that if young people were wanting—and motivated—to get things off their chests, learn about themselves, and/or find different ways of relating and coping, the counselling may have been most likely to of benefit. On the other hand, if the young people found it difficult to open up, felt uncomfortable talking to others, and/or wanted direct guidance and advice, then this intervention did not seem to be most suited.

Finding effective ways of addressing mental health problems in young people remains a priority for policy makers and fund holders. Our study shows that school-based humanistic counselling is a viable option, but it is not a ‘magic bullet’. Rather, it is likely to help some young people some of the time, and should be offered to young people as one out of a range of possible interventions. What is most important now is to carry out equally rigorous evaluations of alternative programmes in the UK; and to develop some understanding of which interventions are most likely to be helpful for whom.

Mick Cooper, D. Phil. Professor of Counselling Psychology

February 2021

References

1.              Cooper, M., School-based counselling in UK secondary schools: A review and critical evaluation, 2013, BACP/Counselling MindEd: Lutterworth.

2.              Stafford, M.R., et al., Effectiveness and cost-effectiveness of humanistic counselling in schools for young people with emotional distress (ETHOS): study protocol for a randomised controlled trial. Trials, 2018. 19(1): p. 175.

3.              Twigg, E., et al., Acceptability, reliability, referential distributions and sensitivity to change in the Young Person's Clinical Outcomes in Routine Evaluation (YP-CORE) outcome measure: replication and refinement. Child and Adolescent Mental Health, 2016. 21(2): p. 115-123.