Self-regulation of the system
Definition of health and disease
Scope of the concept of health
Pathology of disease
Sense of coherence
Causes of health and disease
Health-promoting factors Person’s history
Effect of stressors
Potentially causing disease
Potentially causing disease or promoting health
Implementing effective remedies (“magic bullets”)
Active adaptation, risk reduction, appropriate challenges, and resource development
Antonovsky (1987) explains that SOC is a global orientation that expresses the extent to which one has a pervasive, enduring, though dynamic feeling of confidence that the stimuli experienced in the course of living are structured, predictable, and explicable (i.e., have a comprehensibility), in addition to the extent to which the resources are available to meet the demands posed by these stimuli (i.e., a manageability) and the extent to which the demands are seen as challenges worthy of investment and engagement (i.e., meaning). To have a strong SOC is to be motivated to cope with stress, to believe that the challenge is understood, and to believe that coping resources are available.
The salutogenic orientation emphasizes four spheres in human life in which people must invest if they do not want to lose resources and meaning over time: inner feelings, immediate personal relationships, major activity, and existential issues (Antonovsky 1987). This means, as Lindstrøm (2001) explains, that it is important to be able to form a view of life (ideological, religious, or political), to know people one perceives to be supportive (the function of social support), to have mental stability, and to be involved in rewarding everyday activities, such as work, sports, and education.
Salutogenesis identifies perceived individual and collective GRRs that may promote the effective management of tension in demanding situations. Higher levels of GRRs are associated with a stronger SOC. Because the interaction between a person and the environment will always be in flux, it is not possible to identify all possible GRRs. Therefore, Antonovsky (1979) formulated the following definition that provides a criterion to identify GRRs: “every characterization of a person, group or environment that promotes effective management of tension” (p. 99).
In addition, he identifies the following GRRs as exemplars:
Culture gives people a place in the world. SOC may be enhanced in a culture that enables social participation (e.g., participation in social decision-making, the visual arts, handicrafts, song, music, outdoor life, garden work, and different kinds of athletic sports).
Social support is a crucial GRR. People who have close ties to others resolve tension more easily than those who lack that quality in their relationships. The perceived certainty about the availability of social support is often sufficient for this to be an effective component of GRR, with the quality of social support, such as intimate emotional ties, being especially important. The concept of emotional closeness refers to the degree to which a person experiences emotional ties and social integration in different groups (Sagy and Antonovsky 2000).
Religion and values give direction and meaning to life.
Physical and biochemical resources, such as a strong physique, good genes, and a strong immune system, are key GRRs.
Material goods, such as money, food, clothing, and accommodation, are of obvious significance.
Continuity, overview, and control are macro-sociocultural coping resources that are decided by the culture and society that a person is part of.
Good coping strategies are characterized by rationality, flexibility, and foresight, including the ability to regulate emotions.
Knowledge and intelligence.
Self-identity is a resource on the emotional level and is a crucial coping resource.
The relationship between GRR and SOC is reciprocal. GRRs, such as social support, lead to a stronger SOC, and it is SOC that makes a person able to mobilize and make use of social support (Antonovsky 1979; Landsverk and Kane 1998). When people experience concordance between their use of GRRs and their expectations, wishes, and demands, life’s challenges are experienced as appropriate. The experience of appropriate challenges in daily life strengthens SOC.
A Positive Mental Health Concept
Mental health may be conceptualized in either negative or positive terms. A negative conceptualization of mental health is based on an understanding that the absence of symptoms indicates good mental health. A positive mental health concept focuses on the presence of health-promoting factors, such as meaningful work and good relationships. Mental health is more than the absence or minimization of mental symptoms, since states and capacities have value in themselves. According to the WHO’s definition of mental health, it is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO 2001, p. 1).
