by Aaron Antonovsky
Berkeley, 21 January 1993
I am pleased that so many of you have come to hear my remarks about the transition from adolescence to adulthood. It is a subject from which I am sufficiently distant to analyze with full objectivity, knowing that no generation of adolescents since my own has come even close to equalling us in character, intelligence, commitment and all the other virtues. In fact, it is clear that it has been downhill all the way for those who came after us; they could not even learn from our mistakes, few as these were.
What, then, happens as one ages, moving from irresponsible youth to responsible adulthood, from the serious, genuine teens to the dissembling, realpolitik of the twenties and thirties, from having all the answers to not even knowing the questions? And, for our purposes today, can we better understand this aging transition and its health consequences if we adopt a salutogenic rather than a pathogenic approach?
Oops - I see on Dr.Kaplan's face that something is wrong. Oh, my god, I was reading from my talk to the adolescentologists. Today is Thursday - so you must be gerontologists, and I'm supposed to talk about a different kind of aging.
Or am I? Two years ago I was invited to address experts in developmental disabilities; last year, experts in family therapy. I protested that I knew very little about their specialties. Their response was identical: We are the experts in this area of human reality, but your ideas might help us gain a more profound theoretical understanding of the issues with which we deal. This leads me to think that perhaps aging is aging is aging -- and that what is needed is a theory of aging. Moreover, when it comes to gerontology, I am not a total amateur. Years ago, I had the fortune of having Bernice Neugarten as a project director on a menopause study. And in more recent years, NIA thought I knew enough to support a study of retirement. So let me proceed.
Being facetious was intended to hint at my overall thesis. A salutogenic approach to human functioning in the health area, I suggest, facilitates the confrontation of underlying problems, the formulation of a theory which is powerful in understanding not only developmental disabilities but also family therapy, not only the aging transition of adolescence to adulthood, but also the aging of the elderly. To clarify this point, I will have to backtrack, and spell out what I mean by salutogenesis.
But before doing so, I must be explicit in saying what led me to the idea; It was the profoundly disturbing observation, well supported by epidemiologic data, that entropic, chaotic and immanent stressors, from the microbiological to the psychosocial realms, characterized human existence and made even temporary survival and health a miracle.
One of the pleasures I have had in the last year or two is seeing references to salutogenesis without a footnote saying "Antonovsky, 1979". No one, after all, footnotes "superego" with "Freud, 1895". When I suggested that the word, which I had coined in writing the book in which I first presented what I called the salutogenic model, be included in the title, my publisher's veto was absolute. The changing climate of the last decade or so, however, has provided a warm welcome to a concept for which we previously had no name, though it is as yet far from being a household word. By contrast, just about everybody knows what "pathogenic" means.
Literally, salutogenesis means "the origins of health". This has meant, unfortunately, that the concept has been welcomed by the holistic, healthy life style, preventive medicine, health promotion (and all the other "in" words) camp. Why unfortunately? Because it suggests that I have failed to prevent a basic misunderstanding of my argument, and this by people to whom I feel close. Let me try to clarify the concept, defining it and then discussing five implications of formulating the questions of those of us who work in the area of health, in gerontology or elsewhere, in salutogenic terms.
Conceptually, salutogenesis is defined as the process of movement toward the health end of a health ease/dis-ease continuum. The first implication of adopting a salutogenic orientation is the rejection of the dichotomy posited by a pathogenic paradigm: people are either sick or they are healthy. Note that this dichotomy is common to those in the preventive no less than the curative camp. I propose that all living human beings, at any point in time, are somewhere on a continuum between the two extreme poles. An elderly person with a thick medical folder is no less on the continuum than an active, hungry, screaming and smiling infant or than a strapping adolescent. They are at different points on the continuum; the dynamic prognoses are different. But it is the same continuum. Whether one thinks dichotomously or in terms of a continuum makes a major difference for how one collects data.
If we think of process and dynamics, the second difference between a pathogenic and a salutogenic orientation is even more important. The former is totally preoccupied with movement toward the disease end -- actually, with movement from health across the abyss to disease, or, for those already diseased, to degeneration, complication and death. The fascinating discussions of the last decade about the compression of morbidity are almost totally based on a dichotomous view. The question posed is: How can chronic morbidity be postponed till later and later in life? Success will be marked, a la Fries, when all of us, till age x, are healthy, and then, hopefully for a short period of time before we die, we are sick. The salutogenic orientation focuses on movement toward health, wherever one is on the continuum. Thus the elderly, no matter where they are on the continuum, are viewed as persons who can move in both directions; the movement toward health becomes particularly important. And, as Rose Coser taught us a long time ago in her study of a terminal ward, rehabilitation can be a meaningful concept even for residents in such wards.
