by Aaron Antonovsky
THE SALUTOGENIC APPROACH TO FAMILY SYSTEM HEALTH:
PROMISE AND DANGER
European Congress on "Mental Health in European Families", Prague, Czechoslovakia, 5-8 May 1991. Dr. Antonovsky was the Kunin-Lunenfeld Professor of Medical Sociology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheva, Israel.
Two Parallel Tracks
If one takes a short walk from here to the new Prague town hall on Marianska Namesti, one will see a statue, surprisingly not destroyed by either Nazis or Communists, of Rabbi Yehuda Loew ben Bezalel, the Maharal, the chief rabbi of Prague 400 years ago. One of the most powerful memories of my adolescence is a movie about the Maharal, a movie which has its origins in 18th century folk legends but no basis whatsoever in historical reality. In the legend, Rabbi Loew has, in great secrecy, fashioned a figure from primordial matter, a Golem. (The word "golem" appears only once in the Bible, in Psalms 139:16; it is translated as undeveloped form, or unformed substance.) Unable to bear the sufferings of the Jews any longer, Rabbi Loew cuts the cords which bind the Golem and activates it by engraving in its forehead the three Hebrew letters, Aleph, Mem, Tav, spelling Truth. The powerful Golem wreaks havoc among the persecutors of the Jews... but soon begins to wreak havoc at random. Rabbi Loew, realizing his fatal mistake, reaches up and erases the Aleph, the first of the three letters, leaving Mem Tav, which in Hebrew spells Death. The Golem disintegrates into a small pile of dust - a scene I still see before me, after half a century.
For me, Prague will always be associated with this legend. I have still another adolescent memory, one which may be more familiar to you: Karl Capek's play "R.U.R.", first performed at the National Theatre in Prague in 1920. You will recall that humanity was to be freed of the Biblical curse of work by the products of the Rossam's Universal Robots factory. The denoument is even more horrible than that of the legend of the Golem.
I was invited here to address you about the way of thinking which led me, some twelve years ago, to coin the term "salutogenesis", and to explore how this concept might usefully be applied by mental health professionals in understanding and in working with families. The task seemed easy. In recent research on retirement and health, we have explored coping with retirement from work not only of the individual but of the family (Sagy 1990). In another venture in which I am engaged with a group of European and American colleagues, exploring the philosophical basis of medical education, salutogenesis and systems theory are two central concepts.
The Golem and RUR...salutogenesis and systems theory. Were these two parallel tracks in my mind, which really had nothing to do with each other? It seemed likely. I tried to concentrate on the theme of the Congress, but my other associations with Prague would not go away. Finally, the connection was brought to awareness by recalling a sentence I had written in my second book on salutogenesis: "There are many cultural paths to a strong sense of coherence." (Antonovsky 1987, p.94), the core concept of what I call the salutogenic model. It is the association between the Golem and salutogenesis, between RUR and systems theory, this meeting of parallel tracks, that I would like to explore with you today, after I have discussed the salutogenic model.
The Salutogenic Model: The Question
For those of you who are not familiar with the salutogenic model, let me review its essentials briefly, with apologies to those of you who know my work. As a medical sociologist, I had for years done research on the role of social, cultural and psychological factors in multiple sclerosis, heart disease and cancer. I was firmly rooted, as were and are almost all of my biomedical and social science colleagues, in what I later came to call a pathogenic orientation: the search for the origins of pathologies. My first departure from this path came when I realized (Antonovsky 1972) that there were two sets of legitimate questions. The first focused on the origins of a given pathology. My own interest became the second: the origins of breakdown, of dis-ease, that is, inquiry into the factors which were common to all departures from homeostasis, common to all forms of system breakdown.
