Supporting positive dimensions of health, challenges in mental health care.

This paper will explore two contrasting paradigms in mental health care and their relationship to evidence-based practice. The biomedical perspective of pathogenesis and the health perspective of salotogenesis are two major diverse views in mental health care. Positive dimensions of health are traditionally viewed as software not suitable for statistical analysis, while absence of symptoms of disease are regarded as measurable and suitable for statistical analysis and appropriate as a foundation of evidence-based practice. If the main goal of mental health care is to enhance subjectively experienced health among patients, it will not be sufficient to evaluate absence of symptoms of disease as a measure of quality of care. The discussion focuses on the paradox of evidence-based absence of illness and disease versus subjectively experienced health and well-being as criterions of quality of care in mental health care.

Mental health care has traditionally been criticized for lacking systematic health-promoting interventions (McMullen O'Brien, 1998) and for adopting a biomedical perspective that fails to adequately take account of the multidimensional complexity of the concept of health (Moyle, 2003; Pavis, Secker, Cunningham-Burley, & Masters, 1998). The scientific biomedical model, which is described as the dominant professional view accepted by most health care workers during their education, emphasizes a negative meaning of health as the absence of signs of illness or disease and tends to neglect positive aspects of health (Downie, Tannahill, & Tannahill, 1996; Naidoo & Wills, 2000).

Many attempts have been made to define the concept of health by relating it to the concept of illness where the two concepts are viewed as contradictory or as two endpoints on the same continuum. The two major contrasting views of health appear to be the biomedical perspective of pathogenesis and the health perspective termed salotogenesis (Downie et al., 1996; Naidoo & Wills, 2000). The perspective of pathogenesis is built on knowledge about illness, its origin and treatment and incorporates a dichotomy, where health and illness are seen as separated states. The negative meaning of health represents the absence of disease or illness, while the positive meaning of health incorporates dimensions of well-being, an ability to develop relationships, and to achieve subjective desirable goals. The development and implementation of a holistic concept of health in mental health care that does not just imply an absence of illness or disease may involve a shift of focus from illness and deficits to one of individual health and resources (Read & Stoll, 1998).

The importance of defining health in mental health care

Nursing science as well as mental health care in general has, in fact, comprised both the humanistic paradigm that can be seen as a “bottom-up” approach, where the patient's individual experiences are considered, and the biomedical model that can be regarded as a “top-down” approach toward the patient, where the professionals are viewed as the experts (Lindsey & Hartrick, 1996). The organizational processes such as deinstitutionalization and integration of patients in community-based mental health services have made the challenge to create a clear definition of health at all levels in mental health care even more essential (Magnusson, Högberg, Lützen, & Severinsson, 2004).

An important distinction has been made between illness prevention, which can be described as the avoidance of disease, and health promotion that comprises a number of activities seeking to expand positive potentials for health (Pender, 1996). It has been maintained that, although a more holistic health perspective has been developed in nursing science in recent decades, nursing research sometimes still tends to characterize health as the absence of symptoms of disease or handicap (Hwu, Coates, & Boore, 2001). A divergence has, however, been recognized in the nursing discipline between these two contrasting health care paradigms (Malin & Teasdale, 1991). A focus in health care that remains mainly on illness and deficits tends to reinforce the patient's experience of illness and disability (Simmons, 1989; Svedberg, Jormfeldt, & Arvidsson, 2003). However, the main focus in previous research regarding health in mental health care has been to alleviate and reduce mental illness and symptoms of disease, while frequently overlooking the patients’ needs of support for their health from a subjective perspective (Berg & Sarvimäki, 2003).

Psychiatric symptoms are, from the perspective of pathogenesis, viewed as signs of a malfunctioning in the brain and the main goal of health care is to cure or prevent illness. From this perspective the concept of health is viewed as normality and disease is viewed as a deviation from this normality. According to this perspective, interventions such as prescribing a pill aiming at alleviating illness and symptoms of disease are often simultaneously viewed as health promoting as health and illness are seen as endpoints of the same continuum. However, health cannot sufficiently be explained in a negative way as absence of symptoms because such an explanation tends to neglect the positive aspects of health (Downie et al., 1996; Hedelin & Strandmark, 2001; Naidoo & Wills, 2000). Thus it is of great importance that the staff in mental health care develops a willingness to respect the dignity of patients and to become aware of the patients’ possibilities and resources (Jormfeldt, Svedberg, Fridlund, & Arvidsson, 2007; Svedberg et al., 2003). The adoption of a positive attitude and focus on possibilities has been proposed to motivate people with long-term mental health problems to help them engage in and to take an active part in their own care (Repper, Ford, & Cooke, 1994).

