by Aaron Antonovsky
Lecture at the Congress for Clinical Psychology and Psychotherapy,
Berlin, 19 February 1990
The paper's point of departure is the proposal that the pathogenic paradigm which at present dominates disease research and clinical practice in the industrialized world is of decreasing power as we try to understand and deal with the health and illness of human beings. The limitations of the paradigm are not resolved by preventive medicine or the biopsychosocial model. Five important contrasts are presented to show that the difference between the pathogenic and the salutogenic model, which posits that the great mystery is the origin of health, are fundamental.
The search for the answer to the question "What explains movement toward the health end of the health/ illness continuum?" led to formulation of the sense of coherence concept and its three components, comprehensibility, manageability and meaningfulness. The overarching hypothesis, then, became: the stronger the SOC, the greater the likelihood of moving toward the health end of the continuum.
The major determinants of the SOC are located in macrosocial and historical factors. Finally, it is noted that there are many roads to a strong SOC and health, and that health is not the only value in human life.
STUDYING HEALTH VS. STUDYING DISEASE
Lecture at the Congress for Clinical Psychology and Psychotherapy,
Berlin, 19 February 1990
The paper summmarizes a journey of some 15 years of research. It starts by proposing that a pathogenic paradigm at present dominates disease research and clinical practice in the industrialized world. It suggests that this paradigm, based on the assumption that disease is deviant and puzzling, is of decreasing power as we try to understand the health and illness of human beings. The limitations of the paradigm are not resolved by preventive medicine or the biopsychosocial model. A salutogenic paradigm is offered as an alternative. This paradigm is based on the assumptions of inherent heterostasis and conflict in human existence. The contrasting answers of the pathogenic and salutogenic models to five fundamental questions are presented to show that the differences between them are fundamental.
1. How are people classified in terms of their health status? A dichotomous vs. a continuum classification
2. What is to be understood and treated? A scientific diagnosis of the specific disease of the patient vs. assessment of the overall state of health/illness of persons
3. What are the important etiological factors? The risk factors for the particular disease being considered vs. the total "story" which can explain location on the continuum, including salutary, health-promoting resources
4. How are stressors conceptualized? As somewhat unusual and pathogenic vs. as ubiquitous and open-ended in consequences
5. How is suffering to be treated? The "magic bullet" and wars against diseases vs. strengthening coping resources
The search for the answer to the question "What explains movement toward the health end of the health/illness continuum?" led to the study of resistance resources. Such resources are conceptualized in terms of the overall construct of the Sense of Coherence (SOC) and its three components, comprehensibility, manageability and meaningfulness. The SOC is clearly not a particular coping strategy, but a general orientation to life. The overarching hypothesis proposed is that the stronger the SOC, the greater the likelihood of moving toward the health end of the continuum.
The important determinants of the SOC are to be found in the nature of the society in which one lives in a given historical period, and the particular social role complexes in which one is embedded. Finally, it is to be noted that there are many roads to a strong SOC and health, and that health is not the only value in human life.
STUDYING HEALTH VS. STUDYING DISEASE
Aaron Antonovsky, Ph.D. was the Kunin-Lunenfeld Professor of Medical Sociology and Chair, Department of the Sociology of Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
Lecture at the Congress for Clinical Psychology and Psychotherapy,
Berlin, 19 February 1990
When Dr. Faltermaier invited me to address you, he asked me to present a social science perspective on health and health research, discuss the conceptual shift from an illness to a health orientation, characterize the current situation of the sociological and psychological research on health and illness, analyze the role of the health concept in international research, present my own standpoint, and discuss its consequences for health promotion. I have two alternatives: I shall be glad to deal with the issues raised by Dr. Faltermaier -- on the condition that you agree to listen to me the rest of today and at least all of tomorrow, cancelling everything else on the program. The other alternative is to limit myself to discussing my own model, leaving it to you to relate it to the broader questions. I assume that you prefer the latter alternative.
