NLENDEIT
Complexity Science for Dutch Mental Health Care

Complexity,
clearly explained.

A platform that aims to bring insights from complexity science closer to clinicians, researchers, experts by experience and clients. In mental health care we work with complex systems, and in our view these also call for methods attuned to that character.

Begin with the lexicon Become a member
A path through state space

A person, in our view, cannot be fully captured in a classification. Those who understand someone as a complex, dynamic system, with their own patterns, rhythms and sensitivities, begin to look differently from the way the categorical handbook suggests. That other way of looking gradually leads to other questions and other considerations, and in time perhaps also to other care.

Our philosophy

Our concern is less whether things should change,
than how.

That the categorical model of the DSM does not capture everything that presents itself in the consulting room is, in our impression, widely recognised in the Dutch field: by colleagues in everyday practice, at conferences and in training programmes. The insight is no longer new.

The question that follows seems to us more important: how can we do things differently? With which concepts, methods and ways of working can we move beyond the observation that the existing model falls short? For that question we would rather look for concrete footholds than for fine words.

In our view, complexity science, with its by now rich research tradition, offers concrete points of departure for this. We also consider it important that this knowledge be freely accessible, including to those who have not followed any specific training, and with no more jargon than necessary. We believe that much of it can be explained well, and that is what we try to do on this platform.

Thousands of birds move together in a shape that no one has prescribed, and there is no conductor who determines it. It seems to us worth considering what might be gained if, in the consulting room, we more often looked in a comparable way: at the pattern that takes shape, rather than at a sum of parts.

Video · P K (uair01), Wikimedia Commons · CC BY 2.0

What this might mean for Dutch mental health care.

The ideas on this platform come from an international and largely formal field of research. We have been wondering for some time what they might concretely mean for mental health care in the Netherlands: in the consulting room, in everyday practice and in governance. A few first explorations follow below.

i. In diagnostics

Reading patterns, not only scores.

When we measure repeatedly over time, briefly and with a few variables, over a period of several weeks, the data sometimes show more than an average does. Variability, autocorrelation and the relations between variables can, in our view, say something about how someone is functioning at this moment.

The work of Wichers, Bringmann and colleagues in Groningen, and of Borsboom, Fried and others in Amsterdam network research, also brings this way of diagnostic looking within reach of Dutch practice. For the time being, its application still seems to take place mainly in the academic world, and in our view that is where an opportunity lies.

Read about idiographic work →
ii. In treatment

Phase transitions in therapy: patterns that shift qualitatively.

Some patients improve not gradually but in leaps; in the literature this is called sudden gains. In others, a relapse seems to be preceded by subtle signals: variance increases, recovery after a setback takes longer, the system seems to hesitate. Such signals may indicate that a pattern is about to tip, a phase transition in the time series of a treatment.

That therapy processes often behave in this way, non-linearly and with discontinuous transitions, is by now reasonably well supported. The work of Günter Schiepek and colleagues, building on his collaboration with Hermann Haken, describes psychotherapy as a chaotic, self-organising process and offers instruments to make such transitions visible from day to day. In this light, the therapeutic relationship can cautiously be understood as coupling: a connection in which, under favourable conditions, a shared rhythm can arise.

Read about phase transitions →
iii. In governing mental health care

Care itself as a complex system.

A team, an institution or an entire sector is also a complex, dynamic system. We suspect that many persistent problems in Dutch mental health care, such as waiting times, staff turnover, protocol pressure and divisions between sectors, cannot simply be solved by interventions from above.

A complexity perspective on the organisation of care, with attention to local interactions, to the coupling between teams and to the tipping points at which systems can reorganise, may, we hope, add something to current thinking in governance.

Read about self-organisation →

None of these three avenues has yet been worked out. We hope this platform will become a place where we can explore them further, together and with care.

Our mission.

What we would like to do, and why we think this is a good moment.

Mission

We would like to make complexity science as accessible as possible to everyone who works or lives in and around mental health care: clinicians, researchers, experts by experience and clients.

We do not want to be a platform for any single method, but hope to contribute to a shared language that can enrich thinking in this field.

We would like to bring the insights of a rich, international field closer to everyday practice and the consulting room, in a way that does not require a degree in mathematics.

Vision

We suspect that mental health care has entered a phase in which the thinking that has brought it a great deal no longer seems sufficient for everything that presents itself. We do not wish to tear anything down, but to add something: attention to timing, to patterns, to context, and to footholds that still often remain below the surface.

Our hope is for a gradual movement from technique-based to process-based work, as a complement to what exists and not as a break with it.

In our view, those who work in complex systems cannot do without trial & error, creativity and responsiveness. We would like to explore how these can take shape in a scientifically responsible way.