The perspective of salotogenesis is built on knowledge about health, how it is achieved, and incorporates a continuous view of health and illness. The individual is viewed as a whole person in relation to his or her environment and the main goal from this perspective is to strengthen and promote health. From a holistic perspective, health and illness are viewed as different processes interdependently influencing each other. Health care of today seems to take for granted that interventions aiming at alleviating symptoms of disease automatically promote processes of health as well. However, clinical experiences from mental health nursing show that this is not necessarily the case. Perhaps the promotion of health processes reduces the process of illness to a greater extent than the prevailing, mainly biomedical, clinical praxis of today is able to promote those health processes.

As an example, we can imagine a person diagnosed with “Schizophrenia.” From the biomedical perspective, the diagnosis of schizophrenia is often described as incurable and the patient is often instructed to follow doctors’ prescriptions very carefully because medication is seen as the foundation for treatment and the most superior intervention to alleviate the symptoms (van Os et al., 2006). This intervention may place our patient in the position where the symptoms are partly alleviated but the patient is still at great risk of becoming ill in the event of stressful situations. It is easy to understand that the patient's motivation to maintain hope and follow prescriptions can sometimes be reduced if his or her problems are primarily viewed from this perspective. From a health perspective, the goals and desires of the individual are vital and serve as guidance for the care. The process of reaching individual goals is seen as the superior pathway for a cure from mental illness. An intervention to support our imagined patient to reach his individual goals may place him/her in a position where he/her has a good chance of achieving a good life and a feeling of well-being. If or when medication is used, from this perspective, it is to support the patient in his/her process of reaching his/her goals from a salutogenic perspective of health.

Positive dimensions of health

Valid and reliable measures of a positive multidimensional concept of health in mental health services need to address Autonomy, Social Involvement, and Comprehensibility (Jormfeldt, Svensson, Arvidsson, & Hansson, 2008).

Autonomy incorporates the ability to function in daily life, self-esteem, and to feel positively about oneself. Perceptions among nurses and patients in mental health services have been shown to be very much alike (Jormfeldt, 2010; Jormfeldt, Svedberg, & Arvidsson, 2003; Svedberg, Jormfeldt, Fridlund, & Arvidsson, 2004). However, one difference between nurses and patients’ expressions of health is the importance of feelings of being equal and important to other people. These feelings were related to a feeling of self-worth and health, which nurses working in mental health services do not always express an awareness of (Jormfeldt et al., 2003). Patients in mental health services have described the importance of being looked upon just as anyone else as well as the need for help to reduce the shame of having to request and receive psychiatric care in order to reduce stigmatization and enhance health (Schröder, Ahlström, & Larsson, 2006). Sörgaard et al. (2002) found that overall self-esteem was predicted by being satisfied with family relationships and that having at least one close friend was a predictor of positive self-esteem, while being able to cope without friends was associated with superior self-esteem. Self-esteem has shown to be strongly associated with health while psychiatric symptoms to a much lesser extent have shown to be negatively associated to health (Jormfeldt, Arvidsson, Svensson, & Hansson, 2008).

Social Involvement contains experiences of attachment to others and feelings of being both a recipient and a donor of social support. Mental health patients emphasize the importance of experiences of participation in social contexts and being able to give support to others, while the nurses more often speak of the importance of patients experiencing trust and being part of a social context (Jormfeldt et al., 2007). Hedelin and Jonsson (2003) describe mutuality in relationships between people as a major element in their experience of mental health. The essence of mental health has been defined as the experience of confirmation by means of being noticed, respected, and regarded as a valuable person by others (Hedelin & Strandmark, 2001), and one very important aspect of health is to feel included in a social network. Hansson et al. (1999) have studied clinical characteristics that may be related to quality of life without finding any associations with global subjective quality of life, while one objective indicator, i.e., to have at least one close friend, was associated with superior self-rated quality of life. Unmet needs in the domain of social relationships are related to a worse quality of life (Hansson et al., 2003). Involuntary loneliness and the experience of not belonging to anyone have been described as a lack of participation in the world (Dahlberg, 2007).

