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Life is more than survival: Exploring links between Antonovsky’s

salutogenic theory and the concept of resilience

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 CONTENTS

Preface ix

Cbapter 1 Overview
Kathryn M. Gow and Marek J. Celinski

Part 1: A Closer Look at So me of tbe Concepts and Measures Relating

to Coping and Resilience
Chapter 2 Trends in Resilience Theory and Research 13
Vladimír Kebza and !va Solcová

Chapter 3 Life is More Than Survival: Exploring Links between Antonovsky's

Salutogenic Theory and the Concept of Resilience 31
Monica Erikssan and Bengt Lindstrom

Chapter 4 Social and Emotional Intelligence: Contributors

to Resilience and Resourcefulness 47
Anna M. Pa/ucka, Marek Celinski,
J. Douglas Salman Jr.and Peter Shermer

Chapter S Personality Characteristics Related to Resilience: Seeking

for a Common Core 63
!va Solcová and Vladimír Kebza
Chapter 6 Measuring Coping Versus Symptom Intensity:
Implications for Clinical Practice 81
J. Dauglas Salman, Jr. and Marek J. Celinski

Chapter 7 Use of ' R-SOPAC' in Cases ofPhysical and Psychological

Trauma and Stress 97
J. Douglas Salman, Jr. and Marek J. Celinski

Part 2. How Humans Cope and Survive in a Wide Variety of Life's Challenges

Chapter 8 The Role ofCoping in the Development and Treatment

ofChronic Pain 123
Angela Daugall and R obert J. Gatchel
In: Wayfinding through Life's Challenges ISBN: 978-1-611 22-866-3
Editors: Kathryn M. Gow and Marek J. Celinski © 2011 Nova Science Publishers, Inc.

Chapter 3

LIFE IS MORE THAN SURVIVAL: EXPLORING LINKS

BETWEEN ANTONOVSKY'S SALUTOGENIC THEORY
AND THE CONCEPT OF RESILIENCE

Monica Eriksson' 1 Bengt Lindstrom 1' 2

1
University West, Sweden
2
Folkhalsan Research Centre, Finland

ABSTRACT

Ibis chapter aims to explore, and to sorne extent, clarify the relationships between
the salutogenic theory and the core concept sense of coherence by Antonovsky and the
concept of resi1ience. Since 2003, the authors have conducted an extensive global
synthesis of current salutogenic research ( 1992-2009) based on approximately 900 papers
and doctoral theses. In addition, we had the opportunity to discuss the salutogenic model
of health with Antonovsky befare he died. Both authors co-operated closely with
Antonovsky's colleagues and the inner circle of sa1utogenic research. The evidence base
for the salutogenic research is presented in this chapter and in particular relates to the
concept of resilience. Each concept has its unique and distinctive feature. The
"Salutogenic Umbrella" is presented here as a framework including sorne other related
concepts explaining health and a good life.

Keywords: Sense ofCoherence, Salutogenesis, Resilience, Antonovsky, Health Promotion

t Bengt Lindstrom, Professor, Chair of the IU HPE Global Working Group on Salutogenesis, Folkhiilsan Research
Centre, Health Promotion Research Programme.
32 Monica Eriksson and Bengt Lindstrom Life is More Than Survival 33

