5. Critics and Suggested Additions to Antonovsky's Model
5.1 Health - Disease
5.1 Health - Disease
Concerning Antonovsky’s health-dis-ease continuum, there are several points that remain unclear, for instance the exact definition of a multidimensional continuum of health and how to evaluate it. Different authors criticize that a main component of the salutogenic concept is ignored by using only negative indicators to describe a positive condition of health (e.g. lack of pain). This is reflected in salutogenic research using illnesses as indicators for health (Faltermaier, 2002; Becker, 1992, cited in Waller, 1996). By explaining health only as an absence of illness, the positive aspects of health are neglected. I also completely agree with the critic about the “limitation of the health-dis-ease-conception to physical health-dis-ease” (Becker, 1992, cited in Waller, 1996, p. 17). Faltermaier suggests a definition for the health continuum containing positive aspects of feeling like the bodily and psychic well-being, the ability to perform, as well as a balance between external (social) demands and psychophysical needs. Health itself should be understood as a process and be integrated within a mundane, biographical, social, historical and cosmic context (Faltermaier, 2002). I agree and think that the health definition and its evaluation must be clear and more holistic (going beyond physical and mental health), for instance, oriented on the shamanic example. In my opinion a questionnaire should be developed regarding the elements above, which aims at the subjective positive understanding of health, to deliver different results than a doctor’s analysis of a person’s condition. The insufficient theoretical analysis of the relation between physical and psychical health is criticized as well (Becker, 1992, cited in Waller, 1996). In all these sectors Shamanism provides solutions for all levels of balance, with a positive meaning – not just balance on the physical or mental level as in Antonovsky’s concept, but balance with everything – with the material world, including the environment (plants, animals, rocks, etc.) and the immaterial world of spirits and supernatural forces, etc.. Shamanism offers a different perspective which embodies all aspects of life.
Antonovsky’s model also misses the important aspect of subjectivity within the definition of health, disease and healing, that must be built into his model (Faltermaier, 2002). The place on the continuum depends of one’s own perception and thus can only be pointed by oneself. This necessary subjective perception and construction of health must be regarded on a somatic, psychic and social level (Faltermaier, 2002). Compared to the health-disease-continuum of Antonovsky, inward-oriented Shamanism naturally includes the subjective level of experiences. In my opinion, imagination, as it builds one’s own picture of the world, is very subjective and accordingly is a person’s feeling of meaningfulness, comprehensibility and manageability. Different people can perceive and evaluate similar life events (e.g. illness) completely different, depending on their own experiences in life. Naturally, the coping strategy as well as the practical salutogenic approach must be individually different, considering all aspects of a person’s subjectivity.
Subjective techniques as in Shamanism or psychotherapy offer the potential of healing and growing and raise the SoC and state of health in Antonovsky’s sense. The recent emphasis of therapists on the clients’ view of their (mental) illness is a sign that the individual’s world view or context is meanwhile seen as a critical aspect of mental health treatment (Singh, 1999). Singh writes that the ‘Shamanic Model of Healing’ (health) is already gaining “some momentum in current Western mental health practice” (Singh, 1999, p. 134). Individuals cannot have harmony in their lives, if the prescribed treatment for them is not consistent with their world views (Singh, 1999). “Like the Shamans, who view healing as coming from within the individual and treatment from external sources, modern mental health professionals are acutely aware that long-term mental health gains can only be sustained by building on the individual’s instrumental and spiritual strengths rather than by externally imposed treatments that focus solely on a disease or disorder” (Singh, 1999, p. 134). “Good mental health is not absence of mental affliction but a joyous and harmonious relationship with oneself, one’s community, and the universe” (Singh, 1999, p. 134). This positive definition, including the subjectivity level as well, can be suggested as a part of a positive general definition of health in Antonovsky’s model.
5.2 Mastering of Stressors
I agree with Faltermaier, who suggests that mastering of stressors – as the central path to health stated by Antonovsky – is only one of several others (Faltermaier, 2002, p. 191). Health may be positively or negatively influenced as well through a person’s conscious active shaping on the social (and society) level (Faltermaier, 2002).
