In 1961, Robert McNamara walked into the Pentagon with a clipboard and a philosophy that would eventually break a country. He was one of the “Whiz Kids,” a group of ten veterans from the World War II Office of Statistical Control who had revolutionized the Ford Motor Company by turning every bolt, every fender, and every hour of labor into a data point on a spreadsheet.

When he became the Secretary of Defense, he brought that same cold, numerical hunger to the Vietnam War. He wanted a “Body Count.” He believed that if you could measure the attrition-if the number of enemies killed exceeded the number of your own soldiers lost-you were winning by default. It was a mathematical inevitability.

Except, as the world eventually learned, the number on the page had almost nothing to do with the reality on the ground. The metric became the target, and because the metric was easy to count and impossible to ignore, the actual goal-peace, stability, victory-was quietly discarded in favor of a tally.

The McNamara Era of Mental Health

We are currently living through the McNamara era of mental health. If you pick up an annual summary from almost any major healthcare provider, public or private, you will find a version of the second paragraph that I have seen a thousand times. It is usually in bold, and it usually says something like: “Over 482,730 sessions delivered this year.”

It is a massive number. It is meant to be a staggering achievement. It is a genuine testament to the hard work of thousands of clinicians and administrators who are trying their best to keep a sinking ship afloat. But the moment you stop to look at it, the number begins to dissolve. It is a real number, and yet it is entirely silent on the only question a person actually has when they are drowning in their own mind: is anybody getting better?

There is no sentence in these documents that attempts an answer. Instead, there are more numbers. Appointments offered. Appointments attended. DNA (Did Not Attend) rates. Average wait times. These are the “Body Counts” of the modern clinic. We measure what is easy to count, and then we reorganize the entire sector around the count until, within a single generation, the proxy becomes the objective.

No one remembers choosing it. No one remembers the Tuesday morning meeting where it was decided that a “session” was the same thing as “help.” It was just available. And availability, over time, is the most persuasive force in human systems.

The Pragmatism of the Curb

I think about this every time I’m in the car with Natasha V.K. She is my driving instructor, a woman of infinite patience and a very specific kind of Russian pragmatism that makes you feel like stalling at a roundabout is a moral failing rather than a mechanical one.

Last week, I parallel parked perfectly on the first try. It was a moment of pure, unadulterated triumph. If Natasha were being measured by the metrics of the mental health sector, she would have been incentivized to keep me in that car for sixty hours of aimless cruising. She would be rewarded for the volume of “instruction sessions” delivered.

But Natasha doesn’t care about the hours; she cares about the curb. She cares about whether I can place two tons of metal into a gap with four inches to spare without breaking a sweat. The goal is the skill, not the time spent sitting in the driver’s seat.

But in the world of therapy and psychiatry, we have lost the curb. We have replaced the skill of recovery with the duration of the encounter. A system that reports hours will produce hours. It will distribute those hours in whatever way maximizes the count, which usually means short, shallow contacts spread thin across a massive population.

The Efficiency Illusion

In a spreadsheet, ten 15-minute check-ins look exactly the same as one 150-minute deep-dive assessment. In fact, the ten check-ins look better. They represent ten “units of care.” They look like efficiency.

But for the person who needs 150 minutes of undivided, culturally nuanced attention to untangle a decade of trauma, those ten 15-minute bursts are worse than useless. They are a recurring reminder that the system isn’t designed to see them; it’s designed to count them.

This brings us to the quiet tyranny of the “how this actually works” process. When a large organization-be it an insurer or a government body-commissions mental health services, they operate on a “block contract” or a “per-session” reimbursement model. To get paid, the provider must prove activity.

This involves a process called clinical coding. Every time a patient enters a room, a code is generated. This code travels through a series of administrative layers until it reaches a dashboard. These dashboards are the only thing the people at the top of the food chain ever see.

They don’t see the woman who finally felt safe enough to speak about her childhood because her therapist spoke her mother tongue. They don’t see the executive who avoided a burnout-induced breakdown because his psychiatrist understood the specific pressures of London’s financial district. They see a 45-minute “Unit of Psychology.”

When the Spreadsheet Demands Compliance

Because the funding depends on the units, the clinical reality begins to warp to fit the code. If a clinician feels a patient needs a longer session, they have to fight the system to get it. They have to justify why they are “wasting” two slots on one person.

