Recent decades have witnessed a surge in the development of competency-based, collaborative approaches in working with patients. The competency-focused approach – a method that connects to the already present competences of patients – is intended to discover and expand their skill’s repertoire. By competency we mean that patients have sufficient skills to adequately fulfill the tasks that they encounter in their daily lives.
The basic principles of the competency model are:
- Find the strengths of patients and activate them to realize their goal.
- Acknowledge their needs, desires, limits and norms, and take these seriously.
- Focus on creating new possibilities.
In 1948 the World Health Organization (WHO) defined health as “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Huber et al. (2011), Huber et al. (2016) and Huber, Van Vliet and Boers (2016) proposed to replace this rather outdated definition with a concept where people take center stage, not the disease. In this alternative, the competence to take control and the concept of resilience were included. They named their concept “positive health”.
Based on this competency model we describe the solution-focused model and extend the concept of positive health of Huber and colleagues, to shape our concept of “positive health care” – the title of our book.
The old definition of the WHO was too idealistic, because not everyone can achieve the goal of complete well-being. In this way almost every person is made a patient, who needs help almost continuously. Therefore the definition is not realistic and unintentionally promotes medicalization.
In 2009 an international conference was organized in The Netherlands with the aim to come up with a better description of the concept of health. This led to a new formulation: “Health as the ability to adapt and self-manage, in light of the physical, emotional and social challenges of life”.
This description makes health a more dynamic concept, an ability or a power. The concept makes it clear that patients with a chronic illness or disability can still (partially) regain their health, even if the illness or limitation persists. Health is not a goal in itself, but a means to live a meaningful life.
Because this relational and dynamic description of health has common ground with positive psychology, Huber et al. (2016) named their concept “positive health”. They argued that we should start to think differently: we need to shift our focus more towards the system rather than the problem. With this they meant a system of multidisciplinary collaboration, in which self-management plays an important role.
Huber and colleagues examined the support for the new concept and to what extent this is measurable. They performed qualitative and quantitative research among seven groups of stakeholders: healthcare professionals, patients with a chronic disease, policymakers, insurance companies, public health advisers, citizens and researchers. The qualitative research showed that many respondents find it positive that people, not the disease, are the central focus. Also found positive was that the strengths of patients were addressed. However, the respondents found it negative that it requires a lot of commitment from patients. They also found it negative that the actual disease does not retain a clear position within the new concept. Huber and colleagues, for that matter, stressed that diseases should be dealt with in a conventional manner, but in such a way that people could lead a good and satisfying life.
The qualitative research resulted in 556 health indicators, which were arranged in six dimensions, with 32 underlying aspects. The main dimensions are:
- bodily functions;
- mental functions and perception;
- spiritual/existential dimension;
- quality of life;
- social and societal participation;
- daily functioning.
You do not have to be ill to get better
In the context of quantitative research Huber and colleagues asked respondents whether they considered these six main dimensions and their underlying aspects to correlate with health (on a scale of 1 to 9). This lead to surprising results. Everyone agreed on the importance of the ‘bodily functions’ dimension; for other dimensions opinions differed widely. Patients found all six dimensions almost equally important and saw health as a broad concept. Policymakers and researchers differed most from the other groups. Their understanding of the concept of health is more narrow and mainly biomedically oriented. The healthcare professionals as a group also differed significantly on all dimensions from the patients, except on the dimension ‘bodily functions’. When the group of healthcare professionals was split up, it turned out that the doctors – both specialists and general practitioners – differed most from the patients in their judgement on the different dimensions. Nurses largely gave similar answers as patients; physiotherapists scored in between these two groups. The researchers also looked at the level of education and the age of the respondents. It showed that as people grow older, they score high on more dimensions.
The last question in the quantitative research – “Do you have experience with illness yourself?” – showed a splitting factor. The scores of people without experience showed large differences between the dimensions, with sharp downward peaks for dimensions that they considered irrelevant. Higher and more constant are the scores of people who do have experience with illness. This difference is particularly visible in the spiritual/existential dimension, where meaning in life, acceptance and future perspective are central. According to Huber and colleagues, a meaningful life can be seen as the strongest healing factor.
In summary: all groups find it positive that people are central and not the disease. They also find it positive that the new health concept emphasizes possibilities instead of limitations. General practices should, in the respondents’ opinion, also be concerned with health promotion and not just with the treatment of diseases.
