Weighing up the costs of counselling as a mental health school-based intervention

Counselling in schools
Counselling is one of the most common school-based interventions for mental health and wellbeing for young people. This type of therapy allows young people to explore their thoughts and emotions in a non-judgemental, safe and confidential environment. Most schools source out their own counselling provision from an external provider paid through their existing budgets and will likely weigh up the costs and need for the service during decision making.
School-based humanistic counselling (SBHC): Is it cost-effective?

ETHOS by Cooper and Stafford et al (2021) conducted the first randomised control study to thoroughly explore school-based humanistic counselling (SBHC) for the treatment of psychological distress in young people in England. More importantly, the study provides a comprehensive cost-effective analysis and weighs up the benefits of SBHC and its costs.

Their findings reported a small significant reduction in self-reported psychological distress for young people with moderate to severe symptoms in the SBHC group, which was maintained at a 6 month follow up. These results were consistent across the 18 state funded schools and were linked with increased costs. 

The findings of the cost-effective analysis demonstrated the use of SBHC had no effect on other mental health services, it neither freed up use nor added extra pressure or overstretched these provisions. The sample included participants with data on both service use and outcome measures at baseline and at a 6-month follow-up. Participants were allocated to the SBHC plus Pastoral Care as Usual (PCAU) group or PCAU group. The projected cost of the SBHC intervention was £53·28 per session and total costs at 24 weeks was £382·31.


The authors suggested that SBHC was unlikely to be considered cost effective if the decision makers’ willingness to pay for SBHC was below £390. This was based on a 1 point improvement on the YP-CORE (Young Person’s Clinical Outcome in Routine Evaluation), in addition to the improvement seen in the PCAU group.

The authors suggested that when compared to PCAU, the likelihood of SBHC being considered cost effective would exceed 50% if the decision maker was willing to pay £222. At a willingness to pay £630 for the intervention, the likelihood exceeded 90%.

“Assuming that the estimated increase in costs associated with SBHC (£382) is the maximum willingness to pay for a commissioner, and considering the effect size of SBHC on the primary outcome, the chance that SBHC would be considered cost-effective is only 52%, similar to flipping a coin. The economic data alone do not provide strong support for a decision to provide or expand SBHC.”

Counselling in schools needs to be part of a menu of other therapeutic interventions to support young people's mental health while reducing financial costs for schools

The ETHOS study concluded that SBHC was a worthwhile option in terms of delivering on benefits for some young people, however only as part of a menu of different therapeutic interventions offered in schools. Possible suggestions to reduce costs, lie with improving service delivery.

Not too long ago, it wasn’t uncommon for teachers to undertake counselling as an add-on role, however, there was a significant move away from this. It now appears as though this is seen as emerging good practice (Counselling in schools: a blueprint for the future, 2016).

In light of this, Minds Ahead will be running the first of its kind, a school-based post graduate diploma, the School Mental Health Specialist course awarded by Leeds Beckett University, starting in September 2021. It aims to enable school staff to develop their mental health expertise in student support and wellbeing. The benefits of an improved school-based pastoral support system via the School Mental Health Specialist course could reduce financial costs for schools.

To sum up, most schools use their existing budgets to source mental health provision from external agencies, meaning that they are already weighing up the costs of services versus their school need. A comprehensive cost analysis conducted by Cooper and Stafford et al (2021) explored the benefits and costs of school-based counselling and concluded that although it is a worthwhile school mental health provision for some young people, it would need to be part of a menu of other therapeutic interventions. Improvements with service delivery was a possible remedy to reduce costs for schools.

Cooper, M., Stafford, M., Saxon, D., Beecham, J., Bonin, E., Barkham, M.,  Bower, P., Cromarty, K., Duncan, C., Pearce, p., Rameswari, T. & Ryan, G., (2021) 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. The Lancet Child & Adolescent Health, Volume 5, Issue 3, March 2021, Pages 178-189