BY Dr Nicola Brough

The Fulcrum, Issue 92 May 2024

I first used complementary and integrative medicine over 20 years ago to support my own ill  health. It was reflexology that awoke me to my innate healing ability. I was fascinated by the body-mind results I felt, and responded so well that I decided to train and spread the word. I qualified in reflexology, aromatherapy, massage and Bowen therapy, became a Reiki master  teacher and obtained an integrative massage therapy certificate at the Southern School of Natural Therapies in Melbourne, Australia in 2003. Back in the UK, direct spirit guidance led me to CST. I attended an introductory training at the Karuna Institute in 2004 and by lunchtime on the first day I knew with every fibre of my being that I was in the right place.

I wish for CST practitioners to have the confidence within themselves to give evaluating their practice a go and to see the bigger picture and the opportunity we have as a profession to work together to gather some meaningful outcomes (data) on the mind-body-spirit modality we call CST.

It was while I was supporting carers of patients, working with colleagues who were community psychiatric nurses (and trained in Reiki) in NHS mental health services, that I realised how sidelined complementary and alternative therapies were within the NHS framework. All of the therapies I offered at that time were dismissed from serious clinical consideration as “not having enough evidence” and I became frustrated that I didn’t have a way of capturing the sometimes transformative changes my clients reported and that I saw unfolding during our work together. This was also in the context of the ethical implications of asking for testimonials and the Advertising Standards Agency enforcing new guidelines about what practitioners could claim or write on their website.

How to measure wellbeing

I wanted to challenge that narrative of “not having enough evidence”. Drawing on my earlier  career in a leadership and management company undertaking psychometric testing for  training and recruitment purposes, benchmarking made sense and using tools to measure the “inner world” intrigued me. In 2009 the CSTA were looking to fund a volunteer to undertake a study of effectiveness for CST using the Measure Yourself Medical Outcomes  Profile (MYMOP). I was accepted and commenced a Masters by Research project with the  University of Warwick Medical School, under the supervision of Professor Sarah Stuart-Brown, then Chair of Public Health. As part of the study, I undertook a literature review of potential measures but there was no good fit. After some negotiation, the starting point became an exploration of clients’ experiences of CST to find out what outcomes were  important to them.

I undertook qualitative interviews with twenty-nine CSTA members’ clients to identify what outcomes they believed they experienced as a result of CST and what importance they had  in their lives.

The seminal paper “Perspectives on the effects and mechanisms of craniosacral therapy: a  qualitative study of users’ views”¹ was published in 2015 in the European Journal of Integrative Medicine and I was awarded an MPhil for outstanding work – something no one  else had achieved at that point at Warwick Medical School. This paved the way for a
Chancellor’s scholarship and PhD.

Client experiences as a conceptual framework

The thematic analysis of the earlier interviews informed a conceptual framework of CST outcomes which was refined and validated with CST practitioners and more CST clients who  took part in focus groups. The conceptual framework of CST outcomes (Brough, N., 2017)  identified important domains of health, not explicitly expressed as statements or items in other measures including the “development of self-awareness” and “individuals taking  responsibility for themselves”. I set about using verbatim statements from client interviews to  address all areas of the conceptual framework with statements for a questionnaire. Seventy-two statements were the starting point of the Warwick Holistic Health Questionnaire (WHHQ).

Clinically validated and evidence-based measures

The WHHQ² is a measure of wellbeing (18/25-items) that covers mental wellbeing, physical wellbeing, spiritual wellbeing and social/relational wellbeing. The WHHQ widens the meaning of health and wellbeing because it taps the concept of self-awareness and individuals taking responsibility for themselves with items such as:

My awareness about my health has helped me manage my life
I’m learning about myself and my body
I’ve felt in control of my health and wellbeing
I’ve been able to take care of myself

Although Patient Reported Outcome Measures (PROM) are subjective measures, the development and validation of the WHHQ followed gold standard protocols for PROM  validation, like those used in clinical trials. As a result, the WHHQ is a psychometrically robust measure that is sensitive to change at individual level (client level) and group level (for a service evaluation in a clinic).

To date, WHHQ is the only measure for CST. It is also the only rigorously validated PROM  applicable to other complementary and alternative medicine (CAM) modalities. In recognition of this work, in 2018 I was awarded the Best Complementary Therapy Research Award sponsored by the Federation of Holistic Therapists (FHT).

Positive feedback from CAMs and health professionals

So far, WHHQ has been used in complementary therapy services within NHS Harrogate &  District Foundation Trust – Sir Robert Ogden Macmillan Centre (SROMC), Harrogate  Hospital and there are discussions underway to roll it out to wider multi-disciplinary teams. The implementation paper has been published³ and the positive outcomes for the department included:

• Simple to use, easy to interpret
• Fewer mistakes made due to digitalisation
• Provides a broad perspective of patient wellbeing concerns
• Fewer personnel hours consumed inputting and collating data.

