Practicing Positive Psychiatry E-Book

Fredrike P. Bannink

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2021

Seitenzahl: 312

Beschreibung

A highly practical book for all mental health professionals wanting to know how to apply positive psychiatry in their daily work Positive psychiatry is the science and practice of psychiatry and clinical psychology that seeks to understand and promote wellbeing among people who have or are at high risk of developing mental health problems. In this new approach, the person takes center stage, not the disease, and the focus is not only on repairing the worst, but also on creating the best in our patients.. The authors from the fields of medicine and clinical psychology present over 40 applications and many cases and stories to illustrate the four pillars of positive psychiatry: positive psychology, solution-focused brief therapy, the recovery-oriented approach, and nonspecific factors. The book shows how mental health professionals can significantly increase patient collaboration to co-create preferred outcomes through discovering possibilities and competencies and through building hope, optimism, and gratitude. Essential reading for psychiatrists, clinical psychologists, other professionals working in the field of mental health care as well as students who want to take a positive focus to make psychiatry faster, lighter, and yes, more fun. We have high hopes that positive psychiatry will become a firm part of the psychiatry of the future.

Leseprobe

Practicing Positive Psychiatry

Fredrike Bannink

Frenk Peeters

Library of Congress of Congress Cataloging in Publicationinformation for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2020941013

Library and Archives Canada Cataloguing in Publication

Title: Practicing positive psychiatry / Fredrike Bannink, Frenk Peeters.

Names: Bannink, Fredrike, author. | Peeters, Frenk, author.

Description: Includes bibliographical references and index.

Identifiers: Canadiana (print) 20200280104 | Canadiana (ebook) 20200280457 | ISBN 9780889375772

(softcover) | ISBN 9781616765774 (PDF) | ISBN 9781613345771 (EPUB)

Subjects: LCSH: Psychotherapy—Methodology. | LCSH: Psychiatry—Methodology. | LCSH: Positive

psychology. | LCSH: Solution-focused therapy. | LCSH: Client-centered psychotherapy.

Classification: LCC RC480.5 .B36 2020 | DDC 616.89/14—dc23

©2021byHogrefe Publishing

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

Registered trademarks are not noted specifically as such in this publication. The use of descriptive names, registered names, and trademarks does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Cover image: © Andrey Popov/Adobe Stock

PUBLISHING OFFICES

USA:

Hogrefe Publishing Corporation, 361 Newbury Street, 5th Floor, Boston, MA 02115

Phone [phone]; E-mail [email protected]

EUROPE:

Hogrefe Publishing GmbH, Merkelstr. 3, 37085 Göttingen, Germany

Phone [phone], Fax [phone]; E-mail [email protected]

SALES & DISTRIBUTION

USA:

Hogrefe Publishing, Customer Services Department, 30 Amberwood Parkway, Ashland, OH 44805

Phone [phone], Fax [phone]; E-mail [email protected]

UK:

Hogrefe Publishing, c/o Marston Book Services Ltd., 160 Eastern Ave., Milton Park, Abingdon, OX14 4SB

Phone [phone], Fax [phone]; E-mail [email protected]

EUROPE:

Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, Germany

Phone [phone], Fax [phone]; E-mail [email protected]

OTHER OFFICES

CANADA:

Hogrefe Publishing Corporation, 82 Laird Drive, East York, Ontario M4G 3V1

SWITZERLAND:

Hogrefe Publishing, Länggass-Strasse 76, 3012 Bern

Copyright Information

The e-book, including all its individual chapters, is protected under international copyright law. The unauthorized use or distribution of copyrighted or proprietary content is illegal and could subject the purchaser to substantial damages. The user agrees to recognize and uphold the copyright.

License Agreement

The purchaser is granted a single, nontransferable license for the personal use of the e-book and all related files.

Making copies or printouts and storing a backup copy of the e-book on another device is permitted for private, personal use only.