The crucial leap in my thinking, however, came a few years later. This leap came about because of two realizations. The experts in cancer epidemiology know about cancer rates; their colleagues in mental illness know about psychopathology rates. And so on. When I inquired into rates of dis-ease, of pathology in the singular, I became aware that it is far more prevalent than one might have thought. As I put it (Antonovsky 1979, p.15), "At any one time, at least one third and quite possibly a majority of the population of any modern industrial society is characterized by some morbid condition, by any reasonable definition of the term." My second realization came from a more philosophical or historically- sensitive line of thought. Looking at the physical, microbiological and psychosocial world in terms of the omnipresent pathogens with which human beings are confronted, the epidemiological data began to make sense. Any of you who have raised a child will know exactly what I mean, even if you are not a hysterical parent. The pathogenic orientation starts from the axiom that homeostasis, non-disease, is the normal state of affairs; departure from such "normalcy" is what has to be explained. It became clear to me that such departures, given the nature of our world and, of course, the inevitability of death, were almost self-evident. In your own field, must you not ask: Given the world as it is, how can anyone not go crazy? Or, if you have a philosophical bent: How can anyone not commit suicide?
The question for me, then, became one of seeking to understand the rarity, almost the miracle, of those who do not break down. The question was so unusual that it had no name. This led me to coin the concept of salutogenesis -- the origins of health. I have elsewhere discussed the many implications of adopting a salutogenic orientation. Two are most pertinent here. First, when one thinks pathogenically, one tends to dichotomize people: either one does or does not have disease A, disease B, etc. Salutogenesis leads one to see health/disease as a continuum. At any one time, a person is located, in terms of her or his overall state of health, at a given point on the continuum. Salutogenesis focuses on movement toward the health pole. Second, pathogenesis inquires into "risk factors", a term with which you are all familiar. Salutogenesis inquires into -- what? We do not even have a name, a concept, for factors which promote movement toward health. At best, we speak of protective factors. Without a concept, without at least a tentative theoretical formulation, we do no empirical research that might advance our understanding of movement toward health.
The Salutogenic Model: The Answer
Having formulated the salutogenic question, I began the search for an answer, a search which led me to the formulation of the core construct in my model: the sense of coherence (SOC). The first version of this construct (Antonovsky 1979) was in good measure shaped by systems theory thinking. The human organism is to be understood as a system constantly bombarded, from both sub- and suprasystems, by noise, by entropic pressures. The organism's core problem, then, if it is to survive and function, is not only to screen out noise, but to suck information from all possible sources, to search for negentropic resources, or, to put it simply: to make sense out of the stimuli constantly bombarding us. The general problem, central to all sciences today, is that of "Order out of Chaos". I first conceptualized the SOC as a generalized view of the world which ranges from seeing it as totally ordered to totally chaotic. The more one believes that the world is ordered, the stronger one's SOC, the more adequately can one cope with the stressors of life, and hence the healthier would one be.
My first definition of the SOC (Antonovsky 1979, p.123) focused on structure, order and predictability. It was strongly cognitive in emphasis. As I developed the construct, both through exploratory interviews and efforts at designing an operational measure, it became, I believe, richer and more powerful. Three intertwined but distinguishable components of the SOC were identified. The first is comprehensibility, referring to the belief that the world is orderable. To cope well, however, one also needs to believe that the resources needed are at one's disposal. This component is called manageability. Finally, and crucially, the motivational component of meaningfulness, the wish to cope, provides the motive power. I should, finally, note that the SOC construct is intended to be of a higher level of abstraction than various specific coping resources which have been studied, e.g., social support, money, or cultural stability. Such resources are linked to health, it is suggested, because they strengthen one's SOC, one's sense of comprehensibility, manageability and meaningfulness.
In sum, putting the salutogenic question led me to the formulation of the general hypothesis that the stronger the SOC of a person, the more capable would she or he be of mobilizing negentropic resources, of coping successfully with the endemic, omnipresent stressors of living, and hence of moving toward a higher level of overall health. This hypothesis is now being tested in scores of empirical studies in many countries. The papers that have already been published, as well as unpublished data I have seen, suggest that my ideas are not altogether wrong.
