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Jonathan I. Robison, PhD, MSKelly Putnam, MA
A HOLISTIC MODEL A HOLISTIC MODEL
for for
HEALTH & WELLNESS HEALTH & WELLNESS
inin
THE WORKPLACETHE WORKPLACE
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus
MEDICALIZATIONMEDICALIZATION
“A process by which nonmedical problems
become defined and treated as medical
problems, usually in terms of diseases or
disorders”
Sobal, 1995
OBESITY & MORTALITYOBESITY & MORTALITY
“ Obesity is the second leading cause of preventable death in the United States, exceeded only by cigarette smoking …and it contributes to 300,000 deaths annually in the United States.”
Manson, NEJM 1996;335:659
OBESITY & MORTALITYOBESITY & MORTALITY
Actual Causes of Death in the United States
McGinnis, JAMA 1993;270(18):2208
CAUSES OF DEATH - U.S. 1990CAUSES OF DEATH - U.S. 1990
Tobacco 400,000
Diet/activity patterns 300,000
Alcohol 100,000
Microbial agents 90,000
Toxic agents 60,000
Firearms 35,000
Sexual behavior 30,000
Motor vehicles 25,000
McG
innis, JAM
A 1993;270(18):2208
MENOPAUSEMENOPAUSE
“We salute our heroes. Our mothers, grandmothers, sisters and daughters. Every women who has ever overcome heart disease, cancer, osteoporosis, menopause and depression. Survivors ...remind us to take care of ourselves and make lifestyle choices that can protect us from disease.”
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus Risk Factors
““RISK FACTOR FRENZY”RISK FACTOR FRENZY”
Health = Absence of Risk Factors
Health Promotion = Risk Factor
Reduction
RISK FACTORSRISK FACTORS
How well do they predict disease?
Heart Disease
Prostate Cancer
RISK FACTORSRISK FACTORS
“ Have proved to be quite poor at
discriminating at the individual level
between those who eventually develop
disease (over a certain time period) and
those who do not.”Rockhill, AJPH, 2001;91(3):365-368
THE CONSEQUENCESTHE CONSEQUENCES
Anxiety & Confusion
Loss of Professional Credibility
““RISK FACTOR” RESEARCHRISK FACTOR” RESEARCH
“ We are fast becoming a nuisance to society…People don’t take us seriously anymore, and when they do take us seriously, we may unintentionally do more harm than good.”
Dr. Dimitrios Trichopoulos, Harvard School of Public Health
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus Risk Factors Fear, Guilt & Shame
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus Risk Factors Fear, Guilt & Shame Behavioral Control
SKINNERIAN “BEHAVIORISM”SKINNERIAN “BEHAVIORISM”
REINFORCEMENT
Behaviors that are followed by
rewards are likely to be repeated
B.F. SKINNER: ON LOVEB.F. SKINNER: ON LOVE
When two people meet:
“One of them is nice to the other and predisposes the other to be nice to him, and that makes him even more likely to be nice. It goes back and forth, and it may reach the point at which they are very highly disposed to do nice things to the other and not to hurt. And I suppose that is what would be called being in love.”
Walden II
BEHAVIOR MODIFICATIONBEHAVIOR MODIFICATION
The Skinnerian approach to motivation is
rarely questioned…
There is substantial evidence that rewarding
people in this manner retards learning,
suppresses creativity, inhibits productivity,
and reduces intrinsic motivation.
BEHAVIOR MODIFICATIONBEHAVIOR MODIFICATION
Health PromotionHealth Promotion
Rewards & Incentives
Competitions
Contests
Risk-Rated Insurance
BEHAVIOR MODIFICATIONBEHAVIOR MODIFICATION
“People’s interest in what they are doing typically declines when they are rewarded for doing it…Rewards... actually undermine the intrinsic motivation that promotes optimal performance.”
Kohn, Punished By Rewards
ADVERSE CHILDHOOD ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDYEXPERIENCES (ACE) STUDY
Almost 10,000 adults in an HMO
7 categories of childhood trauma
Health risk behaviors & disease
Felitti, Am J Prev Med 1998;14(4):245-258
CAUSES vs. SYMPTOMSCAUSES vs. SYMPTOMS
28% of women reported sexual abuse
16% of men reported sexual abuse
25.6% lived with substance abuser
10.8% reported physical abuse
Felitti, Am J Prev Med 1998;14(4):245-258
CAUSES vs. SYMPTOMSCAUSES vs. SYMPTOMS
50% reported at least 1 category
25% reported at least 2 categories
6% reported at least 4 categories
Felitti, Am J Prev Med 1998;14(4):245-258
Adverse Childhood Experiences
Social, Emotional, Cognitive Impairment
Health-Risk Behaviors
Disease, Disability
& Social Problems
Felitti, Am J Prev Med 1998;14(4):256
Root Causes of Behavior Poverty, Abuse, Violence, Isolation
SufferingAnxiety, Anger, Fear,
Depression, Hopelessness
Behavioral CopingSmoking, Drinking, Drugs, Overeating,
Overworking, Sedentary Lifestyle
CAUSES vs. SYMPTOMSCAUSES vs. SYMPTOMS
“ The magnitude of the difficulty of introducing the requisite changes into the medical and public health research, education and practice can be offset only by the magnitude of the implications that these changes have for improving the health of the nation.”
