A paradigm is how we see the world, like a pair of eyeglasses that sharpen or color what we see. They’re usually an unconscious product of our culture. Yet every now and then, a new insight shakes us up and we swap our glasses for a new pair. Suddenly, we have the potential to see new colors with more contrast in greater detail.
As a parent of a young adult with physical and developmental disability and multiple chronic conditions and as a healthcare change agent, I’ve been thinking about how paradigms in healthcare influence how I see and experience my life and my work. In particular, I’m noticing how a new paradigm in particular is giving me a greater sense of ease and effectiveness.
The paradigm dominating healthcare since the mid-19th century has been the medical model. Through the lens of this model, we can observe, describe, differentiate, treat and even cure disease. It has given us amazing gifts: vaccines, antibiotics and antivirals, anesthesia, birth control, genetics, radiology, organ transplantation and randomized controlled trials. Good stuff.
Around the 1970s, a new lens emerged—the biopsychosocial model. Still focused on illness and acknowledging biology, this more holistic perspective has allowed for a connection between the body and the mind, made health inequity visible, given rise to person-centered care and supported the de-institutionalization of people with disabilities and mental health issues. Also good stuff.
More recently, a new paradigm has been evolving, the salutogenic model. Simply put, it aims to shift our focus from fixing illness to strengthening what is well. Salutogenesis’ quiet emergence can be seen in the increased focus on prevention, health promotion, patient empowerment, self-care, positive psychology and resilience. At a community and policy level, it expresses itself as asset-based community development and the community inclusion movement. It isn’t meant to replace earlier models or to deny illness or inequity, but to head off issues of illness and inequity upstream by creating conditions that support health.
All three paradigms exist right now, and as a parent and a change agent I live and work in all of them. They all have their place, but they feel very different and I’ve been exploring how they impact my parenting and my work.
The first several years of my son’s life seemed like a series of medical appointments, tests, and hospitalizations, firmly rooted in the medical model, hoping to cure or at least treat everything about him that was different. To be sure, some of what was done has been helpful, even life saving. But it has come at a cost: an identity of brokenness. Often I wonder if much of it actually made any real difference on my son’s health. As a healthcare change agent, I can see a medical model reflected in my early work with a focus placed on understanding what in my healthcare encounters was broken and why. I can recall advocating for competition, standardization, checklists and stronger policy. I can sense it’s still with me when I notice a desire to shame and blame or a desire for a magic pill.
The biopsychosocial model opened up space for me as a parent to see that it was possible for my son to be well despite his chronic conditions. It helped me shift my energy from his physical health to our family’s social and emotional health. Advocacy work spring from this paradigm is still about righting wrongs, but taking a biopsychosocial approach helped me become a systems thinker. New approaches like nudging, motivational interviewing, public narrative, and community organizing made change more complex and sometimes more exhausting, but it seemed to offer a promise bigger than the absence of disease.
The salutogenesis model is newer for me. It feels counter-cultural and uncomfortable, but something is calling me to stay. It’s got me thinking about the power of healing and recovery, how often it just seems to happen with very little effort on my part. I’ve also been reflecting on how my best efforts to make things better have sometimes left me – and the people around me – exhausted and no better off.
I’ve started to pay attention for signs of health in my children, in my family, in myself, and in the world. With my children, this means spending less time worrying about the future and more time helping them see how much I enjoy them for who they are today. In my own life, I’ve been thinking about the people and places where I feel most alive and strong. I wonder whether I need to work so hard to disrupt bad habits or can just let them taper off on their own.
I see shifts in my work too – as an advocate, I’ve started talking more about health than healthcare. I spend more time celebrating good examples and appreciating what’s working. I debrief with colleagues not only on what could be improved, but by noting what went well. I notice I walk into meeting and projects more often without an agenda to change others. There is more ease and less persuasion. I’ve even begun to question whether change is something I can make, or whether I’m just meant to support conditions for growth. My change maker/activist ego is confused but curious.
Dr Amy Johnson, a psychologist and coach who has open my mind to this new perspective, recently spoke about her experiences consulting with the UK’s National Health Service (NHS). In that work, she challenged healthcare providers to see their patients through a new lens with this question: Can you see their health?
I find myself thinking about this question all the time. In my life and in my work, I’ve been experimenting putting on these glasses and seeing what happens. Can I see my son’s health? Can I see my own? Can I see the health of my colleagues and clients? Can I see health in healthcare providers who I ask to care for us? Can I see health in the politicians and policy makers I work with? In the people who have hurt me? Whether I can or if I can’t, what am I then called to do? Most often, the answer seems to be to do less fixing, saving and advising, less measuring, incentivizing and penalizing, and more deep listening, trusting and supporting. Or even to do nothing—just let things unfold, as nature seems to know how to do.
I don’t think I’m meant to let go of the other paradigms, but to instead be aware and curious about them. I think I’m meant to ask: What might salutogenic special needs parenting look like? What might salutogenic advocacy look like? What might salutogenic leadership look like? I’d love to hear about your thoughts and experiences.
After spending years coordinating healthcare and other services for my son, I now lead and support initiatives in which patients and their families, clinicians and policy makers collaborate to create better health and care. I welcome you to join in an on-going conversation about healing health care by subscribing to this blog, in which I write regularly about the experience of living in a complex special needs family and working to create and support change, or by connecting on Twitter or LinkedIn.
I so totally agree with you Cristin. This isuch a beautiful and moving sharing, thank you 💕
Thanks Gunilla. That means a lot. It would be interesting to think about what salutogenesis in quality registries would look like!
Wonderfully eloquent, as always Cristin. We are lucky to have you in the world of all these questions, nudging us towards personal and communal, insights. I resonate with what you say from so many angles I don’t dare elaborate! I like your closing remarks about collaborating — which I think is key — to include a variety of perspectives, whether at the clinical level, or the advocacy and systemic change level.
I find myself butting heads (or despairing) with our mental health system (Ontario, Canada) and the way it has cut out the natural support systems (due to Privacy legislation), leaving paternalistic silos from which to attempt to deal with mental illness, as if a person has no history or social context. In light of your question “Can you see their health?” I see a danger in that we already have a fear of calling mental illness “mental illness.” Instead we speak of “mental health” or “mental health issues” (but meaning mental “illness”) and the field becomes so large and vague that we imagine we can help some people heal if they would only attend the community workshops available for tools to improve their mental health skills. (These are great for mental health maintenance, not very effective for someone who is mentally ill.) Then we wait for them to fail, and fail again, or to “want to” attend to their trauma or mental illness. But they won’t because their mental illness prevents them; and no one is allowed to make a case for their admission to a proper treatment program, because of privacy legislation. Not recognizing and acknowledging the distinction between Wellness and Illness is problematic.
Sorry for my delayed response. I hear you say that it can be frustrating to have to wait for a treatment program. I have been in that position as well. I guess what I’m seeing now is that even our treatment of mental illness is very much based on our culture, and it’s not always that effective. I’m not sure I’m disagreeing with you, but I don’t know that the way we diagnose and treat is all that effective, actually. But it’s just my take, and I respect that it doesn’t look like that to everyone.
You are a very wise person Cristin! Collaboration is the only way forward.