Comprehensibility includes the understanding and awareness of one's own situation, how the situation has emerged, and a view of how to get the situation changed if desired. Comprehensibility could be recognized as meaningfulness, being at peace, and looking forward to something positive, as well as personal growth and seeing suffering as a motivating force to change (Jormfeldt et al., 2003). Health as a process includes the view of suffering as a motivator for development toward change and increased awareness (Jormfeldt et al., 2007) as described by several previous researchers (Herberts & Eriksson, 1995; Lindsey, 1996; Long, 1998). Jones and Meleis (1993) maintained that increased self-esteem, which is often enhanced through empowerment processes, is essential in order to gain the energy that is needed to be able to fully use one's own personal health capacity. A number of earlier researchers have depicted health as an increased awareness and a foundation for increased well-being (Eriksson, 1984; Long, 1998; Moch, 1998; Parse, 1990). The process toward increased awareness and greater personal meaning has been labeled transition and could be encouraged through communication of thoughts and needs (Skärsäter & Willman, 2006). This awareness can, in turn, lead to more constructive behavior in accordance with individual wishes related to the environment. Positive mental health has to be promoted at the individual level (Mezzich, 2005) and include factors such as acceptance, faith, hope, meaningfulness, and meaningful relationships (Edward, Welch, & Chater, 2009). According to this reasoning, the concept of health is far beyond the limits of the wellness–illness continuum (Hwu, Coates, Boore, & Bunting, 2002; Moch, 1998).

Do we need to measure health in mental health care?

Health promotion interventions are determined by the definition of health. To be able to truly promote health in mental health care, we have to define health in a positive manner and not only as an absence of illness or disease. The construct of remission can be seen as an example of measuring absence of symptoms of illness as a measure of health. The symptomatic remission criteria among patients diagnosed with bipolar disorder or schizophrenia is used as an assessment of reduction of symptoms. The underlying presumption is that remission is a prerequisite for everyday functioning among these patients. Remission is suggested to be a good measure of treatment outcome and it is also proposed that remission of clinical symptoms is a required first step toward functional recovery (van Os et al., 2006). On the other hand, the construct of remission pays little attention to the subjective experience of the patient and the focus is entirely on the absence of symptoms of illness even though the concept of remission often is described as a positive concept related to recovery, health, and quality of life. The difficulties in measuring subjectively experienced health in individuals or in populations as well as in mental health services without a clear definition of the positive dimension of health has been highlighted by Jormfeldt et al. (2007) and Naidoo and Wills (2000).

The overall goal of nursing in general health care as well as in mental health care is to promote the patient's subjective experience of health. An important measure of quality of care is thus to assess to what extent this goal is reached. The more ambiguous the definition of health is, the less importance the concept will be given and other more clarified concepts, as symptoms of illness or disease, will be given greater significance when mental health care is evaluated. In health care it has traditionally been easier and more common to measure absence of symptoms of disease as these symptoms often are more clearly defined then subjectively experienced health. Studies evaluating questionnaires measuring patients’ subjectively experienced health in mental health services are rare, and most questionnaires used to measure health in health care have, in fact, been measuring absence of illness in terms of symptoms and disabilities in line with the biomedical view of health (Christiansen & Kooiker, 1999; Whitehead, 2003). Consequently it is often the negative dimension of the concept of health that is being measured, evaluated, and used as a base for evidence. Most evidence-based models appear to understate the importance of non-pharmacological interventions and a lack of knowledge about such interventions is recognized (Hayman-White & Happel, 2007). Nursing care and caring science requires humanistic knowledge with a hermeneutical dimension to achieve real progress in caring (Eriksson, 2002), the challenge is to shape an evidence base for this kind of knowledge.

Conclusions

Health is to a great extent associated with self-esteem and to a lesser extent with clinical characteristics and psychiatric symptoms. Mental health care must consequently involve interventions, relationships, and contexts primarily aiming to support the patient's self-esteem and empowerment if it is to promote health. The key to enhanced health among patients in mental health services is to acquire support regarding self-esteem, empowerment, and quality of life. To view the goal of mental health care mainly as reducing symptoms should not be sufficient when mental health as well as overall health is to such a low level explained purely by psychiatric symptoms. Subjectively experienced health is one of the most important outcome measures of the quality of care provided to patients in mental health care irrespective of type of symptom, illness, or disability.

Implications for further research and relevance in clinical practice

Advanced analysis of the concept of health may contribute to enhanced empowerment strategies in health care. Further research of importance would be to investigate the effects and effectiveness of empowerment approaches in mental health services and to consider every possible causal relationship between psychiatric symptoms and health in order to develop and implement more constructive intervention approaches in mental health services. Clinical interventions aiming at strengthening positive dimensions of health and self-esteem are required in mental health care in order to meet the patients’ needs of enhanced health and to make further investigations possible regarding effects of such interventions.