Salutogenesis
  

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By: Michaela Gloeckler, M.D.
Where can we discover the basis for the health and well-being of body, soul and spirit?

Promoting health or preventing illness?

The word salutogenesis has its roots in the Latin ‘salus’ or ‘salis’ meaning health; and the Greek ‘genesis’ meaning origin. This is the word used to describe a new direction in research which addresses the source of health in relation to body, soul and spirit.

In turning to the underlying causes of health and well-being, salutogenesis creates an exemplary new paradigm in medical research. The paradigm that has held good for medicine for the last 300 years has conversely been Pathogenesis. This word comes from the two Greek words ‘parthein’ suffering; and ‘genesis’ beginning or origin. This word points to the origin, the roots of suffering i.e. illness.

Pathogenesis is directed towards the origin of illness. The idea of prevention is very strongly bound up with pathogenesis in that the attempt is made to prevent or hold at bay that which causes the illness.

Salutogenesis arose as a concept in the English speaking world as early as the sixties. It only entered in the Health field and political and academic discourse in Europe in the nineties. A significant reason for this is obviously the fact that the old concept of Pathogenesis was still financially viable. However the increased services and costs that have appeared in the health delivery systems and all the financial problems tied up with it, have brought about an openness towards a new concept of health, towards the concept of salutogenesis – on an international level. The primary question now asked is: “Where does health originate? How can it be strengthened?” rather than looking only for the origin of illness and how to prevent it.

What is the fundamental difference between the old pathogenic concept and the new salutogenic concept? The pathogenic concept – in the case of an infectious disease for example – is based on the idea of infection, thus posing the questions ‘who gave me this’ or ‘what is it? Bacterial or viral?’ ‘Which antibiotic do I need to take?’

On the other hand the salutogenic concept is based on the question: “why is it that I have been allowed to remain healthy, when others around me have ‘caught’ an infectious illness?” The question as to why one person succumbs to a virus and another doesn’t, is a salutogenic question, a new research question.

What really constitutes good health?
Three pioneers of Salutogenesis

It is the aim of salutogenesis to draw people’s attention to the wellsprings of individual and social health and healing.

Rudolf Steiner (1861-1925) In a lecture to physicians in 1920 Rudolf Steiner had already stated that if the medical doctor wishes to help the individual human being, he needs to have an overview of the whole of mankind. Why is this? It is because every human being is a part of the totality, and can influence other human beings either this way or that – whether consciously or not. In the manner in which he or she interacts with others, both inwardly and outwardly, he/she is actively involved in the development of the earth and of the human being. The more I can act from a broader perspective – even in the small daily detail – then the more I am able to contribute towards the growth and healing of the totality. The more isolated I am and the more disconnected I am in my actions, the more I will be in danger of becoming an ‘illness factor’ in the course of the total development. Health, ‘complete, healed’ means integration. Illness is always the result of isolation or disintegration of single processes, functions or substances in the organism. We need to consider in all our daily deeds the great goals of humanity and not loose sight of them.

Aaron Antonovsky (1923 – 1994) This father of the salutogenic paradigm was given the task of examining the state of health on the older population in Israel. In doing so, he developed criteria for measuring bodily health and mental health. To his great astonishment he established that amongst the healthiest of the older population belonged those who had survived the horrors of the holocaust.

Abraham Maslow (1908 – 1970) Together with Carl Rogers and Eric Fromm, some of the founders of humanistic psychology and psychotherapy, Abraham Maslow came across extraordinary discoveries in his continued research of mental health. In order to establish the criteria for mental health, he examined healthy people. Those whom he felt to be the healthiest had all experienced some form of breakthrough or turning point. They had had experiences of a spiritual nature, such as for example an out-of-body experience, an encounter with God, or some other mystical experience. He also discovered that in every mentally ill soul, there exists an inner kernel that is perfectly healthy. If this kernel is accordingly strengthened the person is then better able to deal with his or her problems and can relate to his human environment in a healthier way.

Psycho-social Health - An Economic Perspective

The concept of salutogenesis has become interesting not only to the government, but also to the economy. Within the framework of a meeting of the World Trade Organization held in 1994, a decision was made permitting trade within the whole realm of social services. This took place during the so called Uruguay Session where the General Agreement on Trade in Service (GATS) was signed. One hundred and twenty countries have ratified this agreement and are now willing to treat the social services industry, for example, the health industry, as a commodity which can now be run as a private enterprise.

As a consequence of this agreement, social services have to be restructured and also have to become more transparent. In order to achieve this, a kind of quality-control procedure has been developed on the basis of which each individual service can be exactly outlined: for example the exact time required to adequately perform a  therapeutic measure.