Implications for Family System Health: The Promise
We can now turn to the direct concerns of this Congress. What are the implications of a salutogenic orientation and the SOC construct for family system health and mental health? The salutogenic orientation, it will be recalled, was developed in terms of systems theory thinking. Order and chaos, negentropy and entropy, information and noise, sub- and suprasystems are key terms. Similarly, the SOC construct evolved from thinking in these terms. But the focus was always on the individual. A rich family systems literature has shown that it makes much sense to think of a family as a system, the sum of whose interacting parts make up a whole with its own emergent characteristics.
I submit to you that it would be valuable to apply salutogenic rather than traditional pathogenic thinking to family systems as well as to individuals. Let me give a few examples which suggest how valuable it would be. Suppose we stop classifying families as either pathological or healthy and instead see them as being, at any one point in time, somewhere on the continuum between complete (and non-existent) health and complete (and non-existent) pathology. Moreover, suppose we search for and emphasize the strengths, the healthy elements, which are always to be found in every family, rather than the weaknesses and pathological elements. Suppose we not worry so much about risk factors and instead look for negentropic, health-promoting factors both within and without the system. Suppose we study those families who are reported, despite the most adverse of circumstances, to have coped with success? Suppose we try to gain a deep understanding of the process which has been called autopoiesis of systems, i.e., the capacity for reorganization, on a higher level of complexity, in families which have successfully gone through such trauma as war, migration, the death of a family member, or chronic unemployment? Suppose we think of family health in terms of vitality, exuberance, joie de vivre and energy rather than in terms of anxiety, depression, etc.?
Let me now turn to another consequence of the salutogenic model as applied to family system health by considering the three components of the SOC. My understanding of the manageability component is particularly relevant, for it has often been confused with the sense of mastery or an internal locus of control. Manageability refers to the belief that, given the demands confronting one, one has adequate resources at one's disposal to meet these demands. In discussing the origins of this belief, I emphasize experiences of load balance, i.e., if, over and over again, demands are placed before one which are commensurate with one's capacities, one will come to have a strong sense of manageability. For the child, the adolescent, and even the adult, the demands which confront one are in large part determined by the family system. Demands, of course, also initiate from within -- but these are also often demands which have become internalized by family expectations, from bowel control to career success. But the phrase "resources at one's disposal" suggests an even more important way of looking at things. It leads us to ask not only whether the individual has within herself or himself the required resources, but whether the suprasystems -- first and foremost the family -- in which the person is embedded place such resources at one's disposal. Similarly, the components of comprehensibility and meaningfulness in the individual's SOC can only be understood in a family context. It is the family system which, in large measure, determines the experiences of consistency and participation in socially-valued decision-making which I see as decisive in shaping the SOC.
Implications for Family System Health: The Danger
I have, hopefully, made clear in some measure the implications of the first part of the subtitle of my address, the "promise" of the salutogenic approach. I should now like to turn to the second part of the subtitle, the "danger". I must admit that, in my enthusiasm for the salutogenic model, I have never given adequate attention to its possible dangers. These arise when one closely examines the interacting variables: the SOC, individual and family system health and mental health. It is in this context that the Golem and RUR return to the picture.
The pathogenic orientation of modern scientific medicine is concerned with somatic diseases of the individual. Health is a residual category. Disease refers to biochemical disturbances and pathological lesions which endanger survival of the organism. The crucial criterion is thus evolutionary. Biological psychiatry fits comfortably into this schema. Even the traditions of psychosomatic medicine, which make room for psychological pathogens, raise no problems. One value judgment, and only one, is made, a judgment with which few would disagree: Non-disease is desirable.