A large school of fish moves as one beneath the surface

A school of fish turns, contracts and stretches out. In the depths there swims no 'true', underlying fish that prescribes this shape. The pattern arises from the school itself, from a few simple local rules that each fish follows individually: keep your neighbour in sight and do not quite touch it. It sets us thinking about our diagnostics, in which we may sometimes be too quick to look for a latent core behind the observable phenomena, while the coherence may partly lie in the interplay itself.

Photo · Adiprayogo Liemena, Pexels

Four ways into complexity in mental health care.

Each path suits a different stage of acquaintance. You can begin wherever it fits best for you; the parts refer to one another.

i. For those beginning

Learn.

An introductory path for those not yet at home in the complexity literature: the small lexicon, short explanatory pieces and an accessible reading list.

To the lexicon → ii. For those who want more

Read.

Longer blog posts on central themes, such as the shallow-lakes analogy and depression, reflective versus formative thinking, ergodicity and process-based work.

To the blog → iii. For data enthusiasts

Discern.

The Graph Reading Lab. More and more clinicians measure over time and are left with a graph. What that graph tells us, we discuss in small groups on the basis of your own data.

To the Lab → iv. For those who take part

Connect.

The community around the platform: two webinars a year, one in-person seminar, two groups (beginners and advanced) and a bimonthly newsletter.

Take part →
Self-organisation · in view

Five metronomes on one board,
and no conductor.

If they are started at random moments, after about a minute they can be heard ticking in unison. This is because the board they stand on moves along with them, very slightly.

This phenomenon ties in with the synergetics of Hermann Haken, which Günter Schiepek has developed further for psychotherapy: in complex systems, under certain conditions, order can arise without anyone directing it. Local interactions play a part in this, as do an appropriate degree of coupling and sometimes a shared rhythm.

Christiaan Huygens described something similar as early as 1665, when from his sickbed he observed two pendulum clocks hanging from a shared beam. He called it "sympathy of clocks". We now know that a related principle also seems to play a role in neurons, flocks and groups of people, and it is cautiously argued that this may hold for processes in psychotherapy as well.

Read about self-organisation

Harvard Natural Sciences Lecture Demonstrations: synchronisation of metronomes.

From measurement to meaning: the pattern that shifts.

Günter Schiepek put a question to us that is central to this platform: where does complexity science touch psychotherapy itself? Part of the answer, in our view, lies in what happens shortly before someone changes.

rising variability phase transition state A state B
An idealised time series of a single variable in a treatment. Before the shift, the swings grow larger and recovery after a dip becomes slower. In the literature these are called early warning signals; they can announce a phase transition, although this does not hold in every case.

A therapy process seldom runs in a straight line. The research of Schiepek and colleagues, building on the synergetics of Hermann Haken, describes psychotherapy as a chaotic, self-organising system, with stable periods, critical instabilities and moments at which the whole tips fairly suddenly into a new state. It is precisely these moments, pattern transitions or transitions in which a time series changes qualitatively in character, that a clinician would like to see coming in time.

What matters to us is that it does not remain theory. Validated methods exist to detect such transitions in patient data, and there is research suggesting that feeding this process information back daily can benefit treatment: it can strengthen motivation, deepen the therapeutic relationship and give clinician and patient a shared "common thread". The therapeutic relationship can be understood here as coupling, the place where, under favourable conditions, a shared rhythm can arise.

A romanesco cauliflower with spiral fractal patterns
Patterns · at every scale

A romanesco.

On close inspection, each protrusion turns out to be a smaller version of the whole, containing a smaller version again. Such a pattern, which repeats itself in a comparable way at different scales, is called a fractal in mathematics.

It may be that some patterns in the consulting room are built up in a similar way. The course of a difficult hour and that of a difficult week sometimes show related shapes. It is a fruitful idea, although it certainly does not hold in every situation.

Photo · Jean-François Frenel, Pexels
Honeybees in a tree hollow form a living structure
A dense crowd of people during the Holi festival, coloured powders in the air

A beehive does not work according to a predetermined building plan, and a dancing crowd follows no choreography. And yet a shape arises, a rhythm, a shared direction. This phenomenon, the emergence of something new from many small movements, is usually called emergence in complexity science.

Photos · Gill Heward & Chalta Phirta, Pexels
Getting stuck is, in our impression, seldom only a matter of personal failure. Often it is the working of persistent patterns that keep themselves in place unnoticed.
In complexity science, instability is sometimes understood as a condition for change. In clinical practice, that thought may allow us to look at unrest somewhat more gently.
We try not to think complexity away, but to take it seriously enough for it to be of clinical use.
More attention to patterns, to functions and to clinical wisdom, as far as we are concerned as a complement to what we already have and not as a replacement.