ARTICLE 5
Complexity science and collaborative mental health care: so what?
Michel Gervais, MD, FRCPC, MBA
For anyone who has worked in the world of health care management, noticing how mental health is perceived as an untameable and peculiar beast is inescapable. If people suffering from a mental illness are stigmatized, the health care system in mental health is also shadowed by the same fate. Mental health looks much more like an amino-acid in the food chain than a strong flesh-eating predator.
The field of mental health has been undermanaged for many decades. It is as if people had given in to the belief that madness was senseless anyway and that its care should be left to those odd psychiatrists without asking too many questions. It would have been so handy to assess the performance in mental health solely by measuring volumes of production like, for instance, the number of hip surgeries done during a period of time. This reassuring perspective would have been in accordance with the “Western principles of Newtonian science” that have focused on the predictable and controllable dimensions of the traditional management.1
Most of the time, health care organizations have been conceptualized as being professional bureaucracies,“... a variant of machine bureaucracies, through our focus on Newtonian ideas of command and control, and prediction and planning, particularly in terms of expectations for how an organization should go about its tasks of resource management and outcomes evaluation.”2
In this context, the dominant metaphor builds on the Newtonian scientific principles where the organization is seen like a machine, the whole of the machine being the sum of the parts. These formulations led to a “remarkable industrial revolution, rational thought, and the mechanical nature of the modern scientific era.”3
The ramifications for mental health seemingly stretch away, through countless dimensions of the state apparatus and of society, as far as the eye can see. The scope of managing mental health extends much beyond the borders of its assigned box on the flow chart of the ministry of health. It is arguable that the list of its stakeholders is both exceptionally extensive and reaches further than the majority of the other medical disciplines. Probably much more than any other medical field, mental health is intertwined with a myriad of interdependent systems, either within or outside the ministry of health. Since there is not enough interest in closing the gaps between the silos and systems, the mental health care system resembles more of a shanty town than a modern functional city of the twenty-first century.
1 Peirce, John C 2000. The Paradox of Physicians and Administrators in Health Care Organizations. Health Care Management Review, volume 25 no. 1 (Winter): 7-28.
2 Anderson, Ruth A., Reuben R. Jr McDaniel 2000. Managing Health Care Organizations: Where Professionalism Meets Complexity Science. Health Care Management Review, volume 25 no. 1 (Winter): 83-92.
3 Peirce, John C 2000. The Paradox of Physicians and Administrators in Health Care Organizations. Health Care Management Review, volume 25 no. 1 (Winter): 7-28.
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Managing the mental health care network resembles more of a large complex ecosystem rather than an automobile manufacturing plant. In addition, psychiatry has been shaped by many disciplines like sociology, anthropology, philosophy, politic, neurosciences, psychology, etc. This is an interdisciplinary field "par excellence." As a result, mental health became the symbol of a disaster-prone area, a kind of Bermuda Triangle, always escaping the control of the Newtonian managerial empire. By nature,
probably much more than any other medical speciality, it could not be dealt with as if it were a machine.
The hospital has been at the center of the development of the health system during the twentieth century. It has developed an unmatched capability to provide care for patients who suffer from severe medical conditions, particularly with respect to acute diseases. In this "complicated context," experts and scientists have had a dominant influence on the evolution of the health care system. We are currently witnessing a major transformation of the health system, namely a shift in focus “... from acute to chronic illnesses,” from hospital to population-based care, and from a complicated context to a complex context.4 Family medicine is already practiced outside of the hospital setting and provides a holistic perspective of care, which is especially conveyed through the concept of “medical home,”5 and is a cornerstone of the upcoming reform. Collaborative mental health care and the Chronic Care Model can be seen as archetypes of this fundamental transformation. Their implementation, with current and upcoming success, is a source of learning that could be both crucial and inspiring for guiding the transformation of other components of the health care network.
