ARTICLE 4
Complexity science: a paradigm for managing mental health within the health care system Michel Gervais, MD, FRCPC, MBA
It is possible to make clear the differentiation between simple, complicated and complex contexts of human actions.1 Depending upon the context, the leader must act accordingly. As it will be shown below, collaborative mental health care and the Chronic Care Model (CCM) belong mainly to a complex context. As a result, their implementation and management rely on specific approaches and on the appropriate mindset.
Simple contexts are the “domain of best practice” and are characterized by “stability and clear cause- and-effect relationships.”2 The archetype is “baking a cake.” It relies on a stable environment that will lead to a stable replicable situation.3 For instance, procedures for admitting a patient to hospital could meet the criteria for a simple context that lends itself to standardization.
Complicated contexts are the “domain of experts.” The archetype is “sending a rocket to the moon.”
Although there is still a clear relationship between cause and effect, “complicated context, unlike simple ones, may contain multiple answers” that not everyone can see.4 Those are contexts in which experts and coordination of their work is crucial. Blueprints, formulas and protocols ensure that processes are aligned in the desired order and according to the latest scientific evidence. For example, the
development and implementation of clinical guidelines for the treatment of depression belong to a complicated context.
Because simple and complicated contexts are “inherently knowable, action within them is often guided by a sense of being able to fully understand and potentially to control the system.”5 They belong to an ordered world, the world of “fact-based management.” Complicated problems are very compatible with the environment of acute illnesses, with highly specialized organizations like hospitals and with the work of the medical doctors, especially the medical specialists who focus "on a particular system of the body."
There seems to be a perfect match between the mindset of the context of acute illnesses, the prevailing medical culture and the traditional scientific management.
1 Westley, Frances, Brenda Zimmerman, Michael Quinn Patton 2006. Getting to Maybe:
How the World is Changed. Chapter 1 in “The first light of evening”, Random House Canada: 1‐26. ISBN: 978-0-679-31444-8
2 Snowden, David F., Mary E. Boone 2007. A Leader’s Framework for Decision Making: Wise executives tailor their approach to fit the complexity of the circumstances they face. Harvard Business Review (November): 70 – 76.
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.
4 Snowden, David F., Mary E. Boone 2007. A Leader’s Framework for Decision Making: Wise executives tailor their approach to fit the complexity of the circumstances they face. Harvard Business Review (November): 70 – 76.
5 Zimmerman, Brenda 2010. How Complexity Science is Transforming Healthcare. In The Sage Handbook of Complexity and Management: edited by Steve Maguire, Bill McKelvey and Peter Allen. ISBN-10: 1847875696
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Complex contexts are the “domain of emergence” and belong to an unordered world which “represents pattern-based management,” as opposed to "fact-based management" that is fit for both simple and complicated contexts. The archetype is “raising a child.” There is no guarantee of success, no winning recipe, and no obvious relationship between cause and effect. "Leaders who try to impose order in a complex context will fail, but those who set the stage, step back a bit, allow patterns to emerge and determine which ones are desirable will succeed."6
As for successfully implementing models of collaborative mental health care and CCM, the outcome is the product of complex interactions. It echoes the words of well-known Montreal paediatrician, Dr.
Gilles Julien (founder of what is called “social paediatrics”) as a motto for engaging many actors of the community to solve complex issues: "It takes a village to raise a child." As one would not raise a child with a blueprint, which obviously would be detrimental as well as senseless, it would be unwise to use tools fit for the complicated contexts for dealing with the complex contexts. Nevertheless, this is what has been done over and over again in mental health during the last decades.
For much of the twentieth century, the world of management was dominated by the desire and the belief that we could plan the future in a predictable and rational way. It was the epoch of the classical management approach with its strategic planning led by an elite group of top managers. This mindset was particularly well-suited to the world of mental asylums where everything was settled in a
predetermined order.
Many components of health care, and also collaborative care, are too complex to be modeled deterministically. Complexity science introduces a refreshing new paradigm for tackling the
management of the health care system in the twenty-first century.7 In a complex context, managing becomes an ongoing journey, much more than a roadmap to arrive at a predetermined destination.
Collaborative care belongs also to a complex context and is a movement known to be mainly a bottom- up phenomenon. According to the "complexity principles," collaboration builds on self-organization (rather than through external forces), relies on distributed control (no central controller) and on connectivity. In other words, instead of focusing on facts/ central control/parts of a machine, the management of collaborative care builds on the relations between the parts and the appreciation of the emergent patterns.