Felitti, Am J Prev Med 1998;14(4):245-258
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus Risk Factors Fear, Guilt & Shame Behavioral Control Professional as Expert
PROFESSIONAL as EXPERTPROFESSIONAL as EXPERT
Client as passive recipient who naturally gravitates towards “unhealthy” behaviors
Professional as powerful, expert provider to police behaviors and prescribe changes to save people from themselves
Goal is behavior change through compliance
COMMUNITY HEALTH CONCERNSCOMMUNITY HEALTH CONCERNS
Drug abuse 47% Alcohol abuse 34% Violence 31% Drinking and driving 28% Poor parenting 23% No health insurance 21% Poverty 19%
COMMUNITY HEALTH CONCERNSCOMMUNITY HEALTH CONCERNS
Tobacco use 13% Teenage pregnancy 12% Homelessness 9% Poor diet / lack activity 7% Emotional problems 5% Serious mental illness 4%
““EXPERT” CONCLUSIONSEXPERT” CONCLUSIONS
“Personal health issues, such as diet, exercise and smoking, are not connected to community health in many people’s minds, suggesting…to health professionals a need for education about the implications to the community.”
Perceptions of Health & Health Care in The Capital Area Community, 1997.
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus Risk Factors Fear, Guilt & Shame Behavioral Control Professional as Expert Individual Focus
INDIVIDUAL FOCUSINDIVIDUAL FOCUS
Disease or illness seen as primarily a
result of individual lifestyle choices
Failure to account for the person and his
or her social, ecological context
INDIVIDUAL FOCUSINDIVIDUAL FOCUS
“ A voluminous body of evidence has
demonstrated that social class is one of
the major, and perhaps even the major
risk factor for disease”
Minkler, Health Education Quarterly, spring 1989
TRADITIONAL TRADITIONAL HEALTH PROMOTIONHEALTH PROMOTION
Disease Focus Risk Factors Fear, Shame & Guilt Behavioral Control Professional as Expert Individual Focus
DOES IT WORK?DOES IT WORK?
“ While short term changes in attitudes
and behavior are common, there is little
evidence that these changes last after
programs end”
O’Donnell, The Art Of Health Promotion, 1997
““HOLISTIC” HOLISTIC” HEALTH PROMOTIONHEALTH PROMOTION
Holistic Health Focus
HOLISTIC FOCUSHOLISTIC FOCUS
Emphasizes That The Interrelationships
Among Spiritual, Biological,
Psychological And Social Factors Are
Critical To Health And Healing
HEALTH DEFINEDHEALTH DEFINED
World Health Organization
“ Health is a state of complete physical, mental
and social well-being and not merely the
absence of disease or infirmity.”
OPTIMAL HEALTH??OPTIMAL HEALTH??
“ Complete well-being is a fantasy… health
(whatever else it might be) is something that
happens not so much in the absence of illness as in
its presence.”
David Morris
If you can start the day without caffeine
If you can be cheerful, ignoring aches and pains
If you can resist complaining and boring people
with your troubles,
If you can eat the same food
everyday and be grateful for it,
If you can understand when loved ones
are too busy to give you time,
If you can overlook when people take things out on you when, through no fault of yours
something goes wrong,
If you can take criticism and blame without resentment,
If you can face the world without lies and deceit,
If you can conquer tension without medical help,
If you can relax without liquor,
If you can sleep without the aid of drugs,
REDEFINING HEALTHREDEFINING HEALTH
“ Health can be redefined as the manner
in which we live well despite our
inescapable illnesses, disablilities and
trauma.”
David Morris
““HOLISTIC” HOLISTIC” HEALTH PROMOTIONHEALTH PROMOTION
Holistic Health Focus Supportive Factors
SUPPORTIVE FACTORS forSUPPORTIVE FACTORS forHEALTH & HEALINGHEALTH & HEALING
Purpose in Life Spiritual Connections Social Support Work Satisfaction Optimism/Hopefulness Perceived Health Pleasure and Play Ability to Express Emotions
““HOLISTIC” HOLISTIC” HEALTH PROMOTIONHEALTH PROMOTION
Holistic Health Focus Supportive Factors Happiness, Meaning & Purpose
HAPPINESS, MEANING & PURPOSEHAPPINESS, MEANING & PURPOSE
Reason for change is primarily to
enhance a sense of purpose and
enjoyment of life
SPIRITUAL CALLINGSPIRITUAL CALLING
“Every crisis a person has over the age
of 30 is a spiritual crisis. Spiritual
crisis requires spiritual cures.”
