Debate
There is also criticism of the concept ‘Positive Health’
In the special issue 04 about ‘Positive Health’ in the Dutch Tijdschrift Positieve Psychologie [Journal of Positive Psychology], November 2017, a critical article by Van Staa, Cardol and Van Dam is included. Under the title, ‘Not new, unclear, misleading and not without risk’ the authors give an overview of their objections to the concept of ‘positive health’ of Huber et al. (2016) based on three themes: criticism regarding (I) the conceptual and methodological level,(II) the practical implementation and application, and (III) a warning against the possible consequences. They call for a debate.
It is always good to debate. This often clarifies viewpoints and can lead to progress around new ideas. We are pleased to contribute to this debate. Besides, in addition to enthusiasm, we also hear criticism as described in the article by Van Staa and colleagues. The concept of positive health, or the presentation of it, is apparently unclear.
We agree with Van Staa and colleagues about the confusion. But we come to a different conclusion about the significance of the concept of positive health. It does not go too far for us: we see it as an important step in the right direction in thinking about health. For us it is actually not far enough. Because when the vision of health as a complex dynamic system is followed and carried through to all consequences, it becomes easier to talk about.
(I) Conceptually unclear
In the concept of Huber and colleagues health is described as the “ability to adapt and selfmanage.” This makes it a complex and dynamic concept. This is a big benefit. But they also divide positive health in a reductionist way into six dimensions: bodily functions, mental functions and the mental perception, spiritual/existential dimension, quality of life, social and societal participation and daily functioning.
This is confusing. Complexity and reductionism do not go well together. The confusion makes it difficult to argue about matters that Van Staa et al. mention in their article such as, ‘classification’, ‘where is the boundary between illness and health?’, ‘where are the objectifiable conditions or the disorder […]?‘ and ‘cause and effect are mixed up’. These are topics that fit in with a reductionist approach, but not with complexity. The separation of the aspects of a complex system and the desire to proceed reductionistically can resolve this confusion. Health as a whole is complex. This does not exclude, however, that research is possible in sub-areas, with sometimes clear results. Attention to both viewpoints is clarifying.
(II) Practical implementation
Ambiguity about the practical implementation leads to criticism. For example, van Staa and colleagues argue, ‘[..] is part of a neoliberal ideology of cost control and engineerable society,responsibility and self-reliance, reduction of claims to collective resources, and community involvement’, ‘victim blaming’, ‘obligation to work on your health, taking responsibility for your health behavior and to be positive’, ‘the compulsion to no longer think in terms of limitations, but in possibilities’ and ‘resistance […] to such use of veiling language and the constant emphasis on opportunities and possibilities without the recognition of misery, loss or inherent vulnerability’. All common misunderstandings.
In our opinion, this is the consequence of the lack of a clear practical approach. We are lucky to have a great deal of experience with the solution-focused approach, a functional model that arose in psychotherapy in the 1980s. It has grown into a fully-developed model that is ideally suited for complex issues where a reductionistic approach is not necessary, undesirable or simply does not work.
It is about finding what works for this patient, in this context, at this moment. It requires a collaboration where it is the task of the professional to invite patients to think differently, to describe their desired future, to notice positive differences and to make progress. This has nothing to do with neoliberal ideology, nor with victim blaming, but it has everything to do with autonomy, competence and relatedness (Ryan & Deci, 1987). After all, patients are experts of their own life and context. In our opinion, complex topics require an approach that is specifically designed for this. The solution-focused model is a useful example of this.
(III) Warning
Another criticism is that the concept of Huber et al. ‘does not distinguish between good or healthy adaptive forms and adaptation mechanisms that we generally do not find proper (such as accepting domestic violence or smoking to handle stress)’. We propose to look at it as follows: A professional and patient who use the concept of positive health have the same knowledge and research results as those who are using the conventional concept. How do Van Staa and colleagues see a difference here, if a distinction between right and wrong, or healthy and unhealthy would be made? How will professionals and patients act differently when this distinction is made?
Is the concept of Huber and colleagues too broad? Does the conversation tool My Positive Health (MPH) lead to the search for happiness or ‘the good life’ instead of to healthiness? We do not know. What we do know is that the solution-focused model does not use the MPH model, but uses open-ended questions about how people like their lives to be (different) and what works in their lives. Moreover, solution-focused questions motivate people to take action. From the extensive solution-focused literature we do not come across the topic ‘too broad’.
