Prevention is better than cure”, or so the old adage goes. And it’s perhaps not surprising to find that when it comes to safe-guarding our future health and preventing illness, a lot of what’s important for healthy backs is also beneficial for our overall health.
INCLUDING THE HUMAN IN HEALTHCARE
The highly complex and multi-factorial traits of health status are a dynamic interplay between genome and envirome – that is to say, our health is an on-going dialogue between nature and nurture. Enviromics is the formal study of factors influencing organismic systems, but to a high degree within our increasingly post-modern societal consciousness we simply intuit the biopsychosocial model. The human organism inhabits several dimensions, at least including biochemical, biomechanical and psychosocial. The recognition and adoption of fuller sets and depths of these dimensions within the healthcare process renders access to more complete and sustainable outcomes for the patient, practitioner and policymaker.
THE PATIENT-CENTRED MOVEMENT
Recent decades have seen an evolution of the values animating the therapeutic alliance between patient and practitioner. We have witnessed a movement away from authoritarian modes of relation towards the increasing realisation of a patient-centred approach. The Institute of Medicine (IOM) defines the patient-centred approach as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” 1. Don Berwick, formerly of the Institute of Healthcare Improvement (IHI), goes a step further to forward a more highly elaborated description: “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care” 2.
BALANCING THE THERAPEUTIC ALLIANCE
This dawning confers an important shift in patient engagement and compliance. Whilst the authoritarian must enforce their prescription, the truly patient-centred practitioner operates in collaboration with the patient. Since the patient is invested in co-authoring their prescription, the issues of engagement, compliance and motivation are transformed. However, whilst the patient’s own goals and values are an important inclusion in this upgrade from authoritarian healthcare, it is the practitioner’s responsibility to balance patient needs with their own, namely the practitioner’s need to foster patient development from reactive/symptomatic towards proactive/preventative and beyond. Simply put, the patient’s own preferences and judgements may be largely incompatible with health. It is important to acknowledge that failing to engage the patient’s intrinsic developmental capacity deprives them of access to increasingly sustainable versions of health and becomes our most insidious and epidemic contravention of the essential Hippocratic edict.
THE RECONSTRUCTION OF HEALTH
Before we can begin to rethink healthcare, it’s important to ensure that we are clear on what we mean by the word ‘health’, and there are at least two routes we can take here. Firstly, a brief lexicographical reconnaissance of contemporary definitions yields important insights. The Oxford English Dictionary defines health in a conventional sense as “being free from illness or injury”. Merriam Webster adds to this picture the notion of “flourishing” as well as the dimensions of “mind, body and spirit”. The Wikimedia Foundation’s Wiktionary speaks of “wellbeing, balance and overall level of function” and alludes to a spectrum of dimensions, “from the cellular level to the social level”. However, of the definitions briefly surveyed, only the World Health Organisation (WHO) makes the final emphasis, in contrast to still-prevailing convention, that “health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity”. This definition has remained unchanged and served as a guiding principle since the organisation’s establishment in 1948. A second approach to the meaning of health is via the etymological route, delving into the origin of words. The word ‘medicine’ derives from the Latin verb ‘medeor’, meaning to ‘heal’ or bring to ‘health’, which in turn are found in the Old English ‘hælan’ (heal), to make whole, and ‘hælþ’ (health), to be whole. Unravelling this notion of becoming whole, we find the Greek ‘holos’, to become entire, complete and to bring to full development. It’s important to note that the etymological route does not lead us to an absence of disease (Old French ‘desaise’, lacking comfort or opportunity) or pathology (Greek ‘pathos’, suffering). It’s also important to be very clear that this ‘word play’ is not an exercise in pedantry. The very orientation of our medical and healthcare departments and institutions, as well as societal health consciousness, hinges upon what these words actually mean to us – the medicine that seeks an absence of symptoms looks very different to the medicine that seeks full human development. As philosopher, Ludwig Wittgenstein (1889-1951) declared, “The limits of my language are the limits of my world”.
A DEVELOPMENTAL MODEL OF HEALTHCARE AND ENGAGEMENT
Once we adopt health has a positive developmental process, it becomes essential to establish a coherent map that can guide the upbringing toward increasingly powerful models of medicine. Maps are merely abstract representations, so the emphasis here is not on dogmatic codifications but rather on a map that is conducive, operational and judged by its consequences. A suggested framework for the comparative assessment of healthcare paradigms would be to consider the following three faces3:
- INDIVIDUAL LEVEL: To what degree does this medicine permit and empower the individual to not only experience fulfilment but to recognise and engage their own development?