Other than as stated in this License Agreement, you may not copy, print, modify, remove, delete, augment, add to, publish, transmit, sell, resell, create derivative works from, or in any way exploit any of the e-book’s content, in whole or in part, and you may not aid or permit others to do so. You shall not: (1) rent, assign, timeshare, distribute, or transfer all or part of the e-book or any rights granted by this License Agreement to any other person; (2) duplicate the e-book, except for reasonable backup copies; (3) remove any proprietary or copyright notices, digital watermarks, labels, or other marks from the e-book or its contents; (4) transfer or sublicense title to the e-book to any other party.

These conditions are also applicable to any audio or other files belonging to the e-book. Should the print edition of this book include electronic supplementary material then all this material (e.g., audio, video, pdf files) is also available in the e-book edition.

ISBN978-0-88937-577-2(print) • ISBN978-1-61676-577-4(PDF) • ISBN978-1-61334-577-1(EPUB)

https://doi.org/10.1027/00577-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

Contents

Foreword

Introduction

Paradigm Changes

For Whom Is This Book Written?

Chapter 1 Two Paradigm Changes

Paradigm Change 1: People Take Center Stage, Not the Disease

Paradigm Change 2: Synthesis in Addition to Analysis

Psychiatry of the Future

Chapter 2 Positive Psychiatry

What Is Positive Psychiatry?

Positive Psychology

The Solution-Focused Approach

Recovery-Oriented Approach

Nonspecific Factors

Culture Change

Chapter 3 Recovery-Oriented Approach

What Is Recovery?

What Can Practitioners Do to Promote Recovery?

A Recovery-Oriented Model for Mental Health Service Delivery

Chapter 4 The Applications

A Focus on Strengths

Resilience

Further Positive Psychology Applications

Further Solution-Focused Applications

Online Interventions

Chapter 5 Reflection

Practitioners

Positive (Peer) Supervision

Feedback by Patients

Future Vision

Chapter 6 Frequently Asked Questions

Epilogue

Lists of Stories, Cases, Applications, Tables, Boxes, & Figures

References

Online Resources

Subject Index

Author Index

Acknowledgments

About the Authors

Peer Commentaries

|1|Foreword

The current times present unprecedented challenges to individual and societal well-being. We are experiencing behavioral pandemics of suicides, opioid abuse, and loneliness on a scale that was never seen in human history, and they are severely and adversely impacting human well-being, health, and even longevity (Jeste, Lee, & Cacioppo, 2020). The rapidly increasing pace and demands of life, the competitive environment faced from early age, and the ever-changing nature of technology leave little time for meaningful pursuits but ample opportunities for failure. The breakdown of family and community structure not only damages the safety net, but it also denies access to conventional wisdom. Fueled additionally by obesity and sedentary lifestyle, the mental health pandemics are manifestations of these stressors. Loneliness, once experienced only by the abandoned old and possibly by young immigrants, is now an everyday reality for large swaths of the society (Lee et al., 2019). The COVID-19 pandemic has made the already dire situation worse.

At the same time, there are silver linings on the horizon. There is growing scientific literature on wisdom, a positive personality trait associated with well-being and health. A number of randomized controlled trials are being conducted to enhance components of wisdom like compassion, emotional regulation, and spirituality, as well as resilience and overall wisdom (Lee et al., 2020, Treichler et al., 2020). This is positive psychiatry. The origin of psychiatry is rooted in medicine’s goal of alleviating mental illnesses, the diseases being its original and natural focus. Over recent decades, however, psychiatry, hand-in-hand with psychology, has undergone several changes in its perspective, shaped by behaviorism, existentialist and humanistic psychology, and, of course, biology which is at the core of medicine. Martin Seligman, following his earlier work on learned helplessness and pessimism developed an interest in quite the opposite: strength and optimism, the positive side of psychology. It was one of those ideas that aged well, it grew upon innate validity. The principles of positive psychology can be witnessed in action elsewhere – it propels the markets for self-help literature and motivational talks. Yet, it has taken centuries for organized medicine and psychiatry to accept the notions |2|of positive personality traits as targets of intervention, and well-being and happiness as outcomes. The first papers with positive psychiatry in their title were published in 2013 and 2015 (Jeste, 2013; Jeste & Palmer, 2013) and the first book on that topic in 2015 (Jeste & Palmer, 2015). Since then, the positive psychiatry movement has been spreading internationally (Machado & Matsumoto 2020; Messias, Peseschkian, & Cagande, 2020).