I submit to you that the Golem, the matter without form, the body without soul, the Rossam Universal Robot, with adequate wiring capacity, should be capable of containing somatic diseases which impair physical functioning and endanger survival. The wiring could ensure adequate damage repair, at least until all reserves are depleted. This might even include severe mental disease with biochemical origins. The Golem could also be programmed to reproduce itself, so that when the reserves are fully depleted, a next generation can carry on with the "species".
There are seemingly built-in problems for the Golem. First, why should it wish to survive? But "wish" is an irrelevant concept. It is programmed to survive. Second, we can presume that the energy supply requisite for survival at least in part has its source external to the Golem. Thus it requires an ecological niche. What happens when the niche changes? I can see no inherent reason why a Golem could not be constructed with at least a moderate capacity of adaptation to a changing niche. And if it doesn't work? Well, the great majority of species, after all, have become extinct.
From a pathogenic orientation, considering the human being as a Golem promises a highly efficient solution to the problem of disease. This is a frightening vision. Its full horror becomes apparent when we consider mental health and the family system. The Golem, we feel strongly, is antithetical to these concepts. The Golem is a system whose relationship with other systems is technical, an engineering relationship. It seems to make no more sense to talk of the mental health or family of a Golem than it makes sense to talk of the mental health of a thermostat, or of a family consisting of thermostat, boiler and room temperature.
But let us examine our instinctive reaction more closely. Once the matter of the Golem acquires form, once the body is infused with spirit, the system is transformed. We can begin to speak of its mental health and not only of its technical survival capacity. We can begin to speak of the emotional quality of its relations to others, such as the members of the family suprasystem. But why? What is at the core of a system which is form, of a body which has been infused with spirit? Of, in other words, a human being? What is at the core of a family system? I suggest that at the most profound level, this means the capacity to ask moral questions, to make value judgments.
Let us once more return to the Bible, to the story of Adam and Eve. We learn that there were two trees whose fruit they were forbidden to taste. They disdained the tree of life, whose fruit promised eternal survival. Instead, they tasted of the Tree of Knowledge of Good and Evil. From then on they were doomed -- or blessed -- with the capacity to ask moral questions; they could make choices. Banishment from the Garden of Eden led to other questions: Am I my brother's keeper? Why survive, if one is doomed to earn one's bread by the sweat of one's brow, suffer the pangs of childbirth, and soon thereafter die? Why, as Job asked, are the evil so often rewarded and the good punished? These are the questions, I submit, which a concern with mental health and family systems compel us to confront.
A pathogenic orientation, I have suggested, is comfortable with the engineering-mechanistic view of the human being as Golem. The moral-philosophical problems are not inherently within its area of concern. But does the salutogenic orientation compel us to confront these questions? Sadly, I am afraid that my answer must be largely, if not completely, in the negative. At best, it only opens a possibility. In this lies its danger. A salutogenic orientation, no less than a pathogenic orientation, defines health and disease in terms of functioning and survival. All that it argues is that the stronger the SOC, the more likely is the system, whether individual, family or society, to function and survive.
Earlier I quoted myself as having written that there were "many cultural paths to a strong sense of coherence" and hence to health. I submit to you that neither a pathogenic nor a salutogenic orientation, which are both scientific, paradigmatic stances, can, in the realm of mental health, direct us to the selection of any one path which is most efficient in leading to the goal. Let us examine some of these paths.
First, and undoubtedly the most difficult to confront: to be a Golem is one path to a strong SOC. We may be programmed by evolution to consider health and survival as the ultimate value. Moral-philosophical questions are meaningless; relations to others are technical. Or, to put it in system terms, such matters are regarded as noise, to be screened out, for they introduce chaos and increase the level of entropy. (When I wrote these words, I had just seen the TV juxtaposition of President Bush's coldblooded statement of non-interference in Iraq's internal affairs and the plight of hundreds of thousands of Kurds. Is this not the behavior of a Golem, for whom "suffering" is a meaningless concept? And is it not good for his health, including his mental health?)