My point of departure is to specify the goal of my professional endeavors, a goal which I, a medical sociologist, share with all of you, clinicians and researchers alike: We seek to advance a scientific understanding of the bodily and emotional suffering of human beings associated with illness. Please note that I exclude grief, misery, unhappiness, frustration and the like, though such emotions involve suffering and may well lead to illness. Also note that I, as well as you, have other goals in life. I will return to both these issues later. Because illness is universal, every human society has developed a paradigm, a philosophy, a set of fundamental assumptions, a set of categories, to provide such an understanding. And every society has developed a social institution, based on its understanding of illness, to deal with the problem. In modern western industrialized societies, what is called the biomedical model provides this paradigm. It is embodied in the complex of medical care institutions which we have created. As patients, practitioners or researchers, we have all internalized this understanding of illness.I have proposed that this philosophy be called the pathogenic paradigm, since its base is a set of assumptions about the origins, nature, course and therapy of pathology. Its point of departure is that specific pathogens or disease agents, or insufficiences or superfluities, come to threaten the integrity of the organism. The resulting symptoms are diagnosed in terms of diseases, as detailed in the International Classification of Diseases, Injuries and Causes of Death, or in DSM-III. The social institution of medicine, including psychiatry, is organized around the identification of the disease and the application of chemical, physical or surgical weapons to repair or minimize the damage to the organism wrought by the pathogen. Research is directed to identifying the pathogens and the search for their elimination.
This is a paradigm which emphasizes the individual person, the material body, the mechanistic interrelationships among the parts of the body, and the cheerful assumption that most of the time, for most of us, the machine does not break down. It would take us too far afield to discuss why this pathogenic paradigm has emerged. But I would suggest that it is a paradigm which is comfortable with the mode of industrial production, whether of a free market or centralized planning type, which has dominated the developed world.
Two major lines of criticism of this paradigm have emerged. The first may be called the school of prevention, whose advocates have advanced an attractive metaphor. They point to what is called "the bias of the downstream focus". Visualize a river with a bend. Downstream, where the river has become very turbulent, we find people desperately struggling to keep their heads above water. Using a great variety of weapons, the disease care professionals, with great devotion, skill and arduous effort, seek to save those in danger of drowning. We pay almost no attention to, and invest few resources in, this school cogently points out, what goes on upstream. We do not ask: Who or what is pushing these people into the river?
The second line of criticism is exemplified in the work of George Engel, which uses a systems theory approach. He proposes that, particularly in an era in which, in the western world, chronic rather than infectious diseases are the main causes of suffering, we must reject the image of specific pathogen/specific disease and apply the concept of multiple causation. Engel has called this view the biopsychosocial model. A wide variety of pathogens, including psychosocial factors such as stressors and life styles, combine to push people into the river of disease and cause suffering and death. Both emotional and somatic disorders are to be explained within the same pathogenic framework.
There is no doubt that the pathogenic paradigm has provided a powerful intellectual and practical way to understand and deal with illness. And when the pathogenic paradigm is modified by a greater focus on prevention and by inclusion of the concept of multiple causation, it becomes even more effective. But even with such modification, the paradigm remains pathogenic! The focus of attention may move upstream; we may pay more attention to non-biological factors which push people into the river and put them in danger of drowning. But the metaphor remains the same.
I can now come to my major thesis, which points to the fundamental inadequacy of the pathogenic paradigm, its Achilles' heel. This is its assumption of homeostasis as the normal state of affairs, its belief that, unless some special combination of circumstances occurs, people do not contract a disease. They stay what is called healthy, remaining safely on the banks of the river. My proposal to you is that heterostasis, inbalance, suffering are inherent in human existence, just as death is. We are all, to continue with the metaphor, in the river from the moment of our conception until we pass over the brink of the waterfall to die. The human organism is a system and, as all systems, subject to the force of entropy. The nature of the river we are in varies. Ethiopians and Israelis and Swedes, upper and lower social classes, men and women, are in different rivers whose currents and whirlpools and other dangers vary, but none of us are ever safely on the shore. Nor is any river very benign. If this is the case, then the real mystery is not that of understanding why people get sick and die. The pathogens are ubiquitous, brilliant, endemic. The epidemiological data indicate that pathology is indeed far more prevalent than is implied by the pathogenic approach. The real mystery is to understand how some people, some of the time, suffer less than others, move toward health. This is the question which forced itself upon me. Finally, when the question became pressing, when its revolutionary implications became clear, I realized that, not by chance, our vocabulary had no word to express the question. This is what led me to coin the neologism "salutogenesis" - the origins of health.
I do not have the space to explain in detail what led me to the formulation of the salutogenic question. In brief, I can point to two sources. Throughout my career as a sociologist, I have been committed to what is called conflict sociology. This school proposes that if we wish to understand social systems, we must focus on the endemic, built-in conflicts which characterize them all. But there is a far deeper and more personal source of my formulation of the salutogenic question, one which is related to the fact that I have never, till now, agreed to spend any time in Germany. I am deeply and committedly Jewish. Two thousand years of Jewish history, culminating in Auschwitz and Treblinka, have led to a profound pessimism about human beings. It has led me to the understanding that we are all, always, in the dangerous river of life. We never stand safely on the shore.
