2016 has been a crazy year. The unexpected happened: the Cubs won the worlds series, Donald Trump became our president, and Army beat Navy. Am I in Bizarro world?
For me Bizarro world would be where up is down, black is white, in is out, etc. I have had the Bizarro sensation lately. The Seinfeld TV series covered this topic. In this episode, George Costanza, the neurotic, self-loathing, short, stocky, slow witted, bald man, and self proclaimed “Lord of the Idiots” character decided he needed to do the opposite of everything. He decided he should do the opposite of what he would have or thought he should do because, so far in his life, what he had done was always wrong (see clip).
I work for a Department of Health Education and Promotion. To me this should mean those in our department are charged to promote, support, and encourage health. Health is the PRESENCE of physical, mental and social well being and NOT merely the absence of disease and infirmity, according to the World Health Organization. This suggests the job of health professionals should be to promote, encourage, support and enable actions that create improved levels of physical, mental and social well-being.
In general, when we determine if things are better, the same, or worse we compare expectations to a reference point. Our reference point, or what we compare our current reality to, is used to determine if things are better, the same, or worse. If it looks like things would be about the same, it would be neutral and therefore likely to maintain the status quo. Please note, people have a noted bias for status quo.
The status quo then would be not having anything worse than how it is, or it could be thought of as a state of not bad meaning no new efforts are needed. Not bad would then be equivalent to a “zero” state. Based on the idea of improvement, not bad or zero would be the opposite of the inherent goal health promotion has to improve health unless we are in Bizarro world. Health promotion should be about going beyond zero by helping people experience a better, true good, state of health or a +3 – as compared to our neutral reference, zero, or status quo. (see video)
Recent experiences have made me feel that I am in Bizarro world. Our department is in the process of hiring 3 new professors for the department of health education and promotion. For these searches we brought in 6 outstanding candidates for interviews and presentations.
Each candidate was highly intelligent, had a great grasp of science and advanced statistics, had completed compelling studies, and had done work of a high caliber. My push into Bizarro world happened because these candidates had focus areas of suicide, HIV, adolescents and alcohol, teen pregnancy, chronic obstructive pulmonary disease (COPD), and cancer. How could any of these areas of focus identify and or discover ways to be more physically, mentally and socially well – beyond the absence of those identified diseases and or conditions of infirmity? One colleague suggested suicide was not about disease. I agreed but still could not understand how suicide investigations would help discover paths to improved physical, mental or social well-being. He concurred.
Several say to me that treating disease or “fixing it” does mean more health. True, but only if you change the reference line from which you compare the current state of health. Most of us are generally healthy so our reference is not bad, neutral, managed or zero. Fixing anything below zero, is just getting us back to the status quo and not creating physical, mental and social well-being beyond our initial reference of not bad, neutral, managed, or zero. As should be obvious and is shown in research, people are less motivated to achieve an outcome of managed, not bad, neutral, or zero than to work toward developing a flourishing, achieving, or thriving outcome.
Research related to those in poverty demonstrated that those in poverty did not perceive receiving more money as a gain but a way to catch up, or get to zero, their reference point. Gains for them were not possible until they were at least out of poverty, their reference. It reminds me of Jim Gaffigan when he explained in one of his performances the arrival of their fourth child. “Yes we are having a fourth baby. To help people understand what is like to have four kids, imagine you are drowning and someone hands you a baby. Thats it.” His focus therefore was maintenance, or not getting worse. In other words, forward could only be possible if they could at least be at zero, swimming with ease, or above the poverty line in the previous example.
To clarify the idea of gains or positive outcomes, lets examine employee’s. When workers are hired they are expected to complete a specific amount of work. These work expectations then create a work level and work completed sets a reference point. If, or when a disease and or infirmity occurs, work falls below that established reference and this creates a deficit.
If health professionals then focused on bringing that workers effort back to that reference, deficit reduction, it is just a return to the status quo, not improvement to higher work levels, growth or gain. This measure, or return to previous work effort level does not even consider lost work time. Health promotion should add physical, mental and social well-being so higher levels of health enable productivity at a better, not yet attained level of performance, rather than merely a return to the status quo.
Health creation has been the focus of my career. To maintain my focus on health creation, I have used salutogenesis as my model or framework. Salutogenesis focuses on the origins of health. (salu = health; genesis = origins) I however am in the minority, most in the health field are guided by pathogenesis. Pathogenesis is a model or framework focused on the origins of disease. Isn’t that the opposite? Are we in Bizarro world? How can more be learned about better health, beyond he absence of problems, if the focus is on the origins or causes of problems in the form of disease and infirmity? Several noted scholars have questioned using pathogenesis as a guiding framework for health promotion. (see video for comparison of Pathogenesis and Salutogenesis)
Pathogenesis leaves one to wonder how an investigation using this framework can inspire strategies that create physical, mental and social well-being beyond the development of strategies for less disease. While less disease is important and morally appropriate, it is important to understand that less disease does not necessarily create more health beyond the absence of problems. Remember, health is not merely the absence of disease and infirmity – it is more than.