The problem with this approach is that anything that does not yield a financial profit will not be included in the covered costs. Personal attention and individual time given to a particular person who, for example, not only wishes to be brought to the bathroom in real time, but may also wish to discuss an urgent question, ought also be included as reimbursable by the system.

However, the argument against is always limited financial resources.
Quality control certainly does increase efficiency, but at the same time it bears within it the danger of regularizing the entire social realm which can then no longer do justice to actual human needs. This poses the question of creating important new forms and structures for a truly modern future-oriented healthcare system in which patient initiatives and civil initiatives urgently need to be included.

In his book, The Sixth Kondratieff, Leo Nefiodow explains that the economy evolves according; to so-called Kondratieff cycles. (These are named after the Russian Scientist Nikolai Kondratieff 1892-1939.) Kondratieff discovered that these were extended cycles of development lasting 40 to 50 years (1926). He noted that every forty to fifty years a totally new development could be observed, which made an enormous impact on world economy.

It was around 1800 that the invention of the steam engine and the industrialization of the cotton industry came about. The steel and railway industry followed, and then came the petrochemical and automobile industry, and lastly, the information and computer industry. Each of these developments brought about a great economic upsurge.

The computer boom shows signs of coming to a more rapid decline than was originally thought. This makes the question as to what will give the economy its next great boost especially fascinating.
In all probability, it is likely to be the area of psychosocial health-in other words, the social services market. If the drug industry continues to rise as steeply as it has in the last twenty years, then, according to the calculations of WHO, every second inhabitant of the industrial nations will be dependent by 2100. In other words, 80% of the population will be addicted and will need some sort of assistance. In business it can already be observed that missed work days caused by psychosocial disturbances are becoming a greater and greater problem.

People are now less able to cope, and call in sick more and more frequently. Added to this comes the psychosocial stresses for those who are unemployed. If the economy wishes to remain stable, then it needs to have sufficiently healthy people. It is then for this very reason that the economy is interested in the concept of salutogenesis.

As we look ahead we are faced with a future society based on a ratio of 20 to 80, where only 20% of the population will be employed while 80% will require social services. This calls upon all of us, especially those of us who are involved in the Association for Anthroposophical Medicine, to take up the task of reversing this ratio. 80% of the population should be employed and able to create new workplaces on the basis of new perspectives which spring from an all-embracing economic and social political vision that would allow the 20% who are unable to work to be cared for. Growing costs and achievements in the health-are system place our work in anthroposophical medicine alongside political and economic structures that wish to promote the general health and well-being of the population to as great an extent as possible.


Where can we discover the basis for the health and well-being of body, soul and spirit?

Expanding the Boundaries of Endurance
In the pathogenic model, the goal of the physical organism is homeostasis, a Greek-derived word indicating a similar or constant condition or state. Homeostasis is, of course, essential for health. The principle emphasized in salutogenesis is heterostasis (hetero=different), the organism’s adaptive and transformative power needed when meeting varying conditions and overcoming conflict for creating homeostasis. In meeting that which is foreign, the human becomes stronger. What becomes essential, then, is recognizing the boundaries of physical and psychological endurance, and expanding them.

This salutogenic principle supports anthroposophical medicine’s position that it is healthy for children to undergo childhood illnesses, because they strengthen and develop the immune system and the capacity for self-regulation and self-healing. Of course, it is always important for physicians to establish whether or not the individual child is strong enough to fight an illness. If a child is too weak, then it is sensible to inoculate the child or to treat with antibiotics and other medicines to reduce the fever.

Naturally, this principle raises questions about the public health system’s strong advocacy for immunization. The significant danger is that through  mass immunization against the entire range of childhood diseases, whole populations are robbed of the chance to build new, far-reaching immunity against illness. A physician applying the pathogenic principle would advise vaccinations against every flu virus to avoid any kind of stress and strain, to take off work or to take this or that pill at the slightest hint of discomfort. Salutogenesis presents a different stance. It asks: how do I learn to cope with all the various situations of life and remain inwardly flexible at the same time? How do I cope with frustration and stress and yet maintain stability and integrity of character?

A Perception that Life Makes Sense
In the psychological realm, salutogenesis is concerned with building a sense of coherence, a feeling for what connects everything that exists. Only when a person can make sense  both in the details and in the wider aspects of his world, can he find meaning in life. How is this achieved?  Antonovsky gives a very concise answer to this question. The child must come to a satisfactory perception of the world through education. He or she must be able to learn that the world is: understandable, valuable, purposeful and manageable. This requires a worldview that helps towards gaining self-knowledge and the ability to cope in life – a perception that life makes sense.