Actually, I have been generous to those who adopt a pathogenic model, again, whether curatively or preventively oriented. It might not be so bad were they to focus on d-i-s-e-a-s-e, if only they were to use the original English pronunciation: dis-ease. But they do not think of dis-ease. They think of, and become experts in, specific diseases. The hip fracture clinician knows little and cares less about dementia; the arthritis researcher has nothing to do with those who study peripheral vascular disease. I believe this is true no less of social than of biological scientists. The two questions which totally preoccupies them are: How can older people be prevented from getting "my" disease X? How can those who have been diagnosed as having disease Y be helped to not get worse? Salutogenesis, by contrast, in focusing on movement toward the health end of the continuum, compels an interest in the overall spectrum of wellbeing;
I have till now suggested three implications of adopting a salutogenic orientation: rejecting a dichotomy in favor of a continuum conception of health-disease; focusing on movement toward health rather than movement toward disease; and third, preferring an interest in the overall spectrum over expertise and compartmentalization. Mention of this last point requires an interjection to avoid misunderstanding. It might well be a reasonable inference from what I have said till now to conclude that I see the pathogenic and salutogenic paradigms as in profound opposition to each other. Given the overwhelming dominance of the former among those of us who are researchers or clinicians in the health-disease field, I have done so in order to shake you up, to point to the shortcomings of working pathogenically. But each has its own power. We badly need theories and understanding of diseases; but no less, and, I believe, even more do we need overall theories of health-illness. God forbid that the pathogenic experts all disappear. As long as there is no such danger, however, I will continue to advocate at least equal time for the salutogenic approach. And, further, I shall try to make it clear why, particularly in gerontology, where the reality of the lives of most of the elderly is a very complex picture and not a neat fit into the box of disease X, a salutogenic orientation takes on an even more compelling urgency.
The second implication, focusing on movement over time, is linked to a fourth implication. If one is concerned with why people get sick, or die, then the basic concept with which one works is "risk factors". We have learned much about risk factors, though there is still much more to learn. Looking back on my own career, well before I began to think about salutogenesis, I am quite proud that my own work helped to demonstrate that being poor or lower class placed one in a high risk category for just about every disease. And I have been disturbed by what I see as a shamefully inadequate awareness of the fact that the indisputable decline in overall mortality over the last decades has been accompanied by a growing social class difference.
Having paid due tribute to the importance of risk factors, which deal with the phenomena that push people toward disease, disability and death, I must ask: And what about the other direction? What pushes us toward health? What is the statistical formulation for a concept analogous to "relative risk"? We do not even begin to have words for such matters, because we don't think of them. The problem is even more acute with respect to the elderly, where risk factors pile up. And because we don't think of such matters, we do not study them and know very little about what I suggest be called salutary factors. We know something about loneliness of the elderly widow, but much less about rootedness; we know something about a physical environment which helps to prevent falls, but next to nothing about an environment which promotes vigorous mobility.
To clarify the point, perhaps I may be permitted to refer to a concept about which I am reasonably ignorant. The literature, wisely distinguishing between aging and disease, refers to senescence, the process of growing old. Aging is seen as due to the breakdown of regulatory mechanisms at the cellular tissue or organ level which destroys homeostatic capability. But I have yet to encounter, certainly with respect to the elderly, the opposite concept: Is it development? Growth? Now, there may well be, obeying Hayflick, no counterpart to senescence at the biological level. But is there not a possibility for what sociologists call functional alternatives? Is it not possible that the ten billion neurons in the human cortex can come up with some replacement for what has senesced? Whatever the case may be for the biological development of salutary factors till the very end of life, as a social scientist, I can surely see the possibility of the growth of social-psychological salutary factors as one gets older. Think of John D.Rockefeller and the accumulation of a very powerful salutary factor called wealth.
May I briefly also note one further aspect of the focus on risk factors. This focus is on risk factors for already labelled diseases. When I published the first version of the salutogenic model in 1979, and wrote "the bugs are smarter", we knew nothing about risk factors for AIDS because it wasn't yet in the books. By contrast, the salutogenic search for strengths opens the possibility, so fluently discussed by Rene Dubos, of focusing on adaptability to whatever history holds in store for us.