In salutogenesis, the primary focus is on the dynamic interaction between health-promoting factors and stressors in human life and on how people can move to the healthier end of the health continuum. A sense of coherence is proposed to be a significant variable in affecting this movement (Antonovsky 1985). Mental health refers to a person’s position at any point in the life cycle on “… a continuum that ranges from excruciating emotional pain and total psychological malfunctioning, at one extreme, to a full, vibrant sense of psychological well-being at the other” (Antonovsky 1985, p. 274).
Antonovsky describes the movement on the continuum toward better mental health as shifting:
[F]rom the use of unconscious psychological defense mechanisms toward the use of conscious coping mechanisms; from the rigidity of defensive structures to the capacity for constant and creative inner readjustment and growth; from a waste of emotional energy toward its productive use; from emotional suffering toward joy; from narcissism toward giving of oneself; and from exploitation of others to reciprocal interaction. (Antonovsky 1985, p. 274)
The concept of mental health has developed over time, becoming more and more directed toward well-being. To a larger extent, newer research in psychiatry focuses on well-being by strengthening positive experiences rather than by limiting treatment to reducing or removing the illness or symptoms. Quality-of-life assessments for people with sustained mental health problems have increasingly taken an overall well-being perspective by assessing multiple life domains, including measures of functional status, access to resources and opportunities, and a sense of well-being.
Næss and Eriksen (2006, p. 39) reveal what mental health is comprised of in relation to quality-of-life (defined as mental well-being) measurements in the figure above (Fig. 14.1).
Mental health in relation to mental well-being
Quality-of-life research searches for knowledge that may contribute to the reduction of problems and the increase of pleasures. Traditional mental health research has not made a distinction between boxes 1 and 3 or 2 and 4. It has aimed primarily at getting people out of boxes 1 and 3, typically by conflating disease and quality of life and by including symptom scales within the measures used to assess quality of life (Rapley 2003). The aim of the salutogenic perspective may be understood as bringing as many people as possible into box 2 with many pleasures and few problems, whereas a sense of coherence is theorized to enhance coping and adaptation by the use of general resistance resources (GRR), which effectively mediate the tension caused by omnipresent stressors and ultimately reduce the number of stressful experiences (Antonovsky 1979, 1987; Landsverk and Kane 1998), thereby increasing overall well-being. This is compatible with the salutogenic definition of mental health.
Mental Health Promotion
Although health promotion is a central focus in society in general, this concept has had a minimal presence in psychiatric services (Berger 2003; Langeland 2007b). Mental health promotion and well-being perspectives allow for the evaluation of people’s broader life situations, as opposed to just narrowly focusing on disease. These perspectives are rooted in postmodern public health and the realization of the Ottawa Charter in terms of salutogenesis and well-being (Lindstrøm and Eriksson 2006). In the Ottawa Charter (WHO 1986), health promotion is defined as the process of enabling people to both increase control over, and improve their health, and health is seen as a resource for daily life. The charter underscores that health promotion action aims at enabling all people to achieve their fullest health potential, including a secure foundation in a supportive environment as well as access to information, life skills, and opportunities for making healthy choices. The main understanding is that people cannot achieve their fullest health potential unless they are able to take control of those things that determine their health. The core component of the principles of health promotion is suggested to be a combination of salutogenesis and well-being, in which salutogenesis is the process that leads to well-being (Lindstrøm and Eriksson 2006). Mental health promotion often refers to positive mental health and involves adopting an approach based on a positive view of mental health, instead of emphasizing mental illness and deficits. It considers mental health as a resource, as valuable, and as a basic human right, which implies the need to create individual, social, and cultural conditions that enable optimal psychological development.