After the second World War there were many children who were burdened by intense anxiety coming from either their wartime experiences or from listening to adults speak about the atomic bomb that was dropped on Japan. In such cases it is essential to have at least one adult available who has some kind of understanding of the child’s situation and is able to answer the child’s questions. This helps the child to build a sense of coherence. At the very least, it makes it possible for the child to bear fears and anxieties of this sort. It also allows for some hope that the fear can be overcome and that something may even be able to be done to remedy the causes of war.

Similarly children and youngsters of today have undergone a comparable experience in the wake of the events of September 11th. What is essential here is that discussions and reports and as many varied sources of information are provided to help make such an event understandable, to make it possible to be processed inwardly. Above all else it is important that there is an adult nearby – preferably the mother or father – who is able to share and be aware of the circumstances, but at the same time who manages to radiate a sense of hope and confidence. It is helpful if, despite experiencing and undergoing dangerous situations, people can still appear “normal,” positive and joyful. This is what really counts.

It is possible to work towards creating a sense of coherence early in a child’s life. Towards this end, Rudolf Steiner wrote the following morning verse, recommending that it be spoken at the beginning of each day by both the students from the 5th grade up and the teachers at the first Waldorf school.

I gaze into the world
In which the sun is shining
In which the stars are sparkling
In which the stones are resting
The living plants are growing
The animals live with feeling
And the soul filled human being
Makes room to house the Spirit.
I gaze into my soul
That lives deep down within me
The Divine Spirit weaves
In the sunlight, in the soul’s light
In the great cosmos without
In the soul’s depths within.
To you, oh Divine Spirit
I will turn, asking
That strength and blessing
For learning and working
Grow deep within me.

The purpose is not to create an ironclad ideology, but rather to foster an inner growth process allowing children to unite themselves more strongly with the occurrences in the world through understanding, through ongoing learning and working. That process is further strengthened by the presence of adults who continue to work on their own sense of coherence for themselves and for the world. According to Rudolf Steiner, creating this coherence is one of the most important tasks of our era (called by Steiner the fifth post-Atlantean epoch, beginning in the fifteenth century, see his An Outline of Esoteric Science). Finding coherence for us, by necessity, entails the task of engaging in an inner and outer struggle with the forces and tendencies towards evil – as represented in Goethe’s Faust in the pact with evil between Mephistopheles and Faust.

By itself, the magnitude of violence and destruction that is spread via television and videos and the media in general ensures that nobody who has not begun to awaken to self-awareness will remain untouched. When one recognizes evil, the danger of falling prey to it becomes somewhat less. In first recognizing and then overcoming evil, the possibility begins to grow that truth, beauty and goodness can develop. There is an old Chinese proverb which says that there are only two paths to wisdom – through insight or through pain and suffering.

Where was God when Auschwitz happened?
The third and most decisive element is one of the most difficult for people to acquire today. That is to build up resistance, spiritual resilience, through faith in the course of human development. How many people are there who fall prey to depression because they have lost faith in God, in other people and in human development?  The horror, violence, corruption, wars and catastrophes that are continuously broadcast can hardly be borne any longer. Illness, drug abuse, medication abuse, acts of terror or despair (including suicide) – all are results. What is essential today is to create an outlook that is able to comprehend that which is negative, evil or destructive and to be able to work through them in a meaningful way.

Hans Jonas (1903-1993) a Jewish philosopher, colleague and contemporary of Antonovsky, played a decisive role in influencing the debate on ethics in the 20th century. Central to his philosophy is a humanistically imbued “principle of responsibility.” Jonas’ mother died in the gas chambers of Auschwitz. For him, as a practicing Jew, this was incomprehensible, because according to the Jewish tradition God lives in history, He works in history accompanying human beings throughout the historical process.  God is, so to speak, historically tangible and never punishes the just. Through the experience of Auschwitz, Jonas asked: Where was God when Auschwitz happened? Had He turned aside from humanity and abandoned it? Had He ever even existed? Or had God simply changed his relationship to humanity…had He developed His relationship further in the course of human development?  In the process of asking these kinds of questions, Jonas achieved an ongoing evolutionary concept of God (see Jona ’The Concept of God after Auschwitz (Der Gottesbegriff nach Auschwitz).