The fifth and final implication which flows from the pathogenic- salutogenic contrast is perhaps the most important. To put it starkly: When we focus on risk factors, on a disease, and on its pathologic development, we are pressured to identify the person with the disease. Bob Scott, now at the Palo Alto Behavioral Sciences Center, many years ago wrote an unfortunately not well known book called The Making of Blind Men. He analyzed how we come to transform a person who is a woman, a shop owner, a mother, a devout believer, etc., etc., and who also has the very important characteristic of having extreme difficulty in seeing physical objects in her proximity -- how we transform her (and how she internalizes the transformation) into a blind person, period. Do we not, functioning on the basis of a pathogenic orientation, transform particularly older persons into cases of disease X? By contrast, a salutogenic orientation compels us, by leading us to search for salutary factors, for strengths, for compensatory mechanisms, for significant social roles and self-images other than that of the sick role, to discover forces which may be far more powerful in fighting diseases and promoting health than any of our medical procedures, valuable as they are. (And I say this having seen what a hip transplant can do.)
I am not raising the moral implications of these transformations, though there are good reasons for concern on this score. Purely in terms of the consequences for health, I suggest that to adopt the salutogenic paradigm is to arm oneself with the most potent scientific stance possible.
I would add one further point here that is particularly germane to our concern of today. Not to be seen as a whole, complex person by those who surround one, who may have some responsibility for one's care and some measure of power over one is a difficult experience for anyone. But for an older person in at least Western society, it is doubly devastating. It fits into and reinforces the in-validity (to use a term I learned from Irving Zola), the non-personhood, of people who are socially defined as being, at best, in a roleless status.
Let me put the same point in other terms, which are particularly important to those of us who work in the health area. I can hardly deny the importance, even the centrality, of the health domain in the lives of older persons. This does not mean, however, that this is the only realm in their (our) lives. Older people also have values, goals, interests, aspirations, concerns other than those which are directly linked to health. The pathogenic orientation, focusing on the disease rather than the person, on the patient role, almost inevitably makes communication impossible.
I have discussed in some detail why I think that adoption of a salutogenic paradigm in place of pathogenesis makes a big difference in the way we think and work. But salutogenesis is, in the last analysis, a question, a way of looking at things, which asks: "How come anyone ever makes it?" We are, then, back to my original thesis, namely: A salutogenic orientation provides the basis for the development of a more powerful theory (and hence guide to action) of health dynamics. Or, to put it simply in terms of my own professional biographical senescence -- oops, sorry, development -- posing the salutogenic question led me to search for an answer. I now turn to the answer. It must, however, be put in a framework, particularly if one is to apply it to the concerns of those who work in gerontology. That is, before I turn to the construct which I propose is the answer to the salutogenic question - the sense of coherence - let me consider briefly some of the stressors of central concern in the later years of the life span.
As a point of departure, let me return, in a way, to adolescence, this time not facetiously. I think there would be general agreement among developmental social scientists that the work of Erik Ericson has been among the most creative and influential in advancing our understanding of adolescence. But Ericson had a model of overall human development. This model, with some oversimplification, consists of three elements. First, the life course is conceptualized in terms of eight stages. Second, in each stage, the person faces a complex of tasks. Third, wrestling with these tasks leads to being victorious or defeated with respect to the core issue of each stage, e.g., identity vs. identity diffusion in adolescence, or integrity vs. despair in old age.
This is not the place to discuss the problematics of Ericson's model or the inadequacies of his disciples. The notion of stages, instead of being seen as a heuristic device, has been confused with reality. Commitment to traditional psychoanalytic theory, which puts an end to human development when genitality is reached, trapped Ericson himself into allotting no more than three stages to post-adolescence. Evidently nothing much happens from the time one has a child or writes a poem in one's twenties or thirties until one is about ready to call it quits in old age. And, in my view most important of all, those who have used Ericson's model have failed badly by disregarding the sources of the challenges or problems of each stage. In this they have betrayed Ericson's own earlier work, as well as the work of no less important predecessors such as Abram Kardiner and Erich Fromm. Without disregarding biology, they saw human development and, at its core, personality development, in an historical-cohort, cultural and social structural context. I propose, by exploiting the strengths and disregarding the shortcomings of Ericson's model, to lead to an answer to the salutogenic question which may be helpful in understanding aging.