Huber, Van Vliet and Boers (2016, p.3): “We concluded that when one wants the patient to take center stage, one should take this broad interpretation of the concept of health seriously. We should distinguish this view from the view that health is ‘the absence of disease‘. That is why the term ‘positive health‘ is used as a working concept. Contrary to positive health one can regard negative health as an indication of health “per exclusionem”. ‘
Based on positive psychology, Walburg (2015, p. 28) stated that there is good reason for describing positive health as: ‘the ability to adapt and self-manage for sustainable development and flourishing’. Therefore, health is a competency that supports development and flourishing. Flourishing is a process towards “well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.
This is the definition of positive mental health of the WHO (2001), which, according to Walburg, can be applied to physical health as well. Flourishing concerns the development of talents and strengths aimed at realizing our goal and ambition. A well-integrated measure for positive health indicates the extent to which there is flourishing and well-being. Various measuring instruments are now available, such as the Keyes Scale (2002) and the Huppert and So Questionnaire (2013).
Huber and colleagues’ concept received also criticism. Van der Stel (2016) argued that the concept puts a one-sided emphasis on behavior as a characteristic of health, as it would only focus on adapting and control. However, in our opinion Van der Stel does not recognize that the ‘ability’ to adapt and to self-manage is determined by countless factors, such as physical condition, psychological state, genetic factors, economic, social and environmental factors. It is not just about behavior.
Poiesz, Caris and Lapré (2016) argued that the new concept is not based on a good, sharp definition. Huber and colleagues’ interpretation would make it difficult to set standards – their concept would be too broad and therefore expand uncontrollably. It also does not distinguish between cause and effect. For example, they indicated that according to the concept of positive health, loneliness can both be a cause and a consequence of living an unhealthy life.
We suggest to look at it from a different angle. Is it possible at all to formulate an unambiguous and sharp definition of positive health? Health seems to be the result of a large number of factors with constant interactions. It cannot be divided into separate building blocks in which the same health characteristics are visible as in a whole. Health is an emergent property of an individual (see Chapter two). There are endless interactions and causes and effects which cannot be unraveled.
We therefore propose to formulate the concept of positive health in a broader sense: “The ability to adapt and self-manage in light of the dynamics of life.” With the dynamics of life we mean both the highs and lows (and everything in between) – and not just the challenges of life, as in the concept of Huber and colleagues, or sustainable development and flourishing, as in the concept of Walburg.
The positive health concepts of Huber, Walburg and our concept – all have the ‘ability’ (the competency) as a central concept – recognize the wide variety of factors that play a part in health. In this vision, we cannot suffice with only the problem-focused medical model. The solution-focused model – with a focus on the physical aspects of patients as well – offers good additional possibilities, especially for professionals working in general practice.
Positive health care
In this book, we propose to extend the positive health concept of Huber and colleagues and Walburg to our concept. Also the general practice should no longer be a place where only problems and diseases are discussed and treated, but a place where the focus is on what works in patients’ lives, where their strengths and resilience are discovered and used, positive emotions are strengthened, and hope, gratitude and optimism are nurtured (Bannink, 2009, 2016a).
The solution-focused approach does not only focus on strengths, but on everything that works in the lives of patients. The solution-focused approach is about patients designing their preferred future and finding the ways to achieve their goal. Using this paradigm, the focus is on building solutions instead of solving problems.
Huber and colleagues mentioned Motivational Interviewing (Miller & Rolnick, 2005) as an instrument in their concept. Our concept does not use motivational interviewing, but instead the solution-focused model. Lewis and Osborn (2004) compared both models. The most important similarities were: in both models the focus is not on the problem or disease, but on health promotion, using the patients’ competences, skills and strengths. Another similarity concerns the cooperation between professionals and patients as a key to change.
One of the differences between the two models is that motivational interviewing adheres to an explicit model of change, while solution-focused counseling does not have such a model, but focuses on new possibilities and perspective taking. Another difference is that motivational interviewing is directive and wants to reinforce intrinsic motivation, while the solution-focused model emphasizes the patients’ preferences for change, cooperation in determining their goal, and devising solutions to make that happen.
The term ‘resistance’ is used in motivational interviewing, while the solution-focused model does not find that idea useful, and assumes that there is always cooperation (see Chapter four). The focus in motivational interviewing is predominantly on the reason ‘why’ patients want to change, while the focus in the solution-focused model is predominantly on ‘how’ they want to change.
In the next chapter we will describe the solution-focused model in more detail, as well as the opportunities within a general practice where the solution-focused approach may be applied.
We briefly describe its history and research, as well as the differences between ‘problem-talk’ and ‘solution-talk’, and the (contra)indications.