The Nature and Assessment of Spiritual Health

Spirituality is a concept that constitutes the relationship between the human being and the divine, and efforts to define it are ongoing. Many studies have highlighted the relationships among spirituality, religion, and health. A wealth of resources has addressed nearly one hundred educators in four types of schools, the result of whose efforts has been to offer a model in which spiritual health can be considered, if not a fundamental aspect of health, then at least a complementary part of other dimensions of health (including physical, mental, emotional, social, and moral health). The quality of the relationships that each person experiences with themselves, others, the environment, and God indicates the state of spiritual health in each of these four domains. This model serves as a basis for assessments of spiritual health/well-being in schools and universities. The present article, while addressing the nature of spirituality and its dimensions, presents a model for spiritual health and, finally, revisits the existing challenges on the path to spiritual health.

Introduction

Day by day, the consensus that spirituality is a real phenomenon and not a product of human imagination is growing. An accurate assessment of this matter requires extensive knowledge regarding spiritual soundness, and this knowledge simultaneously helps us to identify spiritual disorders. This important task, of course, is not solely the responsibility of individuals but concerns the entire world; and it may well be essential for the survival of the human race. Efforts to define spirituality are centered between the human being and divinity. Many individuals claim that spirituality and health (well-being) are two multifaceted constructs that are inherently ambiguous. This, however, has not stopped people from attempting to define spirituality and well-being and their intrinsic connection under the well-known title of spiritual health (or well-being) (abbreviated as SWB).

The Nature of Spirituality

For centuries, the nature of spirituality has been, and continues to be, a subject of debate and controversy. The literature related to this concept indicates that writers have also failed to reach a consensus on providing a precise definition of it. Muldoon and King (1995) believe that spirituality, in a colloquial context, refers to many things, and different people have varying conceptions of it depending on their intellectual and emotional circumstances and requirements. Despite its ambiguity, this concept encompasses a spectrum from traditional institutionalized religion to occult practices. Overall, this term corresponds to the discovery and experience of authentic human life and living within it.

In the Oxford Dictionary, approximately twenty-four separate meanings are given for the word Spirit. The general meaning that forms the basis of all these twenty-four is the dynamic and living principle that is life-giving and transcendent beyond the material and mechanical. This concept, in fact, refers to the authentic essence of human beings, purposefulness, perception, spiritual and psychic powers, and the mental framework and structure. The spiritual also pertains to moral characteristics and intellectual and mental implications. Before entering the discussion, it is necessary to briefly address some issues.

Spirituality, an Inner Matter

There is considerable evidence suggesting that spirituality is a trust lying at the heart of human experience, and anyone can experience it. Human spirituality, in the true sense of the word, integrates and brings coherence to the person as a whole. Leighton (1996), while affirming this, believes that spirituality is a dimension of the human being that shapes the entirety of life, gives it depth, casts a shadow over all aspects of existence, and can be considered an essential and vital component of human functioning.

Spirituality, an Emotional Matter

Spirituality, in its deepest meaning, pertains to feelings and emotions. Spirituality deals with the heart and soul of individuals because it concerns the very core of existence. Individuals cannot live neutrally and without values. Rather, they must strive to be realistic and act objectively in recognizing the components of spirituality and spiritual health, especially in youth.

Spirituality, a Personal Matter

Spirituality is fundamentally a personal or individual matter, and much of its nature lies beyond the reach of scientific investigations and methods. At the same time, science can neither deny nor affirm issues related to metaphysics. That is to say, just as it is helpless in refuting or confirming aesthetics, its blade does not cut in proving or disproving spirituality either. Dyes (1993) says in this regard that scientism (Scientism = those who believe that science holds a status equal to truth) rejects spirituality because they believe this category cannot be studied through scientific methodology. If we can accept concepts such as self-esteem, self-realization, self-actualization, and self-worth, then we can explore spirituality, because these concepts are as complex, indescribable, and ineffable as spirituality. If we say that using the five senses and the empirical method of knowing is the only true science, then logic, mathematics, reason, and psychology will also have no place in science. Overemphasizing the realm of the senses and reducing the human being to mere matter is an old example of confusing form and meaning. To create balance regarding the personal nature of spirituality, Thatcher (1991) says that if we misinterpret spirituality as an entirely inward matter, we must pay a heavy price; therefore, to better understand spirituality, we must reach beyond the inner search.