It would be impossible to here present a systematic, inclusive statement of the central tasks which face older persons. The moment we accept that these tasks derive not only from biology but no less from history, society, culture and psychology and, moreover, that biology is very much confounded with these other sources, it is seemingly impossible to make any generalizations. Not many older Americans have children in Somalia. Almost every Israeli older person has, for 30 to 60 days a year, a son or son-in-law on active military duty, for we are called up to reserves until our fifties. Nonetheless, let me briefly discuss two tasks which, though far from universal and always shaped by particular circumstances, may be sufficiently prototypical and widespread to help in understanding the lives of older people and to allow me to move on to my answer to the salutogenic question.
Not quite parenthetically, I trust that you have noticed that I have spoken of tasks, not of problems or burdens or challenges or opportunities. This is not accidental. A task is open-ended; it may be perceived and evaluated in many different ways. I would have used "stressors", but feared that most of you would not know that I use the term in a completely open-end fashion. I will return to this important remark later.
It would seem that at least for those of us who do research and/or write about gerontological issues -- that is, middle and upper middle class Westerners -- the central task confronting an older person is for her (use of the female is, of course, related to demographic reality and not to PC) to carve out her autonomy and independence. The theme permeates both the professional and the popular literature. May I suggest that this is an unfortunate confusion of one possible answer with the real question. The realities of the life, say, of a 75 year old woman -- by which I mean the changing economic, demographic, geographic, social and biological aspects of her life -- are such as to compel her to confront the task: How am I to relate to others, on the personal, institutional and societal levels, now that I am somewhat hard of hearing, now that my married daughter has moved with the grandchildren to Australia, now that my late husband's life insurance policy has given me a solid bank account, and so on? Or, across town, another woman is asked by life: How should I live, now that my arthritis is more painful, now that it has become too dangerous to walk in the streets, now that the grandchildren no longer need me, and now that Social Security benefits are barely adequate?
Autonomy and independence, I suggest, make up only one possible answer to the task of carving out modified relations to others in the light of changing circumstances. Moreover, it is a culturally shaped answer which is very much a double-edged sword. To promote it is to incur the dangers of what the doctors euphemistically call "side effects": to enhance distrust of others, for we are told that we can only rely on ourselves; to promote guilt for being dependent in areas that we really have no alternative; to disregard the potential for mutual aid; to waste scarce energies trying to be independent; to deprive others of the gratification of giving; to get society off the hook. And, perhaps above all, to impoverish the value of responsibility and commitment to others. A la Carol Gilligan, it is a masculine message par excellence. To put it bluntly: Why on earth should I not be dependent upon my son to worry about my house repairs, or for my daughter to do the shopping? This will give me more energy to do what I can still do well. The problem arises when the burden on others makes them pay too high a price, or when dependence diminishes a potential that is there. But I see nothing virtuous about independence and autonomy as such.
The second task of elderly persons I'd like to comment on is one which, until very recently, was non-existent as far as social recognition goes: What is one to do with one's sexuality? Of course this is a task throughout life. But my point is that because of developments within and outside the person, the task takes on a new character. One's spouse dies; one's state of health raises problems; and, above all, one confronts the dominant social value, probably long ago internalized, of automatic characterization as a dirty old man if a male engages in sexual behavior. There is, I think, no such phrase for older women because any expression of their sexuality is simply unimaginable.
Now, there are a variety of possible ways of coping with this task. One may long ago have come to terms with being asexual, within a framework of religious ideology or otherwise. One may broaden (or limit, as you wish) the understanding of sexuality to intimate physical gratification without intercourse or orgasm. One may be content with masturbation. (I cannot here refrain from quoting a colleague of mine who long ago noted "that the activities within many traditional medical schools bore a strong resemblance to masturbation: pleasant enough, but lacking true object-relatedness and thus doomed to be depressingly unproductive.) Or one may develop new relationships or a rich fantasy life.
There are, of course, other major tasks which could be discussed, such as the near-daily confrontation with the deaths of age peers, or, perhaps above all, the roleless status of the retired person. As I said, however, my concern was limited to pointing to a few major tasks confronting the elderly as a necessary step in the analysis of the response to the salutogenic question: In light of the complexity of the tasks people face, in light of what I called the immanent process of entropy in human existence, how does anyone ever make it, maintaining her or his position on the continuum and even moving toward health? My contention is that failure to adequately resolve the tasks has pathogenic consequences. My concern, of course, is: What enables people to be fairly competent at resolving the tasks they confront?