In addition, positive and negative states are independent. Decreasing and or increasing positive or negative states of health does not necessarily have equating reciprocal effects on the other state. Increasing physical, mental and social well-being or positive health, however, does increase capacity and potential and this improvement enables a greater ability to overcome problems that would not be possible otherwise. (see more about how high levels of health enable better health in: Serendipity? Don’t “Have” a Nice Day – Make it So! and in the story from my recovery from a near fatal car accident) For this reason, it is recommended salutogenesis and pathogenesis be complementary. Complementary use of these frameworks is described in the linked article Salutogenesis 30 Years Later, Where do we go from here?
So what does this mean? I put on many of my students papers, <- ≠ >+, or less negative does not equal or mean more positive.(see more at Less Bad ≠ More Good – We Must Create Good) I mark this because my work and that of many other noted scholars has documented prevention does not create health, just less disease. I explain many of these issues in a previous post, Prevention Can’t Work and Problems are Irrelevant! Health has to be created. In many presentations and classes I explain how it is good to eliminate bad, but we can do more and better should be our focus. To clarify please see short video below, Better than Not Bad:
Many then ask, “But we have to do something about issues such as those of the candidates: suicide, HIV, adolescents and alcohol, teen pregnancy, chronic obstructive pulmonary disease (COPD), and cancer. Absolutely, something must be done, however to be truly effective we should do more than just eliminate the bad. We should create an idealized good that also eliminates the bad as a by-product. For this to happen, the goal must be positive, not just non-negative, and be better than the reference. We should clearly explain a goal by Operationalizing an Idealized Outcome, rather than just a not bad outcome which simply brings everything back to the status quo or reference point. A not bad outcome would only achieve better health by accident, focusing on Idealized Outcomes creates better health on purpose.
I teach the capstone class and introduce my students to the ideas of health creation. At the end of the class I ask them to write a monologue to describe the impact, if any, the class had on them. Despite the possible bias because it is an assignment, without fail most students comment, “I never knew you could think about health this way.” These same comments are heard from professionals at my presentations. This makes me wonder, do we live in Bizarro world? How is it, people who focus on health improvement think it is opposite or odd to focus on discovering actions and environments that cause or lead to better health and think using the traditional techniques of investigating way to prevent bad outcomes is correct? Isn’t discovering causes of bad health the “opposite” of discovering causes of good or better health?
So what can be done? Without question suicide, HIV, adolescents and alcohol, teen pregnancy, chronic obstructive pulmonary disease (COPD), and cancer are important areas. However if we focus beyond the problem to a desired or Idealized Outcome, we can end up better while also eliminating, preventing or managing a disease or infirmity.
For the situations related to these candidates, as illustrated in earlier posts, we should Practice Paneugenesis. The aim of paneugenesis is to generate comprehensive improvements by creating pervasive, reciprocal, selfish, selfless, synergistic interactions so everyone and everything benefits. This can be done by using this 4 step Paneugenesis Process:
1. Operationalize an Idealized Outcome – make sure all involved parties know what is to be created and be sure that it is better than what can be now. The outcome should have pervasive and reciprocal effects that carry meaning and impact to and beyond the individual.
2. Discover Precursors – what must exist now to make the idealized outcome a reality. Discover what skills, abilities, traits, environments are necessary and or must exist to realize the idealized outcome. These precursors are conditions that must be created and are not currently present.
3. Optimize the Process – what must be done to create those precursors that will enable the idealized outcome and precursors to be created and realized. Go do that now! Do what must be done to create and put in place the necessary precursors discovered.
4. Plot Progress – find measures that document and demonstrate progress is being made toward the creation of discovered precursors and or idealized outcomes. Progress measures that indicate movement of actions taken in your process are being made toward the creation of the new, desired reality. Documenting progress is necessary to give meaning and purpose to the process and to help participants maintain motivation.
To use the Paneugenesis Process for Suicide misses the objective. We must move toward a positive and the prevention of a negative will be a secondary benefit. That thought reminds me of my work with people in the military. Originally when we met, their goal was to limit soldier suicide. After our work together, it was agreed their real goal, or Idealized Outcome, was to create great soldiers who were confident, purposeful and had meaning in their life. As discovered, great soldiers were not only more productive, they had lower suicide rates. The goal was then transformed from limiting soldier suicide to developing great soldiers. As a by-product, this approach to develop great soldiers would also limit soldier suicides.
