Wednesday, August 24, 2011

System Failure, System Reboot


By Edd Conboy




Systems thinking has become one important way of making sense of experience in all its complexity. So much so that we sometimes forget that a “system” is a construct, and not some sort of independent “fact out there” sculpting and defining those experiences. Thinking in terms of systems does have the advantage of highlighting the interrelationships of the component parts allowing us to see just how much and how often the whole is greater than the sum of its parts. This thinking can break down at times. Most notably this can occur when systems thinking is applied beyond its engineering and cybernetic feedback roots into the realms of human interaction – from large social systems down to discrete family systems.


My field of family systems therapy for instance was critically informed by the initial research into feedback information processes that ironically were being developed during World War II to figure out how to make anti-aircraft batteries more effective against the constantly improving aircraft bombers raining havoc on Allied cities. By looking at how complex packets of information are exchanged between and among family members (especially across generations), it became possible to see how similar and predictable pathological behaviors can emerge over time in families that seem to have very little in common. This type of thinking and this type of approach continues to prove reasonably effective in clinical settings.


Recently, however, I have been working in larger social systems, and I have begun to notice the impact of the limitations of systems thinking in general, and its effects on vulnerable members of society in which the sum of the parts become greater than the whole. I’d like to describe two such experiences, and how a shift in thinking in one system (health care delivery in one part of a large, urban hospital) seems to have created the possibility for growth and change, while in another (the psychiatric component of the criminal justice system) stagnation and psychological deterioration seems to rule the day.


Last month I was asked to take part in a meeting involving Roxanne, a middle-aged shelter-resistant, homeless woman with whom I had done some work with while doing community mental health outreach. Roxanne is a super consumer of the health care services in Philadelphia, costing the city more than a million dollars this year alone. She is currently hospitalized after falling and hitting her head on one rail of the subway track beneath the platform in the train station she calls home. (Last winter, Roxanne was hospitalized for two months after a passing train amputated her right hand while she lay comatose on those same tracks.) The psychiatric nurse working with Roxanne decided to bring together everyone who had contact with her “in the system” to share information, and begin to design a treatment plan that would address Roxanne’s needs holistically. There were more than a dozen of us at this meeting who were able to share vital information about Roxanne, and her life on the streets.


From the outset I noticed was just how stupid these seemingly bright representatives of the health care system were in that moment (I certainly include myself here). Most of those at the meeting for instance thought that Roxanne’s husband, who stayed in the room with her for several weeks, was a compassionate caregiver. In fact he is not her husband. In fact he is an abusive partner, who is himself homeless, and he was able to stay in an air-conditioned room during some of the hottest days of the summer. (Many people at the meeting were medical staff who rotate through the hospital departments weekly, so only have very limited time to spend with each patient.) Roxanne, caught in a classic abusive cycle of power and control, identified this partner as her “husband”, so no one questioned his presence. Roxanne’s actual husband was convicted of attempted murder and aggravated assault several years ago, and is serving a twenty-year sentence for those crimes – crimes perpetrated against Roxanne.


Since all of us were covered by privacy and confidentiality statutes, we were able to share her medical history, although there were few surprises here. Roxanne is infected with the HIV virus, has severe liver damage due to her chronic alcoholism, high blood pressure, and impaired cognitive functioning due to her life on the streets and repeated head trauma. “The health system” has failed Roxanne repeatedly during the decade that she has been a regular guest at the hospital’s Emergency Room. The city’s social service system had also failed her repeatedly when she would be taken to shelters during severe winter storms only to have her return to the streets as soon as the weather emergency passed. System after system failed Roxanne. Until the end of that meeting.


The system changed. Or at least one member of the team in that system with considerable authority shifted the entire system, made it actually smarter. She said something I had never heard in a gathering such as this. Her clear thinking allowed the system to reboot, making it possible for Roxanne to live a much fuller life going forward. With an emotional intensity I rarely hear anywhere these days, let alone in a conference room in a hospital, she said, “It doesn’t matter what it costs, Roxanne is not leaving this hospital until we are all satisfied that we have a plan in place that will address her needs, especially her need to be safe.”


Suddenly, the system that had been an abject failure was transformed into a team of smart, dedicated professionals invested in the health and well-being of Roxanne, this person of no rank and certainly no status…


Note: The second installment of this series can be found here: System Failure, System Frozen.

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