Spirituality, a Dynamic Affair

One researcher named Priestley (1981) believed that the spirit is a dynamic affair, and before we theorize about it and speak of its concept, we must feel it. Terms such as spiritual growth and spiritual perfection speak of the living, passionate, and emotional nature of spirituality. A person's spiritual health can be high or low. If it is constant, there is neither growth nor perfection. The spiritual quest is like being on a journey: the moment you think you have arrived, you have not yet set foot on the journey (or you have passed away).

Spirituality and Religion

Opinions differ regarding the nature of any relationship between spirituality and religion. Some people consider spirituality equivalent to religious activity and use the term overlap to describe the relationship between the two. While others believe this notion lacks validity. Hill and his colleagues (2000) have spoken of the commonalities and differences between spirituality and religion. Scott (1999) reports a kind of conflict between the views of behaviorists who consider spirituality and religion completely separate from each other. Nevertheless, it must be said that in one sense, religion is based on ideology and precepts, while the foundation of spirituality is formed by experience and connections that lie beyond religion. Some researchers, in their definition of spirituality, include a relationship with the sacred or transcendent. Considering this view, it can be said that spirituality entails a connection with the sacred of any kind. But in the belief of some, including Taylor (1986), spirituality does not necessarily mean talking to God. Abraham Maslow (whom many consider the father of humanistic psychology) and also John Dewey (who is the founder of the school of pragmatism) consider spirituality a part of the human being that is prior to/different from religiosity. Some writers have followed this humanistic thought and have tried to define secular spirituality as a spirituality that has no need for formal religion or God. At the same time, Smith (2000) and Wright (2000) are among the Christian writers who have put forward arguments against pushing religion and God out of discussions related to spirituality. This diversity of views shows how individuals' worldviews and beliefs can influence their perception of spirituality; and this issue is a key and principal characteristic in the spiritual health model that we address in this article.

Types of Spirituality

Koenig and his colleagues (2001) have examined five types of spirituality in the United States; however, these five types can be placed into three categories: God-centered spirituality, world-centered spirituality, and humanistic spirituality. Palmer (1999) has tried to describe these divergent classifications and perspectives by stating that spirituality is, in fact, humanity's ancient and eternal quest to connect with something greater and more certain than our selves, our fellow human beings, our historical worlds, our nature, the breezes of our spirit, and the mystery of our life. The definition Palmer offers bears many similarities to my working definition:

Spirituality refers to a person's awareness of existence and the experience of our inner feelings and inner beliefs that give life purpose, meaning, and value. Spirituality helps individuals live together in peace, love God and neighbor, and be in harmony with the environment. For some, spirituality entails an encounter with God, or a transcendent reality, which can occur within the context of formal religion, while for others, spirituality entails no kind of experience or belief in the supernatural.

Dimensions of Health

Before addressing the relationship between spirituality and health, it is essential to explain the nature of health. Even in ancient Greece, educators and teachers considered an individual to possess complete health only when they enjoyed spiritual health. Thus, from Hippocrates' perspective, it is this nature (i.e., the life force = Pneuma, or Spirit) that heals; this spirit is God's gift to humanity. At the same time, healing can be seen as a type of well-being arising from a deep awareness of the whole and the integration of all dimensions of an existence, which includes the spiritual elements of life.

The authors believe there are six separate yet interrelated dimensions that constitute human health. Health requires more than physical fitness and the absence of disease; health also includes spiritual, psychological, emotional, cognitive, and perceptual dimensions. The social dimension of health pertains to human interaction: that is, the professional realm. And this health, in the very context and core of existence, pertains to the spiritual dimension. And remarkably, it is this spiritual dimension that has the greatest impact on a person's overall health.

Well-being and Spiritual Health

Ellison (1983) believed that spiritual well-being arises from the underlying state of spiritual health and is, in fact, its manifestation, just as the color of a person's complexion, their pulse rate, and their temperament are manifestations of their physical health. Some scholars, in completing this statement, have said that spiritual well-being is an indicator of a person's quality of life in the spiritual dimension or simply a sign of their spiritual health.

There are four main themes within the definitional framework of spiritual well-being provided by the National Interfaith Coalition on Aging (NICA). According to this definition, spiritual well-being is the affirmation of life in relationship with God, self, community, and the environment, which nurtures and celebrates wholeness. When spiritual well-being is discussed, these four types of relationships are referred to in various ways. These relationships can be defined in four realms of human existence: 1) relationship with self, the personal realm; 2) relationship with others, the communal realm; 3) relationship with the environment, the natural realm; and 4) relationship with the transcendent, the transcendental realm.