INTRODUCTION The descriptions of lbe salu1ogenic theory and lbe concept of resilience follow lhe oulline
in Table l.
There are many similarities between lhe framework of resilience and salutogenesis.
According to Anlonovsky, the core of salutogenesis stems from stress research while
scientists in volved in resilience research always refer lo risk and adversities. Second, neither Table 1. An Ovcrview of SimUarities and Differences between Salutogenesis and thc
the scnsc of coherence nor thc concept of resilience are seen as personal characte.ristics, but Concept of Resilience
rather as a process. Third, bolh concepts emphasize resources: lhe salulogenic framework
talks aboul Generalised Resislance Resources, while resilicnce research uses the word Solutog<nosls (Antonovsky)
proleclive faclors. Fourth, lhey both consider the mainlcnance and developmenl of health as a
TH E FRAMEWORKS
proccss in a continuum. Fiflh, bolh Sense of Coherence and resilience can be applicd al lhe Prologue Thc Holocaust
individual, group (including families) or socielal leve!. The two concepls differ when il comes Attention on Stress
to the adjuslment process where lhe resilience concept is connecled always wilh risk fac tors. Approach Contexrual, siruational, systems
Orientation Life orientation, a dynnmic proccss in a
llowever, salutogenesis has a much broader perspeclive beyond just the measurement of the continuum of ease/dis-ease
sense of coherence. Health promotion
Focus Resourccs, abilitics, capacitics, potentials,
assets
The core Tbeorigin ofhealth, what crcates health? Who
Tm; ROLE OF SALUTOGENIC TIIEORY IN REALTH AND W ELLBEING question are tbe people stayin¡ well? Wbat can their
cxpc:ricnce tell us about health resources?
The main focus of Ibis section is lo describe sorne prccondilions for a posilive TH E THEORETICAL FOUN DATION
development of health and wellbeing, that is, we shifl attenlion from risk and weakness to Ocfinition The original definitions of salutogencsis and the
strength and resources by describing lhe essence of the salutogenic theory and its core sense of coherence (Antonovs ky) are generally
concepts Sense of Coherence (SOC) and General Resistancc Resources (GRR) which werc acccptcd. Salutogencsis is a mucb broader
concept than only the measurement of the SOC.
developed by the medica! sociologist Aaron Antonovsky ( 1979, 1987). The salutogenic There are rnany othcr theories and concepts
theory is relaled mainly lo the concept of resilience and to some exlent to the concept of with salutogmic elcments available for
resourcefulness (Rosenbaum, 1990). The authors are currently undertaking a systematic and explaining heahh (sec The Salutogenic
Umbrclla in Figure 1)
analytical review of salulogenic research al the Folkhlilsan Research Centre at The Heallh Kcy conccpts Scosc of Cohc:rence (SOC), muttidimensional
Promolion Research Programme in Helsinki, Finland. In addition, personal communication construct
hetween Lindstrom and Anlonovsky al the heginning of the 1990's suppon ed by lhe ElcmeniS Comprehensibility, Managcability,
Meaningfulness
experiences from chairing lhe !UHPE Global Working Group on Salulogenesis and Prercquisites General Rcsistance Resources
discussions wilh Antonovsky's research colleagues form lhe consideralions and conclusions Status Coherent theoretical framework, extensivcly
in this chapter. and empirically examined, systcmatically and
This book emphasizes in its title resources as responses to challenges. Human analytically synthesized, cvidcnt
development requires challenges. Based on salulogenic theory, to be exposed to severe slrain
can be experienced as a challenge. Strain forces us lo fi nd meaning and molivation lo solve TII E OPERAT IONALISATION
problems, and reduce lension and stress where SOC and GRRs serve as the essential coping The The Orientation to U fe Questionnairc The
mcasurcment original SOC-29 and SOC·IJ ilem-scalcs, sorne
resources. In resilience research, challenges are related to al-risk situations and adversities. modificd versions witb tbc same. que.stions but
Here lhe protective factors are essenlial for a posilive outcome. The ma in focus of Ibis seclion with difTcring scoring altemalives
is on how to deal with challenges and stress and slill stay well, in other words salulogenesis. THE IMPLEMENTATION
How do we creale societies where people, especial! y children, do nol need lo be exposed to Applicability Individual, group (families) and socictal lcvel
serious adversilies and need lo prove lhey can survive? In order to explain this, we have to Outcome Good perccivcd hcahh (mental, physical, social)
differentiate between challenges and stress. Challenges are stimulaling factors leading to and Quality of Life (spirituol hcalth)
positive development, bul challenges moving to prolonged overload and stress are factors that Evaluation The key conccpts of sulutogL·nesis, the sense of
coherence
damage our health. Rutter talks about a so called "sleeling" effecl, meaning that lhe
Effectiveness The global evidence base pi'Ovcs the hcallh
experience of stress or adversily sometimes strengthens rcsistance lo stress later in life model works
(Ruuer, 2006, p. 2).
Resllience (Garmetzy et al.)
Vulnerable, invincible, rcsilient
Risk
Contextua!, situational , systems
A dynamic proccss of rccovery in a
cominuum
Health protection
Resources, abilities, capacitíes,
potentials, assets
Why do sorne peopte stay heahhy and
others do not, regardless of severe
hardships and adversities?
Hard 10 gel a hold of lhe complete
contcnt ofresilicnee. Many di.f ferent
dcfínitions of thc conccpt, bccause of
diffcrent availnble applications on
different lcvcls. However, across the
definitions, a general consensus of
community resilic:nce has emerged.
Rc:silienc:c, ..bouncing back... beatmg the
odds, multidLmensional construct
Protcctive fac1ors
Lack ofa coherent theory base, many
thcorics depending on thc leve! and
d imcnsions explorcd;
Conceptually diffuse, ''slippery" concept,
principie, evidcoce
Diffc::rent qucstiorumires wilh different
ilt.ms depcnding on lhe level and
dimcnsions cxplored
Individual, &roup (families) and societal
leve!
Survival, perccivcd gocxl health and
Qualily of Lifc
No clcar way to evaluate dependent on
the lack o fa sound lhoory base:
Lack of cohcrcnt and comprchcnsive
evidente
34 Monica Eriksson and Bengt Lindstrom
The Frameworks
Thirty years have passed since Aaron Antonovsky introduced the salutogenic theory as a
global orientation to view the world. The origin of the theory derives from interviews with
lsraeli women, conducted during an epidemiological study of the problems that women, from
different ethnic groups in Israel, experience during menopause (Antonovsky, 1979, 1987).
