Sense of Coherence Self-assessment (medical)

When you think of heart health, you probably think of nutrient-rich foods, regular exercise, and excellent fitness. You might be surprised to learn that things like personal relationships, job satisfaction, sunlight, beautiful paintings, pleasant music, and so on are also important factors, too. You might be surprised to learn, for example, that patients who have undergone a significant surgery recover more quickly when there is a potted plant in their hospital room, or if the patient’s friends and family come to visit them while in rehabilitation.

The significance of these non-physiological aspects of medical recovery became more and more important throughout the later decades of the 20^th century. Today they are well-known and used in patient treatment plans, health education, and in medical interventions. But this change did not come about quickly or easily. It required doctors and other healthcare personnel to take seriously the possibility that there was more to health than human biology.

Five-hundred years ago, the most common practice of medicine was called humorism. No, this isn’t the act of making patients laugh in order to help them recover, which was the plot to the movie Patch Adams. The word “humor” referred to the four basic liquids in the human body: blood, phlegm, black bile, and yellow bile. It was believed that these four humors existed in harmony and balance. If this balance was upset, then a patient would get sick. Therefore, when a patient presented with measles or mumps or fever, the doctor assumed that the humors had become unbalanced, and they would use leeches or puncture wounds to drain some of the blood out. General George Washington, the founding President of the United States, died from complications of bloodletting to treat a bacterial infection. Reports suggest that 40% of his blood was drained during the procedure.

Today we know that what Washington needed was Penicillin, which is a prescription antibiotic. But this wasn’t known back then. Penicillin and other common medical drugs were the product of modern medicine. The normal human life expectancy has increased rapidly due to the benefits of modern medicine—sterilization, surgical procedures, antibiotics, nutrition, and hygiene have all played important roles. Modern medicine had been so successful at extending the human lifespan that the leading cause of death—which for many hundreds of years was infectious diseases—fell to the bottom of common causes.

Of course, something had to take its place. Infectious diseases have been replaced by a new most likely cause of death—lifestyle related diseases, such as heart attacks. 

There are many factors that increase the likelihood that your heart or my heart will stop working. The problem is that none of these factors can be linked to heart attacks in 100% of cases. Smoking cigarettes, for example, enormously increases the likelihood that you will have a heart attack. But by smoking cigarettes you are not guaranteed to keel over from a major cardiac event. American author Kurt Vonnegut playfully threatened to sue his cigarette manufacturer because, for over 40 years, the manufacturer, by way of little advertisements printed on the cigarette packs, had promised to kill him. But Vonnegut hadn’t died. 

Other factors that increase the likelihood of heart attacks include diet, inactivity, stress, genetics, stress, and so on. The more factors that are present, the greater the likelihood of a heart attack.

In the 1970s, a medical sociologist by the name of Aaron Antonovsky decided to devote himself to understanding the factors that predict major cardiac episodes. To do so, he decided to examine those people who were at the greatest risk for heart attacks. These people, it turned out, were those who had already survived one heart attack. These people, statistics demonstrated, were 67% likely to have another heart attack. These hapless folks became Antonovsky’s sample. He would examine their food, their activity, how they spent their time, how they interacted with others, how they felt about their lives and medical history, and so on. He would be taking a lot of notes.

What he found not only surprised him. It also changed the course of medicine forever.

Antonovsky observed three factors that, when present in a cardiac disease patient, reliably predicted whether they would suffer another cardiac episode. Remember that these were patients who were 67% likely to have another heart attack. The odds were already stacked against them. But, if these three factors were present, then Antonovsky could say with certainty that they were at the low end of the risk spectrum. It was bananas.

The most shocking part of his observations was that the predictive factors did not concern diet or exercise, smoking or other harmful habits. Not even genetics. The predictive factors had everything to do with the patient’s perspective about themselves and their medical problems. 

During his study, Antonovsky spent many hours with heart trauma patients. He noticed how some heart attack patients coped well. They rested when they were supposed to rest; they changed their diet the way they had been asked; and they accepted the length of rehabilitation. Others coped poorly. They got up and moved around before it was safe to do so; they quickly returned to their normal diet; and they felt targeted by fate. 

Antonovsky found that patients who understood their condition, felt confident and capable of following through on a treatment plan, and saw meaning in their medical condition would be significantly less likely to suffer another heart attack than those patients who showed none of these perspectives and behaviors. Together, he called these three factors “sense of coherence.”