It is, therefore, with great enthusiasm that we welcome Practicing Positive Psychiatry by Fredrike P. Bannink and Frenk P.M.L. Peeters This book is a slightly modified English translation of the first book on positive psychiatry in Dutch published earlier this year. The authors aim at shifting the focus of psychiatry from reducing distress and surviving to successful living and flourishing. They combine the medical model in psychiatry with the synthesis paradigm or functional approach. We were struck by a beautiful sentence in the Introduction: “With this book, we invite you to apply positive psychiatry to not only repair the worst, but also to create the best in your patients, your colleagues, and yourself.” The intent to go beyond treating diseases and disabilities and expanding the mission to bringing out the best not only in the patients but also in the therapists (and readers from all walks of life) is laudable and noteworthy.

The authors have achieved professional eminence and have authored several other important books in the field. Fredrike Bannink, MDR, is a clinical psychologist and lawyer, whereas Frenk Peeters is a psychiatrist and Professor of Clinical Psychology at the Maastricht University in the Netherlands. They have adopted and adapted the ideas from our and others’ work (Jeste, Palmer, Rettew, & Boardman, 2015), shaping them with their valuable first-hand experience.

The book is very well written and the concepts are conveyed very clearly, making it accessible even to lay readers. For those who are interested in research, the book is interspersed with important references to the larger body of work they draw from. The book is structured into five well thought out chapters following the Introduction. The first chapter discusses two paradigm shifts in the field: moving the focus from the disease to the person and adding synthesis to analysis. The second chapter explains the various constructs involved in positive psychiatry. By increasing patients’ intrinsic motivation, the proposed solution-focused model enables shorter interventions, greater autonomy for patients, and less burnout among professionals. The third chapter describes the recovery-oriented approach. The fourth chapter describes various applications. The authors discuss 41 applications, which are summarized at the end of the book. The remarkable fifth chapter titled “Reflection” is a fascinating discourse on professionals’ reflection along with feedback from patients, and a presentation of future vision. Finally, there is a chapter with 31 FAQs.

|3|The authors make a strong case that nothing short of a profound paradigm shift is warranted to successfully practice positive psychiatry. A focus on the patient must also be accompanied by a synthesis that involves patient participation. The book starts out by laying a strong groundwork explaining the envisioned paradigm shift to the intended audience of practitioners who seek better outcomes for their patients. The book is replete with stories, applications, and case studies, written in easily understandable language. The provided applications have considerable utility for the practitioner. These are templates for practioner–patient dialog. They include specific questions, often open-ended and always nudging toward the desired synthesis. The “Taxi Driver” application is foundational, highlighting the fact that where you are headed is relevant, not where you are coming from. Stories provide a meta commentary illustrating key ideas, often borrowing from a wider context, sometimes examples from very different fields, our favorite being “Lessons From the Bamboo”. The case studies are in third person and intended to provide a perspective, connecting applications with patients, while taking care that the patient is never objectified and a disease is not the long-term focus, fitting with the overall paradigm of positive psychiatry.

While the paradigm and procedures are described in earlier chapters, the true spirit of positive psychiatry is captured by the chapter titled “Recovery-Oriented Approach”. The possibility of recovery is first introduced to the practitioner while making her or him aware that it goes well beyond symptom relief and must include leading a meaningful life. This foundational paradigm shift is captured by a key sentence and highly resonates with our philosophy: “One important recovery-oriented practice involves structuring the ethos and culture of mental health services around the premise that persons who experience mental illness can indeed recover.”