One of these groups shared a common experience - they had survived the concentration
camps of World War JI. To bis surprise, he discovered tbat sorne of these women had the
capability of maintaining good mental health and living a good life, in spite of all they had
been through. He claimed that the way people viewed their life would have a positive
influence on their health. Antonovsky also stated that salutogenesis was not limited by the
disciplinary boundaries of one profession, but rather that an interdisciplinary approach was
needed between disciplines to produce better health outcomes. Further, he maintained that
salutogenesis was not just about the individual, but an interaction between people and the
structures of society, that is, the human resources and tbe conditions of tbe living context.
This led to his model of health based on "what creates health?" rather than "what causes
diseases?". Note that the focus was on life, not death and disease.
The concept of resilience was in use airead y in the nineteenth century. In a historical
review of the construct Tusaie and Dyer (2004), two main tracks emerged; the physiological
aspects of coping and the psychological aspects of stress. The physiological aspect started
from a view of life as a balance and homeostasis, continued by discussions on emotional
stress and morbidity in the 1950s, the issue of brain plasticity and psycho-neuro-immunology
in the 1970s-1980s, and finally ended up witb the construct of resilience in the 1990s. The
psychological track is based on a discussion of subconscious defense mechanisms ( 1800s-
1950s), coping as a conscious process in the 1960s, a focus on protective/risk factors in the
1980s, and ends with the concept of resilience in tbe 1990s. In the early stages of resilience
research, much of the focus was on the vulnerability of children, living in at-risk conditions,
still being invincible (Gannetzy and Rutter, 1988, Gannetzy, 1991, Rutter, 1993). Rutter
(1987) centers on four main processes in resilience: (i) reduction of risk impact, (ii) reduction
of negative chain reactions, (iii) establishment and maintenance of self-esteem and self-
efficacy, and (iv) tbe opening up of opportunities. There is a common agreement that
resilience emerges when individuals, faced with negative life events or strains, bave the
capacity to mobilize protective factors or intemal and externa! resources and stay well.
An Asset Approach Focusing on Resources
Health is created where we live, love, leam, work and play (WI-!0, 1986). This is clearly
stated in the Ottawa Charter, the WHO core principie document for health promotion. This
means that research should focus on people in the context of the here and now. The approach
of the salutogenic theory is to focus on the interaction between the individual and the group,
that is, families and the environment. The salutogenic theory of health is derived from the
assumption that human nature is heterostatic rather than homeostatic. This means that we are
affected by stress and daily hassles continuously in our everyday life. Confronting a stressor
results in a state of tension which one has to deal with. Whether the outcome will be
patbological, neutral, or salutary, depends on one's capability to manage tension. In
Life is More Tban Survival 35
Antonovsky's salutogenic tbeory, this was formulated as the Sense of Coherence (SOC) and
Generalized Resistance Resources (GRR).
The basis for homeostatic theories, that is Lazarus' cognitive theory on stress and coping
and life event research, was a life in balance (Antonovsky, 1987). According lo a pathogenic
view of life, a disruption was assumed lo damage the balance and to damage health and
wellbeing. Stressors, according to Antonovsky's thinking, are seen as challenges instead of
sometbing that damage your life. Challenges are more open-ended, initiating an interaction
between the individual and the immediate environment. Jndividuals with a strong SOC are
able to invest energy to solve problem, and are able to construct and reconstruct the
immediate environment to make it understandable. The assumption is that the things you
understand become more manageable. Furthennore, the traditional theories on stress and
coping are mainly focused on tbe concept of control. In the salutogenic theory, the emphasis
is on the person's ability to use available GRRs, botb interna! and externa!, to manage
stressful situations. Tbe core of the salutogenic theory and philosophy is how to manage the
situation tbat life cannot be controlled. The salutogenic view on stress and coping is that one
should be able to live in chaos.
Life Orientation and Processes
Fundamental to tbe salutogenic tbeory is that health is considered as a position on a
health ease/dis-ease continuum and the movement is in the direction towards health, rather
than a dichotomy between health and illness. This means tbat we need to focus on discerning
what conditions give us good healtb. This approacb makes a difference to the outcome. lt is a
dynarnic process-oriented construct, meaning that we are always, to sorne extcnt, healthy
independent of an ongoing illness or disease. Antonovsky (1993a) emphasized tbat the SOC
concept was a dispositional orientation, ratber Iban a personality trait or a specific coping
strategy. Having a strong SOC means tbat the person is flexible and able to use different
strategies in different situations to salve problems. In other words, it reflects a person's
capacity to respond lo stressful situations.
The concept of resilience as a global construct is much more complicated. Findings from
a thorough review of the literature by Vanderbilt-Adriance and Shaw (2008) support the
conceptualization of resilience as a dynamic process that varies within and across time, rather
tban as a stable, static trait. It appears to be uncommon at the highest levels of risk (multiple
risks, low SES, poverty).
The Question is More lmportant than the Answer
lt is essential that we are clear about how tbe way that rcsearch questions are posed
impacts on what is being explored. Therefore, we must focus on what is a salutogenic
question. Both scientists investigating resilience and salutogenesis pose the question why
sorne people, regardless of severe hardships, stay healthy and others do not. In line with the
concept of resilience, the salutogenic theory focuses on people's capabilities, cornpetencies,
potentials, resources for health and a good life - in other words an asset approach (Fonagy,
Steele, Steele, Higgitt and Target, 1994, Luthar, 2003; Luthar and Cicchetti, 2000). While
36 Monica Eriksson and Bengt Lindstrom Life is More Tban Survival 37