In Antonovsky’s observations, those patients who did not accept their medical condition and who did not accept or follow the treatment protocols—in short, those who had a low sense of coherence—believed that life events were random. They believed that they were not responsible for their medical conditions, and that they had little control over what happened to them. These patients with a low sense of coherence felt as though life happened to them. They did not see themselves as the central agent or origin of their lives.

We find the patient with a high sense of coherence in contrast. “At the other extreme,” Antonovsky writes of the high sense of coherence patient, “events in life are seen as experiences that can be coped with, challenges that can be met. At worst—and recall that these are people who have undergone very difficult experiences—the event or its consequences are bearable” (p. 17). 

 

Figure 1.1: High Versus Low Sense of Coherence

 

Sense of coherence has less to do with the health status a person has, and more to do with how they handle and understand their health. Sense of coherence is a perspective a person has about the significance and meaning of their life.

Two people can be diagnosed with lung cancer. They can be given the same prognosis. But how they respond to the diagnosis and prognosis, and the work they put in to treating the problem, rehabilitating, and recovering will depend on their perspective. For the patient with a high sense of coherence, misfortunes are experienced as challenges to be overcome. The patient with a low sense of coherence will think “go figure,” as if there was never anything that could have been done in the past or could be done in the future to protect themselves against the cruelty of fate.

Sense of coherence is divided into three characteristics: Comprehensibility, Manageability, and Meaningfulness.  

Comprehensibility

Comprehensibility is the extent to which a person finds that the problems they confront make sense. Are they understandable? During a traumatic event, it is normal to experience shock. In 2017, our community in Southwest Georgia, USA experienced two tornadoes in three weeks. The periods during and after each storm were surreal. I remember rushing to the safest room in the house while through the windows I could see 300-year-old Oak trees bending down to the ground in the wind. I remember waiting for the roof to get sucked away or the walls to cave in (thankfully, these things didn’t happen at our house). It was a helpless feeling. Many traumatic experiences are. But what happens next indicates the sense of coherence a person has.

If, after experiencing the tornado, I continued to feel helpless about protecting myself and my family against natural disasters, then my comprehension of what happened would be low. To be sure, I cannot control the weather. But this doesn’t mean that there’s nothing I could do to prepare for the next storm. 

There are lots of things I could do. There were lots of things my wife and I did do. For example, we called specialists to come evaluate a few trees nearby the house to see if they were at risk of coming down in a big storm. We rebuilt fencing and an outbuilding that had been damaged during the tornado. We looked at the statistics for our area and calculated the probability of another disaster, and then reevaluated our homeowners insurance. In other words, we focused on those things that we control in order to protect ourselves in the future. 

With comprehensibility, Antonovsky explains that we encounter an event “that is ordered, consistent, structured and clear, rather than as noise—chaotic, disordered, random, accidental, inexplicable” (p. 17). Receiving a medical diagnosis is likely to be a traumatic event. I can remember when my dad received the diagnosis that his spinal cord had been severed in an accident. We had so many questions. These started with “are you sure?” and “couldn’t it just be bruising?” and so on. We weren’t ready for the reality to sink in. Thankfully my family didn’t have to wait for me to accept my father’s injury. They went ahead and began preparing our home for dad’s arrival. My grandfather built a commercial-grade entrance ramp; our car was outfitted with hand-controls; and my mom reorganized the kitchen and their bedroom and bathroom so that dad could use them.

Imagine what life would have been like in the wake of dad’s paralysis if the family had failed to change what it could? No ramp would have been built. No hand controls installed. No reorganization of the house. My dad would have been helpless when he got home. He would never have been able to enter without the help of another person. Indeed, he would never have been able to make himself a cup of coffee. Unfortunately, this kind of low comprehensibility happens when lifestyle related diseases are diagnosed: Type-II diabetics and hypertensive patients go right back to their diets and inactivity, figuring that there is nothing they can do to reverse their conditions.

Manageability

Manageability goes hand-in-hand with comprehensibility. Once a medical problem is understood and the steps necessary to improve the situation are explored, the next step is to begin following through on those steps. 

During the accident that left my father paralyzed, his lungs were also badly injured. Doctors told him that he had ¼ lung-capacity. Part of this capacity could not be rehabilitated. The remaining part, however, could be strengthened such that it could make up for some of the lost capacity. But doing so would take a lot of effort. More specifically, my dad would have to work out the remaining healthy bit of lung in order to strengthen it. This required difficult breathing exercises. My dad understood this enough to explain it to me, his 10-year-old son. So he had the comprehensibility part down. But this didn’t mean that he had the manageability part nailed. The breathing exercises were too difficult or inconvenient to work on, and his lung capacity never improved.