- RELATIONAL LEVEL: To what degree does this relationship fulfil the shared need of both patient and practitioner for the ample provision of effective care, education and inspiration?
- INSTITUTIONAL LEVEL: To what degree does this healthcare system facilitate effective and sufficient access to health within financial and human resource constraints?
Natural systems and the models that describe their development, point us toward a universal toolkit of underlying processes (such as described by Systems and Complexity-type theories). Surface commonalities of developmental models include the unidirectional transition through a series of consecutive, self-consistent paradigms or stages 4. A spectrum model of healthcare and patient engagement is hereby forwarded, ascending through five vertical stages, namely: 1-Palliative, 2-Management, 3-Curative, 4-Preventative and 5‑Integral.
FEELING BETTER OR FEELING LESS?
Palliative care (Latin ‘palliare‘, to cloak/mask) seeks symptomatic relief through the suppression of biological processes. Whilst, palliative care may be a valuable response to acute emergency, the goal is not to feel better, rather to feel less. The underlying implication is that the organism is broken and disease is effectively incurable – rather disempowering in all but the shortest of terms. Relationally, the therapeutic alliance is authoritarian. The patient delegates their health to the objective professional expert. Engagement with the patient’s cognitive and emotional apparatus is economised and typically sufficient only for the overarching goal of compliance. Treating symptoms rather than the individual means that the patient can be processed rather speedily, especially with the dispensation of pharmacotherapy. However, since treatment provides only transient symptomatic relief, the patient remains an indefinitely dependent consumer, unless recovery is allowed or facilitated. Overall, palliative care is the most expensive and least effective option as a standalone medical model.
TAKING CONTROL OF DISEASE
Disease and pain management operates on the understanding that quality of life is subject to multiple influences. The management approach seeks to improve quality of life despite and in the face of on-going illness, most significantly by starting to involve patient psychology. Drug and manual therapies may be employed in conjunction with nutrition, exercise and psycho-technologies (cognitive, affective, and meditative) – harnessing a variety of domains that influence the expression of symptoms and quality of life. However, though this marks the beginnings of a patient-centred model, the inclusion of the mind in the management approach is fundamentally exploitative from the perspectives of higher-order healthcare models (i.e. curative and beyond). Moderating the symptoms/expressions of disease via the mind is essentially a more sophisticated version of biochemical suppression or biomechanical dissipation. In short, as long as disease is deemed incurable, the medical relationship with the human organism is suppressive (as in palliative) or manipulative (as in management) but not truly collaborative (as in curative) or beyond.
RE-ORIENTING SYMPTOMATIC BEHAVIOURS
In keeping with the underlying structure of development, each successive stage includes and goes beyond the power and depth of the previous. Successive models of medicine integrate more of the total human reality. New integrations marking stage transition unlock the emergent properties of new paradigms. Whilst disease management integrates multiple palliative disciplines as well as patient psychology, curative medicine represents the first paradigm to relinquish the imposition or maintenance of limiting/disempowering beliefs (e.g. “chronic pain is incurable”) and their supporting cognitive frameworks. Many of the psychological tools in the curative toolkit may also be found in a management approach, but their power is capped by the cognitive framework into which they are situated. Unlike, palliative care where a drug can be administered in the virtual absence of psychological engagement, the curative process involves a complete reorientation of the patient’s understanding of their disease process from “I am broken” to “disease is a dynamic behaviour”. Again, in keeping with developmental dynamics, the drive toward completeness is balanced by the need for constancy. This latter need manifests in patients as well as practitioners and policymakers as an inability or unwillingness to engage with a higher-order paradigm to the degree that breaches their existing model. Higher-order paradigms can appear ‘soft’, untrue, uncomfortable, and bad or even offensive from preceding perspectives. Management approaches are now popular in modern national and private healthcare organisations, but curative medicine requires a depth of engagement that remains largely prohibitive for patients, practitioners and policymakers at this time.