research on resilience is mainly related to a state of adversities and risk for a negative
outcome of health and well-being, salutogenesis always focuses on the positive end of a Mean SOC (SOC-13) by Mean Age
health continuum. based on general populations 15-81 of age
(15 studies 1993-2003)
100
A Lifelong Development of the SOC

The SOC seems to be relatively stable over time, but notas stable as Antonovsky initially
assumed. He stated that the SOC develops until the age of 30, and thcn is stable until soc
80
60

40
-
-Age
retirement, afier which it decreases. This assumption has not been empirically supportcd. / - soc
Findings show that the SOC develops through the whole life span. Severa! longitudinal 20 ....
studies have dcmonstrated evidence of the stability of the SOC (Eriksson and Lindstrom, o r - ·r-- .1

2005). The variation in means over time shows small differences. From a life orientation
perspective, salutogenesis seems to be a rather stable entity; therefore, it is not surprising that
the SOC is quite stable and resumes its stability afier experiencing stressors, as compared to
other short term phenomena.
One way to look at the development ofthe SOC over time is to explore the findings from
studies using the original SOC-scales (29 and 13 items) on different samples of general
(healthy) populations in different age groups (mean age). The optimal position would be to
follow the same population through life; however, until such a study is conducted, we bave to
rely o n other techniques and comparisons to obtain an answer. Figures 1 and 2 demonstrate
the tendency of the development of the SOC o ver time through the use of mean SOC scores
and mean age on general populations, as variables in tbe time period of 1992-2008. Tbe
tendency is that, independent of sorne lluctuations, the SOC does increase with age.
Mean SOC (SOC-29) by Mean Age
based on general populations 18-81 years of age
(15 studies 1994-2008)
200
2 3 4 S 6 7 8 9 10 11 12 13 14 15
Number of studies
Figure 2. A Lifespan Appro~cb ofthe Development ofthe SOC (13 items).
The stability over time for the SOC and the concept of resilience is interesting. Stability
can be considered as a lack of SOC or resilience. According to Coleman and Hagell (2007),
the concept of resilience can change over the life span. " lt may not be apparent at one stage,
but may then develop at anotber stage because of tbe availability of protcctive factors" (p.
167). In contrast to this view, Rutter (2006, p. 9) considers tbat the concept of resilience is
limited regarding the stability over time. Findings from a follow-up study of children from
profoundly deprived residential institutions in Romanía, who were adopted into families in
the United Kingdom, showed remarkable persistence of continued adverse effects after more
than seven years. The implication seems to be that the pervasively depriving circumstances
took sorne months to ha ve an effect, but when they lasted beyond the age of 6 months, they
tended to ha ve cffects that endured many years.