While this can sound harsh against my dad, it is extremely common for patients to have trouble applying medical advice to their lives. In some cases, there may be confusion about what the doctor or nutritionist or therapist has asked the patient to do. “But I cut out sugary soda,” says one patient. “I don’t understand why I am still prediabetic.” After a few more questions, it becomes clear that this patient replaced Coca Cola with Gatorade without realizing that the sports drink contained just as many grams of sugar as the carbonated soda. In other cases there may be cultural or ethnic differences in lifestyle that make medical advice irrelevant or misguided. “I understand that I’m not supposed to eat fried foods. But what am I supposed to eat at the potluck—a salad?” Oftentimes the risk-to-reward ratio isn’t big enough to encourage patients to follow through on medical advice. This is especially the case with lifestyle changes.

The leading causes of death today, as the introduction has pointed out, are lifestyle-related problems. They are the result of diet, activities, stress levels, relationships, and so on. These are highly habit-bound and extremely difficult to change. Consider cigarette smoking, which has produced an enormous pile of evidence about its link to myriad health conditions. Cigarettes provide little breaks throughout the day: a cigarette with coffee in the morning. Periodic five-minute breaks from the office or high-stress job. A cigarette with a cocktail after dinner. And so on. Imagine that a pack-a-day cigarette smoker decides to quit. That’s two dozen little breaks throughout the day that have suddenly vanished. Without cigarettes, what does a person do? They can still take those breaks, but what is the justification? Perhaps now they will earnestly check to see what the weather is like outside. But what will they do with their hands? Will their coffee still taste the same? In the end, it is much easier to just keep smoking the cigarettes. After all, smoking cessation does not guarantee that lung cancer or heart disease will be prevented. So why go through all of that trouble?

The same kind of story can be found with dietary changes. If I am used to eating red meat five times a week, then how do I get my protein and fat intake if I am instructed to cut it out? Without sugar and white bread, what can I eat to avoid feeling sluggish all the time? Without soda or sports beverages, what am I supposed to drink? This is a lot of hassle based on the seemingly uncertain promise that my blood pressure or blood sugar will become mysteriously balanced.

When instructed to make a lifestyle change, even if doing so is in service to health and well-being, it is easy to take it personally. Just like the admonitions about oral hygiene from a dentist can make a patient feel criticized, treatment plans that being “you have to stop eating this” or include “you need to start doing that” are easily interpreted as “you’re doing it wrong.” The patient is suddenly five years old once again, and feels scolded by mommy. This is specifically what happens when treatment plans are interpreted by people who have a low sense of coherence. For those with a high sense of coherence, by comparison, doctor recommendations are understood differently. More specifically, if a person “has a high sense of manageability,” Antonovsky explains, they “will not feel victimized by events or feel that life treats [them] unfairly” (p. 18). Instead, patients who have a high sense of coherence will see the recommended change as a challenge in service to their health; an opportunity to see what they are made of.

Meaningfulness

The final component is meaningfulness. Meaning has a strange place in the history of Western medicine (which is the conventional kind of medicine practiced in the US and Europe): meaning is irrelevant. If you have an infection in your leg, for example, and surgery and antibiotics have not been successful at treating it, then your leg will have to be amputated. This decision is based entirely on blood cultures or biopsies or something else that needs to be examined under a microscope. It doesn’t matter how the patient—how you—feel about this. “Keep the leg and die,” says your doctor, “or amputate it and live.” Some decision that is.

In some cultures, however, meaning is absolutely essential for understanding what is happening to your leg. The infection could be a curse from God, or a warning from ancestors. It could be punishment dishonoring the family. And so on. None of this can be found in a medical textbook. 

But with medical science there is no deeper personal or cultural significance of an infection. This is because medical science has been predicated on the evolutionary rule of the survival instinct. The survival instinct is the belief that all living things will do whatever is necessary in order to live as long as possible. Flowers will shed their beautiful blooms before they will lose their leaves, because the leaves are what allow it to photosynthesize. If the flower grows too big, then parts of it will die off in order to live on the nutrients it can find. The same goes for humans: if your body is lacking salt, then you will begin to crave foods that are high in salt until it is the only thing that you can think about. If you have too much salt, then the sight or smell of salty foods will make you gag.

The human survival instinct is strong, and it can generally be trusted. But there is a second, more powerful instinct: self-actualization. I talk more about the biology self-actualization in my articles and books (Whitehead, 2017a; Whitehead, 2017b), but for now it is only important to understand that with self-actualization there is more to survival than keeping the body alive. 

You and I are not merely surviving. We are also living. We have ideas about what we will become, and these ideas are based on what is meaningful to us. It is very important to me that I teach and that I write. A brain injury to my occipital cortex—specifically Broca’s area of speech production—would inhibit both of these goals. I would sooner lose my legs than the speech-production area of my brain! I of course value my athleticism and mobility, but these are less important to me than my ability to speak or write about what is on my mind. In other words, I would find a way to go on living were I to lose my legs, but I cannot say the same thing for losing my ability to express myself with words.

Antonovsky gives the example of Austrian psychiatrist Viktor Frankl. Frankl was arrested and imprisoned because he was a Jew. His survived two agonizing and tortured years in the infamous Nazi death campus. On one occasion, towards the fall of the Nazi empire, Frankl had the opportunity to escape. It was what the prisoners had dreamed of month after month. This was Frankl’s chance to save himself. But there was a deeper calling for Frankl that kept him behind. A fellow prisoner was sick and needed attention. Frankl, being a doctor, could not leave him behind. Frankl’s self-actualization as a doctor was more important than his survival as a human.

In the end it worked out for Frankl. He tells this story and others in his memoir Man’s Search for Meaning.

In telling Frankl’s story, Antonovsky reminds you and I that terrible things can happen, but, if we can see meaning in those terrible things, then we “will willingly take up the challenge, will be determined to seek meaning in it, and will do [our] best to overcome it with dignity” (pp. 18-19). 

Sense of Coherence Inventory

Now we get to the inventory itself, which can be found below. In this final section, I want to describe what the inventory is,  what it will mean, and how you will complete it in a satisfying way. This isn't going to be an overwhelming or substantial endeavor. It will not require a weekend of your time. But hopefully the time you spend on it will be outmatched by its importance. 

The SOC inventory below is 29 questions, which is actually one of its shortened version. Each item has a Likert-type scale, which means you are select scores between 1 and 7 for each statement. If you absolutely agree with the statement, then you pick 7. If you're in the middle, you pick four. And if you disagree, then pick 1. It is that easy. 

For example, the first item reads: 

 

“When you talk to people, do you have the feeling that they don't understand you?” 

 

If you feel like nobody ever understands you, then you choose 7. If, however, you feel like people generally understand what you’re saying, then choose 2. 

Once you have rated each of the statements, go through and add up the responses. Pay special attention to if an item has been reverse-scored. In these cases, a 7 becomes a 1, 6 becomes a 2, etc. When you have performed the necessary reverse-scoring procedures, then you are ready to calculate your overall Sense of Coherence. Add up the values, and then use the SOC Analysis Table to interpret your score.

Writing Your Report

      Once you have your SOC score, I want you to write an essay where you share your score and what it means. By itself, the score is just a number. In the report, I want you to explain what it means in the context of your life. What do you learn about yourself? What aspects of your life do you think contribute to a high sense of coherence? Which parts contribute to a low sense of coherence? And so on.

            Structuring Your Report

I recommend the following sections:

1.     An Introduction to Sense of Coherence. In a paragraph or so, explain in your own words what “sense of coherence” means, and describe the inventory.

2.     The Results of Your SOC Inventory. Imagine that you are a health psychologist. Share your results from the inventory along with a few sentences about how you interpret those results.

3.     Personal Reflection on What Your SOC Score Indicates. Write this section like a patient who has received their SOC results. How do you make sense of the score and analysis from Part 2? What does it mean to you? Does it seem accurate? Does the score miss part of the picture?

4.     Plan for Personal Change. In this section, look forward. Is there something specific that you can do to increase your sense of coherence? What would that practice look like? What would need to change in your life?

 

A sample score and report can be found after the inventory.

 

SENSE OF COHERENCE INVENTORY

1.     When you talk to people, do you have the feeling that they don’t understand you? 

 

1          2          3          4          5          6          7 

never have this feeling                  always have this feeling 

 

 

2.     In the past, when you had to do something which depended upon cooperation with others, did you the feeling that it: 

 

1          2          3          4          5          6          7

surely wouldn’t get done              surely would get done 

 

 

3.     Think of people with whom you come into contact daily, aside from the ones to whom you feel closest. How well do you know most of them? 

