20th WCP: Coping with Existential Threats and the Inevitability of Asking for Meaningfulness

Facing the existence threatening and destroying experiences of mankind during the Nazi regime, during the numerous civil and other wars of our time, the medical sociologist Aaron Antonovsky put the question: "What is it that let a few people survive and even remain unexpectedly healthy despite suffering severely from fear, threats, starvation, and torture?" This made him the original and prominent promoter of the concept of salutogenesis, a concept which increasingly determines the political programs of WHO and its members as well as the movement of New Public Health, in contrast to the concept of pathogenesis, so well known and familiar in the field of medicine.

The required scientific dignity of Antonovsky's concept appeared to be assured by his reference to Clausius' concept of entropy and to core issues of the information theories, therefore assured within the framework of scientific realism and empricism. But the fact has been overlooked that in his last years the question of meaningfulness had gained priority of importance in substantiation of his salutogenesis approach. And exactly this brings him into contact with the continental european tradition of ancient philosophy, philosophy of existence, and philosophical hermeneutics, well known to himself, and mirrored in earlier and later titles of his works, e.g. "Health, Stress, and Coping" (1979) and "Unraveling the Mystery of Health" (1987).

Although the neccessity and the importance of concepts of health are meanwhile well recognized in the fields of Public Health and - at least - in preventive medicine, the recent theoretical and historical reflection of these concepts has still remained marginal and poor, esp. when concerning the relationship between health and illness or
disease. Is there a specific difference between health and illness, and if so, is this dependent or not on a scientific and/or on an every-day-life approach?

Antonovsky postulates a continuum health ease/dis-ease, and in this respect he does not differentiate between the subjective view of every day life and the objectifying view of science, esp. empirical science. His very purpose is to introduce an operationable scientific construct which he calls "Sense of Coherence" (SOC), and according to which a better or worse health status should be measureable using item-scaled questionnaires..

Before and in order to discuss Antonovsky's concept more in detail and respecting its relationship to inevitable philosophical questions of the worldly existence of mankind, I want to attract your attention for a moment to the "hiddenness" of health in science as well as in every day life by referring to Jaspers and Gadamer.

In the 1st Edition (1913) as well as in the 7th Edition (1959) of his "Allgemeine Psychopathologie" Jaspers maintains that we would search in vain for a scientific legitimation of the every day life use of the terms "health" and "sick". The modern physician does not question the general meaning of these words; he is much more concerned with manifold biological functions and defined diseases. Considering disease the physician is concerned with a summary of concepts of being, defined disease entities, so to speak according to the International Code of Diseases (ICD), in contrast to the patient who is solely concerned with values of life. Except average as a norma-tive principle there is, acc. to Jaspers, no space for value-related norms in modern science-based medicine, even though Jaspers does not deny the origin of empirical medicine in general value concepts bringing the undertaking of medicine often enough into conflict with its aims.

A few years ago Hans-Georg Gadamer has published a paper "About the hiddeness of health" (1991). He refers to the simple fact that in every day life we do not usually reflect upon our health status or about health, except when being or feeling disabled, disturbed, sometimes unhappy or even threatened, bearing in mind the statement of Leriche: "Health is living within the silence of the organs".

In the french tradition of medical history "health" is reflected to be a resource or reservoir of reaction abilities which allow one to fall sick but also to recover (Canguilhem). This comes very close to what Antonovsky describes as "Generalized Resistance Resources" (GRR). GRRs are individual characteristics acquired by means of socialization and genetics, e.g., favorable socioeconomic status, knowledge, intelligence, ego-strength, social support, preventive health orientation, stable cultural background, resistence towards environmental pollution. The experienced reliable having at disposal of these resources makes up stable and repeating life experiences being used to balance between over-load and under-load and to enforce one's participation in shaping one's own biography. These consistent and repeated life experiences build up what Antonovsky describes as "Sense of Coherence" (SOC). In his own words: "I had defined (the GRRs) as phenomena that provide one with sets of life experiences characterized by consistency, participation in shaping the outcome, and in underload-overload balance. Such repeated life experiences build up the SOC" (1987, p.19).

"Sense" with respect to SOC, in Antonovsky's view is to be understood on the one hand as an essential human sensitivity for coherence of what is going on in the world and/or coherence of one's own often contradictory experiences of the world one is living in. On the other hand, also in Antonovsky's view "sense" is that what makes sense in human biographical events as well as what makes sense within the world beyond separated individual perspectives. "Sense", in these respects, is not ex-
hausted by the english terms "meaning" or "significance", but more by the german term "Sinn". According to Antonovsky "sense of coherence" is therefore a common shared as well as an individual philosophy of life, which in the german language can be differentiated into "Weltanschauung" and "Lebensanschauung"; in Antonovsky's words: "a generalized long-lasting way of seeing the world and one's life in it" (1987, p.22).

Just at this point Antonovsky's construct of SOC touches closely Heidegger's "analysis of existence" or "Daseinsanalyse", layed down 1927 in "Sein und Zeit", in English available as "Being and Time" in the excellent 1996 translation by Joan Stambaugh. But in order to come more reasonabled to this my very issue of concern give me a little bit more space to describe Antonovsky's concept of SOC in detail.