5.3 SoC and Empirical Problems
Interpretations of Antonovsky’s concept often differ or don’t seem to be understood in his intended way. For instance, the SoC in his view “not a coping style or a substantive resource” (Antonovsky, 1996, p. 172), while Waller means that the Sense of Coherence represents the central Generalized Resistance Resource in Antonovsky’s concept (Waller, 1996). Another study supported the opinion that a well-developed Sense of Coherence may act as a generalized, psychological “stress-resistance resource”; since for the SoC the total scores were strongly and negatively correlated with levels of the trait anxiety (Hart et al., 1991, p. 143). Better mental health was found in individuals scoring high on SoC compared to their lower scoring counterparts, while SoC scores were unrelated to the perceived availability of social support (Hart et al., 1991). Faltermaier confirms the different opinions regarding the SoC as being a personal characteristic or a view of life or both (Faltermaier, 2005, p. 68). Antonovsky himself underlines the importance of clarification of the concept of SoC, pointing out the clear distinction between this concept of Sense of Coherence (picture of one’s world, which includes the self) and the concept of ego identity (a picture of oneself) (Antonovsky, 1985, p. 109/110). Becker criticizes that the connecting links and mechanisms between SoC and health-dis-ease are only hinted (Becker, 1992, cited in Waller, 1996). Numerous empirical studies as shown in Bengel et al., basically proved the relevance of the Sense of Coherence in keeping or regaining ones state of health (Bengel et al., 2001). An example is Flannery et al., whose empirical findings supported the reliability and validity of Antonovsky’s Sense of Coherence scales (Flannery et al., 1994). Most empirical studies seem to show a stronger connection between psychic health and SoC than between physical health (general health indicators) and SoC (Lundberg, 1997; Larsson and Kallenberg, 1996, both cited in Duetz et al., 2002; Rimann and Udris, 1998, cited in Fäh, 2002; Bengel et al., 2001). Duetz et al., suggest always using several health indicators and never use solely the psychic health as the only indicator in empirical studies (Duetz et al., 2002). Badura believes the only focus on the personal SoC, as a general bias on the individual level, is too strongly oriented cognitively (Badura, 1992, cited in Waller, 1996; Faltermaier, 1994). He wants to show a stronger influence by objective factors of the social structure, with goes along with Faltermaier, who criticizes the missing level of the society (Faltermaier, 1994). According to Duetz et al., there is a difference in the correlation of health and SoC between females and males, which in females is stronger (Duetz et al., 2002). Contradicting Antonovsky’s assumption that high SoC goes along with high levels of health, Lazar, Blomberg and Sandell found that (after intense psychotherapy) an improved Sense of Coherence correlated with a higher number of somatic treatments than before (Lazar, Blomberg and Sandell, 1999, cited in Fäh, 2002).
Searching for salutogenic aspects in Shamanism, we must take into account the different authors who have criticized the limited empirical testing of the Salutogenic Model so far (Geyer, 2002; Becker, 1992, cited in Waller, p. 17). Unsolved theoretical and methodical problems are also discussed critically by a number of authors (Franke, 1997; Markgraf et al., 1998; Schüffel et al., 1998; all cited in Udris and Rimann, 2002; Bengel et al., 2001). Other researchers confirm the methodical difficulty of empirical-quantitative measuring the Sense of Coherence and ask the question of validity of measured correlations (Rimann and Udris, 1998; Siegrist, 1994; both cited in Duetz et al., 2002). Geyer’s and other recent studies seem to show the tendency to rather measure fear and depression then the SoC itself (e.g. Duetz et al., 2002, Geyer, 2002). Geyer also suggests developing other operational constructs to being able to better judge the substantial content of the model (Geyer, 2002).
5.4 Personal Orientation and GRRs
Nowadays, meaning giving structures and institutions are changing fast, thus it becomes more difficult to develop an identity and a Sense of Coherence. The part which in the past was done by tradition, family structure, sense of family, integration in a regional community and a common religion has to be taken over more and more by individuals. The individuals have to filter out and develop their own values and convictions out of a mass of possibilities (Kolip et al., 2002). In this world of many options, the concept of Salutogenesis describes the helpful capability to develop a feeling or a sense of comprehensibility, meaningfulness and manageability (Kolip et al., 2002). In this context, some aspects in Antonovsky’s concept as well as additional aspects may even have become more important as sources of personal meaning giving structure. Trust - as the factor which protects the individual from feelings of senselessness and paralysis - and confidence are decisive phenomena in personal development (‘ontological security’) (Kolip et al., 2002; Giddens 1991, cited in Kolip et al., 2002). Kolip et al., also suggest relating these phenomena to Antonovsky’s model, with the question: is ontological security needed to develop a strong SoC or the opposite? (Kolip et al., 2002). In this sense it could be viewed as a GRR.
