Salutogenesis

Dimensions and influencing factors according to Antonovsky

Salutogenesis ( Latin salus 'health', 'well-being' and genesis , thus about "health emergence ") describes on the one hand a question and perspective for medicine and on the other hand a framework that relates to factors and dynamic interactions that lead to the emergence and maintenance of Lead health . The Israeli-American medical sociologist Aaron Antonovsky (1923–1994) coined the expression in the 1980s as a complementary term to pathogenesis and placed the influencing factors of understanding, feasibility and meaningfulness as feelings of coherence at the center of the development of health. According to the salutogenesis model, health is not to be understood as a state, but as a process. Risk and protective factors are in a process of interaction.

How health is created

In 1970, Aaron Antonovsky conducted a survey of the adaptability of women of different ethnic groups to menopause . One group was between 16 and 25 years old in 1939 and at that time had been in a National Socialist concentration camp (KZ). Their mental and physical health was compared with that of a control group. The proportion of women with no health impairment was 51% in the control group compared to 29% of the concentration camp survivors. Not the difference per se, but the fact that in the group of concentration camp survivors 29% of women were judged to be “healthy” (physically and mentally) despite the unimaginable agony of living in a camp followed by a refugee life, was an unexpected result for him.

This observation led him to the question of which characteristics and resources had helped these people to maintain their (physical and mental) health under the conditions of the concentration camp imprisonment and in the years afterwards - in general: How does health arise? Antonovsky brought the question of the origin of health into science - in contrast to, but also in addition to, the pathogenetic question of traditional medicine. Antonovsky developed salutogenesis as a concept of the origin of health.

Antonovsky postulated the existence of generalized resistance resources , which can be used in all kinds of situations to support coping with stressors and the experience of tension they cause. What all generalized resistance resources have in common is that they give a “meaning” to the countless stressors that constantly hit us.

Sense of coherence according to Antonovsky

The three dimensions + factors influencing the feeling of coherence according to Antonovsky with quotes from Heiner Keupp

The sense of coherence is a central aspect in the salutogenesis of Aaron Antonovsky (1923–1994). According to Antonovsky, coherence has three aspects:

• The ability to understand the connections in life - the feeling of being understandable .
• The conviction that you can shape your own life - the feeling of manageability or manageability (similar to the concept of ' expectation of self-efficacy ' according to Albert Bandura ).
• Belief in the meaning of life - the feeling of meaningfulness .

He places this sense of coherence, also known as the sense of coherence (SOC) or "sense of coherence", at the center of his answer to the question "How does health arise?":

“The SOC (Sense of Coherence) is a global orientation that expresses the extent to which one has a pervasive, persistent, yet dynamic sense of trust that

1. the stimuli that arise in the course of life from the internal and external environment are structured, predictable and explainable;
2. one has the resources to meet the demands of these stimuli;
3. these requirements are challenges that are worth the effort and commitment. "

Accordingly, the sense of coherence according to Antonovsky is formed of three components, each as (subjective) sensations: first, the understandability , secondly, the handling and manageability , thirdly, the feeling of significance or meaningfulness . In order to measure this sense of coherence, he developed a “life orientation questionnaire” with 29 items , which asks about the characteristics of these three components.

For Antonovsky, health and illness are experiences shaped by subjectivity as well as conditions conditioned by objective factors, the development of which can be thought of on the basis of health-disease continuities. In every person, healthy and sick aspects can be determined as long as he lives. Even in a terminally ill person, there are still healthy parts. Everyone moves on a continuum and is therefore not either healthy or sick, but always in the process of both healthy and sick.

Antonovsky emphasizes that health is a multidimensional event and is strongly linked to the social and cultural contexts. However, he believes that his measurement of the SOC and the relationship to health are independent of culture and gender.

Heiner Keupp describes the three components of Antonovsky's sense of coherence in the following words: “Coherence is the feeling that there is connection and meaning in life, that life is not subject to an uncontrollable fate.

• My world is understandable, coherent, ordered; I can also see problems and stresses that I experience in a larger context (level of understanding).
• Life gives me tasks that I can solve. I have resources that I can mobilize to master my life, my current problems (coping level).
• Every effort makes sense for my lifestyle. There are goals and projects that are worth getting involved (meaning level). "

And he adds: “The state of demoralization forms the opposite pole to the sense of coherence.” Keupp emphasizes that, in his view, the sense of coherence should not presuppose an inner unity, but that options may be open and apparently contradicting fragments can be linked.

Demarcation and integration

Sense of coherence according to Grawe

The English term Sense of Coherence (SOC), which Antonovsky placed at the center of his salutogenesis concept as a “concept of coherence”, has two different meanings: 1. a sense of coherence (coherence, cohesion) and 2. a sense of coherence. Most German translations only deal with the second aspect, the “feeling of coherence”. On the basis of neurophysiological findings, one can assume that humans (as well as many or all animals) are innate with a sense, a neurobiologically central sensitivity for building coherence (coherent connection, within or e.g. also in the social system).

This sensitivity is, so to speak, the inner measuring instrument that gives us differentiated information as to whether and how our need for a compatible material (air, temperature, etc.) and human environment, for being accepted, for belonging is satisfied or not. If someone receives a positive response to their existence from their closest fellow human beings, i.e. if our need for belonging is satisfied, then a feeling of coherence (feeling of belonging, fulfilling, constructive bond, a deep trust) can arise.

Grawe assumes an overriding basic need for coherence (he calls it consistency and congruence), which means the same thing as the overriding striving for coherence as the basic striving of salutogenesis. The sense of coherence and the sense of coherence are different and they are related. The sense of coherence is innate, the sense of coherence arises through relationships , through interpersonal communication . Therefore, communication in a very broad sense is the decisive instrument for stimulating or generating a sense of coherence.

Salutogenesis and pathogenesis

Salutogenesis as the science of the development of health and pathogenesis as the science of the development of disease complement each other. The underlying questions, however, orient the questioner in two different directions: The pathogenetically oriented look at the diseases, their causes and the dangers that need to be avoided or combated. Those with a salutogenic orientation look at attractive health goals that they want to achieve and for which they want to develop as many resources as possible. This different orientation can lead to very different consequences in practice. For example, in many modern chronic diseases of civilization such as obesity , diabetes mellitus and the like. a. look for attractive goals and helpful resources that bring people more joy and success (than fast food and sweets, for example): for children, for example, group games with joy in movement, appreciative communication and the promotion of individual skills. This is known in health promotion as the " empowerment " strategy. There are also great similarities here for strengthening “ resilience ”, “ mental hygiene ” and other related terms. It differs from what has long been widely used by medicine as prevention to prevent individual diseases such as heart attacks, such as: B. Avoidance of fatty and salty foods and lack of exercise. The doctor Eckart Schiffer describes salutogenesis as a "treasure hunt" in contrast to the "error search" of the prevailing pathogenetically oriented school of thought in medicine and education.

Synergy of salutogenesis

The pathogenetic and salutogenetic view can complement each other in the sense of Antonovsky. The interrelationship between salutogenesis and pathogenesis can be described more precisely today with the aid of neuroscience , as Antonovsky explicitly put it: the basis of life is healthy development, salutogenesis. This is supplemented or made possible by diseases or their avoidance.

In the self-regulation of humans and other living beings, these two aspects of life can be found again in the neuropsychic motivational systems for approach and avoidance. The switching system in the brain, called the “approach system”, which is closely interconnected with the pleasure center ( nucleus accumbens ), makes us feel positive and motivates us to develop behavior when it comes to attractive goals. This is activated by a salutogenic orientation. The so-called “averting” or “avoidance system” is an equally vital supplement. It controls behavior when it comes to avoiding or combating dangers such as health risks and diseases. The avoidance system is closely interconnected with the fear center in the brain ( amygdala ). (See also: Approach and Avoidance System by Jeffrey Alan Gray .)

Healthy development is made possible and produced by a good interaction of these two neuropsychic systems. Similarly, a synergetic interaction of salutogenic and pathogenic orientation is also a possibility to optimally promote healthy development, salutogenesis (the emergence of health).

Systemic health

The concept of salutogenesis was extended to the family and their social interactions by Antonovsky and other researchers . Aaron Antonowsky and Talma Sourani show a correlation of the sense of family coherence with general satisfaction without postulating a direct causality, and they interpret the degree of coherence as a possible indication of the ability of families to deal with stressors and conflict. Doris Bender and Friedrich Lösel showed that experiences in the relationship can also have an effect on the sense of coherence. Walter Schmidt speaks of the challenge of partnership-oriented couples to organize parenting and gainful employment in such a way “that the conflicts that arise are made structured, predictable and explainable [,] resources are discovered and made available to deal with these conflicts [, and] conflict management - or at least conflict reduction - is seen as a challenge that is worth the effort and commitment ”. Schmidt also emphasizes the strengthening of generalized resistance resources using the salutogenesis approach as a solution.

Chaos and order

Antonovsky already wrote that the concept of salutogenesis will flourish further when there is more clarity about the principles of how order arises from chaos, such as the so highly dynamic and complex regulation of ours from the seemingly chaotic infinity of biochemical possibilities and processes Organism arises. The doctor Theodor Dierk Petzold elaborated on these thoughts in his books.

People move in more or less constructive coherence and resonance to their external multidimensional contexts: their physical environment, their fellow human beings and their culture and also their global context.

Since 2003, quality criteria for salutogenesis-oriented work have been discussed and developed in quality circles , initially at the University of Göttingen (especially in cooperation with Ottomar Bahrs) and Witten-Herdecke ( Peter Matthiessen ), then also at the Center for Salutogenesis in Bad Gandersheim. In short, a salutogenic orientation means an orientation towards attractive health goals and the development or creation of helpful resources.

The seven characteristics of a salutogenic orientation include people or methods

1. orientate oneself towards coherence, constructive coherence ( connectedness );
2. focus on health (attractive goals , ideas);
3. to resources align;
4. Appreciate the subject and the subjective ( self-awareness , subjective theories, self-activity, etc.);
5. Pay attention to systemic self-organization and regulation (including self-healing ability ) (individual and context-related: social, cultural, global);
6. think dynamically both process and solution-oriented (or are well thought-out) and pay attention to development and evolution;
7. include several possibilities: e.g. B. both salutogenic and pathogenic.

	Salutogenic focus	Pathogenetic Supplement
1.	Consistency - coherence	Problem - disagreement
2.	Attractive health goals	Avoidance goals
3.	resources	Deficits
4th	Subject and subjective	standard
5.	Systemic self-regulation - contextual reference	Isolating Analysis - Small Cause
6th	Development and evolution	State or entropy
7th	Several possibilities: both - and	One possibility: either - or

Research concepts

Six groups in particular have been dealing with salutogenesis for many years:

1. In the Wartburg Talks that have been held annually since 1995 around Wolfram Schüffel (emeritus head of the University Clinic for Psychosomatics in Marburg), from which the handbook of salutogenesis , published in 1998, arose. Here, the connection between salutogenesis and Balint work , philosophy and psychoanalysis is particularly cultivated.
2. In anthroposophic medicine and education around Michaela Glöckler ( Goetheanum , Dornach, Switzerland) and Peter Matthiessen, a co-founder of the private University of Witten / Herdecke (1982). In anthroposophy , a salutogenic orientation is combined with anthroposophic medicine and Waldorf education .
3. In the umbrella organization Salutogenese (formerly the Academy for patient-centered medicine APAM e.V.) and the University of Göttingen , around Ottomar Bahrs (Medicine, Psychology and Sociology University of Göttingen; Society for Medical Communication), concepts for research on salutogenetic orientation in general medical practice are developed in Cooperations developed. The board of the umbrella organization Salutogenese e. V. ( Theodor Dierk Petzold ; Ottomar Bahrs) publishes the first magazine for salutogenesis Der Mensch .
4. In the Center for Salutogenesis with an annual symposium for salutogenesis since 2005 around Theodor Dierk Petzold (doctor for general medicine, lecturer for general medicine at the Medical University of Hanover), the main focus is on further developing the salutogenesis concept both theoretically and practically ( salutogenic communication SalKom ). So far, four thematic anthologies on salutogenesis have emerged from these symposia.
5. In the Health Academy in Bielefeld around Eberhard Göpel ( Magdeburg-Stendal University , Chairman of the Universities of Health e.V. ), Alexa Franke ( University of Dortmund ; HEDE-Training) and Günther Hölling (patient advice centers) are particularly salutogenic-oriented concepts for health promotion worked out. An annual summer academy on health promotion takes place at Magdeburg University of Applied Sciences .
6. In the Thematic Group on Salutogenesis of the International Union for Health Promotion and Education (IUHPE) around Monica Eriksson in Helsinki, which particularly records the international state of research and meta-studies with the SOC questionnaire and similar.

The concept of salutogenesis is also gaining relevance in practice-oriented courses. For example, the Bachelor in Health Promotion and Prevention carried out at the Zurich University of Applied Sciences looks at the question of how salutogenic approaches can be anchored in the professional practice of health promoters.

Critique of Salutogenesis

Antonovsky saw the sense of coherence (SOC) as a health resource that was fundamentally acquired in early childhood and adolescence and would no longer change in any radical way from around the age of 30. This assumption could not be confirmed by two extensive studies. According to a German study, the SOC is developing positively along the lifeline. In addition, this study also shows that women up to around the age of 50 have a stronger SOC than men and that it is the other way around afterwards. This supports the results of a representative Canadian study which came to comparable results.

The questionnaire on the SOC, which so far has shown only very weak correlations between the sense of coherence and physical health - if at all - may be viewed critically, but it does so with psychosomatic illnesses. There is an increasing number of researches on this topic in Germany, but their scientific quality is still in their infancy. The question arises again and again as to which research designs and which questionnaires are suitable for the salutogenic question. The problem is always to make measurable ( operationalization ) of psychological and social subjective sensations. Different terms can mean the same phenomenon as well as the same terms can be understood differently by the respondents. The terms 'understandability, manageability and significance' chosen by Antonovsky are documented very differently in our systems of meaning, as the literature on these topics shows. There is as yet no uniform operationalized definition of these terms that shows how they interact in a dynamic model of the development of health.

It is difficult to clearly distinguish the SOC from other constructs with related content. These include: belief in control , expectation of self-efficacy , optimism , hardiness and resilience . When assessing the constructs, one should primarily look more at the phenomena described and researched and only then look at the terms. In this way, other researches that were not carried out under the concept of salutogenesis and Antonovsky's concept, but which deal with the question of the origin of health, could be considered more or / and newly developed.

literature

• Sefik Tagay : Salutogenesis . In: M. Gellmann, JR Turner (Ed.): Encyclopedia of Behavioral Medicine . Springer, New York 2013, pp. 1707-1709.
• Alexa Franke: Salutogenetic perspective . In: BZgA key concepts for health promotion - online glossary . 2015, doi: 10.17623 / BZGA: 224-i104-1.0
• Aaron Antonovsky: Salutogenesis. To demystify health. German edition by Alexa Franke. dgvt-Verlag, Tübingen 1997, ISBN 978-3-87159-136-5 .
• Marco Bischof: Salutogenesis - On the way to health. Drachen Verlag, Klein Jasedow 2010, ISBN 978-3-927369-48-1 .
• What keeps people healthy? Federal Center for Health Education , Cologne, extended new edition 2001, ISBN 978-3-933191-10-6 .
• Franz-Josef Hücker: Life Experience and Resistance Resources. Correlation of the sense of coherence with age groups and gender . In: Sozial Extra , 2/2014, vol. 38, pp. 12–15.
• Rüdiger Lorenz: Salutogenesis - basic knowledge for psychologists, doctors, health and nursing scientists. Reinhardt, Munich 2004, ISBN 978-3-497-01790-4 .
• Theodor Dierk Petzold: Practical book Salutogenesis - why health is contagious. Südwest, Munich 2010, ISBN 978-3-517-08637-8 .
• Wolfram Schüffel , Ursula Brucks, Rolf Johnen (eds.): Handbook of Salutogenesis. Concept and practice. Ullstein Medical, Wiesbaden 1998, ISBN 978-3-86126-167-4 .
• Hans Wydler, Petra Kolip, Thomas Abel (Eds.): Salutogenesis and Sense of Coherence - Basics, Empiricism and Practice of a Health Science Concept. Juventa, Weinheim 2000, ISBN 978-3-7799-1414-3 .

Web links

• Key Terms in Health Promotion - Online Glossary of Concepts, Strategies and Methods . Federal Center for Health Education
• What keeps people healthy? Federal Center for Health Education , 2001
• Life orientation questionnaire

Individual evidence

1. ↑ Salutogenesis. In: DTV Lexicon. DTV, Munich 2006.
2. ^ Sefik Tagay : Salutogenesis . In: M. Gellmann, JR Turner (Ed.): Encyclopedia of Behavioral Medicine . Springer, New York 2013, pp. 1707-1709.
3. ↑ Ferdinand Schliehe, Heike Schäfer, Rolf Buschmann-Steinhage, Susanne Döll (eds.): Active health promotion. Pension insurance health education program for medical rehabilitation. Schattauer, Stuttgart 2000.
4. ↑ Aaron Antonovsky, cit. in Christina Krause, Rüdiger-Felix Lorenz: What gives children support. Salutogenesis in Education. Vandenhoeck & Ruprecht, Göttingen 2009, p. 42.
5. ↑ Aaron Antonovsky , Alexa Franke: Salutogenese, to demystify health . Dgvt-Verlag, Tübingen 1997, ISBN 3-87159-136-X .
6. ↑ Aaron Antonovsky: Salutogenesis. To demystify health . dgvt-Verlag, Tübingen 1997, p. 36.
7. ↑ Susanne Singer, Elmar Brähler: The "Sense of Coherence-Scale". Test manual for the German version. Vandenhoeck & Ruprecht, Göttingen 2007.
8. ↑ ^{a b} Heiner Keupp: The (im) possibility of growing up - What resources will adolescents need in the world of tomorrow? ( Memento of the original from August 9, 2017 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) Lecture at the “Josefstaler Talk” on June 30, 2002 
9. ↑ Heiner Keupp, Thomas Ahbe, Wolfgang Gmür, Renate Höfer, Beate Mitzscherlich, Wolfgang Kraus, Florian Raus: Identity Constructions: The Patchwork of Identities in Late Modernism . Rowohlt, 1999, p. 245. Quoted from: Kathrin Düsener: Integration through engagement ?: Migrants in search of inclusion . transcript, July 2015, ISBN 978-3-8394-1188-9 , p. 61.
10. ^ Klaus Grawe: Neuropsychotherapy. Hogrefe, Göttingen 2004.
11. ↑ Christina Krause, Nadja Lehmann, Rüdiger-Felix Lorenz, Theodor Dierk Petzold (eds.): Connected healthy - feeling of belonging and salutogenesis. Verlag Gesunde Entwicklung, Bad Gandersheim 2007.
12. ^ Klaus Grawe: Neuropsychotherapy. Hogrefe, Göttingen 2004.
13. ^ Theodor Dierk Petzold, Nadja Lehmann (ed.): Communication with the future - salutogenesis and resonance. Verlag Gesunde Entwicklung, Bad Gandersheim 2011.
14. ↑ Theodor Dierk Petzold: Fundamentals of a systemic coherence regulation. Dynamic and systemic aspects of a salutogenetically oriented meta-theory for health professions. 2011, manuscript (PDF)
15. ↑ Eckhard Schiffer: How health is created. Salutogenesis - treasure hunt instead of troubleshooting. Beltz, Weinheim 2001.
16. ^ Klaus Grawe: Neuropsychotherapy. Hogrefe, Göttingen 2004.
17. ↑ Theodor Dierk Petzold (Ed.): Lust and performance and salutogenesis. Verlag Gesunde Entwicklung, Bad Gandersheim 2010; Theodor Dierk Petzold: Practical book Salutogenesis - why health is contagious. Southwest, Munich 2010.
18. ↑ Aaron Antonovsky, Talma Sourani: Family sense of coherence and family adaptation . In: Aaron Antonovsky (Ed.): The sociology of health and health-care in Israel . In: Studies of Israeli Society , Volume V, 1990, p. 167.
19. ↑ Doris Bender and Friedrich Lösel, cited above. in: Walter Schmidt: Balance between work and family. Co-evolution towards efficient and family-conscious management . Catholic University of Eichstaett 2009, p 170. Source (PDF)
20. ^ Walter Schmidt: Balance between work and family. Co-evolution towards efficient and family-conscious management . Catholic University of Eichstätt 2009, pp. 128–171. Source (PDF)
21. ↑ 22nd Wartburg Talks 2014
22. ↑ Wolfram Schüffel , Ursula Brucks, Rolf Johnen (eds.): Handbook of Salutogenesis. Concept and practice. Ullstein Medical, Wiesbaden 1998.
23. ↑ Salutogenesis umbrella organization
24. ^ Center for Salutogenesis
25. ↑ Center for Salutogenes
26. ↑ Bachelor in Health Promotion and Prevention. Retrieved on May 24, 2019 (Swiss Standard German). 
27. ^ Franz-Josef Hücker: Life Experience and Resistance Resources. Correlation of the sense of coherence with age groups and gender . In: Sozial Extra , 2/2014, 38 vol., Pp. 12–15.
28. ↑ What keeps people healthy? Federal Center for Health Education , Cologne 1998, p. 44.

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