The positive health domain in person-centered integrative diagnosis
International Journal of Integrated Care, 29 January 2010 - ISSN 1568-4156
Section on Person-centered Health Domains
The positive health domain in person-centered integrative diagnosis
C. Robert Cloninger, Washington University, St. Louis, USA
Correspondence to: Robert Cloninger, E-mail:

Person-centered integrative diagnosis is concerned with the assessment of the whole individual in a way that facilitates their recovery of mental and physical health. The recovery of mental and physical health involves more than just the reduction of symptoms and harm. Positive health involves the promotion of a satisfying quality of life, resilience despite stress, and recovery of positive emotionality. Positive health is a state of physical, material, emotional, social, ecological, and spiritual well-being.

Well-being can be defined in four major ways that identify essentially the same individuals: presence of positive emotions and absence of negative emotions, mature character traits, quality of life, and virtuous conduct [1]. In other words, feeling good requires doing good as an expression of a mature and integrated organization of personality.

Physical and mental ill-health is strongly associated with socioeconomic inequality, social disconnectedness, and early childhood stress [2]. In turn, these social conditions impair the development of the character traits of self-directedness, cooperativeness, and self-transcendence, which are needed for positive emotionality and subjective well-being [1]. In contrast, the development of these character traits involves learning to let go of struggles and fighting, to work in the service of others, and to enjoy growing in awareness [1]. Medical specialists often overlook the back that physical and mental disorders increase in populations and in individuals at the same time when there is social inequality, social disconnectedness, or early childhood stress: the common forms of physical disability, such as cardiovascular disease, increase at the same time as the common forms of mental disability, such as depression and alcoholism [2].

Most medical complaints involve acute stress reactions or chronic disorders influenced by lifestyle choices [3, 4]. The absence of positive emotions is more predictive of physical morbidity and mortality than the presence of negative emotions [5]. As a result, collaboration is needed between general physicians and psychiatrists in person-centered assessment and treatment. Such collaboration is needed to reduce the costly burden of disease by reducing the person's vulnerability to disease and increasing the resilience to stress.

For example, most physicians assume that the major antecedents of coronary artery disease are somatic risk factors like LDL cholesterol, blood pressure, and insulin resistance. However, a 27-year prospective study of young Finns has now shown that the temperament dimensions of novelty seeking, harm avoidance, and reward dependence are more powerful predictors of atherosclerosis than any of the somatic risk factors [6]. These temperament traits were measured by the full temperament and character inventory, but the influence of character on risk has yet to be evaluated [7].

Effective person-centered treatment requires recognition of the strengths and weaknesses of patients in order to empower their commitment to a more adaptive, satisfying, and healthy lifestyle [8]. Positive health (i.e. well-being) is the result of letting go of struggles (i.e. acceptance, hope), working in the service of others (i.e. kindness, humanitarian service), and growing in self-awareness (i.e. mindfulness, humble spirituality). In contrast, mental ill-health is the result of physical trauma and neglect (e.g. war, disaster, malnutrition, physical illness), mental trauma and neglect (e.g. verbal abuse, poverty, poor education, social deprivation), and/or spiritual trauma and neglect (e.g. brain-washing cults and cultures, religious persecution, anti-spiritual repression of spiritual aspirations). However, positive health is not influenced by such trauma, neglect, or deprivation, so the determinants of positive health are not the opposite of the determinants of ill-health. As the WHO has long emphasized, health is more than the absence of disease, and positive emotions are more than the absence of negative emotions [1].

The positive health domain is an essential part of assessment along with evaluation of the therapeutic alliance and outcome assessment in person-centered integrative diagnosis. Carl Roger's person-centered therapy is an example of a person-centered approach to psychotherapy [9]. It can be updated to incorporate more recent advances in positive psychology, mindfulness training, and cognitive behavioral approaches. Given the recognition that physical health is also an essential aspect of the expression of personality, person-centered psychotherapy can also be expanded to a more holistic approach that addresses all the aspects of person-centered medicine, as described in the work of Paul Tournier [10] and the work of Juan Mezzich and his colleagues in the World Psychiatric Association Task Force on Person-centered Integrative Diagnosis [11, 12]. The WPA's focus on the positive health of the whole person helps to eliminate the false and stigmatizing dichotomy between physical and mental health. Without a realistic understanding of the interplay of physical and mental issues in most medical problems, physicians can only treat symptoms and not their causes. Without a reduction in stigma, patients avoid treatment and lose hope. As a result, psychological medicine must recognize the key role of the positive health domain in order to promote well-being and health effectively.

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