5.5 Further Suggesstions to the Model
Taking into consideration shamanic aspects, there are some suggestions for the Salutogenic Model. In my opinion, one major aspect for the outcome on the health-dis-ease continuum, is the meaning of inner wishes, dreams and desires of a person, which want to be experienced (‘calling’). Some shamanic culture ensured through life cycle rituals that a person would find his own ‘calling’ (inner wishes, desires). Often this was not only supported, but forced in each person of the tribe – at a certain life stage (e.g. reaching adulthood). In order to do so, the person had to undergo e.g. a vision quest. This aspect is not explicitly regarded in Antonovsky’s model. Becker seems to include this aspect in his model (integratives Anforderungs-Ressourcen-Modell) by his ‘psychic internal demands’ (Becker, 1992, cited in Waller, 1996, p. 19). Shamanism pays respect to these demands focusing inward and on experiences within ASC. This way the subconscious, suppressed feelings, emotions, wishes and desires come to the surface. Other influences like effect of landscape / wilderness / nature / surroundings on us, our health and well-being, are addressed in Shamanism as well and should definitely be added to the Salutogenic Concept accordingly. To a certain extent, these aspects could be seen as being included in the sociocultural and historical context of Antonovsky’s model. Their influence should be made explicitly clear, especially in their meaning for modern human beings, whose moving between cultures, countries and different environments has become much more frequent. Halifax expresses the need of “educating others in the content of the wilderness and tribal peoples. These worlds are now disappearing, and I am convinced that their loss has a profound effect on our individual and collective physical, social, and psychological well-being. We not only are less without these worlds but these worlds heal us as well” (Halifax, 1990, p. 53). Not in Salutogenesis, but in Shamanism these influences form a basic part. Nature means protection and security, offers resources and also mirrors what is inside: inner health reflects outer health and vice versa. How can we be healthy while our surroundings are sick and/or polluted? In contrast to Antonovsky’s model of health, environmental and ecological aspects have already been described in addition to psychological, social and biological influences within in an existing model of disease called ‘öko-bio-psycho-soziales Krankheitsmodell’ (eco-bio-psycho-social model of disease) (Engel 1979; Wenzel, 1986, cited in Faltermaier, 2005, p. 49). However, here the focus is on disease.
Shamanism includes spirituality and some aspect of religiosity (see chapter 3). Antonovsky mentions religion in his list of Generalized Resistance Resources. He doesn’t specifically point out the human need for spirituality and religion, although he himself was Jewish and did most of his research with Jewish people. Krippner, with whom I agree, writes about spiritual needs of human beings which exist to provide meaning for their existence (Krippner, 1987). I assume that religion had an obvious meaning in Antonovsky’s own life, but – according to himself – it only plays a role within his concept as an aspect of culture. In his opinion there is no need within his Salutogenic Concept, “to discuss play, secular rituals, mythology, and artistic expressions of society as well as ideologies and philosophies”, because “at one ideal pole of the continuum, not to be remotely approximated in human history, a culture provides ready answers, clear, stable, integrated; with keening for a death, an explanation for pain, a ceremony for crop failure, and a form for disposition and accession of leaders. At the other extreme, which at times becomes a reality for individuals and groups, there is only utter chaos; there are no answers” (Antonovsky, 1985, p. 118).
Antonovsky implicitly states that religion, as a GRR, grows out of every culture. He describes its functions (chapter 4.3, Macrosociocultural GRRs) as well as positive effects of religious belief and ritual (Antonovsky, 1985), but he doesn’t mention spirituality in his model. In Shamanism the spiritual component is practically included and should be recognized in my opinion as a basic human need and GRR in the Salutogenic Model. In this regard, Yeginer suggests as well, that Antonovsky’s model must explicitly include a spiritual component (Yeginer, 2000). The spiritual component, as well as the relation between religiosity/spirituality, should also be included in other traditional models of coping (e.g. concerning severe illnesses) and paid respect to in coping research (Yeginer, 2000). Maslow confirms this by writing of health as the result of mature and integrated life experience or ‘spiritual schooling’ (Maslow, (2), 2000), thus supporting the ‘health’ path of the Shaman who undergoes intense spiritual schooling.
Additional effects, in Shamanism often seen as supernatural, are nowadays described in scientific research. Examples are positive effects on health by different means such as prayer, spiritual healing, energy healing, therapeutic touch, etc., and distant prayer for e.g. hospitalized cardiac care patients (e.g. Byrd, 1988, cited in Ellison and Levin, 1998). These findings led to more unusual hypotheses, including the operation of subtle bioenergies, morphogenetic fields, psi-effects, non-local consciousness and divine or supernatural influences (Ellison and Levin, 1998). Faltermaier too takes cosmic influences on health into consideration (Faltermaier, 2002). The fact that science can’t explain everything yet, is in my opinion no reason for not accepting and integrating those known effects and influences on health into the model.
In our Western societies there is a need – not only for (re)establishing health and self responsibility but also for spirituality and traditional, holistic healing systems. They offer the holistic perspective of the human being – without separating body, mind and soul. This need as well as the need for ASC has expressed itself through increasing member numbers in different cults and religious as well as spiritual groups and organizations. Sinnott confirms the tremendous increase in interest and exploration of traditional healing systems as well as in spirituality over the last two decades, but at the same time decreased religious practices such as church attendance (Sinnott, 2001). He suggests, for our general cultural development, making use of some elements of these spirituality-incorporating healing / growth traditions such as Shamanism (Sinnott, 2001). He calls them body-mind-emotion-spirit healing systems. I find his reasons for these suggestions explained so well that I would like to cite them here: