A Move Beyond Measurements
Nancy Hervey Bathurst
Mental Healthcare in the UK quite understandably exists on measurements. It relies, like any organization, on funding, and to receive any bank of funding, you must be able to evidence your results, to show what you did last time and why you should be able to do it again. Results here chart the course from diagnosis to clearance, from illness to health, from crisis to consistency and comfort. Numbers are the ladders and the steps in this journey. The number of times you visited, the dosage of medication you were prescribed. Both of these are helpful and secure. In an area ridden with uncertainty and often with bias, and in a sector where it is difficult to compare experiences and yet one has to in order to come to any further conclusions, numbers offer the best possible framework to navigate an impossible task.
And yet, mental experience is an area where even numbers offer little guidance. In many situations numbers only tell you how many people are struggling, and then not even that, as they really only tell you how many people have made it as far as an appointment or even a phone call in order to then be logged onto the system. Eating disorders have a particular reliance on numbers: weights, inpatient and outpatient timings, numbers of bed, numbers of wards, numbers of referrals & re-referrals. It is a illness where both the symptom and the treatment are encrypted in the numerical, and yet recovery is usually defined by a freedom from these numbers, a time where the patient no longer leads a life led by calorie counting, binging or purging, maintains a healthily relaxed (unmeasured) relationship to weight and food, and feels a sense of manageability but not numerical control within their life. More generally, mental health and the path from mental illness to mental wellness is infamously personal, infamously difficult, and - by many testimonies - often consists of a conflicted, back-and-forth pathway to recovery, best navigated with a wide ecology of support structures & strategies. None of these seems applicable to the 40 session, up and out style appointment that is currently available.
Is there a way to propose and to implement a different kind of system, a system that coordinates a quantitative record and a qualitative appraisal of each case?
It is impossible to abandon measures and numbers completely and important not to. Whilst each process is personal, the subjective is a precious and rare thing, and often very helpful for patients and doctors and when it comes to illnesses that wreak such impact on patients’ lives and yet are so mercurial. Diagnosis and data are critical hinges to begin to build a structure in the unknown. However, alongside this, there must be a better way to expand and incorporate the breadth of knowledge and insight that can be gained from diverse therapies and counselling sessions - the relationships built, the human factors and context that surround each case - which often affect the progress a patient may be able to make.
To take the case of Eating Disorders, both body weights and mentalities can fluctuate widely, and are often out of sync with each other. If, after a stint of hospital care a patient has managed to reach a healthier weight, and yet still holds the same attitude and feelings towards themselves, or has not received the therapeutic tools to navigate the feelings that arise around the food they eat, the recovery is often short term. Without a range of tools and ongoing support, one can feel unable to ward off the overwhelming anxiety that stems from such a speedily and radically changed body and relationship to food. When environmental factors compound this, recovery is understandably fragile. During my own time receiving in-patient treatment for Anorexia Nervosa on the NHS, I lived this experience and saw it in others many times. During a (usually 8 week) stay in hospital, patients would be fed and prevented from ‘acting out’ (binging, purging, exercising or restricting) after meals. You would reach a healthy weight, but without substantial therapeutic architecture around this. This would not last long, and very often, patients would be readmitted, their health regressed or worse than it had been to begin with. If they are an out-patient, they are discharged after a fixed number of appointments, regardless of their mental health or progress towards recovery. Many had been on the same cycle for over fifteen years.
After my experience of this, I was lucky to be able to travel abroad to find affordable private care in a specialist treatment centre where I spent three months. Here, amongst the same strict food programmes, was a different approach. From 9am to 5:30 we would be in talks and workshops, learning therapeutic approaches (including Transactional Analysis, Family Therapies, Dialectical Behavioural Therapy). Half of each session would be spent learning the formats and systems these offered for understanding and exercising mental and emotional challenges and experiences. During the next half, we would be encouraged to apply these to our own process and situation, working in groups and independently to cast our lives within the frameworks provided. What this amounted to was a short course in psychotherapies, garnering a roster of understandings and mechanisms with which we could scrutinize, engage, and navigate our own personal experience of illness and mental health. These were essential in the moment, and have proved invaluable since, particularly under the threat of relapse. Ten years later, and with an ongoing engagement with the diverse therapies I learnt in that centre, I have achieved a consistent recovery in my weight, shape and relationship to food.
Is there a place for measuring mentality, behaviour and action, creating more nuanced and intuitive scales with which to acknowledge mood, mentality and a patient’s sense of risk to self, alongside the body weights, incident records and hospitalisations currently ongoing? Could this help the situation at play? Studies have shown that the long term recovery rate, both for eating disorders and other associated mental health conditions is disproportionately higher when given access to the level of care currently only available in private institutions. The central reasons behind these do not unfortunately need to be spelled out. More funding can facilitate a lot - increased staff and attention per patient, improved facilities, more diverse and intensive therapies, more consistent care and consideration to suggest a few - each factor from which any individual process would benefit hugely. Evidently, the best thing would be to find a way to offer greater financial resourcing to the public centres, so that they may too offer a similarly rich, and hopefully, similarly successful offer as their private counterparts, though importantly one which doesn’t come at such a prohibitive cost to the patient. That point has been made many times though, and the speed of change within public services and resource allocation has been shown to be critically slow, whilst the need for a shift in perspective is urgent. There needs to be a re-evaluation of the therapies on offer, and a provision of more funding to therapies beyond feeding programmes. Food-centred counselling offers something that provides greater support and trust to the patient and health care workers, allowing the teams within each structure to appraise an individual’s progress in a way that does not reduce the condition to numbers and measures but is built upon holistic progress.
For those diseases where numbers and measures become as detrimental as is the case in many mental health cases, the integration of less numerically fixed therapies alongside measurements could offer a different and dynamic track to better health, and, hopefully, a recovery approach with more longevity on offer. Could the trust and support of the healthcare workers who specialize in these areas and are working directly with individual patients in turn help lead to better outcomes, with the pressure taken off conforming to the fixed limits of a system which has been proven to struggle if not fail. This suggestion is not so much a radical but instead repetitive call for something suggested before, but yet to be implemented. I am not in the medical profession, and my insights are observational- taken only from my own experience and reflections on this. But it is the only approach which I found to help and perhaps an evolution can be as good as an overhaul. Might a move away from numbers alone offer a stronger measure of recovery and success particularly in the slippery processes of mental health care and therapy.