Realizing that mental health is more than the absence of illness can be helpful to people with mental health problems and to their careers. Protective health resources and positive mental health can coexist with occasional severe mental symptoms, such as in people living with schizophrenia. This highlights the value of developing more comprehensive clinical approaches with an additional focus on people’s positive mental health, such as their strengths, capabilities, and personal effort in the recovery process. Assessing and building on strengths help people to cope with mental health problems in order to avoid being further diminished by them (Schmolke 2003). Three health-promoting factors have been identified as important to the recovery process (Anthony et al. 1994; Strauss 1996), which are that people (a) perceive themselves as something other than just a diagnosis and a disease, (b) explore themselves with respect to their whole person, and (c) take control over their own lives. Additional factors such as hope, identity, meaning, and personal responsibility have emerged as central in the recovery process (Slade 2010). Moreover, data from 40 years of research provides strong empirical support for the benefits of privileging participants to their role in the process of change. As a result, treatment should be organized around participants’ resources, perceptions, experiences, and ideas (Duncan et al. 2010).
The Salutogenic Model Applied in Clinical Settings
Research shows the significance of the salutogenic approach in mental health promotion, including various mental health problems (Langeland 2007b; Langeland and Vinje 2010; Griffiths 2009), schizophrenia (Schmolke 2003; Bengtsson-Tops and Hansson 2001; Landsverk and Kane 1998) and depression (Skärsäter et al. 2005; Carstens and Sprangenberg 1997). The Sense of Coherence Questionnaire (Antonovsky 1987) has been used in many intervention studies in mental health to measure outcome (Blomberg et al. 2001; Kørlin and Wrangsjø 2002; Lundqvist 1995; Sack et al. 1997; Weissbecker et al. 2002). To the best of our knowledge, however, the entire salutogenic model of health (including all the basic assumptions and core concepts about health) developed as salutogenic therapy principles and interventions has not previously been applied in either a research or clinical setting and is not described in the literature. Nevertheless, there is some literature on the different aspects of the application of salutogenesis. For example, one study has attempted to adapt the core concept of SOC as a theoretical basis of previously established psychological education in schizophrenia (Landsverk and Kane 1998). Other studies have used elements of salutogenic thinking, such as the creation of empowering dialogues in general practice (Malterud and Hollnagel 1999), in the treatment of depression in schizophrenia (Menzies 2000), in the treatment of conduct disorder (Hansson et al. 2004), and in couples therapy (Lundblad and Hansson 2005), and a salutogenic framework of family members’ experiences with palliative home care staff has been developed (Milberg and Strang 2007). Others have developed models with elements of salutogenic thinking, such as an assets model (Morgan and Ziglio 2007) and the Red Lotus Health Promotion model (Gregg and O’Hara 2007).
Based on this, one may conclude that there is a need for intervention studies in which the primary outcome sought is SOC, coping, and health (defined as a person’s subjective experience of being in a positive state of well-being). Furthermore, it has been suggested that the most immediate research of the salutogenic model of health should now be implemented as a guide to mental health promotion initiatives and research (Erikson and Lindstrøm 2005). Bengel et al. (1999) emphasized that developing salutogenic therapy principles and intervention programs is of great importance for the future development of salutogenesis in the recovery framework.
Theoretical Framework for Salutogenic Talk-Therapy Groups
Theory is a frame of reference that is crucial in research and in program evaluation. An intervention is not ready to be evaluated unless the theoretical basis of the intervention has been developed and implemented, given that the judicious use of a theoretical framework can illuminate areas that might otherwise not be visible (Taylor 2004). An intervention may serve as a guide to mental health practice when better coping, well-being, and positive mental health are the main targets.
The salutogenic talk-therapy group intervention program has been developed for people with different mental health problems and consists of 16 talk-therapy meetings which last for 2 h and 15 min each, with additional homework, for a period of 16 weeks. Although the intervention program described in this chapter has been specifically developed for people with mental health problems, we will argue that it may also be adapted to people with different health problems, as the salutogenic approach primarily gives a general description of how SOC, health, and well-being may be strengthened. Additionally, anyone whose aim is increased coping and thriving in everyday life should focus on mental health.
