Moving beyond RCT evidence: Complexity frameworks in psychiatric leadership and research 

To the Editor

Psychiatrists should position themselves as leaders in mental health care. In ANZJP This Month, Porter (2018) argued that given the infinite complexity of mental health problems, traditional randomised controlled trials fail to provide meaningful responses to the hypotheses they attempt to answer. He proposed that innovative methodological trials are required to provide answers to ‘what works’ in mental health prevention and treatment. Such a view is supported by the Cynefin sense making framework. Pronounced ku-nev-in, cynefin is a Welsh word that acknowledges multiple factors in our environment and experience influence us in ways we may never fully understand (Snowden and Boone, 2007).

The Cynefin framework was developed as a way of making sense of complex systems, in order to take effective action. It differentiates between ordered and unordered systems. Ordered systems have defined cause and effect relationships, where the right answers are determined on facts, analysis and research. Unordered systems are open ended, where there are few clear or apparent relationships between cause and effect, and relationships are usually understood in retrospect. Suitable answers and actions are based on the recognition of emerging patterns and are context dependent. In applying the framework, leaders seek to understand the nature of the domain they are trying to influence and then select an appropriate intervention.

The Obvious domain is an ordered system characterised by a discernible cause-and-effect relationship, with self-evident and undisputed answers and solutions. Leaders sense what is going on, categorise the issues or concerns and base their response on established practice. This is the realm of true best practice, of straight forward directives and easily delegated decisions. Such contexts rarely exist in the treatment of mental illness.

The Complicated domain is also an ordered system, where relationships exist between cause and effect. However, there is more than one correct pathway, which may not be clear or readily discernible, and requires research and analysis to come to agreement. This domain asks leaders to sense, analyse and respond. It is the realm of good practice, as opposed to best practice. It assumes there is a set of treatment principles that applies to everyone. Randomised controlled trials sit comfortably in this domain and have resulted in some of medicine’s great successes, such as in the fields of infectious disease and trauma management (Grey, 2017). Complicated systems are uncommon in psychiatry, where a person’s mental well-being is impacted by multiple factors beyond their (or the trial’s) influence and control.

The Complex domain refers to unordered, open-ended systems characterised by ambiguities and uncertainties that are impossible to map or predict. Same things do not happen in same ways; context is paramount. Cause and effect are only understandable in retrospect given the multiplicity of factors involved. It is the realm of emergent practice, governed by sets of principles rather than prescriptive rules. The aim is to first probe, then sense and respond. Instructive patterns emerge if psychiatrists are put in positions where it is safe to fail, while allowing time for the way forward to reveal itself. As outcomes are often unpredictable, dissent and formal debate (like those published in the ANZJP) are valuable communication assets, as they encourage the emergence of well-forged patterns and ideas. According to the Cynefin framework, psychiatrists should focus on creating an environment from which good things emerge, rather than trying to bring about predetermined change and risk missing unexpected opportunities. Or as Porter puts it, trials need to be pragmatic, where challenges to supported decision-making practices are acknowledged.

Finally, there is the chaotic (crisis) domain, where the only choice is immediate action. The event is completely unexpected. No discernible patterns exist, only uncertainty. In the chaotic domain, a leader’s immediate job is to act, sense and respond. It is the realm of novel practice. In this era of knee-jerk reactions to unpredictable events, psychiatrists need to provide steady leadership to staunch the proverbial bleeding and move to either take directive control or try multiple small experiments to stabilise the crisis.