The final chapter includes FAQs, an essential companion to the applications provided throughout the book. The FAQs handle exceptions to scripted applications and often link back to the subject matter. What we particularly appreciated in this chapter is the emphasis on pragmatics rather than on high philosophy. For example, regarding a question on the role of diagnostics in positive psychiatry, the authors write that “The role of diagnostics is important, but diagnostics should not only be about problems, symptoms, disorders, and what is wrong in the patient’s life, but also about their strengths, resources, and what is going well.” We also applaud the authors’ list of “What if” questions from the perspective of patients as well as treating clinicians. One rarely encounters a book with such varied scenarios accompanied by appropriate “how to” responses. This reflects on the authors’ decades of thoughtful clinical experience and expertise.

|4|We have long held the view that psychiatry is defined by the skill set possessed by mental healthcare providers (Jeste et al., 2015). These skills are shaped by expectations of outcomes held by psychiatrists and other practitioners. Pessimism on outcomes by a practitioner will certainly limit what can be achieved for the patients. The efficacy of psychosocial factors in enhancing patient well-being, including alleviation of today’s greatest challenges such as obesity and hypertension, to promote health and longevity is well acknowledged (Diener & Chan, 2011; Schutte, Palanisamy, & McFarlane, 2016; Wiley, Bei, Bower, & Stanton, 2017). By shifting the focus away from disease and by inviting the patient to envision a desirable future, we can set up a gradual but positive trajectory for the outcomes reinforced by focusing on health and biology and refined over the course of the treatment. This promotion of positive psychosocial factors like resilience, optimism, social-engagement, and wisdom is the essential skill defining positive psychiatry.

This is indeed a timely book, and we are delighted and honored to write this Foreword. We congratulate the authors on having done an outstanding job in packaging a subject matter that we share as the core of psychiatry practice and research. It is our belief that positive psychiatry and a focus on wellness can produce lasting results, augmented by psychopharmacology and various other treatments. We also hope that this approach replaces less effective and limiting approaches. Since the days of William James, an educator and the father of American psychology, not only has psychiatry come a long way, but at many points, reset the direction of the field. This book defines a critical time point in the evolution of psychiatry.

Dilip V. Jeste, MD, Past President of the American Psychiatric Association and Distinguished Professor of Psychiatry and Neurosciences, University of California San Diego

Varsha D. Badal, PhD, Postdoctoral Scholar, Fellow, Department of Psychiatry, University of California San Diego

|5|References

Diener, E., & Chan, M. Y. (2011). Happy people live longer: Subjective well-being contributes to health and longevity. Applied Psychology: Health and Well-Being,3, 1–43. Crossref

Jeste, D. V. (2013). A fulfilling year of APA presidency: From DSM-5 to positive psychiatry. American Journal of Psychiatry,170, 1102–1105.

Jeste, D. V., Lee, E. E., & Cacioppo, S. (2020). Battling the modern behavioral epidemic of loneliness: Suggestions for research and interventions. JAMA Psychiatry. Advance online publication.Crossref

Jeste, D. V., & Palmer, B. W. (2013). A call for a new positive psychiatry of ageing. The British Journal of Psychiatry,202, 81–83. Crossref

Jeste, D. V., & Palmer, B. W. (Eds.). (2015). Positive psychiatry: A clinical handbook. Arlington, VA: American Pychiatric Press. Crossref

Jeste, D. V., Palmer, B. W., Rettew, D. C., & Boardman, S. (2015). Positive psychiatry: Its time has come. The Journal of Clinical Psychiatry,76, 675–683. Crossref

Lee, E. E., Bangen, K. J., Avanzino, J. A., Hou, B., Ramsey, M., Eglit, G., … Jeste, D. V. (2020). Outcomes of randomized clinical trials of interventions to enhance social, emotional, and spiritual components of wisdom: A systematic review and meta-analysis. JAMA psychiatry. Advance online publication.Crossref

Lee, E. E., Depp, C., Palmer, B. W., Glorioso, D.Daly, R., Liu, J., …. & Yamada, Y. (2019). High prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: Role of wisdom as a protective factor. International psychogeriatrics,31, 1447–1462. Crossref

Machado, L., & Matsumoto, L. S. (2020). Psicologia positiva e psiquiatria positiva: A ciencia da felicidade na pratica clinica [Positive psychology and positive psychiatry: The science of happiness in clinical practice]. Sao Paulo, Brazil: Mandole.

