Vignette Research on Messy and Confusing Problems in Primary Mental Healthcare


  • E. H. (Dineke) Smit
  • J. J. L. (Jan) Derksen


The average primary care psychologist feels an ever-widening gap between objective, measurable reality as described and the complex and dynamic reality they experience. To obtain a better understanding of this complex dynamic reality, we conducted an exploratory mixed-method study of primary care psychologists. We asked our participants to write vignettes about messy and confusing problems in the complex context of mental healthcare. We then examined the data in portions, exposed the patterns in the data, and subsequently analysed all in conjunction. The 113 vignettes showed experiences of psychologists dealing not only with the patient, but also with the family of the patient and/or employers, working together with other healthcare professionals, struggling with dilemmas and having mixed feelings. However, using the Cynafin Framework, 36% of the vignettes were still rated as simple. Was it because those vignettes contained fewer words (p = .006)? Or because it is difficult to grasp complexity when cause and effect are intertwined with emotions, norms and values? In the discussion, we suggest examining a complex dynamic system in terms of both the consistency of its various elements and the dynamics of the system. We also discuss how to optimize the system’s adaptive self-organizing ability and how to challenge ourselves to invent negative feedback loops that can keep the complex system in equilibrium.