Facing the complexity of the terminological construct of SOC and for reason of its operationalization, Antonovsky differentiates three components or elements of SOC: comprehensibility, manageability, and meaningfulness, maintaining mutual interrelationships between them.

"Comprehensibility" of phenomena occurs if stimuli of the internal and external environment make sense in a cognitive way so that they turn out to be clearly ordered and structured, and that insofar "a solid ability to review reality" is witnessed (1987, p.16f.).

"Manageability" of our internal and external world is represented by the measured ability to make use of the resources at one's disposal in order to cope adequately with severe demands.

"Meaningfulness" Antonovsky claims to understand according "to the emotional and not only according to the cognitive meaning of the word". "Life makes emotionally sense", even more so if "disastrous experiences are willingly accepted as challenges to search for sense and to overcome them in dignity" (1987, p.18f.).

Antonovsky postulates that the strength of SOC, resulting from the actual dynamic interrelationships of its mentioned three components has "direct physiological consequencies and, through such pathways affects health status" (1987, p.154). Unfortunately, empirical research has not yet sufficiently verified this hypothetical conclusion of Antonovsky's theoretical salutogenesis-approach, and he himself failed also in this respect. SOC and somatic health status are only but weakly correlated, and it is noways clear whether weak SOC causes symptoms of illness or whether illness symptoms cause a weak SOC. But what in fact empirical research showed very clearly is, that there is a strong correlation between SOC and general well-being. Antonovsky himself as well as the authors of a recently published study by Larsson & Kallenberg 1996 explain this result by a partial identity in concept of SOC and well-being.

From the point of view of empirical research a decisive weakness of Antonovsky's salutogenesis approach is thus shown. But moreover, and despite this weakness, a different result of the above mentioned population related study deserves our attention, i.e. a strong inverse relationship between SOC and "fear" (1996, p.179) - allow me, please, to give preference to the german term "Angst"; I will very soon explain, why I do so.

By these results a central concept as well as phenomenon of existential analysis has revealed its utmost importance in human health related empirical research. Using some examples of recent research experience of our threatened and threatening reality, the concept of "Angst" seems suitable for bridging the gap between the demand of empirical research for explanation and the demand of the humanities for understanding.

The neccessity to bridge this gap regarding the humanistic intentions of modern medicine is well known and becomes increasingly an urgent demand within the framework of a philosophy of medicine (Wulff et al. 1990). And this demand is noways only related to the phenomenon of "Angst" as encountered in actual medical practice - so often misunderstood as a mere pathological symptom - whereas this demand is much more related to "Angst" as an ubiquitous event encountered in the world we are living in. Accordingly, "Angst" is encountered less as a feeling, but more as a human condition (or "Befindlichkeit") urging us inevitably to take our things, our whole existence in any respect into our own hands.

At this point I would like to demonstrate the close relationship between Antonovsky's SOC-concept and Heidegger's existential analysis where "Angst" as a human condition or "Befindlichkeit" plays the decisive role. I shall cite parts of the english translation of Heidegger's "Sein und Zeit" which underline the existential specificity of "Angst" as opposed to "fear"(Stambaugh 1996, p 174-176):

"The fact that what is threatening is nowhere characterizes what Angst is about".

"The world has the character of complete insignificance".

"The "world" can offer nothing more, nor can the Mit-da-Sein of others".

"Everyday familiarity collapses. Da-Sein is individuated ... not-being-at-home ... uncanniness".

"Therefore, what is threatening cannot approach from a definite direction within nearness, it is already 'there' - and nowhere. It is so near that it is oppressive and stifles one's breath - and yet is is nowhere".

"What Angst is about may not remain absent, like that what we fear".

"So if what Angst is about exposes nothing, that is, the world as such, this means that that about which Angst is anxious is being-in-the-world-itself".

"When Angst is quieted down, in our everyday way of talking we are accustomed to say 'it was really nothing' ".

"Angst reveals in Dasein its being toward its ownmost potentiality of being, that is, being free for the freedom of choosing and grasping itself".

Coming back to Antonovsky: SOC, understood in context of existential analysis, is finding sense of existence as well as finding oneself only within Angst and through Angst, recognizing all, even the most adverse circumstances. Antonovsky is aware of giving hints of how to strengthen SOC by individual effort, by communication, interaction, even therapy, and alteration of social and political relationships, but my concern was not discussing the basic elements and relationships of his central concept. It was more the purpose of gaining and conveying some insight into its importance within the framework of the philosophy of practice and of human existence. Aware of his approach's limitations regarding the demands of empirical research for testing operationalized hypotheses Antonovsky tried to justify his approach with the following words in his last work: "God ... is not a mathematician, but ... he may be a poet. His works are full of allusion, illusion, question, contradiction, open-ended alternatives, puns, despair, and love. Yet we can seek to understand a poem. My own work has been devoted to studying the ways human beings cope with the reality of the poem that is social existence" (Antonovsky 1987, p. 170).