Messias, E., Peseschkian, H., & Cagande, C. (Eds.). (2020). Positive psychiatry, psychotherapy and psychology: Clinical applications. Cham, Switzerland: Springer nature. Crossref

Schutte, N. S., Palanisamy, S. K., & McFarlane, J. K. (2016). The relationship between positive psychological characteristics and longer telomeres. Psychology & Health,31, 1466–1480. Crossref

Treichler, E. B. H., Glorioso, D., Lee, E. E., Wu, T. C. X., Tu, M., Daly, R., ... & Jeste, D. V. (2020). A pragmatic trial of a group intervention in senior housing communities to increase resilience. International Psychogeriatry,32, 173–182. Crossref

Wiley, J. F., Bei, B., Bower, J. E., & Stanton, A. L. (2017). Relationship of psychosocial resources with allostatic load: A systematic review. Psychosomatic medicine,79, 283. Crossref

|7|Introduction

From what’s wrong to what’s strong

Applying positive psychiatry in our daily practice – in times where we see standardized treatments and confection instead of customization – requires two paradigm changes as well as a culture change, and we are convinced it will undoubtedly enhance the quality and effectiveness of our treatments. With this book, we invite you to apply positive psychiatry to not only repair the worst, but also to create the best in your patients, your colleagues, and yourself. In doing so, we have high hopes that positive psychiatry may become a firm element of the psychiatry of the future.

Paradigm Changes

Until recently (mental) healthcare concentrated on reducing (psycho)pathology. Treatment providers focused primarily on treating diseases and were not, or virtually not, knowledgeable about promoting well-being. They were not used to looking beyond the imperfections of life. Fortunately, today we see two paradigms changes.

The firstparadigm change places people at the center stage, instead of the disease. Mental healthcare should no longer be the place where only problems and disorders are discussed and treated, but also be the place where the focus is on what works in the lives of our patients, where their competences and resilience are discovered and developed, where positive emotions are strengthened, and where hope, gratitude, and optimism are nourished.

If we want to flourish and if we want to have well-being, we must indeed minimize our misery; but in addition, we must have positive emotion, meaning, accomplishment and positive relationships. The skills and exercises that build these are entirely different from the skills that minimize our suffering. Seligman, cofounder of the positive psychology movement (2011, p. 53).

|8|Today, competence-based work is integral in (mental) healthcare. It is a methodology that seeks to match the existing competences of patients, focusing on the discovery and expansion of their skills. Competence means patients have sufficient skills to be able to perform their daily tasks in an adequate manner. Basic principles of the competence model are to:

connect with the strengths of patients and encourage them in the realization of their goals;

listen to their needs, wishes, limitations, and norms – and take these seriously; and

focus on creating new opportunities.

The secondparadigm change is the addition of the synthesis paradigm to the analysis paradigm. In the philosophy of science, we can discern two ways of understanding the world and our lives: the analysis paradigm and the synthesis paradigm.

The reductionistic medical model (the analysis paradigm) can be complemented with the functional solution-focused approach (the synthesis paradigm),which involves designing an outcome that was not there before. This outcome is about our patients’ new and better life. You can compare working from the medical model to the work of an archaeologist and working from the solution-focused approach to the work of an architect.

Symptom reduction does not work well when the complexity of a system increases, as is the case in a number of mental health issues; well-being is the result of a very large number of factors with interdependent interactions, which cannot be achieved purely by analyzing the individual parts.

In sum: A system is a whole that cannot be understood by analysis only. We also need the synthesis paradigm to be able to use the best of both worlds. We describe both paradigm changes in more detail in Chapter 1.

For Whom Is This Book Written?

Increasingly more psychiatrists and other practitioners working with psychiatric patients and the patients themselves are discovering the possibilities of employing a (more) positive focus. This focus is shaped by positive psychology, with an emphasis on patients’ strengths; by the solution-focused approach, with an emphasis on their preferred futures and what works in their lives; and by the recovery-oriented approach, aimed at maximizing (remaining) possibilities.

|9|This is the first book in which the analysis paradigm (the medical model) in psychiatry is supplemented by the synthesis paradigm (the solution-focused approach). It is also the first book where we address not only the what, but also the how of positive psychiatry, which led us to title this book Practicing Positive Psychiatry.

It is intended for all practitioners who are dissatisfied with the one-sided focus on psychopathology and would like to focus (more) on competences, possibilities, and what works in the lives of their patients. It is also aimed at all practitioners who wish to expand their repertoire of therapeutic techniques and wish to collaborate optimally with their patients. They will discover an approach that can significantly increase patient motivation and cocreate preferred outcomes as well as finding pathways to achieve this.

