In 1979, Aaron Antonovsky, an Israeli-American medical sociologist, posited that health cannot be understood by studying sickness and disease. When conducting an epidemiological study of menopausal women in Israel, Antonovsky was struck to discover that a subset of the women who had survived Nazi concentration camps were able to thrive in their physical, emotional and relational health in spite of their very difficult histories. As a result of this research, Antonovsky created the word salutogenesis (meaning of the origins (genesis) of health (saluto)) and the salutogenic model.
His model examines the factors that contribute to and promote health and well-being, as opposed to the pathogenic model, which examines disease. Salutogenesis is also characterized by a particular focus on coping mechanisms within us. These coping mechanisms allow us to preserve health despite the inevitability of stressful conditions. Thus, health is perceived as a continuum of health ease and disease, instead of positioning health and disease opposite to one other. And in contrast to the pathogenic model, which emphasizes the use of external healing interventions to eliminate sickness, salutogenesis emphasizes our internal healing resources and our ability to adapt.
Forty-two years later, the dominant approach in healthcare remains on targeting, diagnosing, controlling, and eradicating and/or managing sickness. There continues to be minimal emphasis on understanding what contributes to our health ease.
From my own experience working on the inpatient psychiatric unit of a prestigious teaching hospital, the revered attending physician on my team declared the unit “a therapy free zone.” What this meant was that when discussing patients in morning rounds (without them present), or when meeting with patients and families, the model of care was one of medication and “treatment compliance.” I could see the difficulty patients had feeling motivated or hopeful in the face of such a focus. Nowhere in the intake or treatment process was there any institutional attention on the patient’s perspective: their wishes, dreams, or their experience in the here and now. This exemplifies the challenges of the pathogenic model in mental healthcare. From a salutogenic perspective, the primary focus of treatment would be on the patient’s experience in the here and now, with medication used as a means to support the person’s goals, dreams and visions they hold for themselves.
Health, and how we create health, is constantly on my mind.
We are all a part of a “pathogenic culture” that emphasizes problems, deficits and disease, and how to eradicate them, while often ignoring what allows us to be most vibrant and alive. When someone comes into therapy, the most common question therapists tend to ask is, “What is the problem that brings you here?” While there is nothing wrong with this question, it’s incomplete. Historically, we, too, have been trained to identify problems and symptoms, glossing over signs and signals of health.
One of my mentors, Hedy Schleifer, in working with couples, starts their first meeting with the question, “What is your wildest dream for your relationship?”
I find when I ask the question of an individual client early in treatment, “What is your wildest dream for your life?” people often get stuck. Many of us have never been given permission to dream. And people often don’t know how to identify their strength, capacity to adapt, and hopes for what might be possible. One of our jobs as therapists is to collaborate with our clients to embrace a salutogenic approach. We can help people to identify, focus on, and soak in their internal resources and ability to adapt. And from this place, we can begin to look to a future of possibility. In doing so, we begin to give our clients permission to dream.
As Hedy says, “Dreaming is a human capacity that allows humanity to unfold its true potential.”