Holistic approach to change behavior (e.g., towards a smoke-free identity)
This article is distinguishing holism from reductionist concepts and critically analyzes the application of holism in the mental health topic of long-term smoking cessation. By identifying some current state indicators the article suggests a definition of a holistic approach going forward. The effective maintenance of long-term nicotine abstinence is considered to be positively influenced by applying an extended biopsychosocial model that also includes cultural and world-view beliefs of personalities on their journey to a smoke-free identity. Implications and challenges for future holistic practice design and multi-disciplinary and integrative health care roles are discussed. The article concludes with a daring outlook towards a possible revolutionary human self-healing personality capability as a logical consequence of the current self-development movement.
2. Holistic approaches in psychology
The Cambridge Dictionary defines ‘holistic’ as “dealing with or treating the whole of something or someone and not just a part” (“Holistic,” n.d.). The subject of concern in psychology is the human being, the person, respectively an individual’s personality. Holism in psychology is juxtaposing a reductionist view. An example for a reductionist view in psychology is behaviorism. Behaviorism is studying human behavior principally as a mechanism that is not considering systematically any further parameters than those given by a stimulating input and an observable output of behavior of a subject. Medicine may be perceived as still practicing with a predominantly reductionist stance. However, the reduction of the human being to its physiology or certain parts of its personality, or approaching health issues with single-track methods do nowadays not appear to be state of the art. Rather, modern mental health care may promise a broad, comprehensive, and integrative attitude in psychological research and the prevention and treatment of mental health issues.
“We are not doctors for particular diseases, or particular stages in the life cycle — we are doctors for people” (Freeman, 2005, p. 154).
Humanism, a psychological viewpoint that has developed over the last decades towards a more holistic perspective on human beings, opposes physicalist and determinist (and consequently also reductionist) views and asserts the values and abilities of human beings. As Aanstoos (n.d.) describes vividly: “The humanistic self is an engaged, involved, situated self, concerned and caring about the whole of Being, of which it is an interrelated manifestation” (p. 128). Positive Psychology builds on the fact that personal development, happiness, and fulfillment are integrated into the culture and therefore is, according to Aanstoos (n.d.), “quite aligned with what humanistic psychology had been advancing from its inception” (p. 123).
Another contra-reductionist model is the biopsychosocial model that defines “that phenomena on bio-psycho or psycho-social level cannot be explanatorily reduced to a bio-medical understanding” (Kompa, 2012, p. 3). Freeman (2005) points to the fact that EURACT, the European Academy of Teachers of General Practice, extends the “biopsychosocial model by two further dimensions, which are ‘cultural’ and ‘existential’ respectively ‘spiritual’” (p. 154). It seems to be a logical step to complement the intra-personal and interpersonal interaction of an individual with an extra-personal positioning.
Despite all the knowledge and efforts to establish whole-person concepts, it seems not to be easy to assume holistic views and approaches in medicine and psychology. Nilsson (2014) says that
There is today still no integrated concept of personality, which has a significant impact on personality psychology whose goal is to understand the whole person (p. 18).
The trait theory has described five traits to categorize people’s disposition to react in specific ways. Social-cognitive, as Nilsson (2014) is criticizing, assumes quite a deterministic view of human behavior in social situations. Nilsson (2014) refers to the holistic concept from McAdams and Pals that adds to the layers of trait theory and socio-cognitive theory
A third layer. This extension is “consisting of life-story narratives, which are developed over time, internalizing narrative forms and contents from culture, to ﬁnd unity, meaning, and purpose in life and form a personal identity” (p. 19).
In summary, the concept of the whole person consists of the unity of body and mind, inclusive the acknowledgment of social and cultural contexts and by encompassing a humanistic personal identity that builds on self-empowerment and an individual belief system of the world. This holistic definition shall establish the lens through which we analyze the case study of nicotine addiction recovery in the next section.