All those familiar with the history of science are aware that important advances come with the formulation of new questions. The question is the breakthrough; the answer comes with difficulty,but it is the new question that is important. The salutogenic question, I submit to you, is a radically new question, which provides the impetus for formulating a new paradigm to help us understand health and illness. It has serious implications for researcher and clinician, biological and social scientist alike.
But is it really a new question? Is it not just the other side of the pathogenic coin? Does it indeed open up new ways of thinking, lead to different hypotheses, different avenues of research and practice? I leave it to you to judge. I will raise five basic questions. In each case, I will note the answers given by those who base their work on the pathogenic paradigm -- the great majority of you. I will then suggest the answers which flow from a salutogenic paradigm.
(1) How are people classified in terms of their health status? A pathogenic orientation leads to a dichotomy. People are classified as being either healthy or sick. This is true whether one has a preventive or a curative emphasis, whether one thinks in biopsychosocial or in biomedical terms. A salutogenic orientation, by contrast, compels us to adopt the approach of a continuum. Total health and total illness are the extreme poles. No one is ever at either pole, from the moment of birth till the moment of death. There are forces pushing us in one direction or the other, but we are all, in this view, in part healthy, in part sick.
(2) What is the focus of attention, what is to be understood and cared for? I have been kind to those who work with the pathogenic orientation in putting its answer to the first question. In reality, they see people either as non-patients, and hence presumably "healthy", or as patients, as cases, on whom a specific disease label, a diagnosis, must be pinned. Data are to be obtained only on those things which bear a direct, demonstrated relationship to the hypothesized disease. Since the categorization and treatment of diseases is a very complex matter, both therapist and patient come to think that what the patient has to say is not particularly important. After all, he or she has not studied medicine or clinical psychology. Having studied medicine makes the physician more comfortable with organic diseases. What cannot be classified as an organic disease is either disregarded or turned over to the psychiatrist. Note further that the practitioner or researcher, an expert in this or that disease, has little reason to communicate with colleagues who specialize in other diseases. Why should an expert in anorexia-bulimia talk to an expert in sex therapy, not to mention one in lung cancer? The salutogenic orientation, on the other hand, leads to a concern for all persons, located at any point on the health-illness continuum, not only for patients; it confronts the overall state of their suffering. All aspects of a person's wellbeing must be assessed, both by "objective" signs as well as by "subjective" symptoms. Thus the person does not become a case of disease X. This is not because the salutogenic practitioner is more humane than his or her pathogenically-oriented colleague, but because the philosophic approach compels an assessment of the whole person. The sufferer remains a person, not a case of liver, kidney or brain chemistry or eating behavior disturbance.
(3) What are the important causal factors? It follows from the above that the pathogenic orientation leads us, in research or in clinical work, to focus on etiological risk factors for specific diseases. This is true whether one is still caught in the bind of the classical germ theory of disease or whether one has adopted the concept of multiple causation and the epidemiological triangle of agent, host and environment. We search for those pathogens, physical, microbiological or psychosocial, which might account for why the individual with disease X was so afflicted, or why a certain population group has a high rate of disease X. The salutogenic orientation, in its search to explain the location of a person on the health-illness continuum, leads us to get to know what has been called "the story" of the person. The story of the person, moreover, includes not only the risk factors in his or her life, but factors for which we do not even have a name, so rarely do we look for them. Thinking pathogenically, we may note the absence of risk factors; we may even pay some attention to protective, buffering or mediating variables. But we do not, unless we are salutogenically-oriented, search for those factors which actively promote movement toward the health end of the continuum. I proposed that these be called salutary resources.