Since the order is created from the interactions of many elements and actors, and is no longer imposed from a top down perspective, “recognition of the importance of self-organization challenges the command and control paradigm which has dominated health
care since the early 20th century. ... Complexity science provides a new way to understand public policy as being coherent across populations while, at the same time and paradoxically, ’inconsistent’ in application because it allows for variation in response to local needs.”8
The potential for innovation and creativity is closely linked to prevailing local conditions and to the context. They are mainly bottom-up processes that cannot be designed from above, and that come from
6 Snowden, David F., Mary E. Boone 2007. A Leader’s Framework for Decision Making: Wise executives tailor their approach to fit the complexity of the circumstances they face. Harvard Business Review (November): 70 – 76
7 Holden, Lela M. 2005. Complex adaptive systems: concept analysis. Journal of Advanced Nursing, volume 52 no. 6: 651–657.
8 Zimmerman, Brenda 2010. How Complexity Science is Transforming Healthcare. In The Sage Handbook of Complexity and Management: edited by Steve Maguire, Bill McKelvey and Peter Allen. ISBN-10: 1847875696
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self-organization (self-steering units). This acknowledgement may be disconcerting for fans of top-down organization-by-design.
As is the case for collaborative care and the Chronic Care Model, the management and the design of the system are distributed. At the end of the day, nobody takes credit for the outcomes. It also resonates with the concept of an/the "engaging manager" that is breaking away from the outmoded culture of a/the "heroic leader." The truth is, “many of the most successful strategies are not conceived in isolation at the “’top’ ... They grow throughout the organization via a kind of distributed leadership.”9
Managing collaboration is managing connectivity. Relationships are key to the functioning of a complex system. They provide the connections between the components of the system. They play a similar role as the synapses between the neurons of the brain. The relationships building are more important than role definition: “... relationships between parts are more important than the parts themselves.”10 Optimal connectivity between the parts promotes the full potential of creativity of the system as a whole. Collaboration is a journey, not a destination. Collaboration is an intangible asset nested in
communityship, a term coined by Mintzberg11, that creates bridges among people and systems. Through multiple actions, collaborative care finds local solutions to clinical / managerial challenges.
A collaborative mindset does not involve so much managing people (the so-called human resources) as the relationships among individuals. In order to achieve it, the manager pictures himself more as being part of a network rather than sitting at a level of a pyramidal hierarchy: “To be in a collaborative mindset means to be inside, involved, to manage throughout. But it has a more profound meaning, too – to get management beyond managers, to distribute it so that responsibility flows naturally to whoever can take the initiative and pull things together ...”12.
Complexity science provides very appealing theoretical frameworks and metaphors. However, as in a love affair, a truly complex business that can carry anyone to the edge of chaos, it is probably prudent to step back at a certain point in time. No matter how sexy the adventure turns out to be, some drawbacks might come with it. In the world of medical care management and policy, like so many misleading sirens' songs, there are "enthusiasms for particular ideas or practices ... like for the business management fads that come and go ... There is a persistent pursuit of policy panaceas."13
Concerning those fads, one may think about re-engineering, zero-based budgeting, devolution, mergers, empowerment, total quality management, etc. In fact, the problem is that “policy panaceas, just like management fads, prompt oversimplified answers to complex problems.”14
The desperate quest for the Holy Grail is the utopia of a perfect world that would finally be dominated as if it was a big machine. In contrast, complexity science invites us to address the world by other means
9 Mintzberg, Henry 1999. Managing Quietly. Leader to Leader (Spring): 24-30.
10 Plsek, Paul E, Tim Wilson 2001. Complexity, leadership and management in health care organisations. British Medical Journal, volume 323 no.29 (September): 746-9.
11 Mintzberg, Henry 2008. Leadership and communityship. Gestion, volume 33 no. 3 (automne).
12 Gosling, Jonathan, Henry Mintzberg 2003. The Five Minds of a Manager. Havard Business Review (November): 1-11.
13 Marmor, Theodore 2004. Fads in Medical Care Management and Policy. In The Nuffield Trust for research and policy studies in health services, London, Published by TSO (The Stationery Office). Available on http://www.tsoshop.co.uk/. ISBN:
9780117028630
14 Marmor, Theodore 2004. Fads in Medical Care Management and Policy. In The Nuffield Trust for research and policy studies in health services, London, Published by TSO (The Stationery Office). Available on http://www.tsoshop.co.uk/. ISBN:
9780117028630
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– with a drastically different mindset, in fact. Its promises are indeed more realistic and do not appear as panaceas: "there is not guarantee success ... a certain mindset is crucial, framed by inquiry not certitude, one that embraces paradoxes and tolerates multiple perspectives."15
Complexity science is born to tango. In such a sentimental ballad, one keeps up the right pace, enjoys the ride and chooses among the many opportunities that will inevitably come up. The perspective of complexity science embraces life itself and, to paraphrase Kierkegaard, it invites you for a journey that
"is lived forward, but understood backward." The metaphor applies as well for implementing and managing collaborative care.
15 Westley, Frances, Brenda Zimmerman, Michael Quinn Patton 2006. Getting to Maybe:
How the World is Changed. Chapter 1 in “The first light of evening”, Random House Canada: 1‐26. ISBN: 978-0-679-31444-8