Can we not conceive of a family as a Golem, with a strong SOC? The rules are laid out clearly. Normative expectations are sharply defined, specifying rights and responsibilities. Measured rewards and punishments are allocated, commensurate with deeds, assuring motivation. Resources are available which enable the family members to fulfill demands. The programming, in other words, is well-engineered. The advances in biological psychiatry will provide us with the drugs or, for that matter, brain surgery, to handle any vaguely-labelled emotional disturbances.
A second cultural path to a strong SOC is the internalization of the answers that a god or tradition or the community or the party gives to the moral-philosophical questions. In a recent talk, the writer V.S. Naipaul (1991) writes of societies in which "all poetry had already been written." He dramatically contrasts the tightly-woven, richly-tapestried traditional world of his Hindu forefathers with what he calls "the idea of the universal civilization", to which nothing human is alien, in which no answers are immutable. But if we are to ask "Who is likely to have a stronger SOC?", then I am afraid that the answer would have to be in favor of the closed, stable world of his forefathers.
Such a stable world, in which everyone has and knows his or her place, in which clear rules and answers and meanings are given in terms of ancient tradition, is applied to the medieval European family, and particularly to husband-wife relations, in Ivan Illich's book Gender (1982). I myself am more familiar with traditional Eastern European Jewish ghetto life, a life built around family and community and unequivocal commitment to the prescriptions and beliefs of religious orthodoxy. Some of you may prefer to think of the Lutheran burgher family, or of David Reiss' portrayal (1981) of the American pioneering family.
Let me press you further by giving one more example of a social structure which can provide the basis of a strong SOC: the world of the Nazis. All Germans -- men, women and children -- had their clear places in the world. The family fitted tightly into the community of the party, and the lives of all were made meaningful by the aspirations and the ideals voiced by the Fuehrer. Threats to this great integrated world were posed by the many enemies and, above all, by the Jews, to be eliminated so that the Reich could survive for millenia. Or, speaking in Prague, one could refer to the SOC of Bolsheviks. These, then, are very real examples of a structured, tradition-bound path to a strong SOC.
We may note, in at least some of these last examples, what really should be considered a third path to a strong SOC: that which is based on overt and/or covert power, control, manipulation, exploitation and oppression, from the level of the individual family to that of a total society and beyond. Rulers -- in the family, in groups, institutions, movements, parties and societies --will often have a strong SOC, since it is they who lay down the rules, control the resources and receive the rewards. Their health is at the expense of the health of the oppressed. But they themselves are healthy.
What is it that disturbs us, in a congress on mental health and family systems, about specifying such paths to a strong SOC as that of the Golem or of powerful tradition or of the opressor? Have I made you uncomfortable? Has each of you, thinking in terms of your own experience, come to think of persons and families with a strong SOC and considerable health whose reality upsets you because you cannot bring yourself to like or respect or admire these families and the social-historical suprasystems which foster them? The point should be made very clearly. We reject these paths not because they are unhealthy, but because they contradict our values, our answers to moral-philosophical questions.
I wish that I could have said something very different. But I am afraid that, if we are to be honest, we must say that both the pathogenic and the salutogenic orientations, in their focus on biological health, on functioning and on survival, on homeostasis and fitting into ecological niches, must acknowledge the power of the Golem, of fundamentalist religion, of patriarchy, of a ruling class and, yes, even of the Nazis, to provide the basis for a strong SOC for some.
I repeat: I am painfully aware that the health of those who follow these cultural paths to a strong SOC is most often at the expense of the health of others: the health of the Golem, at the expense of the health of everyone else; of the patriarch, at the expense of women and children; of the believer, at the expense of the infidel; of the Nazi, at the expense of those of us who were categorized as subhumans. But they themselves are healthy.
