Thoughts on a different method for uncovering psychiatric crisis knowledge
Spitballing on learning without controlled experiments
I've been thinking and learning a lot about experimental psychology, hypothesis testing, randomised controlled trials, and the general process by which knowledge is 'discovered' and becomes legitimised within psychology and psychiatry. I wrote a bit about a possible pattern within experimental research on new kinds of therapies in The Relational Reimbursement Paradox.
From my own, subjective perspective on the replication crisis and the way that scientific knowledge is used to legitimise treatment within mental health environments, it seems like the current process of theorising, developing hypotheses and doing experiments to test those hypotheses is not producing obviously helpful answers to 'how should practitioners treat patients'.
I have an idea I've been mulling over, for a different approach to take, which is at once very simple and yet something I don't see being done within normal scientific channels.
Cedric Chin, a business writer, has been writing a lot on the process of developing expertise in unstructured domains. An unstructured domain is simply one where any given concept can be instantiated extremely differently in different situations. A domain like chess has highly structured rules and limited variation in how concepts can play out, while a domain like business has many few rules and concepts can look extremely different depending on the context and specific characteristics of the situation you encounter them in. If you are interested in this idea, I recommend reading Cedric's writing on it.
If 'treating a patient in a psychiatric crisis' or 'handling your own psychiatric crisis' are unstructured domains, then 'developing a system for treating patients in psychiatric crises' is even more so. For all three domains, there do exist theories that predict success and failure, many of which contradict each other, and none of which appear to be extremely good at helping people succeed in a wide variety of contexts (inside hospital, outside hospital, within different social classes, with different levels of resources, etc.). I have an upcoming post about this; there seems to be a great deal of political conflict around the adoption of various theories of treatment which seems to muddy the question of 'what helps people succeed?'.
After an in-depth conversation with someone who works on understanding the progression of early-stage science, I developed a (seemingly) very simple idea for moving towards a vision of better crisis care that I would like to try, that I think accepts (with some humility) the fact that almost every currently adopted theory is not very successful, including the theories that critique mainstream theories. (Some theories work exceptionally well when used by people on board with that theory, and fail to generalise to other cultures or contexts).
Rather than searching for theories, treatment processes or observable mechanisms to explain successful crisis response, I want to look for concrete examples of success. There are three kinds I am interested in:
People who have recovered and are flourishing after their own experience of psychiatric crisis.
Clinicians and others who see patients who have an extremely successful track record of enabling the recovery and flourishing of many patients, consistently, over a period of time.
Similar to 2, clinics or centres that have such an extremely successful track record.
I'm focused initially on finding these groups, and first on group 1. Although I have nothing but the utmost respect for people who are going through their own process of wrestling with psychiatric crises, I do think there is something unique to be learned from people who are at the point where they are thriving and no longer seemingly at risk of destabilising crises; and there may be things they have in common. Similarly, many people have tried to initiate reforms to change the system one way or the other and I have been learning important things from them, including in case studies I'm ongoingly investigating, but there is something unique to be learned about the extremely small minority of people and contexts that seem to be able to consistently cause transformations in the people they serve. Even if only a handful of such people and clinics exist in the world I think it is important to find them.
And then? Once there's a group of 'success stories', then what?
Well, Cedric Chin has some more advice for what to do, for discovering the nature of expertise in an unstructured domain. He prescribes a kind of interview which draws out details about the nature of expertise without imposing pre-determined assumptions about the shape of such expertise, or the level of abstraction on which it exists. I intend to do some. It may be the case that a generalisable 'theory of change' about how people encounter and go through psychiatric crises is not the right unit of analysis at all, and some other level of abstraction is more helpful. It is almost certain that there are skills that experts learn by experiencing a variety of different 'cases' and comparing them, that cannot be generalised easily into a unified theory. I don't know the answer to these considerations, but 'learn about the nature of contextual expertise held by people who have been successful at encountering psychiatric crises, either themselves as individuals, or repeatably as clinicians' seems like a useful start.
I've been broadcasting a survey to find some people in this first category (those who have gone through psychiatric crises and are now thriving), and I am looking for more people!
Please pass this survey on to people you think might fit the bill, as I'm looking to cast as wide a net as possible. I will start looking for clinicians, but more slowly, and once I have made some progress on interviews with people with direct experience first.
Once I have a group of 'experts' either at their own recovery or at enabling the recovery of others, I imagine it is possible to do kinds of research that tease out what this group are doing differently.
As far as I can tell, this is different from existing reform efforts which focus on advocating for a particular ideal process of care, justifying it by comparing it to other, existing processes, and then aiming to get that process implemented, in part by building a coalition of supporters who all believe in the process's core tenets, with varying degrees of empirical certainty. This seems to have the benefit of simplicity ('do X instead of Y!') at the expense of checking 'but how well does this work in the variety of different contexts we would like to implement it in?'.
The approach I'm suggesting should start from an observation of as wide a variety of people who are already succeeding at this task as possible--and I would expect to find that many of them have contradictory theories of change! Or perhaps not. This is something to discover.