Well-being: moving deliberately from deficit- to strength-based thinking

Frequently, we marvel at the effects of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) and the 2010 Patient Protection and Affordable Care Act (ACA). Together, almost overnight and unmistakedly, they have changed the landscape for insurance coverage, care access, and care integration throughout the behavioral health field. These large-scale changes are palpable and visible in every corner of our country.

But do these legislative landmarks also have much more subtle effects? Yes, most assuredly. Of great interest to us, the ACA and MHPAEA also are changing our concept of care outcomes.

First, let’s recount a little history. For almost the past 50 years, our efforts to measure care outcomes have evolved from a focus on diagnosis, to a focus on functional impairments, to a focus on promoting wellness. In each instance, this work is based upon deficit-based thinking, in which the role of care is to remedy some type of problem in the person.

However, for the past decade, consumers and peers have been developing a strengths-based approach. In this new framework, the purpose of care is not only to reduce disease, but also to “recover” and enhance a person’s strengths. Similarly, the ACA and MHPAEA are shifting the fulcrum from a solitary focus on disease care to one that also includes disease prevention and positive health promotion. Thus, our new legislative framework is adding an emphasis on maintaining and enhancing personal strengths.

This distinction between deficit- and strength-based approaches is much more than an academic exercise. A few moments reflection will convince you that our traditional deficit-based outcome assessments will not fit very well in a world that combines the two. For example, in this new paradigm, to say that we only have reduced the symptoms of an illness or only reduced a functional impairment sounds strangely incomplete. Consumers and peers actually demand much more, and they have been telling us this for almost 10 years. They want care that has a salutary effect upon their lives.

Thus, we need a new approach to outcome assessment that can simultaneously reflect disease reduction and health promotion. Fortunately, such measures already do exist.

The framework for these measures comes from the 1946 Preamble to the Constitution of the World Health Organization, which declares, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” And it also goes on to say, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”  

Based in this fundamental concept of well-being, a new field of positive psychology has evolved during the past quarter century in the United States. Led by figures such as Martin Seligman from the University of Pennsylvania, Ed Diener from the University of Virginia, and Rosemarie Kobau from the Centers for Disease Control, this work is eventuating in a strong conceptual framework for well-being and a clear set of well-being measures.

A person’s well-being derives from the physical, mental, and social domains of life. Physical well-being means that one feels healthy and full of energy, and has a high level of vitality. Mental well-being reflects general satisfaction with one’s life, and is usually associated with strong feelings of optimism. Social well-being is based in one’s interaction with others, and reflects the degree of interpersonal support one receives and gives to others.

Already completed research on well-being documents that those with higher levels of well-being cope better with life stress, experience more days of good health each month, enjoy life more than others, have more social support, and report greater life satisfaction. Because of the importance of these factors to national well-being and productivity, many developed nations now conduct periodic national assessments of well-being, including the UK, Germany, Switzerland, and Australia.

Thus, this is a strong call to action for our behavioral healthcare field. Clearly, we do need a new approach to outcome assessment; simply adding more and more to the deficit-based Tower of Babel of current measures will not serve us well in the ACA and MHPAEA era. The strength-based approach of well-being does hold considerable promise for us.