Thc T heoretical Foundation

Figure l. A Lifespan Approach of the Development ofthe SOC (29 items).
Salutogenesis stcms from the Latin salus (health) and the Greck genesis (origin) meaning
the origin of health. lt is the opposite of the pathogenic concept whcrc the focus is on
obstacles and defi cits. The salutogenic theory was formulated by Antonovsky as a conclusion
of his analysis of interviews with women under severe stress. He realized that health research
had been looking in the wrong direction, towards pathogenesis, and developed an instrument
for measuring health (the SOC) which has since been extensively tested in empírica( studies
across the world, and analyzed and synthesized in a large-scale systematic review. This has
shown that the salutogenic theory is sound. Regardless of what term - theory, concept,
principie or model - is used, two cbaracteristics are importan!. Firstly, the ability to generalize
across settings and populations is fundamental; and secondly, it has the ability to test and thus
establish the validity of a theory which will distinguish it from other systems of beliefs and
ideas (van Ryn and Heaney, 1992).
38 Monica Eriksson and Bengt Lindstrom
In contras! to the salutogenic theory, the concept of resilience is a construct, not a single
theory. In a critica] review of the concept ofresilience, Atkinson, Martin and Rankin (2009, p.
139) state that "resilience is an importan! concept but the curren! state of knowledge in terrns
of theorelical models and clinical as well as practica! application remains very much a work
in progress." In resilience research, varying theories are used depending on what leve! is
studied.
Definitions of the Concepts
Salutogenes is is defined as the movement in a continuum between total ill health (dis-
ease) and total health (case) (Antonovsky, 1993a). The SOC is defined as follows: "Sense of
coherence is a global orientation that expresses the extent to which one has a pervasive,
enduring though dynamic feeling of confidence that: (!) the stimuli from one's interna! and
externa! environments in the course of living are structured, predictablc, and explicable; (2)
the resources are available to one to meet the demands posed by these stimuli; and (3) these
demands are challenges, worthy of investment and engagement" (Antonovsky, 1987, p. 19).
This capacity is a combination of people's ability to assess and understand the situation they
are in, to find a reason to move in a health promoting direction, and also having the capacity
to do so. These are the core dimensions of the SOC: comprehensibility, meaningfulness and
manageability.
In the salutogenic theory, the GRRs give the prerequisites for life experiences which in
tum maintain and strengthen a positive development of health. At least three Ji fe experiences
seem to be relevan! in the development of a strong SOC; consistency, emolional load balance
and a sense of belonging (Sagy and Antonovsky, 1996). Further research has shown that the
most relevan! childhood experience related to the adult SOC is panicipation in shaping
outcomes (Sagy and Antonovsky, 2000). In research on resilience, the so called protective
factors serve as prerequisites for a good outcome. A GRR is "a physical, biochemical,
artifactual-material, cognitive, emotional, valued-attitudinal, interpersonal-relational or macro
socio cultural characteristic of an individual, primary group, subculture or society that is
effective in avoiding andlor combating a wide variety of stressors" (Antonovsky, 1979, p.
103). Thc GRRs can be found within people as resources bound to their person and capacity,
but also in their immediate and distan! environment, as of both material (money, housing,
food, clothes) and non-material (health and social services, social support, social integration).
At least four of the GRRs have to be available to enable the development of a strong SOC:
meaningful activities, existen tia! thoughts, contact with inner feelings and social relations.
There are three key aspects of salutogenesis. Using Antonovsky's vocabulary: first the
focus is on problem solving/linding solutions; second, it identifies generalized resistance
resources that help people to move in the direction of a positive outcome; and third, it
identifies a global and pervasive sense in individuals, groups, populations, or systems that
serves as the overall mechanism or capacity for this process - the sense of coherence
(Lindstrom and Eriksson, 2006). Using the SOC questionnaire is not the same as being
guided by the salutogenic perspective. Salutogenesis, that is the perspective on resources,
means that this is a much broader concept than simply the measurement of the SOC. This is
an importan! poinl to bear in mind as we proceed through the chapter and in other readings on
the concept and questionnaire.
Life is More Than Survival 39
The concept of resilicnce is a somewhat more complex to grasp. Resilience is defined in
different ways depending on which specifie disciplinary framework is used. The core
theoretical foundation has emerged from a convergence of psychological, psychoanalytical
and social cognitive theories of child development. Garrnetzy and his colleagues were among
the first to emphasize the importance of examining protective factors in high-risk populations