In this beginning of the twenty-first century, along with this paradigm shift towards complexity science, it may well be that the mental health care system, which was considered as being the lowest of the low, will metamorphose itself to reach a new gold standard. This makeover of mindset may well open doors for enhancing the management of the entire health care network. In this new era of chronic disease management, of highly customized care, and of community-based care, mental health can play a key leadership role in building the appropriate strategic vision for dealing with such complex contexts. It would be a spectacular turnaround.
The German sociologist Max Weber made a parallel between the mechanization of industry and the proliferation of bureaucratic forms of organization. He put forward the following definition of
bureaucracy: “... a form of organization that emphasizes precision, speed, clarity, regularity, reliability and efficiency achieved through the creation of a fixed division of tasks, hierarchical supervision, and detailed rules and regulations.”6 Bureaucracy is based on the mechanistic model of organizations that had proliferated during the industrial revolution. Because the government of a democratic society performs extremely diverse functions in all sorts of dimensions of life, there is no ideal organizational model that can assume all these responsibilities. The bureaucratic machine, which remains the dominant model, offers "consistency in policy and reliability in execution ... and can be a major countervailing force to corruption and to the arbitrary use of political influence."7 The strengths of the mechanistic model are apparent in conditions where the environment is stable, where the tasks are repetitive and when the aim is to always produce the same outcomes. This is an asset especially for
4 Peirce, John C 2000. The Paradox of Physicians and Administrators in Health Care Organizations. Health Care Management Review, volume 25 no. 1 (Winter): 7-28.
5 The College of Family Physicians of Canada 2011, Position Paper, A vision for Canada, Family Practice: The Patient’s Medical Home, September, p. 1-63
6 Morgan, Gareth 2006. Images of Organization. SAGE Publications: 1-504. ISBN: 978-1-4129-3979-9
7 Mintzberg, Henry 1996. Managing Government – Governing Management. Havard Business Review, volume 74 no. 3 (May- June): 75-83.
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dealing with issues that belong to simple and complicated contexts, for instance access to different surgeries or standardization of blood banks processes.
When this bureaucratic machine experiences difficulties in implementing its policies, it tends to turn toward the highest level of the pyramidal hierarchy to settle them. Because of the strong focus on vertical forms of accountability within such institutions, it is expected that top managers will exert a
"strong leadership" that will force regional and local organizations to comply with the policies and to perform their operations accordingly. As this is often the case in mental health, the excessive
strengthening of the vertical line of authority often has negative impacts because it is at odds with the management of complex adaptive systems: “... the machine metaphor lets us down badly when no part of the equation is constant, independent or predictable.”8
A government bureaucracy may turn into a "psychic prison" when its leaders become ensnared in the illusive belief that they can and must find, from their top-down viewpoint, solutions to complex issues arising anywhere in the system: “Favored ways of thinking and acting become traps that confine individuals within socially constructed worlds and prevent the emergence of other worlds ... culture gives us our world...and it traps us in that world.”9 Such a context becomes a breeding ground for a toxic overdose of "heroic leadership"10 that creates a disempowered workforce. Neglecting managing, a corollary of "heroic leadership," is a desperate headlong flight. Thus, the organization becomes doomed to ask for more leadership (and money) until the day the structure falls apart – a good way to eagerly dig one's own grave. In short, the lack of fit between the provisions of the bureaucratic machine and the skills required to manage in complex contexts generates a lot of significant negative impacts. This finding may explain why the management of the mental health care network has been experienced as being so challenging, when it is not truly an impossible task.
8 Plsek, Paul E., Trisha Greenhalgh 2001. Complexity Science: The Challenge of complexity in health care. British Medical Journal, 323 (September): 625‐628.
9 Morgan, Gareth 2006. Images of Organization. SAGE Publications: 1-504. ISBN: 978-1-4129-3979-9
10 Mintzberg, Henry 1999. Managing Quietly. Leader to Leader (Spring): 24-30.