In addition to a description of positive mental healthcare and positive psychiatry, this book describes 41 applications; a list of the applications is included at the end of the book. Chapter 6 includes 31 frequently asked questions. We do not pretend to have all the right answers, but we hope you will find them useful. The 22 stories and 21 cases illustrate how positive psychiatry can be employed and how the use of a positive focus may make our work better, faster, lighter, and, yes, more fun. Not only for our patients, but also for ourselves.

Psychiatrist:After focusing nearly 20 years on everything that is wrong in the lives of my patients and in the organization, this approach feels like a breath of fresh air.

We think our field is ready to embrace positive psychiatry. Are you as well?

Fredrike Bannink, clinical psychologist and lawyer

Frenk Peeters, psychiatrist and psychotherapist

|i|Cartoon by © Sigmund

|11|Chapter 1Two Paradigm Changes

Ask not what disease the person has, but rather what person the disease has.

William Osler

In this chapter we describe two recent paradigm changes, which are not only found in (mental) healthcare, but also in education, organizations, and society as a whole. Let us start by explaining what exactly we mean by paradigm.

The term paradigm refers to models and theories within a scientific discipline that form the framework of that which is being analyzed and described. We no longer consciously perceive paradigms that have been longer in existence: They are self-evident from what we have learned, by adherence to professional guidelines, and by our way of working together.

Science philosopher Kuhn suggests successive paradigms are mutually equivalent: Variances – or inferiority – of paradigms do not exist; they are only different. Kuhn is particularly known for his book The Structure of Scientific Revolutions(1962), in which he describes that science is not always a gradual evolution; paradigm shifts sometimes create abrupt dramatic changes. The Internet is an example of a technological development that resulted in a rapid, dramatic paradigm change. After each change in paradigm, the world looks incomparably different. Perhaps the greatest barrier to a paradigm shift is the reality of paradigm paralysis: the inability or refusal to see beyond the current models of thinking.

|12|Story 1. Paradigm Paralysis

New paradigms tend to be most dramatic in sciences that appear to be stable and mature, as in physics at the end of the 19th century. As an example, physicist Kelvin claimed: “There is nothing new to be discovered in physics now. All that remains is more and more precise measurement.”

Five years later, Einstein published his paper on special relativity, which challenged the set of rules that had been used to describe force and motion for over 200 years.

In the first paradigm change in healthcare that we propose people take center stage, not the disease. The concept of positive health is an innovative concept that is derived from a renewed and general characterization of health that aims to solve the limitations of the current World Health Organization (WHO) definition of health (Huber et al., 2011; 2016). The resulting positive (mental) healthcare is described by Delleman (2009), Bannink (2009), Bannink and Jansen (2017), and Bannink and Peeters (2018). This positive view on health may lead to significant innovations and subsequent cost savings in healthcare.

The second paradigm change in healthcare adds synthesis (the functional model) to regular analysis (the medical model). The synthesis paradigm is especially useful when problems or diseases are complex and rapidly changing.

Finally, in this chapter we describe – and more extensively in Chapter 5 – how positive psychiatry may well become a crucial element of the psychiatry of the future, and what this means for practitioners, medical specialists, their training, and the organizations in which they work.

|13|Paradigm Change 1: People Take Center Stage, Not the Disease

The WHO in 1948 defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Back in 1948 this was a ground-breaking definition, because it overcame the negative definition of health as the absence of disease and included physical, mental, and social domains. But the WHO definition turned out to have some major limitations. The definition was very idealistic. The goal of total well-being is, after all, not granted to everyone. Thus, almost everyone becomes a patient, which would also require continued treatment or assistance. This is not realistic and, moreover, promotes unintentional medicalizing.

Subsequently, an ever-greater competition arose among healthcare providers in the hopes of reducing medical costs. However, the opposite turned out to be the case. More and more expensive treatments led to burgeoning costs. And because only treatment and care were funded, little attention was paid to prevention. As a result, healthcare has competed more on price than on value for the patient (Porter & Teisberg, 2006).