(4) What are the consequences of stressors? I turn now to my particular field of expertise, the study of psychosocial stress. Ever since Hans Selye's pioneering work, there has been a powerful trend to see stressors as risk factors, as dangerous and damaging, in short, as pathogenic. In fact, once the notion became popularized, a large-scale industry has developed, promising to remove stress from our lives. Whether it has done so is questionable. (I would, though, guess that it has been successful in decreasing the financial stressors of the practitioners in the industry.) The data do indeed point convincingly to the connection between stress and various diseases. For those who focus on pathology, the chain "stressor-stress-disease" is not to be ignored. A salutogenic orientation, however, though no less aware of the dangers of stress, starts out from the premise, you will recall, that life is always permeated by psychosocial as well as by microbiological and other stressors. But it leads us to take two giant steps. First, it proposes that stressors are no more than potentially pathogenic. That is, it proposes that a stressor need not lead to stress and to disease if it is coped with successfully. Second, and even more fundamental, because of its focus on salutary factors, it leads us to be open to the possibility of seeing a stressor as potentially positive, as health-promoting. Think of getting married, or having one's first baby, or becoming chair of one's department, or retiring -- surely these are major stressors. Or, for that matter, think of unhappy stressors, such as bereavement, being fired or divorce. Are such stressors pathogenic or salutogenic? The salutogenic orientation leads us to see that they may be either.
(5) Finally, how is suffering to be treated? This issue is linked to the third one, the question of etiology. Just as the pathogenic orientation leads one to focus on "the germ" or combination of germs or risk factors which "causes" disease X, so it leads one to search for the specific treatment for disease X. This is what Rene Dubos has called the "magic bullet" approach. The fact that the illness/health of the person is a far more complicated matter than just disease X is ignored. But the problem is even more profound when considered on the level of social policy. The "magic bullet" approach, Dubos warns us, leads to "the mirage of health". It implies that all we need is a war against smallpox, another war against cancer, then a war against HIV and schizophrenia and, and, and...and soon, if we devote enough resources to these wars, we will all be permanently healthy. The salutogenic approach, seeing the struggle to move toward health as permanent and never fully successful, focuses our concentration on those salutary factors which will help people to cope as successfully as possible throughout their lives.
To sum up my discussion of salutogenesis versus pathogenesis: I have proposed that, throughout our lives, we are all swimming in a river full of potential danger. Or, to change the metaphor to one which may be more appropriate to winter in Germany, we are all skiing down a long mountain slope, at the end of which is an unavoidable cliff with no bottom. The pathogenic orientation deals primarily with those who have hit a rock, a tree or another skier, or who have fallen into a crevice. Second, it tries to perpetuate the illusion that one should not ski at all. The salutogenic orientation asks, first, how the ski slope can be made less dangerous, and second, how do people learn to ski with a high degree of skill?
I have noted earlier that, in science, the question is more important than the answer. I have therefore devoted much of my time to clarifying the implications of asking the pathogenic versus asking the salutogenic question. I now turn to the answer to which asking the salutogenic question has led me. I call it "the sense of coherence" (SOC).
The road to developing the SOC concept was lengthy. I shall not here discuss the details of the journey. These are recounted in two books published in 1979 and 1987. But it is important to specify the point of departure of this journey. I started out by looking for generalized resistance resources or, as I came to call them, salutary factors, factors that helped one cope well no matter what the stressor. The idea of social supports was becoming prominent. My own research pointed to such factors as money and cultural stability. But what did these factors have in common? What made them resistance resources? How did they work to promote successful coping with stressors and movement toward health?
The first commonality I identified was that such salutary factors strengthened one's belief that the stimuli from one's environment made sense. This cognitive emphasis characterizes the earlier presentation of the salutogenic model. Later I came to call this component the sense of comprehensibility.
In the course of time, it became clear to me that the belief that stimuli made sense, were ordered, structured and predictable, was essential but not sufficient to cope well. It was not enough to believe that one understood. The second factor common to salutary resources was that they led to instrumental confidence. One rejected the idea that the cards of life were stacked against one. The stimuli or, if you will, the stressors, were always there, making demands, requiring coping. But if one was persuaded that a variety of appropriate resources to meet these demands were available to one (in one's own hands or in the hands of those in whom one trusted), one would be able to cope well. I called this second component of the SOC the sense of manageability.
But something was missing. To believe that one comprehends and that one can manage is not enough. The motivational element is crucial. One must wish to cope. One must see the demands posed by the stimuli as "making sense" emotionally, as posing a challenge and not a burden. The stimuli may be immensely painful and sad, such as the death of a loved one. One can lift up one's hands in despair, or one can be determined to continue the struggle. What resistance resources seem to do is provide one with the third component of the SOC, the sense of meaningfulness.
The sense of coherence, then, can formally be defined as:
a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement.