Despite the power of the curative paradigm and its incidental consequences, the therapeutic alliance is only formed once the individual becomes symptomatic. The curative focus remains a return to health rather than a growth towards increasing health. By contrast, preventative medicine begins to integrate medicine with lifestyle, transforming the temporal dimension with respect to patient engagement. It’s important to point out that by far the most commonplace and visible conception of ‘preventative medicine’ is merely the addition of preventative prescriptions to the palliative and management models. Fully fledged, preventative medicine is the embodiment of an entirely new orientation and outlook on living whose instillation resembles education rather than traditional healthcare. Unlike preventative prescriptions, where ‘exercise’ and ‘healthy eating’ are advised and subject to the compliance issues of an authoritarian relationship between patient and medicine, true preventative medicine is embodied by the individual for reasons that are their own, i.e. health becomes an identity rather a coerced/incentivised subscription. Nutritional and psychophysiological practices become subject to the same category of motivational mechanisms that drive and govern an individual’s pursuit and attainment of high-level proficiency in a serious hobby about which they are passionate. The role of the practitioner is transformed from remedial to educative, ensuring the individual’s health-promoting practices are effective and fully differentiated – for example: the lay “exercise” conception may be differentiated into cardiovascular, strength, calisthenic protocols; and the lay “think positive/don’t stress” conception may be differentiated into cognitive, affective and meditative protocols. Whilst the focus remains the maintenance of health, effective psychophysiological practices catalyse the individual’s exposure to the experience of health as a growth process, thereby paving the way for further stage transition and emergence.
THE PRIMACY OF PURPOSE
Individuals who truly engage with the preventative paradigm often gravitate towards the field of ‘personal development’ as they naturally search for frameworks and communities that support their evolving outlook. However, even with healthcare and lifestyle firmly integrated, there remains at least one further integration and transition to be made. Once the individual feels that their basic needs (survival, comfort, socialisation and success) have been largely met 5, a switch occurs from a sense of deficiency to abundance driving a newly predominant need for generative expression, particularly in the context of a perceived purpose or in fulfilment of a social/world need. This marks the integration of one’s life with one’s work as the primary focus shifts from material remuneration to serving a purpose beyond personal biography – the term ‘life mission’ is apt to convey the sense of primacy that accompanies this emergence 6. The role of the ‘healthcare professional’ is again transformed in a move towards increasing decentralisation of the medicine, from the authoritarian doctor to preventative educator and now to the role of the mentor who inspires growth through an embodiment of growth. Intriguingly, this stage also marks a re-orientation from the ‘comfort zone’ to its boundaries and beyond where life conditions are more challenging but also more conducive to further growth. Disease itself is recognised as valuable feedback and part of a conscious internal dialogue on the ‘efficacy’ of one’s life path. With sickness, health, life and work all integrated into one deeply coherent stream of personal effort and experience, this stage is termed ‘Integral’.
The fundamental premise of any developmental model is a ‘vertical’ dimension/axis along which growth through stages of increasing power is realised. In cannot be over-emphasized here that the ability to grasp and embody a given stage is a consequence of actual growth rather than of being convinced or persuaded. Just as one cannot be usefully persuaded into being a concert pianist or being fluent in a foreign language, so too can one not be persuaded into embodying a stage of development that has yet to grow within. This caveat serves two purposes: firstly to disarm the aforementioned notion that development is a matter of opinion; and, secondly, because there are profound consequences for how we apply a developmental approach to healthcare. Understanding that stage transition cannot be persuaded into patients, practitioners or policymakers alike, there is a three-fold duty to: meet them where they are, facilitate best practice at their existing stage, and foster stage transition through the design of ‘educational’ initiatives. To close on a thought-point, literature on the nature of such ‘educational’ initiatives suggests that development occurs in response to experiences that are “structurally disequilibrating, personally salient, emotionally engaging, and interpersonal” 7.
SUMMARY TABLE OF THE 5 PARADIGMS BY THE 3 VALUE SPHERES
|“Health is…”||“Therapy is…”||“Medicine is…”|
- Institute of Medicine. “Crossing the Quality Chasm: A New Health System for the 21st Century“.
- Berwick, Don. “What Patient-Centered Should Mean: Confessions of an Extremist“.
- The three irreducible value spheres – 1st person/subjective, 2nd person/inter-subjective and 3rd person/objective – are found in numerous works throughout history, including those of Plato, Karl Popper, Jürgen Habermas, Immanuel Kant, Gautama Buddha, and Ken Wilber.
- Examples of developmental models comprising discrete consecutive stages include: Jean Piaget’s theory of cognitive development; Michael Commons’ model of hierarchical complexity; Jane Loevinger’s stages of ego development; and Lawrence Kohlberg’s stages of moral development.
- As in Abraham Maslow’s ‘Heirarchy of Needs’ with the appeasement of basic, ‘deficiency’ needs as being pre-requisite to the emergence of ‘being’ needs.
- See the work of Søren Ventegodt. He has nine papers archived on PubMed with “life mission” in the title. Full text is available for most of these.
- See “Promoting Advanced Ego Development Among Adults”, by John Manners, Kevin Durkin and Andrew Nesdale in the Journal of Adult Development (2004) – full text is freely available online.
- See “Spiral Dynamics – A Model of Human Values Development”, by Don Beck and Christopher Cowan, based on the work of Clare W. Graves.