However, it is known from the literature within psychotherapy that the solution-focused approach leads to shorter treatments than traditional forms of psychotherapy, the autonomy of patients is guaranteed and there is less burnout among healthcare providers (Franklin et al., 2012, Stams et al., 2006, Medina & Beyebach, 2014). We are not worried by the risk, stated by Van Staa and colleagues, that governments, sports clubs or churches will also engage in the health domain.
The solution-focused model (Bannink, 2010; 2015) can be very useful as a working method for (positive) health. In addition, we should consider how we can combine this model with the regular medical model. We call this combination “Positive Healthcare”.
With our concept of Positive Healthcare we use the following assumptions:
(1) Health is a complex (non-linear) dynamic system.
(2) In sub-areas within the health system, there are relatively clear and stable processes where cause and effect can be recognized, a reductionist approach is possible and results from research make a difference.
(3) There are two fundamentally different ways to approach issues. In terms of philosophy of science, we distinguish the analysis paradigm and the synthesis paradigm.
(4) Within the health domain, both paradigms are needed.
(5) Separate and yet combinable working methods are needed for both paradigms.
The solution-focused functional model can be easily combined with the reductionist medical model. A solution-focused approach uses everything that works in the life of the patient.Results from research are seen as good examples and not as guidelines or protocols.To represent what the integration of the medical and solution-focused model might look like, we use ‘the entropy model of uncertainty’ (EMU) by Hirsh, Mar and Peterson (2012). EMU is based on the information theory and thus designed to make choices or to choose a direction in a complex dynamic environment. A dynamic environment is constantly changing and directions must change accordingly. How are directions determined? The entropy model assumes that an organism, like any self-organizing system, has an interest in constraining entropy (also interpreted as ‘uncertainty’ or ‘disorder’). Hirsh and colleagues argue that goals and belief structures reduce the spread of affordances and help to constrain entropy. We state that research results are also part of these ‘belief structures’ and also limit the number of options. Research evidence that is strong and fits the context of the person can greatly reduce the number of choices— the lowest entropy determines the direction. And because the circumstances are constantly changing, this is a continuous loop.
What is sufficient evidence? An interesting development is the ongoing discussion about sharpening the p-value threshold to 0.5 percent, instead of the traditional 5 percent (Benjamin, 2017). This makes the need for an alternative to the reductionistic approach much greater.
For doctors who already work with a combination of the medical and the solution-focused model, the balance varies per consultation. In the case of psychological conditions, a consultation can be (almost) completely solution-focused. Sometimes it is restricted to a number of solution-focused questions such as, “What have you already done against the pain that helped, even just a little bit?”
In between these two models, perhaps the most important question is, “How do you interpret results from research (with averages) to the individual patient?” We realize that more research and practical experience is needed. In our opinion, however, there are good reasons to continue with the development of opportunities for positive health (and positive health care).
Bannink, F.P. (2010). 1001 Solution-focused questions. Handbook for solution-focused interviewing. New York: Norton.
Bannink, F.P. (2015). Book series: 101 Solution-focused questions for help with 1. Anxiety, 2. Depression, 3. Trauma. New York: Norton.
Benjamin, D.J. (2017). Redefine statistical significance. Nature Human Behavior, 01 September 2017 https://www.nature.com/articles/s41562-017-0189-z
Deci, E. L., & Ryan, R. M. (1987). The support of autonomy and the control of behavior. Journal of Personality and Social Psychology, 53, 6, 1024-1037.
Franklin, C., Trepper, T.S., Gingerich, W.J. & McCollum, E.E. (2012). Solution-focused brief therapy. A handbook of evidence based practice. New York: Oxford University Press.
Hirsh, J.B., Mar, R.A., & Peterson, J.B. (2012). Psychological entropy: A framework for understanding uncertainty-related anxiety. Psychology Review, 119, 2, 304-320.
Medina, A. & Beyebach, M. (2014). The impact of solution-focused training on professionals’ beliefs, practices and burn-out of child protection workers in Tenerife Island. Child Care in Practice, 20, 1, 7-36.
Stams, G.J., Dekovic, M., Buist, K. & Vries, L. de (20016). Effectiviteit van oplossingsgerichte korte therapie: Een meta-analyse. Gedragstherapie, 39, 2, 81-94.