Improving mental health is a Wicked problem
Updated: Oct 26, 2020
There’s little dispute that we face a crisis in mental health. The needs are huge and yet it is unclear that we have made much progress in either understanding or treating mental health problems. For example, a review of 435 random controlled trials (RCT) of psychotherapies for children showed no improvement in outcomes in the last 53 years. Compare that to advances in the treatment of heart disease or airplane design or computing in that same period. Yet the authors’ recommendation is that what we need is to “intensify the search for mechanisms of change” (emphasis added).
At this point we should be reminded of the statement attributed to Einstein, “The definition of insanity is doing the same thing over and over and expecting a different result.” The problem is that the solution here lies in how we search. And to understand why, one needs to understand the difference between a Kind (sometimes referred to as a “tame” problem) and a Wicked problem, a distinction formally described nearly 50 years ago.
A Wicked problem is a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Typically, a Wicked problem involves many stakeholders with different values and priorities. The roots of the problem are complex and tangled. Every wicked problem can be considered to be a symptom of another problem. Wicked problems are difficult to come to grips with and the solution changes with every attempt to address it.
In contrast, a Kind problem can theoretically be solved, although it may not be easy. Kind problems are typically solved using the scientific method: forming a hypothesis, defining terms, making a prediction, running a controlled test and refining the hypothesis based on the results. A proof that the solution is correct is that it is replicable. To put matters in a current context, developing a vaccine for Covid-19 is a Kind problem; dealing with a pandemic is a Wicked one.
This does not mean that Wicked problems can’t be solved as well. But given their nature, Wicked problems won’t be solved by way of standard research designs searching for the mechanisms of change. With Wicked problems, the mechanism of change is not a single mechanism. Wicked problems are by their nature complex, with interacting causal chains. Instead, to solve a Wicked problem one should follow an iterative, hypothesis-guided, empirically validated trial-and-error process. Such a process is efficiently guided by ten rules.
10 Rules for Solving Wicked Problems
From the beginning, if you are researching solutions to real problems, do so in the real world. From the outset, implement your trials in as many suitable locations as possible.
Move quickly. Test the approach under as many conditions as possible. Use what you learn in each trial to refine what you are doing. Take setbacks as learning experiences. Revise and try again.
Make sure goals and objectives align among all the concerned parties, or establish multiple goals. Be prepared to modify goals based on results.
Make sure goals can be stated in measurable terms. If you can’t “say it with numbers”, what are you actually saying?
Create an efficient mechanism for collecting your measurements. If it is too difficult, too costly or you lose too much information, the process won’t work.
Emphasize immediacy of data collection and feedback. The fresher the information, the more useful. You can’t correct what you are doing if you only hear about the problem months or years later.
Minimize barriers to implementing and testing solutions. Keep costs low for both the innovator and the implementer. Look for ways to keep the process self-sustaining.
Encourage flexibility. Allow the implementers to adjust the innovation to fit their needs.
Be open with your results. Don’t cherry pick your results or withhold your findings to the end.
Don’t over-claim, but don’t minimize the significance of what you do achieve.
Improving mental health care is clearly a Wicked problem. A brain-training procedure called neurofeedback has demonstrated clinical effectiveness with a broad and inclusive clinical footprint, and it has done so largely by the above-recommended pathway. Yet despite over 40 years of published studies, including several with random-controlled designs and more recently, actual advocacy by prominent experts with no financial connection to the field, it is clear that neurofeedback continues to face resistance by the medical, scientific and insurance industry gatekeepers. Some of that resistance is probably grounded in unreasonable professional caution or financial self-interest. But it is also because the gatekeepers keep insisting on the solution for a Kind problem, one that focuses on the mechanism of change rather than measures of change.
Our approach is not to convince the gatekeepers in the conventional manner but rather to consolidate the case for neurofeedback by using the model for addressing Wicked problems. Accordingly, our mission statement aims to implement neurofeedback in our existing healthcare system with particular concern for agencies working with the underserved. We are now in nine agencies, having started with an initial trial with three. We work with existing staff and clients. Our Results Tracking System (RTS) is a HIPAA compliant online data collection system built on Google Sheets. Our primary outcome measure is the reduction in the severity of client-selected, client-rated concerns. These ratings are collected at every session. We also track changes in medication usage, ability to cope with stress, substance use, arrests and disciplinary actions, ER visits and hospitalizations, and No-shows and Late Cancellation rates and treatment side effects at repeated intervals during treatment. Clients, therapists and agency management can all see multiple outcome measures including cost and benefit data. All of this occurs in real time.
To get a picture of the clients, we get ratings of Adverse Childhood Experiences (ACE’s), psychosocial stressors before treatment, and as treatment progresses, and the number of concurrent problem areas (i.e. sleep, depression, pain) and whether they are Medicaid, Pro Bono or Fee-For-Service clients.
We use this information during our bi-weekly Zoom-based therapist case discussions. When a therapist presents a client, we can share their screen so everyone can see all the data, including the client’s session-by-session progress and the protocols used. This insures fidelity to the treatment model and creates a wonderful vehicle for trainees to hone their clinical decision-making.
Ultimately, the success of the advocacy will depend on our results. There is realistically no limit on the number of agencies that enroll, the number of clients they serve or even the variety of protocols that are tried. To date, the results look very promising. Covid-19 slowed us down, but agencies are starting to get back to seeing clients and we are recruiting new agencies and adding to our database. What we are doing will never be a “controlled experiment”. But it may get us to where we need to go. After all, helping people is a Wicked problem.
* Evidence-Based Treatment
** Neurofeedback Advocacy Project