Five Keys to Real Transformation in Health Care

Introduction

A transformative revolution in the way wellness and lifestyles are viewed is long overdue. Chronic diseases such as diabetes, cardiovascular disease, arthritis, and some forms of cancer are the most preventable and costly aspect of our health care crisis. ¹ Most health problems develop over time and relate to health lifestyles. ² Almost half of preventable deaths in the United States and other developing countries are related to lifestyle. ³ Understanding the complex holistic and systems relationships associated with lifestyle and chronic disease is of paramount importance. ^{1,2,4 –6}

There are five keys to real transformation in health care. The first key is to harness the wisdom and passion of complementary and alternative medicine (CAM) practitioners. ⁵ The second key is to maximize and coordinate the structures in place from clinics to communities, to the new health reform legislation. ^5,6 The third key is to develop a strong evidence base for a wide variety of prevention and promotion practices, such as McCoy's study. ⁷ The fourth key is to assist individuals to personally transform at the opportune time. ⁸ This latter key is essential for a revolution in wellness and lifestyles. A sense of timing for the individual's change with a shift in focus toward reorganization rather than restoration ⁸ is central to sustainable change. Finally, the fifth key integrates all four by using an integral map, one that guarantees that none of the keys is left out, development and growth is emphasized, and a deep holism is embraced. ^{9 –12}

The First Key: Harnessing Wisdom and Passion

CAM practitioners are poised to lead a “great health renaissance.” ^{5, p.521} This is the first key to health care transformation. With a holistic view of healing and a common ground with regard to healthy lifestyles, CAM practitioners collectively hold a cultural authority regarding prevention and promotion. This, together with the unprecedented initiatives in the Patient Protection and Affordable Care Act of 2010, ¹³ suggests that a renaissance could indeed be on the horizon. To transition from renaissance to revolution will require a new and more complex view of health, disease, wellness, lifestyles, and transformation.

Helping people get healthy and stay well is a source of passion for most CAM practitioners. However, regaining health differs from adopting a healthy lifestyle. Adopting a healthy lifestyle differs from achieving one's potential. Placing human potential and the creation of emergent and sustainable levels of wellness at the center of health care is to forever change it, and that is where the revolution begins. By embracing such a wider vision of health as human potential, CAM practitioners can become an even more united cultural force. This builds on our commonality, passion, and authority by reorienting toward the compelling benefits of human flourishing.

The Second Key: Optimizing Structures

Optimally utilizing clinics, communities, and the law is the second key to transforming health care. Through these structures, practitioners extend their impact and cultural authority. The potential to assist millions in the creation of positive lifestyle change is inherent in the health care reform legislation (HR3590). ¹³ This could impact all wellness-oriented clinics and communities. Laws impose significant structural constraints on healthy lifestyles. For example, it was not until smoking was banned in many places that it became socially unacceptable, and a decline in smoking ensued. Adding the force of law to the cultural authority of CAM practitioners, with a focus on human potential, lends hope for powerful changes.

A crucial aspect of the legislation is its support of wellness initiatives, health promotion, and lifestyles. ¹⁴ Evidence-based wellness programs initiated by businesses are supported by $200 million in grants. ^{13, p.860} Furthermore, as Redwood points out, “structures for coordination” ^{5, p. 522} center on the newly created National Prevention, Health Promotion and Public Health Council. This high-profile council requires a task force to create proposals for “evidence-based models, policies, and innovative approaches for the promotion of transformative models of prevention, integrative health, and public health on individual and community levels across the United States.’’ ^{13, p. 421} This section of the law sets the tone for significant change and emphasizes the next two keys of health care transformation: evidenced-based and transformative models.

It is in these four words, “transformative models of prevention,” undefined, now the law of the land, where seeds of transformation lie. What would new policies look like that were based on transformative models? Defining this appropriately, with practices and methods of establishing further evidence, has the potential to lead the revolution.