For the candidate who had studied and sought to limit suicide in India, I would suggest adjusting the research goal toward the Idealized Outcome of finding purposeful groups in India. Groups doing good in that area are also likely to have lower suicide rates. Such an example was shown in the December 18th, 2016 60 Minutes program show about the “White Helmets” group in Syria. The “White Helmets” groups are a trained force of 3000 rescue workers that offer Syrian civilians help and hope.
For the candidate who focused on HIV and MSM, (Men who have Sex with Men) an alternative approach may prove more useful. Most of the work focused on the positive or negative feelings these individuals had about themselves, their community and or religious group, and their homosexuality. An analysis of these variables with safe sex practices and HIV was conducted. The goal was to have less bad, as measured by HIV and negative personal feelings, and not to create true good beyond the absence of HIV and negative feelings. Questionable benefits from this work were highlighted when findings from this work documented that those that felt more negative about themselves were the individuals that more regularly used condoms and therefore had safer sex practices.
An alternative aim for this work, using the “all good” or Paneugenesis approach, would seek comprehensive improvements and Idealized Outcomes in this situation to the individual, the community/congregation and all related stakeholders. To do this, a beginning study would investigate multiple community and or religious groups to determine which groups had homosexual individuals with good personal feelings about themselves and if homosexual’s in those groups had a higher life satisfaction and safer sex practices.
Upon discovering a more health creating group, the research would then seek to Discover the Precursors or conditions, such as a more accepting or more closely integrated community/congregation, that enabled that group to do and be better. It would also be necessary to understand the Processes used, possibly community functions or congregation by-laws, that created those Precursors. Follow-up intervention research would then work to create identified successful Precursors in other communities and or congregations by Optimizing the Processes to enable Idealized Outcomes. Research would investigate processes and outcomes.
The researcher who investigated adolescents and alcohol hoped to lessen problems associated with adolescents using alcohol such as accidents and school difficulties. An alternative aim using the “all good” or Paneugenesis Process would be to measure positive outcomes such as graduation and college acceptance rates. Increases in these rates are related to purpose and direction in life and also, as a by-product, show lower or more managed alcohol use.
The same alternative “all good” or Paneugenesis Process could be used by the researcher who focused on teen pregnancy. In my discussions with this candidate I asked, if you lower teen pregnancy, what do you get? She admitted there was no clear direction toward something positive and agreed a positive outcome such as higher graduation rates and college acceptance rates would be a good aim. She confirmed, those thinking about future generally have more meaning and purpose while also having lower pregnancy rates.
It think it can be seen how using the Paneugenesis Process to Operationalize an Idealized Outcome will create a process that can lead to outcomes beyond less bad. For the other candidates who focused on Chronic obstructive pulmonary disease (COPD) and Cancer, the aim of improved physical, mental, and social well-being such as is possible with a whole food plant based eating style may be appropriate. Whole food plant based eating style improves well-being and provides extensive environmental benefits for all and this provides purpose and meaning to their lives from their food choices. Beyond improved health, a by-product of a whole foods plant based eating style prevents and can sometimes reverse chronic diseases.
Operationalizing the Idealized Outcome is a vital component. The outcome must be positive or the Paneugenesis, creating all good process, is not possible. Every Idealized Outcome should operationalize, or make clear, that work is directed toward an outcome that creates meaning and connection. It also should be explained how this outcome will have an impact beyond the individual. As Dan Ariely explains in “Payoff: The Hidden Logic that Shapes our Motivations“, when effects move beyond ourselves, our social circle, and even our existence – this drives people to work extra hard to gain meaning. To maintain motivation and effort, it is vital to document progress is being made. People must see measures that Plot Progress and demonstrate movement forward. The by-product benefit of having a meaningful Operationalized Idealized Outcome is the enhancement of inherent joy and the minimization of confusion. This outcome reciprocally leads to higher passion and improved productivity.
So how can this help Make 2017 Great? Use this to clarify to yourself and others (operationalize) a personal or work Idealized Outcome to achieve in 2017. Investigate and discover Precursors that must be true to realize the desired outcome. Do you need a degree? Co-worker with other skills? What skills, abilities, connections or conditions must exist for you to realize that Idealized Outcome? After you Discover the Precursors that must exist, design your life in 2017, Optimize Your Process, so you create those needed Precursors. To keep moving toward your goal and to maintain your motivation you will need consistent reminders of the progress you are making. To give yourself reminders or notices that you are moving toward your goal, find a way to regularly Plot Your Progress. Good luck.
I look forward to hearing how you will generate comprehensive improvements by creating pervasive, reciprocal, selfish, selfless, synergistic, interactions so everyone and everything benefits.