I am afraid that many of you, horrified by this picture I have painted, will be tempted to take the easy way out, to reject my limited definition of health as functioning and survival. But you then face the danger of defining health so that it becomes a catchall for anything that you think is good. Health, then, becomes not a scientific concept, but confused with a set of answers to the moral-philosophical problems I have raised.
I have only one response to this unhappy picture, a response which is not that of a scientist concerned with analyzing reality. The response is one which holds that there are two problems which must be differentiated from each other. One is the question of health; the other is the question of values, of moral-philosophical issues. Even if we confine ourselves to the problem of the somatic health of the individual, it is not easy to escape consideration of the question of values. But when we move to the sphere of mental health and of family systems, the confrontation becomes imperative.
Let me take two examples of values: the struggle against tyranny, and equality. Many of you sitting here know, from bitter personal experience, that very often the struggle against tyranny demanded a terrible price in physical and mental suffering, and even in death, for oneself and one's family. It was hardly a salutogenic experience. With regard to equality: Few who are not feminists, I am afraid, have often thought of the likelihood that the health of males was very often achieved at the expense of women and children. I am not saying that there is an inherent contradiction between health and other values we may hold dear, between what is good for the health and what we regard as good. I am saying that the distinction must be made.
Often, when we think of mental health and of the mental health of families, we think of words like autonomy, creativity, solidarity, generosity, growth, exploration, responsibility, sensitivity, self-fulfillment. We are seldom aware that these are code words particular to a given social class in a given society in a given period of human history. Have there not been other cultures whose primary values have been obedience, respectability, "morality", and so on. Were families in these cultures less likely to be mentally healthy than in our culture? I doubt it.
The last thing in the world I would wish to be understood as saying is that we should forget about the values we hold dear. I would even go further than saying "Keep values and health separate". I am saying that, as scientists, we should study what promotes health, somatic and emotional, individual and family, and I have proposed that the SOC is a key answer to this question. And for those of you who are clinicians, working with families, I am saying that it is crucial, in setting your goals, to distinguish between what may be good for the emotional health of the family, and what you, as a human being, think is good. More important, it is essential to clarify what the family, as a system, and what its individual subsystems, believe is good. The two, I repeat, do not often go together, and often may well be dissonant and even incompatible.
One last point. A salutogenic orientation does have one advantage beyond that of pathogenesis. Because it goes beyond non-disease and leads us to focus on the positive pole of health, it opens up the possibility of asking: Which of our values are also, by great good fortune, good for the mental health of families? Responsibility may be one such value; solidarity may be another; commitment may be a third. I am not at all sure that creativity and autonomy and experimentation are necessarily good for the health. But, as I need not remind many of you in this audience, democracy hardly solves all problems. One must then make choices. My own preference is to suggest that health is not the supreme value.
I hope, then, that you now understand why I chose to open my talk by speaking of the Golem and of RUR. I have done my best, in the time available to me, to convey the essentials of what I call the salutogenic model and its core concept, the SOC. I then sought to apply this model to the theme of our Congress, to show how it could be of value in understanding and dealing with the problems of the mental health of family systems. In an excellent review of research on resilience in children which has just appeared (Luthar and Zigler, 1991), one finds that, despite more than a decade of research, there are no more than bits and pieces of theory to guide research and clinical practice. I should like to think that the SOC construct is a reasonable attempt at a useful theoretical model.
But, because my talk was to be given in Prague, and this led to certain associations in my mind, I felt it important to point up not only the promise but also the danger of salutogenesis. Let me close by referring to a third association with Prague. Had Franz Kafka been a member of a mentally healthy family system, we might not have had The Castle and The Trial. I do not hold, with Thomas Mann, that neurosis and creativity always go together. But they certainly need not be positively correlated. Your president, my Czechoslovak hosts, in his 1991 New Year's address, said it much better: "A year ago we were all united by the joy of having liberated ourselves from the totalitarian system; today we have all become somewhat neurotic from the burden of freedom." The choice is not always "neurosis or freedom"; but it sometimes is.
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