(Garrnetzy and Rutter, 1988). Their research created the basis for the resilient approach. Sorne
view the concept as a personality trait (Wemer and Smith, 1982, 2001), oras the ability to
bounce back from a crisis and overcome life's challenges (Walsh, 2006), while others
describe resilience as the adjustment and recovery from adversities and as a process in a
continuum at an individual, group or societal leve! (Carver, 1998; McCubbin et al., 1998).
Luthar (2000, p. 858) defmes res ilience "as a dynamic developmental process reflecting
evidence of positive adaptation despite significan! life adversity." At its core, " ... a resilient
individual is one who exercises the most resourceful response when faced with an
environmental demand. This requires the capacity to choose from an availability of personal
resources ... to problem solving, processing two or more stimuli, or even flight if the
circumstance demands" (Goodyer, 1995, p. 443). In addition, Coleman and Hagell (2007) talk
about a "slippery" conccP,l referring to the complexity of a construct describing both a process
and an outcome (p. 166).
However, across the definitions, a general consensus has emerged for the concept of
community resilience, a relatively new terrn. Community resilience is defined as "a process
linking a set of adaptive capacities to a positive trajectory of function ing and adaptation afier
a disturbance" (Norris et al., 2008, p. 130). Across the separate definitions, there is consensus
on two points: fi rst, resilience is better conceptualized as an ability or process than as an
outcome, and second, it is better conceptualized as adaptability than as stability.
The Operationalisation
The strcngth of salutogcnesis stems from its empírica! and qualitative approach in the
analysis of the narra ti ves of the survivors of lhe Holocaust. Bascd on the narratives, a valid
and reliable instrument, the Orientation to Life Questionnaire, was constructed (i.e., the Sense
of Coherence scale). The SOC instrument has been empirically tested in severa! countries on
general populations and on different samples based on age groups, professional groups, and
patient groups over the past 30 years.
lts strength has been presented in a systematic research synthesis on the SOC between
1993 and 2003. This evidence base demonslrates the effectiveness of the salutogeuic theory,
and how it can be applied in rescarch as a positive and health-promoting construct (Eriksson,
2007, Eriksson and Lindstrom, 2005, 2006, 2007). The SOC scale seems to be a mulli-
dimensional construct, rather than a single construct consisting of one general factor with the
three dimensions, a JI interacting with each other. The concept of resilience, like the SOC
construct, is multi-dimensional rather than uni-dimensional (Luthar, Doemberger and Zigler,
1993).
The original vcrsion of the SOC questionnaire consists of 29 items and the shoner forrn
of 13 items. To date, the SOC questionnaire has been widely tested in Westem countries and
in countries such as South Africa, China, Eritrea (Eriksson and Lindstrom, 2005, Almedom,
Tesfamichael, Mohammed, Mascie-Taylor and Alemu, 2005), Korea (Han et al., 2006),
40 Monica Eriksson and Bengt Lindstrom
Taiwan and Sudan {Tang, Li and Chen, 2008) - at least in 40 countries in more than fifty
languages. In addition to the original SOC questionnairc, there is an array of altemative
instruments. At leas! 15 different versions exist with different scoring altematives, including
two vcrsions of the family sense of coherence scale, a questionnaire especially adjusted for
children and the sense of school coberence instrumenl (Eriksson and Lindstrom, 2005). Tbe
number of items range from 3 to 29 including modified scoring altematives. However, the
questions are the same as in the original versions of the Orientation to Life Questionnaire
(SOC). Tbe SOC scale seems to be a reliable, va lid, and cross culturally applicable instrument
measuring how people manage stressful situations and stay well (Eriksson and Lindstrom,
2005).
The lmplementation
Does the salutogenic construct, SOC, and the theory have any use in practice? In our
opinion, they do. Tbe salutogenic approach is relevan! for health promotion, because health
promotion has lacked a strong tbeoretical foundation. Tbe SOC can be applied at individual,
group and societal levels; however to date, most of the salutogenic research has been applied
at the iodividuallevel. However, in Antonovsky's view, a collective (family) SOC also exists,
(Aotonovsky and Sourani, 1988, Sagy aod Aotonovsky, 1992). Tbe idea behind the SOC as a
group property is that the collective SOC is more than the sum of the individual SOCs. In a
similar manner as the SOC concept, resilieoce can be considered as a group property focusing
on fami lies (Black and Lobo, 2008; McCubbin, Thompson, Thompson and Futrell, 1999).
Based on a review of family researcb and conceptual literature, Black and Lobo identified the
prominent factors of resilient families as: positive outlook, spirituality, family member
accord, flexibility, family communication, financia! managemeot, family time, shared
recreation, routioes and rituals, and support networks. All these factors can easily be related
to the core concepts of the salutogenic theory, the SOC and the GRRs.