The occurrence of the holocaust shows, Jonas concludes, that as far as mankind is concerned, God can no longer be almighty and all-wise. Rather, God has given complete wisdom and complete power  to human beings so that they can have the chance to choose the good in freedom. That freedom allows the possibility to choose error and to go astray in the worst way conceivable. Man must now be responsible for what he does. He is responsible for his handiwork, not God. Jonas discovers also that the region of the heart, of conscience and of love is the actual realm of humanity. It is this center that is compatible with the freedom of human beings and their independent knowledge. Only this realm has been the stable connection between human beings and God, from the very first day of creation until now. While knowledge and power can be abused, they also serve the development of the human being’s capacities and self-consciousness. Love, however, is.  It characterizes the eternal core of the human being which remains united with God – even in Auschwitz.  God is love. This God can exist in Auschwitz and accompany human beings to the gas chamber. This “Concept of God after Auschwitz” rescued Jonas’ picture of God. It is at the same time the strongest possible salutogenic principle. It is the principle of the will-imbued human spirit, willed by the ego that mobilizes the entire resources of resistance in human beings. It answers the question: What allows me to withstand physical, mental and spiritual attacks so that I can remain healthy?

Making the Well-Springs of Health Accessible - The New Task of Medicine


The underlying principle of salutogenesis which is based on heterostasis* and the activation of the body’s own resistance, brings about an all encompassing renewal in all branches of modern medicine.
 
Healthy nutrition  with foods grown in a vital and healthy manner  is one very important element that belongs here. The process of digesting and transforming these foodstuffs into bodily substance demands more effort from the organism than when pre-cooked canned vegetables or synthetic vitamins are taken in. Everything that is pre-digested, substituted or offered as “ready-made” asks too little of the organism’s own activity. Activation rather than relief and protection is the basic tenet of healthy nutrition.
 
Medications offered by anthroposophical medicine, have as their goal the strengthening of the patient’s own bodily resistance. The work of the body should not be taken away, rather the medication should help the organism to develop and mobilize its forces of resistance, the forces for self-healing.
 
An Education aimed at the child, helps to provide age-appropriate boundaries and allows the child to experience itself and develop.

Here it is important for the child to be provided with examples in its environment by means of which it can learn to take up challenges and cope with obstacles.

Children should have the opportunity to measure their own forces through their disputes with trusted adults; to be able to experience and stabilize their own capabilities.

A good education is one that is characterized by honesty, love and respect for the other. In this regard, honesty provides the basis, because important as love and autonomy are, they lack foundation if they are not accompanied by honesty, which is so to speak, love on the level of knowledge. Through clear thinking, which is what health really means on a spiritual level, the child learns to place itself within the context of the world and to find its place there.
 
When a child breaks a toy, he comes trustingly to an adult and asks, “Can you fix it for me?” Fix in this sense means to make it whole, to heal it. Health is integration, the harmonizing of all functions. It also means holy, the holy in us.
 
Anthroposophy as a science of the spirit and soul of the human being, can embrace this new salutogenic concept of health down to the very last detail. It lays a great responsibility – especially upon anthroposophical educators and doctors, to contribute through their own research so that this concept can be widely spread and  realized.

It makes it necessary to bring the reality of the spirit into the natural-scientific medical debate and not to rule it out as “transcendant” – relegating it to the theologians and philosophers alone.
 
The health of modern man depends entirely upon how he thinks of himself as a human being and upon which path of development he travels.

Salutogenesis: Seven Requirements for Healthy Growth and Development


Everyone who becomes aware of divine spiritual existence, who "awakens" to it, can learn how to become healthier and more human. Rudolf Steiner, an experienced teacher in the realm of self-development, has described how this can be done. In his books Esoteric Science, Theosophy and How to Know Higher Worlds, he clearly states that the acqui­sition of knowledge, the striving for higher development or meditative exer­cises can only be beneficial if we make the results of this work fruitful for daily life. For ultimately, how can such mag­nificent human characteristics as venera­tion, inner peace, courage, confidence, hope, loyalty, devotion, love and hon­esty must become autonomous and, in turn, confirm the autonomy of others. To be learned, these qualities must be rooted in everyday life, and in fact, have to be developed and proven in daily life.

The First Requirement

"The first requirement is that we turn our attention to improving our physical and mental or spiritual health. Our health does not in the first place depend on us, yet we can make the effort to improve it." "

From the above statement, we might surmise that we are given free li­cense to egotistically cultivate our own health. However, the right balance be­tween pleasure and duty can be found. We are very much bound up, both men­tally and physically with our daily tasks—so much so that we often overlook our health. We may skip a meal, or we work through half the night—or even all night to make ends meet. In other words, the demands of our work often prevent us from paying adequate attention to our own well-being.

The Second Requirement

"The second requirement is to feel ourselves fully part of life. It holds true for the smallest thing as well as greater ones. For example, out of such an attitude I will be able to look at a criminal totally differ­ently, holding back my own judgment and saying to myself: he is a human being just as I am. My particular upbringing prob­ably prevented me from a destiny like his. If his teachers had taken the same trouble with him as mine did with me, he may have thrived. I will reflect that I have en­joyed privileges that were denied him, and that I can thank my circumstances for the good fortune that was granted me. Then the realization that I am simply a mem­ber, a segment of the whole of humanity, will not be foreign to me, and that as such I am co-responsible for everything that hap­pens."

Whoever practices this require­ment, comes to the somewhat shocking realization as to just how much power is exerted by our own actions. If someone annoys me, and I react on that level, the situation can easily escalate or lead to lasting discord. If I avoid reacting to the person but instead ask myself: how should I act so this person can express their better nature—or: what was he experiencing inwardly—what may have happened to him at home that his tol­erance level is so low? Even if we are unable to answer such questions, the very fact that they are posed non-judgmentally is an important step. It is not uncommon that, faced with such an attitude, the other person begins to change his/her behavior after a time.

The Third Requirement

"... that we win through to the con­viction that our thoughts and feelings are as important for the world as our actions. Hating someone is just as destructive as a physical blow. This leads to the insight that I not only do something for myself when I perfect myself, but I do something for the world. The world is served as much by my pure feelings and thoughts as it is by my good deeds."

Anyone who knows someone for whom they feel love, respect and ven­eration, knows just how effective good thoughts and feelings are in relation­ships. Children treated with loving re­spect grow up in an atmosphere that acts as a moral wall of protection against common daily mishaps and fearful ex­periences, and they grow up with quite a different inner confidence than would be possible without this kind of protec­tion.

The Fourth Requirement

"The acquisition of insight that our true nature lies within. If we see ourselves merely as a product of our physical envi­ronment we cannot accomplish anything in esoteric training. The basic requirement is to consider ourselves as a being of soul and spirit. When we manage to break through to this conviction we are in a position to discriminate between inner call­ing and outer achievement, discovering that one is not necessarily measured by the other. As esoteric students we must find the middle balance between what outer circumstances demand and what we know to be true to our character. This practice develops what, in esoteric science, is termed the ‘spiritual scales.’ On one of its scales lies a heart open to the needs of the outer world, and on the other 'inner certainty and unshakeable endurance'.”

The Fifth Requirement

“Steadfastness in following through on a resolution once it has been made. Noth­ing should lead us to abandon something we have decided upon except the insight that we have made a mistake. Each reso­lution we make is a force that works in its own way — even when it is not immedi­ately successful in the area where it is first applied. Success is crucial only when we act out of longing, and any action moti­vated by craving is worthless from the point of view of the higher world. In the higher world, love is the only motivation for ac­tion. Everything which stirs the esoteric stu­dent to action should come to expression in this love. Then we will never fail to transform resolutions into deeds, regard­less as to how often we have failed in the Past.”

The Sixth Requirement

“A sixth requirement is that we de­velop a feeling of gratitude for everything that human beings receive. We must real­ize that our own existence is a gift of the whole universe. What a great deal is nec­essary so that each one of us can receive and sustain our existence! How much we owe to nature and to other people! Those who seek for esoteric training must lean towards thoughts such as these if they are to develop the all-embracing love necessary to attain higher knowledge.”

Conclusion

“All of the aforementioned require­ments must unite in a seventh: to continue to understand life in the sense that these requirements demand. By doing so, the eso­teric pupil creates the possibility for giving life the character of unity. The individual expressions of his life will be in harmony and will not contradict each other. He will be prepared for the peace of mind to which he must attain during the first steps in eso­teric mining.”

It becomes clear to us, when we take a look at our own path of development, that although we are imperfect, we are capable of development. Becoming more human allows us, if we are will­ing, to follow these requirements, to practice them and be willing to try ever anew. If we are able to make the sources for them more and more accessible, we are then at the same time increasingly able to achieve good health at the three levels of our existence, in the physical, soul and spiritual. Apart from this we will also acquire a basic healthy ethical attitude which can stimulate the devel­opment of our humanity in all realms of life.

Italicized quo­tations are from How to Know Higher Worlds by Rudolf Steiner. Available from www.steinerbooks.org

* A Greek-derived formulation for balance in the midst of change.

Michaela Gloeckler, M.D. has been Head of the Medical Section at the Goetheanum, the School of Spiritual Science in Dornach, Switzerland since 1988. She co-authored A Guide to Child’s Health, Floris Books.  This article is adapted from a lecture given in September 2001.  Special thanks to Anne Sproll for translation from the German






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