Acquiring and applying this knowledge about salutogenesis in one’s practice may be used as a tool for shedding light on people’s strengths and raise people’s consciousness about their health and well-being. All knowledge that may help implement a salutogenic approach in the best possible way is therefore relevant for practitioners, researchers, and other professionals. In addition to the salutogenic model of health, the approach in our research consists of knowledge from positive psychology (Snyder and Lopez 2007), which includes mental health as flourishing (Keyes 2007a, b), flow as optimal experience (Csikszentmihayi 1997; Lutz 2009), authentic happiness (Seligman 2002), recovery processes (Slade 2010), and the self-tuning model of self-care (Vinje and Mittelmark 2006; Vinje 2007). One theory of social support (Weiss 1974) supports the operationalization of social support, which Antonovsky regards to be a vital resistance resource. Both Weiss and Antonovsky emphasize the importance of the quality of social support. Rogers’ experience of person-centered therapy (Rogers 1957) corroborates the fact that the attitudes of unconditional positive regard, accurate empathy, and genuineness perceived by participants in their helpers are necessary for therapeutic progress. Bandura’s (1991) self-efficacy theory points to various ways of strengthening in a group process, whereas Antonovsky’s other vital resistance resource, self-identity, uses the five unique capacities through which he claims a person learns: self-regulation, symbolizing, vicarious learning, forethought, and self-reflection (Antonovsky 1991). Narrative therapy (Anderson and Goolishian 1988, 1992) provides tools to encourage participants’ awareness of their coping histories, thus increasing their consciousness in relation to their internal and external resources. Interventions drawn from solution-focused therapies can be effective when the aim is to increase participants’ insight into their coping ability (de Shazer 1991; Watkins 2001). These theories and knowledge support, supply, and emphasize the interpretation and operationalization of a salutogenic approach.
Implementation of Theoretical Perspectives
Aim of the Salutogenic Approach
The main aim of a salutogenic approach is to increase participants’ awareness of and confidence in their potential, their internal and external resources, and their ability to use these to increase their SOC, coping, and level of mental health and well-being. Accordingly, the focus is on how to enter into a good circle or positive feedback loop. The intervention has been developed for people with various, but relatively stable, mental health problems who are able to have a dialogue and live in their private homes, but need some support from the health system. The concept of mental health problems used here typically encompasses mental suffering, mental illness, mental disorders, mental problems, and psychosocial problems.
Salutogenic Talk-Therapy Groups
In salutogenic talk-therapy groups, the leaders arrange for participants to acquire experiences that strengthen and increase SOC and well-being. It has been suggested that experiences which are characterized by consistency, emotional closeness, load balance, a sense of belonging, and participation in shaping outcomes contribute in promoting SOC (Antonovsky 1991; Sagy and Antonovsky 2000). These experiences may enable the participants to stay well or get well, and are sought within the groups.
The intervention is specially developed for talk-therapy groups, with mental health professionals as the group leaders. The intervention consists of the salutogenic therapy principles that reflect the attitudes desired and the focus of the program, illustrating what the topics and homework in the sessions might look like. In talk-therapy groups, a central ideal is that conversations are characterized as a therapeutic dialogue (Egan 2002), while the groups are characterized by mutual, egalitarian relationships, in which the tenor of conversations between the group leaders and participants is similar to those between the participants themselves (Antonovsky 1990; Gilligan and Price 1993; Rogers 1980). Traditionally, mental health professionals learn to maintain their distance and stay in control. This is important, though research demonstrates that intimacy, spontaneity, and personal engagement may have therapeutic effects (Borg 2007; Langeland and Wahl 2009).
The reason for choosing a group as the best method is the beneficial effect of symbolic interactionism (Blumer 1969). Further, Yalom (1975) identifies 11 interdependent therapeutic group aims: to give hope, to encourage universalization, to share information, to engender altruism, to try new approaches, to develop social competence, to promote vicarious learning, to promote learning between people, to encourage group solidarity, to achieve catharsis, and to encourage existential viewpoints.
The Role of the Group Leader
The group leader focuses on creating a conversational and interactional climate that will promote a desirable change in the participants. By acknowledging one’s inability to know the participants’ truth, the group leader conveys a combination of unconditional positive regard, empathy, and genuineness by respecting that the participants are experts on themselves and their unique situations and experiences, including their pain, suffering, and concerns (Rogers 1957). From a salutogenic perspective, the group leader functions more as a dialogue partner, achieving a balance between listening empathetically to participants’ difficulties while taking into account their strengths and resources (Duncan et al. 2010). It is the attitude and confidence in people’s innate potential for growth and development that is in focus. The group may function as a facilitator of self-definition, and a considerable onus is placed on providers and consumers to build the type of relationship that can inspire hope that will help bolster positive thoughts against the negative impact of societal stigma and marginalization (Stanhope and Solomon 2008).
To be qualified as a group leader, the leaders participate in a 3-week training program containing the theoretical framework of salutogenesis, the supporting theories, and implementation of the salutogenic therapy principles (see the next chapter), including how to be a good group leader and dialogue partner (Langeland 2007b).
The Mental Health Promotion Process: A Salutogenic Approach
The basic assumptions and core concepts in salutogenesis, including supporting theories, may be operationalized into a salutogenic approach, as illustrated in Table 14.2.
A mental health promotion process in talk-therapy groups based on a salutogenic approach
Salutogenic therapy principles
1. Health as two continua
– Movement toward health
– Increasing tolerance for various feelings
– Universalizing mental health problems
– Improving active adaptation
– Introducing the metaphor of the stream of life
2. The story of the participant
– Diagnosis as a narrow description
– Experiencing oneself as a person
– Listening to the participant’s narrative identity: shedding light on individual coping ability
– Structuring life experiences that reinforce sense of coherence
– Increasing perception of coping in the narrative identity
3. Health-promoting (salutary) factors
– Extending coping resources
– Improving self-identity
– Paying attention to what is currently functioning well and asking questions to increase the awareness of resources
– Increasing perception of the quality of social support such as attachment, social integration, opportunity for nurturing, reassurance of worth, reliable alliance, and guidance
– Promoting resistance resources, particularly social support and self-identity
4. Stress, tension, and strain as potentially health promoting
– Discussing appropriate challenges
– Increasing acceptance of one’s own potential and coping ability
– Universalizing the feelings of tension
– Experiencing one’s resources
5. Active adaptation
– Promoting a climate of unconditional positive regard, empathy, and genuineness
– Experiencing motivation for change
– Developing participants’ unique capacities
– Thinking more salutogenic and developing positive patterns for health promotion
– Developing crucial spheres in human existence
– Increasing perceptions of comprehensibility, manageability, and meaning; improving SOC – Increasing emotional, psychological, and social well-being; positive mental health
– Stimulating flow experiences
The five basic components or therapy principles in this intervention are as follows: (1) the health continuum model, (2) the story of the person, (3) health-promoting (salutary) factors, (4) the understanding of tension and strain as potentially health promoting, and (5) active adaptation (Antonovsky 1987).
Health as Two Continua
Movement Toward Health
To promote health from a salutogenic perspective, the primary focus must be on the dynamic interaction between resistance resources and stressors in human life and how to help the participants to move toward the healthy end of that continuum. For example, this can be done by asking a rating question: “On a scale of 0–10, in which 0 is the worst and 10 is the best you have ever felt, how do you rate yourself today?” If the answer is 7, you may ask why the answer is 7 and not 5. By the use of such a solution-focused question, one may increase a person’s attention on coping possibilities, on good experiences, and on the perceptions of health-promoting factors. The next question may be “What do you need to do to move yourself up to an 8?” This may be a method of increasing the participant’s awareness of coping, of positive experiences, and/or of different health-promoting factors. In this way, one’s attention is focused on possibilities, and the attention is placed on adding resources and on what is functioning well in their lives.
Newer research reveals that it is clinically relevant to define mental health as a two continua model because people may have symptoms of both mental health and mental illness, thereby indicating the need for health professionals to support a reduction of the symptoms of mental illness and an improvement in the symptoms of mental health (Keyes 2007a). Keyes’ study documents that symptoms of mental health and of mental illness are two different dimensions that have a relationship which, together, constitute the overall level of mental health. Confirmatory factor analysis reveals that the latent factors of mental health and mental illness are correlated at –.52. From a clinical standpoint, this means that although there is a tendency for mental health to improve when mental illness decreases, this connection is moderate (see Fig. 14.2, Keyes 2005, 2007b).
Mental health as two continua
The mere absence of the symptoms of mental illness does not necessarily mean a happy life, whereas the presence of these symptoms does not necessarily mean an unhappy life (Keyes 2007a, b; Hyland 1992). It is necessary to experience the presence of salutogenic factors in order to thrive and attain well-being. Symptoms do not always cause problems because the relationship between these two variables is moderated by other psychological factors (Hyland 1992). These factors may be various coping strategies (Bandura 1991) and the experiencing of flourishing as emotional, psychological, and social well-being (Keyes 2007a).
The clinical relevance of this view of health became obvious in one of the talk-therapy groups when a participant discovered that she could be healthy, even though she had an illness. It was a good “aha” experience for her to think that she could be both depressed and in a good mood, but not at the same time. Although she had a diagnosis of depression, she could feel healthy. This is an example of how a person is influenced by the concepts we describe ourselves with and in how we define each other. By defining herself in a more constructive way, one that she acknowledge as meaningful, she experienced a more encouraging self-image.
Accordingly, knowledge about how to promote good mental health may yield important therapeutic insights on how to strengthen health-promoting competence among people with long-term mental health problems. From a salutogenic perspective, Keyes argues that the signs of mental health may be emotional, psychological, and social well-being. Emotional well-being is characterized by being happy, interested, and satisfied with life. Signs of psychological well-being are self-acceptance, environmental mastery, positive relationships with others, personal growth, autonomy, and purpose in life. Social well-being includes making a contribution to society, social integration, social growth, acceptance of others, social interest, and coherence (Keyes 2007a).
Universalizing Mental Health Problems
People have different levels of health, but on the same two continua. This universalism is a precondition to understanding and judging another participant’s expression. Some examples of topics that the participants and leaders may recognize as universal in daily life are existing and possible new relationships, how to organize the day, how to receive criticism and praise, how to balance activity and rest, how to practice self-care, and how to cope with sleeping problems. To illustrate universalism and health development, Antonovsky uses the following metaphor, which can be presented to a salutogenic talk-therapy group.
Introducing the Metaphor of the Stream of Life
All human beings are in a river that is the stream of life, and nobody stays on the shore. It is not enough to promote health by avoiding stress or by building bridges to keep people from falling into the river. Instead, people have to learn to swim. There are forks in the river that can lead to gentle streams or to dangerous rapids and whirlpools. The crucial, salutogenic question is “Wherever one is in the stream, what shapes and promotes one’s ability to swim well?” (Antonovsky 1987). This way of looking at life may be useful in group work because the participants can easily identify with it, thus acknowledging and accepting their own ups and downs and focusing on adaptive behavior (how to swim well) in everyday life.
The Story of the Participant
Mental health professionals can help people to structure life experiences in such a way that may enhance and reinforce SOC. A person’s individual story is important because only in the awareness of one’s life situation can the resources that contribute to recovery be found, understood, and fostered. The pathways to recovery are uniquely defined by each person individually and need to be holistic in scope since mental health problems are complex interactions of mind, body, spirit, and social environment that are unique to each individual. Accordingly, the focus in the groups is on each participant as a whole and on their own experiences. Participants use their own words and describe their inner lives. Stories about recovery processes may reduce stigma by illustrating that people with mental health problems are as ordinary and human as others; consequently, such stories may represent good, vicarious learning. It is often a challenge to get people out of their diagnosis (the diagnostic box), but only when they do so will they experience and increase the consciousness of their own individuality and identity.