Eventually, the clinicians get tired of fighting. They start to truncate the work. They start to fit the human experience into the 50-minute hour, not because it’s clinically optimal, but because the spreadsheet demands it. The convenience of the number at the beginning determines the shape of the entire sector at the end.

We have reached a point where the sector has optimized for throughput at the expense of outcome. We are very good at moving people through the revolving door; we are significantly less interested in what happens once they are back on the street. This is the core frustration of modern care. It is a system built for the convenience of the counter, not the needs of the counted.

The Necessary Deviation

This is why the approach taken by Mind a Porter feels like such a necessary deviation from the norm. When you look at their model, the emphasis isn’t on how many sessions they can churn out in a fiscal quarter. The emphasis is on the breadth and specificity of the match.

They haven’t built a factory; they’ve built a bridge. If you are an international professional living in London, your mental health isn’t just a collection of symptoms; it’s a complex tapestry of cultural context, linguistic nuance, and the specific isolation of the expatriate experience.

If you try to fit that tapestry into a standard-issue, monolingual “volume” clinic, something is going to get torn. You might get your sessions. You might check the box. But you won’t be understood.

By offering services in 22 languages and covering 28 different therapeutic approaches, the focus shifts back to the curb. It asks: “What do you actually need to get better?” rather than “How many slots do we have left on Tuesday?”

The reality is that finding the right professional is a fragmented, exhausting process. Usually, the person who assesses you isn’t the one who treats you. The person who can prescribe your medication doesn’t talk to the person who does your CBT.

And almost none of them speak the language you use when you’re dreaming or when you’re crying. You end up having to retell your story, over and over, to a succession of strangers, each of whom is holding a stopwatch and a tally sheet. It is a process that retraumatizes the patient in the name of administrative efficiency.

The Trap of “Output”

I’ve made my own mistakes in this area. Years ago, when I was managing a small project, I became obsessed with “output.” I wanted to see the numbers go up. I thought that if we were doing “more,” we were doing “better.”

I ignored the fact that my team was exhausted and the quality of our work was thinning out like a cheap soup. I was playing the McNamara game. I was winning the body count while losing the war. It took a very blunt intervention from a mentor to make me realize that a high volume of mediocrity is just a slow way to fail.

The mental health sector is currently serving a high volume of mediocrity because it has mistaken the map for the territory. It has decided that “access” means “a phone call within six weeks” rather than “meaningful help from someone who understands you.”

We have built a system that is terrified of the unquantifiable. We are scared of the fact that healing is messy, slow, and doesn’t always fit into a 45-minute block.

Reclaiming the Mirror

When I parallel parked that car, Natasha didn’t look at her watch. She didn’t check a spreadsheet to see if I had used up my “allotted units of reversing.” She looked at the distance between the tire and the stone. She looked at the outcome.

We need to start looking at the outcome again. We need to stop celebrating the number of sessions delivered and start asking how many lives were actually reclaimed.

The weight of the system is heavy. It is easier to count a session than it is to measure the return of hope. It is easier to bill an insurer for an hour of “Psychology” than it is to explain the value of a therapist who understands the specific cultural shame of a first-generation immigrant.

But the cost of the easy path is the slow erosion of the human being. We become data points. We become “throughput.” We become the bold text in the second paragraph of an annual report that no one actually reads with their heart.

It is time to push back against the moral authority of the metric. Just because a number is available doesn’t mean it’s meaningful. Just because a session was delivered doesn’t mean help was received.

We have to be brave enough to demand the long contacts done properly over the short contacts spread thin. We have to prioritize the match over the volume. Because at the end of the day, when the spreadsheet is closed and the lights in the clinic are turned off, the only thing that matters is whether the person who walked in the door feels a little bit more like themselves than they did an hour before.

Everything else is just a body count. We have to stop counting the sessions and start counting the people. We have to stop measuring the time and start measuring the truth.

It’s a harder way to run a sector, and it’s a much more difficult thing to put into a bold-text summary. But it’s the only way to ensure that when we say we’re helping, we actually mean it. We need to get back to the curb. We need to make sure we’re actually parking the car, not just driving in circles until the fuel runs out and the clock stops ticking.