When Disease Requires a Complexity Framework

Leadership context

The preceding source chapter describes using Cynefin’s domains in leadership development, internal meetings, and client work. Its references are retained below.

References

1. Berger, Jennifer G, and Keith Johnston. Simple Habits for Complex Times: Powerful Practices for Leaders. Stanford University Press, 2016.
2. Cultivating Leadership, as our name implies, is a firm focused on leadership development. See CultivatingLeadership.com
3. The seed from this idea comes from Laloux, F. (2014). Reinventing organizations: A guide to creating organizations inspired by the next stage in human consciousness. Nelson Parker.
4. This excerpted from the letter to the firm in early 2015.
5. The Catalyst team is the group of staff who creatively support our work.

When Disease Requires a Complexity Framework

Riva Greenberg and Boudewijn Bertsch

About the authors

At the time of this account, Riva Greenberg had lived with type 1 diabetes for 48 years. A health researcher, coach, and author, she works on collaboration between people with diabetes and health professionals.

Boudewijn Bertsch is a coach and leadership-development facilitator. With Greenberg, he explores relationship- and complexity-based approaches to chronic care.

Source chapter information: chronology piece 5 of 18; a theoretical treatment of Cynefin principles.

When Disease Requires a Complexity Framework

Riva Greenberg and Boudewijn Bertsch

The Cynefin Framework changed how we understood our experience. The realization that living with type 1 diabetes (T1D) and managing blood sugar is primarily complex, not complicated, changed our thinking, our actions and lifted our emotional burden. We believe this perspective can also help healthcare professionals work collaboratively with people with T1D.

Boudewijn’s story: “I saw her burden of living with nearly 40 years of self-criticism and judgment fall away.”

When I married Riva, she’d been living with type 1 diabetes for twenty-nine years. T1D is among the most intensively self-managed chronic conditions. People with type 1 diabetes must manage their blood glucose (sugar) throughout the day, every day. Blood glucose management can reduce the risk of complications, including damage to the heart, kidneys, eyes, and nerves. Health also depends on access to treatment and other factors beyond an individual’s efforts. Long-term exposure to high glucose can damage blood vessels and contribute to these complications. (1)

Riva taught me about her target blood sugar range at that time: 70 to 180 mg/dL (3.9 to 10 mmol/L). She aimed for it throughout the day and had often been told to “control” her blood sugar. Staying within her target was intended to reduce both longer-term risks and the immediate danger of hypoglycemia, or low blood sugar.

When we married, Riva checked her blood sugar four to six times a day on a simple device called a glucometer (blood sugar meter). Each time she checked and saw the number that indicated her blood sugar, she’d have to make one or more decisions to stay, or get back, in range: Take more insulin? If so, how much? Eat something? If so, what and how much? Take a walk? Or simply do nothing?

Riva ‘trained’ me early in our marriage to better understand T1D, and believe me it wasn’t easy. She would come back from a walk and announce, “If I look pale, what would you do?,” “If I’m low, what would you bring me and where do we keep it?” Often she’d show me her blood sugar number and share why she thought she’d got it, the next action she would take, and why. She also shared her confusion when she couldn’t explain a number and felt anxious and uncertain about what the right next action was.

Intrigued, and concerned about Riva’s welfare, I started to problem-solve with her. At times Riva’s numbers seemed a fairly logical result of her efforts. Relying on good habits, experience, and steady determinants, she could get numbers close to what she’d hope for. But frequently, we could only determine what led to a surprising number in hindsight. For instance, struggling over a number she might say:

“Wow, for two days I couldn’t figure out why my blood sugar was so high! But I realized my insulin had gone bad and I didn’t realize.”

She could only have determined this looking backward because so many things were happening simultaneously and affecting the outcome. Yet sometimes even looking back there was no apparent rationale and our search for one was a frustrating and failed exercise.

Ever the researcher, I was keen to crack the puzzle of her blood sugar numbers. I was sure it just needed proper analysis: find the set number of common root causes and she’ll be able to manage the variables. In my mind managing blood sugar was simply a matter of analyzing the impact of food, insulin dose, exercise effects, stress levels, and a few other things, and voila, we’d find the golden formula. I assumed that living with T1D was an ordered, mechanical process, one of cause and effect.

But one night while out to dinner I saw the limits of that assumption. Riva ordered her meal and started her calculations of how much insulin to take. She guessed at the carbohydrate count in the food she’d eat, the impact of the wine she’d drink, the long walk that morning that could still be lowering her blood sugar level. Riva planned to take her insulin twenty minutes before eating, so as the waiter walked away she injected it into her leg.

Twenty minutes later the waiter came back and told us an accident in the kitchen would delay our meal another 25 minutes. Riva now had a new situation to contend with: her blood sugar could drop too low before the food arrived. A plan based on the expected meal time had to be reconsidered as conditions changed.