Why do some people stay healthy in spite of adverse physical and psychological circumstances, while others are already knocked off course by a slight headwind? Why do some recover quickly from illness, while others lie on the deck for a long time? It was questions like these which the neurologist and psychiatrist Aaron Antonovsky encountered during an epidemiological study involving former concentration camp prisoners. He poured the answers which he ultimately found into a conceptual model, which he called salutogenesis (salus, Latin: salvation; genesis, Greek: formation). It represents in substance an alternative to pathogenesis, that is to the approach which is determinatively employed in today’s medicine.
In simple terms, salutogenesis means
- inquiring into the causes of health, not into those of illness
- dealing with resources, not with risk factors
- to see health and disease as part of a continuum, not separated by a boundary
- to understand health and illness as processes, not as outcomes
A harmonious life
A central role in this model is played by what is called the sense of coherence (SOC). According to one Anonovsky metaphor, this means the ability to swim along with the river of life – or less poetically put, the sense that one’s life runs with consistency and is able to be constructed. The sense of coherence is manifested at three levels: comprehensibility, manageability and meaningfulness. The world is understandable if one can classify messages from one’s own body, thoughts and feelings, correctly interprets information from the environment and also sees problems in a larger context; the world is manageable if one has sufficient physical, psychological, material and psychosocial resources of resistance at hand for coping with demands that are made; and it is significant when one has a clear idea of one’s values, conceives life as meaningful, and is engaged in it.
“Antonovsky’s idea was that all resources which a person has acquired during the course of his life get concentrated in the sense of coherence”, explains lecturer Dr. Ulrich Wiesmann, trauma therapist at the University of Greifswald. “A person with a strongly developed sense of coherence should respond flexibly to demands and master them; a person with a low sense of coherence, however, would respond more rigidly because he or she has fewer resources for coping with these demands”. But is it therefore also a predictor of mental and physical health, as Antonovsky assumed?
6000 Publications per year
Thanks to an ever increasing number of research pieces on salutogenesis – PubMed had last listed under the heading around 6,000 publications per year – this question can be answered quite soundly today. “The sense of coherence correlates well with mental, but less well with physical health”, Wiesmann summarises from the available data. He himself found similar results in studies done as part of the Greifswald Ageing Study. And he was also able to show something Antonovsky had not considered possible.
“Antonovsky assumed that the sense of coherence develops until about age 30 and then remains stable”, says Wiesmann – so to speak, as a more or less strong armour with which a person then has to live his or her life. “In our study however, healthy seniors with an average age of around 66 years succeeded in increasing their sense of coherence significantly through endurance and strength training, yoga and meditation”, says Wiesmann. “In parallel, general well-being, physical well-being and mental health improved, and important resources such as self-efficacy and self-esteem had been strengthened”.
Exemplary use in the field of prevention
“Relationships between the sense of coherence and various health indicators have now also been demonstrated in longitudinal studies”, confirms Professor Dr. Toni Faltermaier, Flensburg. “These include, for example, subjectively-perceived health, but also symptom related measurable dimensions such as absenteeism from work or the risk of coronary heart disease”. This makes it clear why salutogenetic approaches are currently widely used particularly in prevention and health promotion.
As an example Faltermaier mentions working with young people at risk of addiction. “Addiction or problem behaviour is often the consequence of unresolved development tasks. However one does not find remedy for them by telling young people that 20 years of alcohol leads to cirrhosis”. Instead, one could try to transfer to them resources such as self-esteem or self-efficacy, so that they no longer need to drown their sorrows. “This is not always pinpoint in effect because it is employed non-specifically, but one reaches young people better than through pure risk prevention”, says Faltermaier. And something else also holds true here: positive effects are not only obtainable by younger people.
Salutogenesis training for mentally ill people
Gerhard Cramer, a social worker at the Center for Disease Management at the Technical University of Munich, uses salutogenetic principles in order to protect patients with depression and schizophrenia against a relapse. “We have also adapted existing salutogenesis training to meet the needs of mentally ill people and we offer it as part of our “Munich Model Integrated Care”“.
The training consists of nine units of one and a half hours duration each to be held weekly. “This program will educate the patient in particular to identify resources from which they can draw strength”, says Cramer. “They might be sport, a hobby, relaxation techniques, social contacts, or even a timetable that will help them to structure the day without getting stressed”.
Healthy parts in focus
Meanwhile in Munich around 40 patients have completed the training, and Cramer is convinced by the results. “Patients there are engaged with their healthy parts, not with what makes them sick. The result is that in these groups much more time is spent laughing than in others, and the patients quickly come to understand that they can support each other”. And in the end, the effect reveals itself in their sense of coherence. “Ten weeks after the end of the course we have been able with almost all patients to record a significant improvement, which is also significant on average. “Cramer therefore hopes that relapse incidence of depressive or schizophrenic episodes also decreases.
Therefore salutogenesis should actually also be an interesting approach for physicians. “In the area of general medicine, with cancers, chronic diseases and in research, these approaches are actually there to be seen again and again,” says Faltermaier. “Today we know that illness management and the chances of recovery also increase with a better sense of coherence”. It’s quite possible that salutogenesis still has its best years yet to come.