A collective SOC at a socictal leve! (communities) is much less explored. Tbe potential
of the salutogenic theory on a societal leve! has been rather neglected. In an article
"Complexity, conflict, chaos, coherence, coercion and civility", Antonovsky ( 1993b)
fonnulated his tboughts about how tbe SOC can be applied within a systems theory approach
in societies. Knowing Antonovsky was a medica! sociologist, it is easy to understand that
salutogenesis stems from a sociological framework . Tbe sociological character of the SOC
construct "lies not only in its structural sources. In its emphasis on resources and flexible
coping tactics, ... it opens the way for inclusion, in studying the stress process ... collective
coping and macro variables, ofteo disregarded in this psychology dominated field"
(Antonovsky 1993b, p. 972). Complexity refers to the leve! of organization of systems,
providing both sets of problems and poteotial for the interaction between the individual and
the environment (Antonovsky 1993b, p. 969). Conflict here refers to interna! tensions of
being a human being, tension between individuals and between the individual and the supra
systems. Tbe greatcr thc complexity, the greater are the possibilities for choice, flexibility,
adaptive change or reorganiza! ion of tbe system (Antonovsky 1993b, p. 970).
Some attempts ha ve been made to explore the use of the SOC at a societal leve!, through
two case studies on how to crea te a salutogenic society (Eriksson, Lindstrom and Lilja, 2007,
Lindstrom and Eriksson, 2009). A separate questionnaire aiming to measure the community
Life is More Tban Survival 41
SOC is under development. However, at present, studies have only been carried out in Israel
showing that the questionnaire has to be furtber improved, before it comes to general use
(Personal communication between Monica Eriksson and Professor Shifra Sagy, Ben-Gurion
University of the Negev, Israel, Oct. 22, 2009).
The Evidencc Base of Salutogenesis
Tbere seems to be different effects of the SOC concept on various dimensions of health.
Tbe SOC appears to be strongly associated with perceived good health, especially mental
health, at least among people with a strong sense of coherence. This relationship is manifested
in study populations regardless of age, sex, ethnicity, nationality and study design (Eriksson
and Lindstrom, 2006). Further, SOC secms to have a main, moderating or mediating role in
the explanation of health. In addition, tbe SOC seems to be able to predict bealth. The very
strong correlation with detenninants of mental health, especially with positive emotions and
opposing negative affectiviry, raises the question if SOC is a parallel expression of mental
health. At least, it means that someone with a strong SOC can cope with stressful situations
and stay well better than a person witb a low SOC.
Kouvonen and colleagues (2008) showed that, among adult Finns, a strong SOC was
associated with about 40 percent decreased risk of psychiatric disorder during a 19-year
follow-up period. This association was not accounted for by mental health-related baseline
characteristics, such as sex, age, marital status, education, occupational status, work
environment, risk behaviours or psychological distress.
One arca of research where the potential of both the salutogenic framework and the
concept of resilience becomes apparent is around the adjustment to life events. Research on
how major life events, such as the death of a family member, divorce, serious illnesses and
unemploymeot, may impact on the individual and the family is extensive and impressive both
in resilience and salutogenic research. McCubbin ct al. (1999, preface) describe resilient
adaptation and creation of meaning in families facing unexpected life events and changes
such as health-related crises. Without using the salutogenic tenns, SOC and Generalized
Resistance Resources (GRRs), the findings from this qualitative study reflect salutogenic
theory, especially with regards to the dimension of meaningfulness. Moreover, findings from
salutogenic researcb on life events have showo tbat higher levels of the SOC are associated
with lower levels of self-reported psychopathology among young men (Ristkari, Sourander,
Ronning, Nikolakaros and Helenius, 2008), and that the SOC can act as a moderator of the
effects of life events on health (Richardson and Ratner, 2005), and also that it is a factor in
modifying inadequate coping related to life events (Bergh, Baigi, Fridlund, and Marklund,
2006).
ln resilience researcb, sorne attention has been given to the negative impact of life events
in the fonn of disasters and trauma related to terrorism, especially after September 11th. In
their review, Williams, Alexander, Bolsover and Bakke (2008) gave recen! evidence for a
model of psycbosocial care of children after disasters. They conclude that a resilient model of
care should include the principies of good service design, which integrales responses to the
psychosocial needs of children and adolesceots, works with families rather than individual
children, and focuses resources on increasing the capabilities of the community to providc
assistance and support for families. Tbe salutogenic framework has the potential for enabling
42 Monica Eriksson and Bengt Lindstr6m Life is More Than Survival 43