The Third Key: Developing the Evidence Base

Evidence-based protocols, the third key, fuels practitioners, structures, and transformative models. McCoy's study in a previous issue of this journal is a good example. ¹⁵ It is a retrospective look at 180 individuals, from 54 clinics, over an 18-visit protocol, with a central data repository. The individuals changed their diet (meal planning and nutrition) and exercise (aerobic and strength training), with psychologic support through coaching and audio programs. The overall improvements were robust, considering the number of participants and the eight factors measured: weight, resting heart rate, systolic and diastolic blood pressure, strength, body mass index, body fat, waist circumference, and forced vital capacity. Expanding the evidence base on standardized protocols by including a data repository is an important step in wellness and lifestyle research.

Wellness lifestyles were defined by Schuster et al. ^16,17 to include health lifestyles, health promotion, and CAM use for wellness enhancement. They acknowledge a distinction between CAM for wellness and CAM for restorative therapeutics. ⁸ Schuster et al. write, “Moreover, while most CAM practices share a holistic, even vitalistic philosophy toward health, healing, and the body, the trend toward ‘integrative medicine’ has led to the application of various CAM practices in a reductionist, treatment-oriented paradigm.” ^{16, p. 353} This proves important in researching evidence-based protocols. For example, the clinics involved in the McCoy study utilized chiropractic for general health and well-being rather than musculoskeletal symptoms, yet this was not accounted for in the study. ¹⁵ As McCoy notes, future research should include such use. Schuster et al. found Network Care had a direct relationship on enhanced benefits of healthy lifestyles as well as distinct self-perceived wellness benefits. ¹⁷ Expanding the evidence base while keeping important data on wellness enhancement protocols as well as gender, race, and sociodemographics will assist us in better understanding the dynamics of wellness and lifestyles, especially with regard to the individual's personal transformation.

The Fourth Key: Timely Self-Transformation

Personal transformation at the opportune time was described in a seminal article by Epstein et al. ⁸ It is the fourth key. Reorganizational Healing (ROH) is a transformative model. It suggests that everyone has the ability to change; however, the depth of change often depends on the individual's resources of body, emotion, mind, soul, and spirit, and the timing of change is crucial. ROH could easily be adopted by CAM practitioners able to see beyond the physical distress or disease. Assisting people to find deeper meaning at the opportune time will truly help the individual to transform. ^18,19 ROH can be used on its own, in conjunction with restorative therapeutics, or as a way to assist CAM to emphasize human potential through new levels of health and well-being.

ROH developed from decades of empirical research, case reports, clinical observations, as well as retrospective and longitudinal studies. ⁸ Recent data point to the observation of nervous system and spinal reorganization ^20,21 (Jonckheere et al., unpublished observations). Individuals can develop sustainable change at the right time. This leads to higher levels of organization and new resources to draw from in body, emotion, mind, and spirit.

ROH opens possibilities for prevention and promotion. The focus goes to reorganizing new behavioral, perceptual, and structural levels of health and wellness. This approach embraces transformation of the individual consonant with their unique moment in life. Instead of focusing on behavior choices, change of the very self and personal meaning is the emphasis in the context of life as a whole. ROH offers a transformative revolution in health care.

Timing of change for each individual is vital for sustainable reorganization of lifestyle aimed at optimal human potential. Seeds cannot be planted in winter. Fruit cannot be harvested in spring. Change is more sustainable when the time is right. Without being attuned to the individual's right moment for change, lifestyle change is reduced to a prescription. By working with timing and the rhythms of life, a person's readiness for change is paramount. This type of readiness is different from the classic Stages of Change Model, ²² whereas the individual is assessed in terms of precontemplative, contemplative, preparation, action, or maintenance. In the ROH model, there is a vertical dimension to change readiness.

