7 Moving to a positive paradigm
Aaron Antonovsky (1984) has called the emphasis on illness and disease the pathogenic paradigm and has stated that this disease-focused paradigm has dominated our healthcare system. He claims that there are five important consequences of this domination:
‘We have come to think dichotomously about people, classifying them as either healthy or diseased’ (p. 115). Those categorised as ‘healthy’ are normal, those categorised as non-healthy or ‘diseased’ are deviant. There is no place in this dichotomy for those who have a chronic illness yet are able to function perfectly well or for those who have a handicap yet are well satisfied with life.
We have come to think of specific diseases such as cancer or heart disease instead of being in a state of disease. We have become obsessed with morphology instead of theory and practice in relation to generalised disease and its prevention.
We look for specific causes for these specific diseases in order that the causes can be eradicated instead of accepting that ‘pathogens are endemic in human existence’ (p. 115). He believes that we need to explore the capacity of human beings for coping with pathogens.
The pathogenic paradigm deludes us into thinking that if we can eliminate ‘disease’ we will have health. This ‘mirage of health’ (Dubos, 1960) has been the driving force behind the ‘technological fix’ and ‘magic bullet’ attitude to eradicating disease.
The pathogenic paradigm concentrates on ‘the case’ or identifies high-risk groups instead of studying the ‘symptoms of wellness’ (p. 116). Adopting this approach would entail studying the smokers who do not get lung cancer or the ‘fat eaters’ who do not have heart trouble.
Antonovsky claims that instead of assuming that the normal state of the human organism is one of homeostasis, balance and equilibrium, it makes more sense to acknowledge that the ‘normal state of affairs for the human organism is one of entropy, of disorder, and of disruption of homeostasis’ (p. 116). He suggests that none of us can be categorised as either healthy or diseased but that we all can be located somewhere along a continuum which he sets out as ‘health-ease-dis-ease’. He explains:
... we are all somewhere between the imaginary poles of total wellness and total illness. Even the fully robust, energetic, symptom-free, richly functioning person has the mark of mortality: he or she wears glasses, has moments of depression, comes down with flu, and may well have as yet nondetectable malignant cells. Even the terminal patient's brain and emotions may be fully functional.
(Antonovsky, 1984, p. 116)
Antonovsky believes that instead of focusing on eradicating disease we should think ‘salutogenically’ which would involve putting an emphasis on helping people move towards the health end of the continuum despite disease. He is not suggesting that this reorientation towards health should minimise the achievements of medical science, nor impede the progress of technological change. Rather his purpose is to redress an imbalance inherent in the way we view health, not to abandon the struggle against disease but to widen the armoury and explore other ways of achieving health. We need the availability of hip replacement surgery but we also need to understand why one person copes well with the operation and fully regains mobility while another does not. We need to identify all the factors which might help us move along the continuum and not just focus on the disease. We should ask not so much how we can eradicate certain stressors but how we can learn to live with them, concentrating on the ability to adapt.
Another feature of the salutogenic paradigm is that it turns on its head the notion of a high-risk group. As Antonovsky says, all of us by virtue of being human are in a high-risk group (p. 117). If we locate people dynamically along a continuum of health then we are less likely to stereotype certain people such as ‘the elderly’ as diseased. By adopting a salutogenic paradigm we can reconceptualise questions about health to concentrate on why and how people cope well with chronic illness and disability. The questions change from what stops people becoming sick to what helps them to become healthy in spite of disease.
In an attempt to define the mechanisms which help people to cope with adverse health conditions and to move towards the ‘health’ end of the continuum, Antonovsky developed a construct which he calls a ‘sense of coherence’ which has three main components – comprehensibility, meaningfulness and manageability.
Comprehensibility is the ability to see one's own world as understandable, to have confidence that sense and order can be made of situations (p. 118). One views the future as reasonably predictable rather than chaotic, disordered or unpredictable.
Meaningfulness is the emotional counterpart of comprehensibility; life makes sense emotionally (p. 119). Life is worth living for those who see their lives as comprehensible and meaningful.
Manageability reflects the extent to which people feel that they have adequate resources, mental, physical, emotional, social and material, to meet whatever demands are put upon them.
Antonovsky's argument is that wherever a person is located on the health-ease-dis-ease continuum at any particular time, those with a stronger sense of coherence are more likely to move towards the health end of the continuum.
When faced with a chronic illness it must be hard to see the world as understandable or to have confidence that order can be made of situations. The future is unpredictable and it is hard to make sense of one's life. The uncertain trajectory of chronic illness and its unpredictability require constant reconstructions of a person's narratives about themselves if they are to maintain comprehensibility and meaningfulness.
Chronic illness can also stretch the mental, physical, emotional, social and material resources needed to meet the demands that are made on people and so life can feel unmanageable. But a person's resources do not occur in a social vacuum and they are to a degree dependent on the economic and social resources available to them.
A person's sense of coherence is built up from a range of experiences and sources through the life-cycle and should be well developed by adulthood. Antonovsky sees the sense of coherence developing from the degree to which our life experiences provide ‘consistency’, an ‘underload/overload balance’ and provide for participation in decision making. We experience consistency when a given behaviour results in the same consequences whenever we exhibit it and when people respond to us in consistent ways. This allows us to predict the outcome of behaviour and therefore our lives seem reasonably predictable. Underload/overload balance is achieved when the demands made upon us are appropriate to our capacities. Underused capacity due to lack of challenges can be as harmful as not having sufficient capacity to meet the challenges with which we are faced. The extent to which we participate in decision making is important to the emergence of a strong sense of coherence and is the basis of the meaningfulness component. When everything is decided for us and we have no say in the matter, when the rules are set by others without consultation, then the experience is alien to us. The issue is not so much having control over the events of our lives but in having some part in the decision-making process.
Adverse housing or working conditions serve to erode the sense of coherence.
There are strong messages here for healthcare workers about the need for people to be active participants in their own healthcare if they are to feel in control of their own health. In order for this to happen they need to be listened to and they need to know that their concerns are valued. But above all Antonovsky's ideas enable us to keep positive health as a goal, exploring ways in which people might move along the continuum towards the health end in spite of chronic illness or disability.