the management of stress by creating a sense of coherence out of chaos. Further, an ambition
to create a salutogenic society, where people do not need to go to the limit of survival,
becomes fundamental in healthy public policy (Lindstr6m and Eriksson, 2009).
The "Salutogenic Umbrella"
Salutogenesis is a much broader perspective than only the measurement of the sense of
coherence. The "Salutogenic Umbrella" is a framework which includes other related concepts
and convergen! theories for the explanation of health and a good life as shown in Figure 3.
group or society leve! (Lindstr6m, 2001. Sorne oftbe theories can be applied atan individual
and at a group leve! (i.e., hardiness, self-efficacy, learned resourcefulness, leamed
hopefulness, connectedness, action competence, will to meaning, locus of control), whereas
others are related to system theories ecultural capital, social capital, the ecological health
theory, interdisciplinarity). A detailed description of tbe concepts and bow they differ from
the salutogenic theory is not possible within tbe space of this chapter (see Eriksson and
Lindstr6m, 201 O for further details).
From Learned Resourcefulness to Healthy Learning

Finally, the concept of "learned resourcefulness" has to be recognised (Rosenbaum,

1990) in terms of bealthy leaming, and linking personal and specific personal characteristics
witb repertoires of self-controlling skills. Rosenbaum was clearly inspired by cognitive
bebavioural theory and the concept of self-efficacy (Bandura, 1997). He asks the same
question, as in resilience research, about why sorne people stay healthy despite exposure to
risk factors and others do not. In contras! to the salutogenic theory, the concept of learned
resourcefulness stresses the control dimension of human bebaviour, tbereby differing from,
more than resembling, the SOC (for a full description and discussion on healtby leaming see
An assets approach Lindstr6m and Eriksson, 2010).

Lnrud nsomnflll~.u '

CONCLUSION
Hanli.,.n (RosmiHium) CUl~r2l~tl.l E~ LocmofcOilfnll
(Koba>a) Lulll.elloptim:ism (Bourdieo) (F...U.) (Rolter) To conclude, it is possible to identify severa! unique and distinctive features of both
So<iol CApÜlll
(Sttignw¡)
(PulomD) \1/lll lo .....;.g millbting
resilience and salutogenesis. First, Antonovsky referred to stress, whilst resilience researcbers
QualilyuCür.
Stlf-dkacy Lnr.d haptfialo6s (Fnald) (B<cku) referred to risk and adversities. Second, neither the SOC measure nor tbe concept of resilience
(lhadun) {Zillllllm2UII) (LiDd•trOIII)
Ecolo;ical sysh!m th10ry is a personal characteristic, but a process. Third, both concepts empbasize resources: called
CaaoedtdDt3S
(Biom) (Broofeabre110e., General Resistance Resources in the salutogenic framework and protective factors in the
Smseofcobenoct- Fhorishia&
(AIII<lDDnky) resilience framework. Fourth, they both consider the maintenance and development of bealth
.Adicla compeh!ace (K.I!yes) lllfwdicipliurit}"
{BntUilJHSea) (Kl8a) as a process in a continuum. Fifth, both the Sense of Coherence and resilience concepts can
be applied at the individual, group (i.e. families) or societal leve!. The two concepts differ
when it comes to the adjustment process, because the resilience concept is always connected
with risk factors. Rutter (1987, p. 329) concludes that "The phenomenon of resilience is due
Figure 3. The Salutogenic Umbrella- Convergen! Concepts and Theories Contributing to Explanations
of Health and Quality of Life. in part to vulnerability and protection processes by which there is a catalytic modification of a
person' s response to the risk situation". !f Rutter' s conceptualization of resilience is seen
There are similarities and differences between the salutogenic theory based on its core through salutogenic eyes, the development of a strong SOC would serve as such a catalytic
dimension Sense of Coherence and sorne of the theories and concepts shown in the figure converter in buffering the stress ofyoung people exposed to adversities through the life span.
above. All the listed theories and concepts include salutogenic elements and dimensions.
Sorne concepts are shown, but a closer examination of the literature could further extend the
umbrella. However, the focus here is on resources for health and Quality of Life. Quality of
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