This is my theoretical answer to the salutogenic question. The hypothesis, then, is: The stronger a person's SOC, the more successfully will she or he be able to cope with the inevitable, continual, built-in stressors in human existence. It would take us too far afield to discuss how it works. But I wish to make it clear that the SOC is not a specific style of coping. In fact, it works precisely because it enables one to select that mode of coping, those resources, which seem to be appropriate to the particular stressor complex which one faces. The hypothesis accords well, I believe, with much empirical data. Its acceptance, of course, requires an extensive program of research, some of which is under way, by myself in Israel and by colleagues from New Zealand through Sweden to the United States. I shall be glad to meet this afternoon with any of you who may be interested in conducting such research.
I should like to devote the remaining minutes of my talk to two fundamental issues, each of which merits a separate lecture, and each of which, in a sense, refers to the political implications of the SOC concept. First, what determines the strength or weakness of a person's SOC? Kindly recall that I am a sociologist who sees the concepts of conflict and power as crucial in explaining the lives of human beings. I do not deny the importance of early childhood experiences and immediate interpersonal relations, though I would stress that these are shaped by their macrosocial environment. But the most profound sources of the SOC are to be located in the nature of the society in which one lives, in a given historical period, and in the particular social role complexes in which one is embedded. These are the forces which determine how dangerous the ski slope is, and how well or how badly one learns to ski. To be more concrete: the strength of the SOC is determined by the consistent experiences one has as a woman in a patriarchal society, as an alienated worker, as a discriminated-against immigrant; or, on the other hand, as a successful entrepreneur, a respected professor or a powerful politician. I leave it to you to draw the appropriate inferences for clinical psychology from this view.
With regard to the second issue, I should like to say that I cannot think of any occasion at which I felt that it was more important to make the point than now, in speaking to a largely German and Austrian audience in Berlin. In a way, the possibility of saying this was what made it possible for me to come to Germany. The point can be summed up by saying: There are many roads to a strong SOC. I wish I could say that a strong SOC is only possible in a society which fosters autonomy, creativity, freedom, equality, warmth in human relations, dignity and respect for all persons. These are values which I hold. But unfortunately, I must say that a strong SOC is not only possible but can be promoted in many different social and cultural contexts. It is quite compatible with many different ways of life, including those which violate many of the values I hold dear. Who says that health is the only, or even the most important, value in human existence?
It is often asked whether it is possible to be healthy in a sick society. I do not know what a sick society means. I do not think that Nazi society in Germany and Austria was a sick society; I do not think that the vast majority of your grandparents and parents were sick; I do not think that until you work through this heritage you will be sick. The concepts of illness/health belong to a different realm of discourse. Nazi society and most of its inhabitants manifested the peak of human barbarism. The problems you face in dealing with your heritage are profound. But this says little about health/illness. Guilt and fear may be pathogenic; but all too easily, people can be free of these unpleasant emotions by casting their lot with the powerful.
Of course, it must be said that the strong SOC and resultant good health of Nazis, of religious fundamentalists, of patriarchal males, of colonialists, of oppressive aristocrats and capitalists and commissars are achieved at the expense of their victims. And there are substantial segments of the population -- the Yuppies of Reagan and Thatcher and Kohl -- who can, without being oppressors, and in the privacy of their affluent society lives, also have a strong SOC. A salutogenic orientation provides no prescription for a good life in the moral sense of the term; it can only help us understand health/illness.
I have tried, in the time available to me, to summmarize a journey of some 15 years, a journey, I might say, that has strengthened my own SOC. I proposed to you that the pathogenic paradigm which at present dominates disease research and clinical practice in the industrialized world is of decreasing power as we try to understand and deal with chronic illness. The limitations of the paradigm are not resolved by preventive medicine or the biopsychosocial model. Five important contrasts were presented to show that the difference between the pathogenic and salutogenic models are fundamental.
I then discussed how the search for the answer to the question "What explains movement toward the health end of the health/ illness continuum?" turned me to the study of resistance resources. Seeking for commonalities in these resources, in turn, led me to the sense of coherence concept and its three components, comprehensibility, manageability and meaningfulness. The overarching hypothesis, then, became: the stronger the SOC, the greater the likelihood of moving toward the health end of the continuum.
I briefly pointed to the important determinants of the SOC: the nature of the society in which one lives, in a given historical period, and the particular social role complexes in which one is embedded. Finally, I noted that there are many roads to a strong SOC and health, and that health is not the only value in human life.
The two books by Dr. A. Antonovsky referred to in the text are: Health, Stress and Coping (1979) and Unraveling the Mystery of Health (1987). Both are published by Jossey-Bass Publishers, San Francisco.