Redefining Health

In 2009 an international conference was organized with the aim of producing a more adequate description of the concept of health. This led to a new formulation by Huber and colleagues (2011, p. 1, 2016). According to these authors, health is: “the ability to adapt and self-manage, in light of the physical, emotional and social challenges of life.”

This description makes health a dynamic concept, a strength or ability. It emphasizes that patients with a chronic disease or disability can still (partly) recover their health, even while the disease or restriction continues to exist. In this concept health is not a goal in itself, but a means to a meaningful life.

The participants preferred to replace the term definition with concept or conceptual framework of health in all three domains: physical, mental, and social. A definition implies a set of boundaries and a precise meaning; a conceptual framework is a generally agreed upon direction in which to look. They also stated that operational definitions were needed for measurement purposes, research, and evaluating interventions.

In a critical analysis of thinking about health in terms of the absence of diseases or of failing brains and evidence-based protocols with treatments founded on diagnostic criteria, we conclude that a new focus on positive health can be an element of innovation.

|14|Walburg (2015, p. 24), a professor emeritus of positive psychology at the University of Twente in The Netherlands, describes health as “the ability to adapt and self-manage in favor of a long-lasting development and flourishing.” Health is thus a skill that supports development and flourishing. Flourishing is the process toward “well-being in which the individual develops his or her competences, can cope with everyday setbacks, is productive, and able to contribute to society.” This is the WHO (2004) definition of positive mental health, which according to Walburg also applies to physical health. Flourishing concerns the development of talents and strengths focused on the realization of the purpose and ambition of people.

Bannink and Jansen (2017, p. 22) surmise that health is the result of a very large number of factors, with continually mutual interactions. According to them, health cannot be divided into separate building blocks in which the same health features, found in the whole, would be visible. Health is, therefore, an emergent property of an individual. Infinitely many interactions and hence infinitely many causes and consequences, which often can no longer be untangled, play a role. Therefore, they propose to widen the concept. Their concept of health is “the ability to adapt and self-manage in the light of the dynamics of life.” The term dynamics of life means both the highs and the lows (and everything in between) – not just the challenges of life as described in the concept offered by Huber and colleagues, or of sustainable development and flourishing as proposed by Walburg.

The concept of positive health is, moreover, not only about how patients can function optimally with as few complaints as possible or with as many competences and resilience as possible. It is also about dealing as best as possible with sometimes serious somatic and psychiatric disorders, suffering, and despair. It also offers guidance in dealing with traumatic experiences and losses. Consider, for example, the discovery and promotion of resilience and posttraumatic growth (Bannink, 2014; Vaillant, 2015).

|15|Case 1.1. Nothing Is Gonna Help

Anne is a 31-year-old qualified lawyer who has never practiced in her field. Since puberty she has experienced severe psychiatric symptoms. She completed her studies with difficulty and they were interrupted because of prolonged clinical admission for depressive symptoms, bulimia, and personality disorders. So far, she has experienced no positive effect from previous and current psychotherapeutic and pharmacological treatments, including those as an outpatient; therefore, she has stopped all treatments: Nothing is gonna help!

Referred to a psychiatrist by her general practitioner, she feels at this point in time severely depressed and suicidal. She requests electroconvulsive therapy for the depression and, if that is not possible or viable, euthanasia.

It appears Anne has not yet been exhaustively treated pharmacologically and, after due explanation, she agrees to start a strict pharmacological treatment. Her condition benefits from treatment with a classic monoamine oxidase (MAO) inhibitor: The depressive symptoms disappear for the most part; she suffers less from binge-eating and she feels more capable of handling satisfactory relationships with family and friends.

Although there is much progress in this area, the sense of well-being has not progressed at the same rate. From the viewpoint of life development, as a single, incapacitated woman she substantially lags behind her peers, who have careers and have started families. She principally focuses on what she cannot do (her competences remain somewhat limited) and she sees no possibility of starting work as a lawyer. Within a couple of sessions with a psychologist, using exercises in positive psychology, she is able to shift her attention to what she still can do. She successfully undertakes a training course, below her educational level, to follow a career path of which she had dreamed since childhood.