 

1          2          3          4          5          6          7

you feel that they are strangers     you know them very well 

 

 

4.     Do you have the feeling that you don’t really care about what goes around you? 

 

1          2          3          4          5          6          7

very seldom or never                                very often 

 

 

5.     Has it happened in the past that you were surprised by the behavior of people whom you thought you knew well? 

 

1          2          3          4          5          6          7

never happened                                               always happened 

 

 

6.     Has it happened that people whom you counted on disappointed you? 

 

1          2          3          4          5          6          7

never happened                                         always happened 

 

 

7.     Life is: 

 

1          2          3          4          5          6          7

full of interest                                           completely routine 

 

 

8.     Until now your life has had: 

 

1          2          3          4          5          6          7 

no clear goals                                                  very clear goals 

 

 

9.     Do you have the feeling that you’re being treated unfairly? 

 

1          2          3          4          5          6          7 

very often                                      very seldom or never 

 

 

10.  In the past ten years your life has been: 

 

1          2          3          4          5          6          7 

full of changes                              completely consistent 

 

 

11.  Most of the things you do in the future will probably be: 

 

1          2          3          4          5          6          7

completely fascinating                              deadly boring 

 

 

12.  Do you have the feeling that you are in an unfamiliar situation and don’t know what to do? 

 

1          2          3          4          5          6          7 

very often                                      very seldom or never 

 

 

13.  What best describes how you see life: 

 

1          2          3          4          5          6          7 

I can always find a solution                            there is no solution
to painful things in life                                   to painful things                                                          

 

 

14.  When you think about your life, you very often: 

 

1          2          3          4          5          6          7 

feel how good it is to be alive            ask yourself why you exist 

 

 

15.  When you face a difficult problem, the choice of a solution is: 

 

1          2          3          4          5          6          7 

always confusing and hard to find                  always clear 

 

 

16.  Doing the things you do everyday is: 

1          2          3          4          5          6          7

a source of deep pleasure        a source of pain and boredom 

 

 

17.  Your life in the future will probably be: 

1          2          3          4          5          6          7 

full of changes                        completely consistent and clear

 

 

18.  When something unpleasant happened in the past your tendency was: 

1          2          3          4          5          6          7 

to “eat yourself up” about it               to say “ok, that’s that.” 

 

 

19.  Do you have very mixed up feelings and ideas? 

 

1          2          3          4          5          6          7 

very often                                      very seldom or never 

 

 

20.  When you do something that gives you a good feeling: 

 

1          2          3          4          5          6          7 

it’s certain that you’ll                         it’s certain that something
go on feeling good                              will happen to spoil the 

feeling 

 

 

21.  Does it happen that you have feelings inside you would rather not feel? 

 

1          2          3          4          5          6          7 

very often                                      very seldom or never 

 

 

22.  Do you anticipate that your personal life in the future will be: 

 

1          2          3          4          5          6          7 

totally without meaning                            full of meaning 

 

 

23.  Do you think that there will always be people whom you’ll be able to count on in the future?

1          2          3          4          5          6          7 

you’re certain                                you doubt there will be 

 

 

24.  Does it happen that you have the feeling that you don’t know exactly what’s about to happen? 

 

1          2          3          4          5          6          7

very often                                      very seldom or never 

 

 

25.  Many people – even those with a strong character – sometimes feel like sad sacks (losers) in certain situations. How often have you felt this way in the past? 

1          2          3          4          5          6          7

never                                                         very often 

 

 

26.  When something happened, have you generally found that: 

1          2          3          4          5          6          7

you over/underestimated                          you judged it’s 

importance                                                            importance well

 

 

27.  When you think of difficulties you are likely to face in important aspects of your life, do you have the feeling that:

1          2          3          4          5          6          7

you will always succeed               you won’t succeed 

 

 

28.  How often do you have the feeling that there’s little meaning in the things you do in your daily life? 

1          2          3          4          5          6          7

very often                                      very seldom or never 

 

 

29.  How often do you have feelings that you’re not sure you can keep under control? 

1          2          3          4          5          6          7

very often                                      very seldom or never 

Scoring the Inventory

Before adding up your results, go through and convert the reverse-scored items. For reverse-scored items, choose the opposing values: (1=7, 2=6, 3=5, 4=4, 5=3, 6=2, 7=1). The reverse-scored items are 1, 4, 5, 6, 7, 9, 11, 13, 14, 16, 20, 23, 25, 27.

Once you have reverse-scored the above items, you may add up the values of your answers to get a cumulative total.

 

Figure 1.2: SOC Scoring Key