3. From smoking cessation to long-term abstinence
To overcome tobacco addiction means overcoming two different challenges. First, smoking has to be quit and second, the smoking cessation has to be maintained. Studies find that
Maintenance of nicotine abstinence requires different conditions, i.e. different motivations as the smoking cessation itself.
Studies that measure smoking cessation support effectiveness over a limited period do not say much about the long-term success of a quit attempt. Borland et al. (2010) state that “there is a need to develop more effective interventions to help smokers remain smoke free. Motivation is a complex set of beliefs and inclinations that we don’t know enough about, especially postquitting” (p. 510).
Many of the smokers who do attempt to stop smoking are relapsing over short or long. As studies like the one from Boudrez, Gratziou, Messig, and Metcalfe (2011) indicate, pharmacological aids and interventions focus on smoking cessation attempts. Nicotine dependency is a chronical disorder, and medications can help soften the perception of physical symptoms in the first time of abstinence. However, it doesn’t seem to be the full story if cessation success is measured at three months (at the time the medication ends) for the last time without later follow-ups. The following facts support the need for a more long-term view. “Studies have found that 75% of smokers who achieve 4 weeks of abstinence relapse within the first year (Ferguson, Bauld, Chesterman, & Judge, 2005) and of these a further 30% relapse after that (Etter & Stapleton, 2006)” (Vangeli, 2010, p. 21).
Even in the study of the effectiveness of Varenicline (a substance to help overcome the nicotine weaning symptoms), it was recognized that “an individual approach by experienced counselors, specialized in the area of nicotine addiction and familiar with the guidance of Varenicline intake, seems to provide an important explanation for the high percentages of smoking abstinence observed” (Boudrez et al., 2010, p. 774). It is not difficult to see the logic that
For mental health related issues such as nicotine addiction the whole person needs to be addressed, e.g., physically, mentally, emotionally, behaviorally, and socially.
4. Holistic approach for effective long-term results
Boudrez et al. (2010) and Vangeli (2010) both mention behavioral support programs that complement the medication with Varenicline. And indeed, as the support is described to address mainly coping strategies for the resistance of temptation and the prolongation of the nicotine absenteeism by means of motivation and continued adherence to the medication, it can only be accounted for a complementary factor in the smoking cessation process, but not more. Boudrez et al. (2010) further detail that “the positive effect on the quit candidate provided by the personalized approach of an experienced tobacco specialist has been observed in previous research” (p. 774).
Despite positive signs for the awareness of the effectiveness of complementary counseling for long-lasting behavior change, Carson et al. (2013) identify that “insufficient research and clinical attention are given to maintaining abstinence once a person has made a quit attempt” (p. 100). Further Carson et al. (2013) see, concerning more effective long-term abstinence treatments, the need for changed support practices and the implementation of new cessation strategies and in-depth consultations (p. 100). Dale and Lee (2016), inspired by new primary health care models in the United States of America, are reporting about an integrative ‘Behavioral Health Consultant (BHC)’ role “that is working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing” (p. 1). Further, Dale and Lee (2016, p. 1) point to the desired effect of increased intervention efforts to allow for behavioral change and self-management of patients. This is exactly what long-term nicotine addiction interventions could look like.
What is, however, a concern is that
There seems to be no mature theory and practice of a human holistic personality that could serve as a standard framework supporting new roles and practices in whole-person health care. A holistic personality framework would facilitate the assessment and personalized support of individual changes in behavior in specific situations over time, as it should be considered to be necessary for the successful long-term recovery from addiction. It is likely that a sustainable identity as a non-smoker requires a change in self-perception that is reinforced by according social contacts, status and cultural environment that is supporting the recovered addiction free self-image.