Fisher (1998) has elaborated in detail on each of these four domains and provided extensive definitions for each. He considers spiritual health to be a dynamic state of being that occurs in the quality of a person’s harmonious relationships with others. In his view, the personal domain is an interpersonal domain in which the person engages with their own self and is in search of meaning, purpose, and life values; and self-awareness is, in fact, the driving force or transcendent aspect of the human spirit that seeks identity and the discovery of self-worth. The communal domain, which is manifested in the quality and depth of interpersonal relationships, pertains to morality, culture, and religion, and these in themselves are expressed in love, forgiveness, trust, hope, and faith in humanity. The environmental domain, beyond nutrition and the physical dimension, pertains to a sense of awe and wonder, and some believe this domain concerns the concept of unity with the environment. And the transcendental domain, in truth, refers to the relationship between a self and a singular entity beyond the human realm (i.e., an ultimate concern, cosmic force, transcendent reality, or God). This matter entails faith, adoration, and worship of the source of the universe’s mysteries.

This definition reveals the continuous and dynamic nature of spiritual health, in which harmony depends on a kind of deliberate self-cultivation that itself arises from the coherence between meaning, purpose, and values crystallized and experienced in life at the personal level. This occurrence results from confronting personal challenges that go beyond meditation and ultimately reach a state of bliss that some interpret as inner harmony.

Morality, culture, and religion are encompassed within the communal domain of spiritual health, and according to Paul Tillich (1967), all three interpenetrate one another and continuously perpetuate the unity of the spirit; at the same time, these three elements, while inseparable, are distinguishable. Tillich adds that the separation of religion from morality and culture leads to what we call the secular.

A Model of Spiritual Health

The following diagram clearly illustrates the interconnected relationships among the constituent components of the definition of spiritual health we mentioned earlier. Here, each domain of spiritual health consists of two aspects: knowledge and inspiration. Knowledge is the cognitive framework that is effective in interpreting the transcendent or inspirational aspect, the aspect that constitutes the essence and motivation of each domain of spiritual health. Here we again encounter the two concepts of mind and consciousness working together, both seeking harmony. When this harmony is achieved, it manifests itself clearly in well-being.

In this model, individuals’ worldviews can be observed through the knowledge dimensions, and their beliefs through the inspirational dimensions. The main characteristic of this model has a somewhat distinct nature; at the same time, the knowledge and inspirational dimensions of each of the four domains of spiritual well-being are intrinsically interconnected.

The quality or soundness of the relationship in each domain, in fact, determines the spiritual well-being in that domain. The indicator of each person’s spiritual health is determined by the combined effect of spiritual well-being in each domain. Therefore, spiritual health is the result of a positive and growing relationship in each domain and naturally increases through the inclusion of more domains.

The concept of progressive synergism is used to better explain the relationship between the domains of spiritual health. When the levels of spiritual well-being in the four domains are combined, the result will be something more than the mere quality of the relationship between the individual domains. Progressive synergism means that as the capacity of the spiritual health domains increases, it can encompass more elements of well-being. The above diagram clearly illustrates the progressive synergistic relationship among the four domains of spiritual well-being.

When relationships are not right or no relationship exists, there is no wholeness or health. Spiritual illness grips our hearts. Depending on changing circumstances, effort, and the person's worldview and beliefs, the quality of relationships in each domain changes over time, and a relationship may even disappear. Many people believe that they themselves are the sole factors influencing their spiritual health. The concept of progressive interaction states that the growth of personal relationships (in connection with meaning, purpose, and life values) is enhanced by the growth of collective relationships (i.e., the growth of ethics, culture, and religion).

Union with nature and the environment helps strengthen personal and collective relationships. Cultural differences are important here: many people from Western societies have a different view of the environment compared to others, such as the Indigenous Australians and the Māori of New Zealand. Westerners prefer to know about the environment rather than to have a deep connection with it and, so to speak, achieve union with it.

The preceding diagram also shows that a person's connection with a particular transcendent being may enter other domains of spiritual health. For example, firm faith in God may well enhance all other relationships in the domain of spiritual health. As the individual moves beyond their existential boundaries, the spiritual dimension of life deepens, and the person finds a more honest and authentic relationship with themselves and becomes ever more God-like.

Just as spiritual health is a dynamic essence, it is through life's challenges that the honesty and trustworthiness of a person's worldview can be tested. Spiritual health can increase or decrease. If we have a way to assess the current state of spiritual health as a friend, counselor, parent, or teacher, we have a basis upon which we can strengthen relationships and enhance our own and others' spiritual well-being to a desirable extent.