Also, the WHHQ is currently being trialled in Staffordshire Combined Mental Health Trust within the department of Clinical Health Psychology. The psychologists within the team really like the WHHQ content as it gets patients reflecting on what’s working in their lives instead of what’s not.

A digital platform for the wellness sector

Measure Well Ltd was set up as a means of making the WHHQ accessible to practitioners. The pandemic sobered me into thinking that digitalisation was the way to go and in winter 2023 we launched the Measure Well Hub, enabling exclusive access to the digital WHHQ, developed to collect, store, analyse and report on client/patient outcomes. It’s very easy to use and provides practitioners with a quick snapshot of where their client perceives their wellbeing to be.

The WHHQ is more than an outcome measure, it is an eye-opener for clients, making them think about the way they are living, what they need from a series of treatments and where they would like to be. It also gives me insight into how gently I need to engage with a client; a low score means I am super gentle, slow and soft in my manner. Having used it for six months, I will never treat a new client without it.

I think the validated data will be a valuable tool for individual practitioners and the CSTA to raise awareness of the efficacy of CST. The more of us that use it, the better it will be for the profession as a whole.

Lulu Ferrand, RCST

I see so much potential for its use across the wellness sector. Over time I would like for Measure Well to be in a position where we can report back to the different areas of the wellness sector about the outcomes we have collated. I am keen to increase awareness of the benefits of outcomes evaluation and excited to see how the WHHQ might be used in the wellness sector as a whole.

Supporting CST clients and practitioners

With regard to CST, uptake has been slow despite CSTA members having been given free access to both the Measure Well Hub and WHHQ. But it’s early days and I feel optimistic. From my own experience, the benefits include greater focus, authentic feedback, benchmarking progress and professionalism.

I use the WHHQ every time I have a new adult client come to see me. A link is sent out via email along with my online case history form. We discuss the scores at the initial consultation and I use the statements that have been highlighted as problematic areas to guide discussions along with what the client is bringing in the moment. Clients are asked to complete a follow-up WHHQ at a future session depending on our treatment plan. I find it helps to focus the sessions. The WHHQ is scored 0 – 100 (the higher the score the greater the wellbeing) and it enables me to get a handle on where someone perceives themselves to be and/or if they are masking on arrival.

I can monitor the progress of each of my clients quickly online and I can benchmark across all of my clients. I use the WHHQ results to write reports when clients need to make Personal Independence Payment claims, for those that get funding for sessions or for GP letters. I certainly feel it adds an extra dimension of professionalism to what I am doing.

Building credibility and professionalism in CST

Although research papers are now available to some extent, CST still has a long way to go to build an evidence base. Evaluating wellbeing outcomes can help build the case for CST and the benefits are adaptable to organisational, practitioner and client levels.

• Improves the credibility of a profession
• Increases the public profile of an intervention
• Enhances funding applications
• Demonstrates the value and shows visible progress of therapies
• Improves client communication and understanding of progress made
• Provides tangible reporting

I wish for CST practitioners to have the confidence within themselves to give evaluating their practice a go and to see the bigger picture and the opportunity we have as a profession to work together to gather some meaningful outcomes (data) on the mind-body-spirit modality we call CST.

It’s now my mission to promote the benefits of measuring outcomes and help others to access the WHHQ. Measure Well runs CPD training for practitioners including “How to use the WHHQ” and “How to undertake a successful service evaluation”.

Nicola Brough is a craniosacral therapist, reflexologist, reiki master teacher and a clinical supervisor. With over 20 years of experience working with adults and families, she offers integrative therapy from her busy practice in Staffordshire. Author of the WHHQ and founder of Measure Well Ltd, she promotes the benefits of WHHQ internationally and runs CPD training and support for CST practitioners and a podcast series.
www.measurewell.co.uk

References

1. 1. Brough, Nicola, Lindenmeyer, Antje, Thistlethwaite, Jill, Lewith, George and Stewart-Brown, Sarah L. (2015) Perspectives on the effects and mechanisms of craniosacral therapy: a qualitative study of users’ views. European journal of integrative medicine, Volume 7 (Number 2). pp. 172-183. doi:10.1016/j.eujim.2014.10.003 ISSN 1876-3820.
   2. Brough, Nicola, Stewart-Brown, Sarah L., Parsons, Helen and Perera, Chinthana (2021) Development and validation of a PROM to capture holistic outcomes in traditional, complementary and integrative medicine – The Warwick Holistic Health Questionnaire (WHHQ-18). European Journal of Integrative Medicine, 47. 101375. doi:10.1016/j.eujim.2021.101375 ISSN 1876-3820.
   3. Brough, Nicola, Crossman, Julie and Perera, Chinthana (2023) A service evaluation and implementation of the Warwick Holistic Health Questionnaire (WHHQ-25) in a National Health Service (NHS) oncology department using complementary and integrative approaches to healthcare in the UK. European Journal of Integrative Medicine, 60. 102250. doi:10.1016/j.eujim.2023.102250 ISSN 1876-3820.

The opinions expressed in this article are those of the author and do not necessarily reflect the viewpoints of the CSTA.