Treatment teams as "Communities of Practice"

Still thinking about the intersection of clinical practice, risk assessment, knowledge management (KM), and Dave Snowden, which I blogged about yesterday.

In KM world, what mental health clinicians call a "treatment team" could be considered a Community of Practice. There are many definitions of this term and treatment teams fit some more than others. But Dave Snowden is clear in the videotaped discussion I pointed to yesterday that one of the failures of contemporary knowledge management is the inability to promote fruitful communities of practice. Snowden argues that organizations make the mistake of trying to organize communities of learning and practice using language, structures, and concepts that are not "naturalistic." That is, we ignore the processes by which people naturally come together to form knowledge-sharing communities and either over-organize (imposing a hierarchy and structure that we think will promote good functioning, but ultimately stifle innovation) or wrongly organize (bringing people together around a concept or structure that does not promote natural affinity).

Our organization is considering a redesign of our ambulatory service into diagnostic-based treatment teams (e.g. "Comorbid depression team"). The aim is to have well-functioning teams that promote evidenced-based practice. As I listened to Dave Snowden talk about communities of practice, I coudn't help but think that organizing this way has hints of the kinds of non-naturalistic grouping that Snowden warns against. The intent is good and the organizational principle makes sense on the surface, but grouping clinicans by the DSM diagnosis of their patients has the potential to be structure-rich, story-poor, and human-factor-ignoring.

One of the principal reasons stated for considering organizing by diagnosis is that the research literature about effective treatments is organized by diagnosis. It is an "evidence-based" decision. However, evidence associated with a particular epistemology (categorical psychopathology) is privileged over that of other epistemologies like cognitive science, organizational behavior, human factors research, and systems theory are ignored. Just because treatment studies organize patients into diagnostic groups, doesn't mean that human clinicians will work most effectively with the human problems and stories we see by grouping ourselves by our patients' Axis I diagnosis.

What would be a more narrative-rich way or organizing ourselves? Well, if we think of theoretical paradigm as a narrative, than perhaps that could be starting point. Or perhaps provide freedom for people to organize themselves into natural groupings. Or maybe there's a way of listening to clinicians and patients' stories about themselves and seeing trends and themes that we don't now see. It would take time and a new set of methods, those more akin to what Snowden promotes, to discover these themes. But we're taking time and energy either way. I'm not sure, to be honest, but I think the principle Snowden promotes is a good one: don't impose a community of practice based on a predetermined epistemology, especially one that is reductionist and devoid of narrative...rather, look at how productive human networks form naturally and spend your time and energy discerning the conditions in which these can develop.