Looking at the whole person in a health intervention places high demands on interdisciplinary and collaborative skills of any involved health practitioner. Policies and education need to support the broader establishment of such quality professional capabilities and need to stimulate appropriate shared interests for the benefit of patients and those seeking holistic health advices. In the light of culturally differently shaped personalities whose, for example, emotional perceptions of similar matters may be quite different, represents a further challenge in the realization of truly holistic and personalized treatments. Khenti et al. (2016) find that “it is also critical to incorporate ‘consumers/survivors’, or individuals with mental health and/or addiction issues, as key contributors and stakeholders of mental health policy, planning, legislation, service provision and evaluation processes” (p. 40). One may agree that the involvement of affected people may increase the reality and the relevance of support measures. There are for sure further possibilities to ever more customized approaches for increased personalization and degree of holism in (mental) health. Economic considerations may pose boundaries for what is feasible, though. Holistic intervention design and efficiency (i.e., the swiftness of progress in interventions) may be well balanced.
It is to hope that progressive forces are continuing to support the ambition of holistic mental care
and will not resign in the face of increased complexity of content and approach on the one side, and economic pressure on the other side. It is also to hope that the extensiveness of a whole-person approach does not awaken temptations for returns to easier to overlook quick fixes, be it from one-sided pharmacological medication or dubious spiritual healing promises.
While first steps towards more holistic frameworks of human health and their application in practice exist, there is still a lot of research necessary. That there are so many approaches and terms that address continuous extension, integration, and a combination of aspects of human life and related mental health and well-being, is indicating that there is and will be a lot of movement also in the future. I wouldn’t be surprised to look back to our times in a couple of decades, having witnessed a
Humanistic revolution going beyond self-enablement and fulfillment. Humanity further progresses in understanding the world and themselves in a holistic way and may arrive at unlocking related possibilities for self-healing as the progress in research, application and education of whole person health approaches becomes more mature and accessible to more and more people.
A shift towards increased self-responsibility would be logically in line with the parallel shift towards a more person-cantered health approach and would likely have positive effects not only on mental health care effectiveness but also on the economic sustainability of highest quality health for all.
Aanstoos, C. (n.d). The relevance of humanistic psychology. Journal Of Humanistic Psychology, 43(3), 121–132.
Borland, R., Yong, H., Balmford, J., Cooper, J., Cummings, K. M., O’Connor, R. J., & … Fong, G. T. (2010). Motivational factors predict quit attempts but not maintenance of smoking cessation: findings from the International Tobacco Control Four country project. Nicotine & Tobacco Research: Official Journal Of The Society For Research On Nicotine And Tobacco, 12 SupplS4-S11. doi:10.1093/ntr/ntq050
Boudrez, H. )., Gratziou, C. )., Messig, M. )., & Metcalfe, M. ). (2011). Effectiveness of varenicline as an aid to smoking cessation: Results of an inter-European observational study. Current Medical Research And Opinion, 27(4), 769–775. doi:10.1185/03007995.2011.557718
Carson, K. V., Brinn, M. P., Robertson, T. A., To-A-Nan, R., Esterman, A. J., Peters, M., & Smith, B. J. (2013). Current and Emerging Pharmacotherapeutic Options for Smoking Cessation. Substance Abuse: Research & Treatment, (7), 85–105. doi:10.4137/SART.S8108
Dale, H., & Lee, A. (2016). Behavioural health consultants in integrated primary care teams: a model for future care. BMC Family Practice, 171–9. doi:10.1186/s12875–016–0485–0
Freeman, J. (2005). Towards a definition of holism. British Journal of General Practice, 55(511), 154–155.
Holistic. (n.d.). In Cambridge Dictionary. Retrieved October 31, 2016, from http://dictionary.cambridge.org/dictionary/english/holistic
Khenti, A., Fréel, S., Trainor, R., Mohamoud, S., Diaz, P., Suh, E., & … Sapag, J. C. (2016). Developing a holistic policy and intervention framework for global mental health. Health Policy & Planning, 31(1), 37–45. doi:10.1093/heapol/czv016
Kompa, J. S. (2012). Holism, General Systems Theory and the Biopsychosocial Model
Nilsson, A. (2014). Personality psychology as the integrative study of traits and worldviews. New Ideas In Psychology, 3218–32. doi:10.1016/j.newideapsych.2013.04.008
Vangeli, E. (2010). An exploration of the role of identity in smoking, cessation, maintenance and relapse.