In the ROH model, there is seasonality and a hierarchy to change. For example, a person may change because of personal or physical suffering, emotional “charge,” or frustration. At a higher level, the person may change because they have had enough of the status quo, or they are embracing a new source of empowerment. At yet a higher level, the person may be seeking to break through the blocks that have held them back or release all of the patterns from the past that have kept them from being who they are truly meant to become. This hierarchy of change is central to working with a person's timing. By working with the individual's “season,” the most potent possibility for change in that moment of their life can be supported. For example, 2 men, who just had heart attacks, decide to embrace healthy lifestyles. One does so from fear (“emotional ‘charge’”), the other from a new source of empowerment to take his life into his own hands. The first might not be ready for a full lifestyle modification. He might need to start slowly with diet and exercise. The second might be ready to change everything and truly reorganize his diet, exercise, relationships, social supports, the books he is reading, and even his spirituality. Timing is essential. ^8,18,23,24

CAM practitioners hold the unique opportunity to be change agents and inspire a cultural transformation toward wellness and human potential. ROH can become the dynamic core of a shared vision, implemented through structures and practices at clinics and in communities and bolstered by an expanding evidence base with an emphasis on wellness lifestyles. Timing and individual reorganization could be a fulcrum for this transformation in health care. Yet one more key is central to integrating these elements: an integral map. Before describing the map, it is important to more fully understand the territory. The territory of health lifestyle change can best be described in terms of social/cultural chances and personal choices.

The Collective Territory: Social and Cultural Chances

Schuster et al. ¹⁷ emphasize the sociological roots of “lifestyle” in terms of social status, modernity, individuality, class culture, and self-identity. “Wellness lifestyles” is viewed in terms of the dialectic between choice and chance, with chance as a structural and environmental variable. Cockerham builds on a similar approach to health lifestyles with regard to medical sociology, although without the distinction between wellness and health. ^6,25 He defines health lifestyles as “collective patterns of health-related behavior based on choices from options available to people according to their life chances.” ^{6, p. 160} He emphasizes bringing structure, or chance, to the forefront of any discussion of health lifestyles.

Cockerham offers a new paradigm for understanding and researching the complexity involved in health lifestyles. ^6,25 The first step acknowledges the profound role structure or chance exerts on agency or choice. Sociodemographics, age, and gender affect life chances and socialization experience. This shapes life choices. Choice and chance can best be understood with Bourdieu's concept of habitus. Habitus is an internalization of the social values and expectations creating daily habits of life. Such habits are part of an open system, which structure and are structured by the environment. Our daily habits are constrained by our chances, because they develop from internalizing our socialization. This further creates our social situation, thus embedding the habits more deeply. Habitus then leads to practices or actions (such as smoking, checkups, alcohol use, and diet), which become health lifestyles. Health lifestyles form a feedback mechanism with habitus. Thus, we choose our behaviors, yet remain constrained by our economic and social circumstance, and by “intersubjective ‘thought communities',” or the internalized values of our culture. ^{25, p. 59}

It is through these “intersubjective thought communities” that CAM practitioners can teach about wellness lifestyles and reorganization. These cultural memes are expressed through the structures. Structures comprise the interobjective domain such as social and economic situations as well as access to health clinics, and community and business wellness programs. Yet it is through the self, the mediator between these domains, that this health care transformation really happens.

The Individual Territory: Self-Identity and Development

Self-identity is at the heart of lifestyle change. ^6,26 Asking an individual to change their lifestyle is asking them to change who they perceive themselves to be. Individuals attach the meaning of who they are to their lifestyle. Lifestyle, once assumed to be the purview of the leisure class, has become one of the main defining features of self-identity in developed countries. ^6,26 One's health and even shape of their body has become the individual's responsibility. Negative social consequences or stigma is attached to poor lifestyle behaviors. ^6,25 One cannot change lifestyles without changing one's self. But it is not only the self of the lifestyle changer that is important. As noted in the first key, the CAM practitioners, as the cultural authorities, have the potential to be the leaders of the transformation.