Carl Gustav Jung
““HOLISTIC” HOLISTIC” HEALTH PROMOTIONHEALTH PROMOTION
Holistic Health Focus Supportive Factors Happiness, Meaning & Purpose Internal Trust
INTERNAL TRUSTINTERNAL TRUST
People are currently doing the best they can given their particular circumstances
People have a natural desire and ability (internal wisdom) to be healthy
““HOLISTIC” HOLISTIC” HEALTH PROMOTIONHEALTH PROMOTION
Holistic Health Focus Supportive Factors Happiness, Meaning & Purpose Internal Trust Professional as Ally
PROFESSIONAL as ALLYPROFESSIONAL as ALLY
Professional facilitates reconnection with people’s own internal wisdom about their body and their life
Goal is to assist people in understanding and healing life issues that underlie illness and behavioral struggles
CHANGING THE ROLECHANGING THE ROLE
“ The field of health promotion needs to revive and reorient its practices toward bringing people together as citizens and community members to decide for themselves the kinds of lives they think are most worth living.”
David Buchanan, An Ethic For Health Promotion
““HOLISTIC” HOLISTIC” HEALTH PROMOTIONHEALTH PROMOTION
Holistic Health Focus Supportive Factors Happiness, Meaning & Purpose Internal Trust Professional as Ally Cultural Perspective
HEALTH & THE “WEB OF LIFE”HEALTH & THE “WEB OF LIFE”
Nearly 50% of low income, full-time workers have no health insurance
More than 8 million children have no health insurance
25% of children live below the poverty line
US Census Bureau, Oct. 1999
“HOLISTIC” HEALTH PROMOTION
Health Focus Supportive Factors Joy, Meaning & Purpose Internal Wisdom Professional as Ally Cultural Perspective
TRADITIONAL HEALTH PROMOTION
Disease Focus Risk Factors Fear, Guilt & Shame External Control Professional as Expert Individual Focus
Jonathan Robison PhD, Karen Carrier M.Ed., 1999
IMPLICATIONS for HELPING IMPLICATIONS for HELPING & PREVENTING “BURNOUT”& PREVENTING “BURNOUT”
AVOID–Fixing
FIXINGFIXING
“Frequently, our reactiveness to suffering takes the form of having instantly to do something, do anything. It’s the “we gotta” syndrome: “We gotta” fix this up right away…It’s tricky, because this impulse may arise from genuine empathy, but the form of action is compulsive.”
Ram Dass, How Can I Help?
IMPLICATIONS for HELPINGIMPLICATIONS for HELPING & PREVENTING “BURNOUT”& PREVENTING “BURNOUT”
AVOID–Fixing–Reductionism
““MEDICAL TERRORISM”MEDICAL TERRORISM”
“ The important point is that worrying too much about anything--be it calories, salt, cancer or cholesterol--is bad for you, and that living optimistically, with pleasure, zest and commitment is good. Medical terrorism shouldn’t attack life’s pleasures.”
Ornstein & Sobel, Healthy Pleasures
IMPLICATIONS for HELPINGIMPLICATIONS for HELPING & PREVENTING “BURNOUT”& PREVENTING “BURNOUT”
AVOID–Fixing–Reductionism –Blame and Shame
BLAME & SHAMEBLAME & SHAME
personal focus
failure
shame
hopelessness
helplessness
decreased self-esteem
?
IMPLICATIONS for HELPINGIMPLICATIONS for HELPING & PREVENTING “BURNOUT”& PREVENTING “BURNOUT”
AVOID–Fixing–Reductionism –Blame and Shame–Judgment
NONJUDGMENTNONJUDGMENT
“ When we have for so long been judged
by everyone we meet, just to look into
the eyes of another who does not judge
can be extraordinarily healing.”
Dr. Jack Kornfield, A Path With Heart
IMPLICATIONS for HELPINGIMPLICATIONS for HELPING & PREVENTING “BURNOUT”& PREVENTING “BURNOUT”
INSTEAD–Listen
LISTENINGLISTENING
“ Now we can begin, perhaps for the first time, to hear them. Less busy pushing away suffering, less frenzied having to do something about it, we’re able to get a sense of what they’re feeling, of what they feel they need. We may be startled to discover that what they’ve been asking for all along is entirely different from what we’ve been so busy offering”
Ram Dass, How Can I Help?
IMPLICATIONS for HELPINGIMPLICATIONS for HELPING & PREVENTING “BURNOUT”& PREVENTING “BURNOUT”
INSTEAD–Listen–Acknowledge & Validate
Support & Encourage
WHAT REALLY HELPS?WHAT REALLY HELPS?
What We Door
Who We Are
WHAT REALLY HELPS?WHAT REALLY HELPS?
“ We can, of course, help through all
that we do. But at the deepest level we
help through who we are..”
Ram Dass, How Can I Help? `
IMPLICATIONS for HELPING & PREVENTING “BURNOUT”
INSTEAD
• Listen
• Acknowledge & Validate
• Support & Encourage
• Be Aware of Our Own Issues
WHAT REALLY HELPS?WHAT REALLY HELPS?
“We work on ourselves, then, in order
to help others. And we help others as
a vehicle for working on ourselves.”
Ram Dass, How Can I Help? `
WHAT REALLY HELPS?WHAT REALLY HELPS?
“ Placing service in a spiritual perspective in no way diminishes what we have to offer through training, experience, individuality, special skills, or sense of humor. Quite the reverse. Our particular talents and unique qualities are likely to come forth more reliably when we have a richer and more spacious sense of who we are.”
Ram Dass
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