What is the gap between what we value in the work of therapy, and how we measure it?
We have the merchants of Venice to thank for our present system of accounting. Luca Pacioli, a Franciscan friar, chess master and professor of mathematics, first recorded it for use by merchants and bankers on the Rialto Bridge in renaissance Venice. Double entry book-keeping became established as a way of tracking goods and money, and understanding profit and loss in a company’s trading patterns.
During a severe recession in Europe in 1772, Wedgwood turned to double-entry book-keeping to understand where his profits were, and how to expand them. If you need to work out how much each piece of work costs, for improving profits or reporting to shareholders, say, this is a reliable method. It illuminates decisions about production and prices and profit. A whole branch of learning and practice in management accounting has emerged, which relies on a system of measurement rooted in the marketplace.
Much of what we value in the world of mental health, however, in my view, is outside this account.
The use of the book-keeping frame of accounting strips out multiple values that work in a child and adolescent mental health clinic creates. This kind of account was simply not designed to capture a whole range of aspects of the intrinsic value of mental health.
When cost is the dominant frame for evaluation, and we fail to measure real values such as qualities of connection and relationships, then the danger is we work to cost measures only and lose all the relational value that as clinicians we know is essential for real and lasting change to happen. As Dr Duncan Law explains in a previous ACAMH blog, “What we choose to measure and how we choose to evaluate services will impact on how services are organised and where limited resources are deployed”. He warns that if we evaluate services only on the speed at which they see children, those services will inevitably devote resources to seeing children quickly, losing traction on the actual purpose and value of a child and adolescent mental health clinic – having a real positive impact on children’s lives.
Furthermore, working to an evaluation frame that does not fit the nature of the work and cannot capture its full value inflicts tension on people working in mental health, far beyond the stresses of the work itself. We have now the working context of what Rustin (2004) has called “the pervasive systems of audit and inspection which now plague every inch of the public sector”. These tend to create a culture in which there seems to be no room for curiosity about causes, or awareness of a wider political, social and relational context, just narrow critical scrutiny in pursuit of less and less realistic targets.
Yet as professionals we know this account does not tell the whole story of what matters. In fact, we leave out the emotional information at our peril. The Tavistock observation model, underpinned by modern neurobiology, understands emotional undercurrents as information, literally in-forming behaviour and responses and therefore therapeutic results. I have written elsewhere (Sutton, 2019:27) of how, if we experience an external perspective as unfeeling, as an inspection, we will concentrate on the look of things, which tends to preserve the status quo, and precludes curiosity, learning and development. The outside perspective is necessary for growth and learning, but it is potentially experienced as critical – especially if it is coming from an authority figure interested in outcomes and not causes: the what and not the how.
McGilchrist (2009) has warned of the dangers for Western civilization of prioritizing the left brain’s focus on what rather than how. We urgently need new ways of measuring what we actually value in the mental health clinic that include not just content but process, not only what happens but how it happens. These are the new paths that are made by walking: the new neural connections wired in through the qualities of the relational process at the heart of therapeutic progress.
In the child and adolescent mental health clinic (as elsewhere, in fact) value is relational, and emerges as a relational quality of systems of relationships. Longitudinal studies have shown the positive quality of resilience, for example, to be a dynamic process, a fluid interaction between the individual and their relational environment (Rutter, 2012).
Gathering an account of mental health progress is a social process, which needs to consider what we can count, certainly, but also the dynamic relational qualities of how we feel and how we connect. We need not only to think in terms of calculation, but also of the less visible though vital value of emotionally-nuanced calibration of contingent responses, and the crucial value of capacitation, the building of relational capacity that lies at the heart of good mental health for the individual, the work team and the wider network.
Reframing the account in favour of the professional’s felt experience of value seems vital. If we are to measure what we really value, rather than only permitting ourselves to value what we currently measure, we need to find ways of incorporating our felt experience into the account we give.
At the learning studio, we have been considering ways of expressing and developing value in public sector and social enterprises for a number of years and have developed a revaluation process. It has been used in contexts where the reported account of value does not fully account for a great deal of experienced and developmental value. These have included social movements, health and care settings, services aiming for social change, and policies pursuing multiple benefits. One particularly relevant context was the Family Nurse Partnership in Scotland. Here’s a link to the report.
In the revaluation process, in each context, between us, we tell the story of what is really of value in the work we do, and record it in a number of ways. These include visible and hitherto invisible values, what is known and what is potentially knowable, single source data and combined data, emerged value to date and emergent value to come, direct and indirect value, and crucially the building of connections and capacity.
It is high time in the world of children’s mental health to make visible the vital values which have been rendered invisible, through being outside the received account. We need a new way of accounting for ourselves and the work we do, which incorporates our felt experience as crucial information. Working towards this is in itself is a developmental process, which benefits the individual child and family and also the team and network around them, creating and enhancing value in shared new understandings and ways forward.
Conflict of interest statement: The author declares that they have no competing or potential conflicts of interest in relation to this article.
Family Nurse Partnership (2019). Family Nurse Partnership in Scotland: revaluation report.
McGilchrist, I. (2009). The Master and His Emissary: The Divided Brain and the Making of the Western World. New Haven, CT: Yale.
Rustin, M.J. (2004). Rethinking Audit and Inspection. Soundings, 26: 86-107.
Rutter, M. (2012). Resilience as a dynamic concept. Developmental Psychopathology, 24(2): 335-44.
Sutton, S. (2019). Psychoanalysis, Neuroscience and the Stories of Our Lives: The Relational Roots of Mental Health. London: Routledge.