According to Korp, the missing piece in the field of health lifestyles is the impact of the “Western middle-class lifestyle.” ^{27, p. 25} The dominant notion of healthy lifestyle comes from a specific worldview shaped by affluent social and economic forces. Korp writes, “Health experts need to know what it is they are promoting and the ideological presumptions behind their strategies.” ^{27, p. 25} This insight brings a self-conscious awareness to the field and adds greater depth to a potential revolution. It shifts the focus from the individual creating change to the lifestyle experts and CAM practitioners, the leaders of the intersubjective thought community.

This type of awareness can best be understood through constructive developmental research. Theorists and researchers have shown the adult self develops through a series of levels of structural complexity. ^28,29 Perspectives through which individuals make meaning and view their own world and lifestyle can be viewed as structures shaping choices. ¹⁰ By viewing the self as a developing system shaped by the environment and its own structural developmental dynamics, we can more fully grasp the complexity with which behavior choices are embedded. We can also situate the expert in relation to this developmental trajectory by drawing from the most complex worldviews we can, such as systems, holistic, and integral worldviews. This position also helps us to approach the monumental and exciting task of redefining the self with increased reverence, humility, and compassion. We are no longer talking about just helping individuals to change lifestyle or the self, but also about assisting the practitioners to develop through self-reflection, increasing complexity, and the ability to view the world through more perspectives. Therein lays the heart of the transformation.

The Fifth Key: An Integral Map

American philosopher Ken Wilber suggests that the self is situated in four domains: personal experience (subjective); body and behavior (objective); social and economic circumstance (interobjective); and habitus, worldview, or culture (intersubjective). ^9,30 These four domains, known as the four quadrants, are the foundation of Wilber's Integral Theory, and the map we will use to integrate the other four keys.

Central to this map is the view through and the view from. ¹⁰ All sentient beings view the world through these four domains or perspectives. Additionally, any object or individual could be viewed from each of these domains. This distinction situates lifestyles in a deeply holistic way. It accounts for the observer and the observed, the doctor and patient, or researcher and researched. It also holds the whole or Spirit as the unity of these poles as the always present ground. For example, each CAM practitioner views the world through each of these four domains. Each individual seeking lifestyle change also views the world through each domain and can be observed from each domain as an object. Thus, we assess each individual in terms of a receiver of an intersubjective message or culture, a recipient in an interobjective structure, such as a clinic, community, or law, a physical body, who acts and chooses behaviors that can be objectively studied, and a subjective person transforming and developing in their own time. At a higher or more basic level of insight, all these domains represent one nondual whole, a gestalt. Integration is the fifth key because it explicitly unites all other facets of the whole.

Several authors propose Wilber's model be incorporated across medicine. ^{31 –36} It could act as a heuristic tool to operationalize holistic and integrative approached. ³⁶ By embracing all four domains, a deep holism is ensured whereby nothing gets left out and each of the major domains of human experience is integrated. ¹² Inclusion of interiors and subjectivity, a strength of CAM approaches in general, is not always included in practice or evidence-based research. ^16,37 Attempts at being holistic often leave these domains out while focusing on the systems of the body or social systems. Rarely does research include intersubjectivity as Cockerham proposes, and rarer still is an explicit acknowledgment of the self in terms of the individual and the practitioner or expert. Integral research was developed to include all four domains, ^11,38 and may prove useful to explore transformative models. This would emphasize reorganization to more complex and integrative levels in each domain. ⁹

Conclusions

By embracing these five keys, we can use this unique moment in history to shift cultural perspectives toward human potential in a deep way. Since lifestyle is central to the definition of the self in modern culture, we can consciously embrace lifestyle change as subjective and intersubjective transformation. By including reorganizational healing as the core of this new vision, the break from the status quo is inevitable. ROH includes change at the most opportune time and access to new resources of body, emotion, mind, soul, and spirit. It is this type of deep transformation, coupled with a strong evidence base, that sets the tone of real change and a new direction. Using an integral map ensures that a very complex view of human possibility is incorporated. Integrating intentional, behavioral, social, and cultural perspectives into the transformation of health care is to include all facets of the whole, whereby a more compassionate, holistic, and Spiritual system could naturally evolve.