Three Doors to Health Change

Three doors in Pontevès, France — Spencer Means via Flickr (CC BY-SA 2.0)

It takes courage to see health the way it actually exists. For, health is mostly learned from others and rarely discovered by the self. We ask others for interpretations of our health, forming judgements about it in the process. Choosing to see health as it actually exists requires us to challenge our learned experience.

Think of the last time you experienced a sense of peace when thinking of your potential… your health. Chances are, you didn’t feel invincible in that moment. You likely felt very human, very mortal. Speaking truth about health requires us to stare past the noise, to accept our place and potential.

For many of us, our family domesticates our beliefs around health at an early age. They show us whether to expect a long life or a short one. They tell us what a healthy weight is. They shape our view of “normal” and often sustain our most powerful (hardest to treat) health illusions.

The Domestication of Health Beliefs

Imagine a busy mom, overworked and struggling to make ends meet. She cooks food for her son, often resorting to the basics: lots of pasta, some meat, and a bit of veggies. Her son’s body intuitively says he is full, but he is encouraged to finish his meal. In this case, the son’s health reality suggests it would be better to eat more peas and less pasta. But, the meal is already cooked and served. There is lots of pasta and hardly any peas (as they came from a single can). Through acculturation, her son learns what normal starch and vegetable consumption is.

Enter the nurse, decades later. She doesn’t quite understand why her patient resists simply increasing his vegetable intake. (It seems pretty simple.) But, when you account for his childhood experiences and life history, is the change so simple?

There is a sense of tension in the air as the nurse introduces the plate method for dietary change. The method is met with incredulity. It seems normal to eat a starch-filled plate. Eating healthy is essentially an abnormal behaviour.

A Basic Operating Model for Intrinsic Health Attitudes

Intrinsic attitudes towards health (a) often are a choice between three operating conditions: victim-dependent (v), hunter-independent (h), warrior-interdependent (w)

If patients are conditioned to project health beliefs in certain ways, it should come as no surprise that each patient takes on different attitudes at the start of their change journey.

Today, I describe three attitudes at the initiation of health change:

The Victim-Dependent Phenotype

The modern clinician is so often successful in creating victims of health change. This attitude essentially states:

(1) I am affected by a permanent condition/disability/disease

(2) Without help, I am powerless.

(3) Therefore, others must cure my condition/disability/disease

From this standpoint, it is easy to judge the patient as inherently flawed or without motivation. Acceptance and support for the patient’s circumstance is so often conditional on whether they comply with health advice. It lends well to a charitable perspective, where the clinician aims to fix the patient with their care.

As a concept, the victim-dependent phenotype is attractive for two main reasons: (1) it objectifies the role of health professionals, and (2) it requires continual compliance by the patient. The dependent patient who resists care would theoretically remain in a cycle of victimization until they build supportive systems around them.

Ironically, this approach works for many patients with inherent weaknesses or unstable health factors. Creating system dependencies can address self-care limitations and create a sense of stability for health change to occur.

The victim also possesses a unique strength in health change: the power of the average. By acting in concordance with system expectations, dependent patients achieve change primarily through standardization and system supports. If they adhere to what we know works, they can expect a fairly average course to their disease.

The Hunter-Independent Phenotype

In clinic, we so often want people to refuse to accept their current condition. Hunters best reflect the intrinsic attitude of independence some people have. This attitude essentially states:

(1) I am affected by a transient condition/disability/disease

(2) Without help, I remain powerful.

(3) Therefore, I can fully cure my condition/disability/disease

Society tends to value the hunter-independent phenotype, noting their independence and self-control in the face of illness. However, evidence points to the fact that patients who are not connected to supportive health services tend to have worse health outcomes. Asserting complete control over your disease condition creates a sense of survivorship, but also a harsh care reality.

Despite its many limitations, the hunter attitude benefits from a unique strength: the power of the outlier. Most patients will perform below average, but there will always be that survivor. Strong, independent patients with the right amount of luck can use their tenacity to achieve substantial change.

The Warrior-Interdependent Phenotype

There are always those wise patients among us. A warrior is one attitude to health change that is less common, but tremendously valuable. The warrior so often transcends from a hunter, realizing that their disease can be controlled but never completely conquered. This approach essentially states:

(1) I am affected by a controllable condition/disability/disease

(2) Without help, I am less powerful.

(3) Therefore, I can work with others to control my condition/disability/disease

Perhaps because we seek sustainable change in patients, many health professionals admire the warrior spirit. We acknowledge that the system is not designed for their needs, and we are drawn to their cause. Warrior patients have founded marathons to “fund their cure”. They routinely make the news, or radically shift our perspective about a person’s abilities.

The attitude of the warrior tends to skew towards a new liberalism. And, the warrior possesses a unique strength in health change: the power to shift the average. By acting to change system expectations, interdependent patients primarily achieve change through mobilizing the right resources and sustaining personal motivation.

But, what attitude is most effective?

Like many things, we just don’t know. We need to investigate the context (situational risks and benefits) of each attitude. Depending on where care is provided or what disease requires treatment, we know that support for each of the three attitudes shifts dramatically.

Early in my nursing career, I was trained to endorse the warrior-interdependent phenotype as a cancer nurse. Other nurses — who so often work with vulnerable populations —tend to endorse the victim-dependent phenotype. While, in my current home of primary care, the predominant philosophy supports the hunter-independent phenotype.

My long-term goal is to measure health change interventions more systematically, and that is why I started to blog. You may have noted a partial equation above. As I continue to blog, I will attempt to operationalize core concepts behind the “black box” of my work, with a view to designing measurable interventions in the future. Intrinsic attitudes — the doors we all enter health change through — seemed like a logical place to start.

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