Mental Health

For many years, mental health has been defined as the absence of psychopathology, such as depression or anxiety. But the absence of psychiatric symptoms is a minimal outcome if we look at one’s entire life. It is, therefore, important to conduct research not only into psychopathology but also into how optimal mental health can be achieved.

In 2005, the WHO described mental health as a state of well-being in which the individual can realize his/her opportunities, can cope with the normal stresses of life, can be productive in his/her work, and can contribute to society.

|16|This definition is split into three components: emotional, psychological, and social well-being (Westerhof & Keyes, 2010).

Emotional well-being. It is the satisfaction with one’s own life and the experience of positive feelings such as happiness and interest. This is also called subjective well-being (Diener, Suh, Lucas, & Smith, 1999).

Psychological well-being. It focuses on optimal performance in the individual’s life. Self-realization is central. This includes the experience of a purpose and direction in life, the idea of development, and a positive attitude in relation to oneself (Ryff, 1989).

Social well-being. It focuses on optimal functioning in social groups and society. This includes the idea of being part of a community; the idea that others appreciate your activities; and a positive attitude with respect to those around you (Keyes, 1998).

Two-Continua Model

An important question is how positive mental health relates to mental illness. The two-continua model of mental illness and health holds that both are related, but are distinct dimensions: One continuum indicates the presence or absence of mental health and well-being, the other the presence or absence of mental illness. Keyes (2002, 2005) studied the relationship between mental health and mental illness using data from the study on Midlife Development in the United States (MIDUS), a representative survey of 3,032 American adults between the ages of 25 and 74. The data provide strong support for the two-continua model. Mental health is therefore best viewed as not merely the absence of mental illness, but also as the presence of well-being. This model has been replicated with US adolescents (ages 12–18; Keyes, 2006), with Dutch adults (Westerhof & Keyes, 2008) and with South African adults (Keyes et al., 2008).

Thus, psychiatric problems are more often associated with poor positive mental health than with good positive mental health. However, this relationship is limited. The degree of psychopathology does not say much about the degree of positive mental health, and vice versa. A person with psychological problems may be able to experience well-being, and the absence of psychological complaints does not guarantee the experience of a high level of emotional, psychological, and social well-being. An important implication is that it is not sufficient to measure only psychiatric problems. To fully understand the mental health of an individual, aspects of positive mental health must be included. This is also essential for evaluating the effects of the various interventions (see Figure 1.1).

|17|

Figure 1.1 Two-continua model of mental health (Keyes, 2005).

Positive Mental Health

We would like to propose a form of integral psychiatry, whereby the use of a negative, problem-focused perspective is embedded in a positive strength-focused perspective, with an overall focus on well-being. Use of the patients’ and their environment sources of strength must be applied to maximum effect, and their well-being should be the focus in diagnostics as well as in treatment. Another important point is that, whenever and wherever possible, patients should be provided assistance within society: An isolated life in a protective environment should be avoided.

The approach of positive health by Bannink and Jansen (2017), applied in the general practitioners’ field, incorporates both the medical model and the solution-focused approach. The solution-focused approach is about designing the patients’ preferred outcome and finding the road to achieving this goal. It is about building solutions instead of solving problems. The solution-focused approach concentrates not only on competences, but on everything that works in a patient’s life, and thus has a broader focus than positive psychology has. The approach contains its numerous solution-focused questions and its language (solution talk instead of problem talk; see Chapter 2), whereas positive psychology and the recovery-oriented approach (still) lack these.

In the concept of positive health, Huber and colleagues suggest that the person takes center stage, not the disease. O’Hanlon and Rowan, both solu|18|tion-focused practitioners, as early as in 2003 suggested: “Ask not what disease the patient has, but what patient the disease has,” based on a quote by William Osler (1913,https://www.goodreads.com/author/quotes/138654.William_Osler). We endorse this in our concept of positive psychiatry and propose that the patient is never the problem or is never a diagnosis, but is a person with many sides who has a problem or has a diagnosis. Frequently heard qualifications (such as “he is autistic” or “she is borderline”) should be avoided. All patients are indeed always much more than their problems.

Patient: