Salutogenesis and ACEs, Part 1

A few weeks ago, in the last part of our conversation with Henriëtte Markink, one of the topics we mentioned was salutogenesis. This is what we said about it: “This approach asks about the origins of health, leading to very different follow-up steps than western medicine’s more common ‘pathogenesis’ (the questions about the origins of disease). Salutogenesis is prospective (looking ahead – how can we maintain this?) and proactive (what does one need to stay healthy?) and searching from trust and confidence towards the good things in life. Pathogenesis is more retrospective (looking back – how did this problem arise?) and reactive (what can we do to solve the problem?) and working from avoidance (of risk factors). The founder of the concept, Aaron Antonovsky, described it like this: ‘Pathogenesis sees life as a river full of risks that you should not end up in. This view focuses on prevention (do not fall in) and treatment (do not drown, we will save you). Salutogenesis says that all of us are always in that river, because in life, anything can happen to us at any time. What to do…? Learn to swim!’ ” This week, we will take a closer look at this fascinating view on health.

Salutogenesis is a concept introduced by Aaron Antonovsky (1923-1994), a medical sociologist for whom two things were as plain as day: first, humans are always in interaction with the larger social context, and second, continuous change, disturbance, and deterioration are not the exception, but the rule. For that last process, he used the term ‘entropy’, which in sociology terms refers to ‘inevitable disintegration’. Humans are mortal. The road to the end of life is longer, healthier, and happier for one than for the other, but sooner or later we all take our last breath. That may sound like a pretty dramatic, pessimistic approach: is there nothing but misery, and are we all inherently flawed? What is the purpose of all our efforts? Strangely enough, the idea of inevitable disintegration is somehow full of compassion, full of softness and optimism: nobody is perfect; we are all vulnerable; each and everyone of us can fall prey to adversity; we all go through ups and downs and highs and lows on a daily basis. This, in full truth, is a realistic view on life that opens up a new perspective. It does not assume a smooth, linear life trajectory as the status quo. It leaves room to, without shame, be allowed to make mistakes, to experience things as difficult. This awareness connects us as humans with one another. To slow down the entropy, we can look for factors and processes that actively counteract the decline. We can, then, proactively strive for the things by which health (‘saluto-‘) is being created (‘genesis’), instead of nervously, incessantly preventing all that is dangerous and might threaten our health and wellbeing. The challenge, Antonovsky said, lies in learning to deal as well as possible with what life brings and make sure we can weather the storm… or the swell and surges, to stick with the image of the river.

In all of that, he did not view health as a dichotomy, a divide by which you can only be in one of two categories, in this case ‘healthy’ or ‘not healthy’. Antonovsky saw a continuum, a line on which people move back and forth: there are times they feel better and healthier than at other moments. Even if they go through tough times, however, they can still work towards maximizing wellbeing, given the circumstances. Even if everything seems to be working against them, people can tap into resources that bring light to the darkness. Even if you are really ill or heavily traumatised, comfort and reassurance can ease your fate.

Looking at health this way, the core question becomes: what do we need? How can we enjoy as long as possible the years we are given? What makes us feel happy and healthy and consider life as meaningful, even if there is disease or adversity? The interesting thing is that Antonovsky did not give a really concrete answer to these questions; he recognised that this can differ greatly per person, per context, and per life stage. He did develop a number of important ideas that do have a quite general validity and that are mentioned in the image above. We see, for example, above the upper blue arrow, the words ‘Generalised resistance resources’ (GRRs), resources and tools that can help you handle stress factors. Antonovsky described them as follows.

This means that these resources are effective to avoid or combat the stressors that life may bring to a person. What does that amount to? It can mean that you can breathe, relax, ease your mind and feel better again because you are physically able to go and do sports or take a long walk, because you have a sweet neighbour whom you can have a cup of tea with, because you live in a community where the atmosphere is good and safe. Those who have such resources available (and there are many others), will be better able to keep the faith and the courage when life hits hard, to pick up where they left off when things got rough.
Antonovsky’s work specifically asks us to pay attention to the positive things in life and go look for them very consciously, because they help us to swim through the river of life – or, put differently… to develop resilience.
When we translate all this to ACEs, we can see beautiful connections. We know, based on neurophysiological research, that the human brain is built and develops in response to the environment – the larger social context that Antonovsky took as his starting point. We can make an effort to organise society in such a way that we can optimally safeguard the positive influences on that development. Examples? Well-attuned, responsive adults are vital GRRs for a child. Teachers who see the child’s potential and support and encourage the child, create cognitive and emotional GRRs. A social environment that acknowledges children’s interests, forms a precious interpersonal and macrosociocultural GRR. A natural environment where people co-live with nature peacefully, stimulates (among others) physical, material and attitudinal GRRs.

Next week, we will look at the core of Antonovsky’s work: the Sense of Coherence, the confidence that your internal and external environment are predictable and reliable, and that somehow all will be well.

Posted in Theory.