Let me make clear what I am profoundly convinced is not the answer: the adoption of any substantive coping strategy to cope with all the tasks. I am particularly distressed, as I suggested above, by the assumption that autonomy, independence, self-reliance, mastery or whatever one wishes to call it, is the answer to the tasks which confront the elderly. Nor do I hold much brief, as a scientist, for any other substantive answer, such as social support or not keeping things in or whatever the current rage among experts happens to be. I am, perhaps, too sensitive (for good biographical reason) to the dangers of the Marxist notion of false consciousness, that is, we know the truth for you. This does not mean that scientific research has nothing to contribute. On the contrary.
The very first thing we know, I believe, is that because the tasks are variegated, no one type of coping resource can always work. Sometimes it is best to flee; call it denial. Sometimes calling for help, or tackling a problem as a collective works best. For some, prayer, for others, stoicism. The point is that the most effective way to cope successfully with tasks is the capacity to be flexible and adaptable, choosing what seems to be the most appropriate available resource at one's disposal.
Underlying the task-resolution behavior, the flexible employment of appropriate resources, is the belief that one indeed has such resources at one's disposal. Note, at one's disposal, not in one's control. Control may be in the hands of a legitimate other: a spouse, a friend, a God, an institution, even a doctor.
What I have been speaking of here is one of the components of what I see as a major answer to the salutogenic question, the sense of coherence (SOC). I call this component manageability. It bears some similarity to Bandura's concept of self-efficacy. Unlike Bandura, however, I do not believe that such an instrumental component is adequate for successful task-resolution. Cognitive and motivational components are no less essential. Further unlike Bandura, I stress the sense of manageability as a generalized orientation toward life, whereas he insists on the proximal character of self-efficacy.
We can hardly, however, judge whether appropriate resources are at our disposal to cope with a task unless we believe that we have some understanding of its nature. I call this cognitive component comprehensibility. Again, it bears some similar to Lazarus' concept of appraisal, but it too expresses a generalized orientation, a belief that the signals transmitted are information, not noise, can be structured and are not chaotic.
The third component of the SOC is meaningfulness, the motivational belief that it makes emotional sense to cope, that, though life may have its pains, one wishes to go on. Surely the clinicians among you will well know what I mean. This component is akin to Frankl's meaning in life construct.
The SOC, then, is a global orientation to the world, perceiving it, to a greater or lesser extent, as comprehensible, manageable and meaningful. It is, I submit, a central dispositional orientation in the lives of all human beings. I have proposed that (1) the elderly, as much as people throughout the life career, confront a variety of tasks shaped by biological, historical and psychosocial forces; (2) that the more successful they are in resolving these tasks, the more likely they are to maintain or improve their places on the health ease/dis-ease continuum; and (3) that the SOC is a major determinant of such success. Since the publication of my two books on the subject in 1979 and 1987, there has been not inconsiderable research devoted to testing the theoretical model. Tomorrow some of us engaged in such research will gather and report on our findings.
I must, however, ask you to bear with me for a few more moments, and share one further element of my thinking, which may well not be to your liking, particularly if my approach appeals to you. The strength of the SOC begins to be shaped well before kindergarten. By the time we have become stably functioning adults (for those who are in their forties and still in the moratorium of post-adolescence, I am afraid that almost by definition one must say that they have a weak SOC), this dispositional orientation has largely been set. One's interpersonal and work experiences, shaped in a framework of one's social class, gender and ethnic group membership at a given time in history, have done their work.
Thus, by the time one is elderly, I doubt that much change is to be anticipated. Those of us with a strong SOC will continue to suck what is called negentropy from the environment; those of us who are less fortunate will increasingly see the world as incomprehensible, unmanageable and meaningless. For those of us who make a living in gerontology, it might be useful for our own SOC to think that we can make much of a difference to others. And I would be the last to deny that we can, indeed, using the power of a good theory, make a bit of a difference, which is not to be sneezed at. But we should have no illusions: if we want to make a major difference, we should go into education or industrial sociology or, better yet, start remaking the social structure.
One final word. In all of science, the question is always more important. I do hope that the SOC construct, even in the abbreviated form presented here, makes sense to you. But if I have to pick, then it is far more important that you seriously ponder the meaning of salutogenesis than that you buy the SOC. Thank you.
Berkeley, 21 January 1993