Assessing Spiritual Well-being and Health

Many researchers have worked on assessing spiritual health and well-being. At the same time, the main problem in making sense of this volume of research is that the theoretical foundations of these studies are very different from one another. Most of this research has limited religion and spirituality. Although there are commonalities between these two constructs, they are not synonymous. All measurement instruments are built upon a set of value foundations, and most instruments establish norms (guidelines) for studies. The guidelines of different groups are so different that a norm for spiritual health and well-being might be positive in one group and negative in another. At the same time, each group believes that its own specific criteria for true spirituality are better than the other group's and that its guidelines should be the foundational basis for all humanity. Moberg (2002) disagrees with this issue, because all individuals are spiritual, and yet uniform methods can be used to assess the spiritual health and well-being of different populations (especially religious groups and minorities). He adds that research on spirituality is difficult and complex because no single measure can be considered complete, and each measure reflects a specific phenomenon and has its own consequences, and it cannot be assessed directly.

Most measures are self-report; however, they may not reflect reality, because feeling good does not necessarily indicate being good. Therefore, checking the validity of each instrument and measure is essential. Can this measure accurately assess spirituality and its components? The power of a questionnaire depends on the theoretical basis and the precision applied in its design.

Almost all existing religious/spiritual measures pose a question about lived experience. In the best measures, these questions are posed based on theoretical frameworks of the relationships between spirituality and health. The scores and ratings given are also according to optional indicators related to spiritual health and well-being, especially if the number of items questioned or tested is numerous. Spiritual health depends simultaneously on beliefs and worldviews as well as individuals' lived experience. Therefore, creating a single measure intended to provide an objective criterion by which individuals can be compared challenges the multifaceted nature of spiritual health.

Dooling and colleagues (2004) studied several cases in this area that were relevant to collective spiritual health and well-being. Egberston (2006) also conducted research on questions related to the personal domain. Overall, based on the author's investigation, approximately 190 quantitative measures concerning spirituality, spiritual health, and well-being had been carried out by 1967. By 2001, numerous other religious measures had been added to this total.

Spiritual Health and Global Health Challenges

In recent years, the crucial and fundamental role of spirituality in the field of health, both generally and specifically, has been heavily emphasized in various studies. Addressing spiritual issues not only enhances health levels but also helps improve quality of life. Nevertheless, despite efforts made, spirituality does not have a significant presence in the literature and educational programs of global health. Drawing on the ethics of social justice, global health emphasizes improving health and equity in access to health services in all its dimensions, including spiritual health. The language global health uses to describe itself testifies that it is rooted in a spirituality based on love and compassion; love and compassion that few religions have failed to mention. The foundation of global health must be traced back to missionary medicine in the nineteenth and early twentieth centuries, which is manifested in a kind of purposefulness and spiritual vision directly connected to formal religion, particularly the evangelical branch of Christianity. Here, of course, religion refers to a collective tradition that includes the experience of the sacred, shared beliefs, sacred texts, and fundamental theoretical frameworks. The relationship between religious institutions and the spirituality that religion underpins is inherently complex. Krista Tippett (2015) likens spirituality to water and religion to the glass that holds it. To better understand the role of spirituality in the practice of global health and to identify the influencing factors that realize it within health-related settings, one can refer to open-ended interviews the author conducted between 2010 and 2014 with over three hundred leaders, practitioners, physicians, nurses, and students in the field of health and spirituality.

However, regarding spiritual issues and the challenges ahead, it must be said that four interrelated spiritual themes can be extracted from the core of these interviews. These four themes, which have also become four challenges, are: 1) long-distance compassion, 2) doublethink, 3) the conspiracy of silence, and 4) the necessity of saving the world.

Long-Distance Compassion

The nature of global health inherently creates specific challenges for generating and expressing compassion. What does it mean to show compassion to populations that are geographically, culturally, or economically miles away? Many of the practitioners I interviewed speak of compassion as a powerful motivation for entering and influencing global health, yet at the same time, they feel that their connection to this compassion has been severed by their daily work. Theoretical models of compassion proposed by Batson (1987) and others provide us with a suitable framework for understanding this disconnection. These models show that compassion requires three components: awareness of suffering (cognitive attunement); empathy (affective attunement); and action (appropriate to the suffering). First, a compassionate response or reaction requires mental stability and clarity to recognize suffering as suffering. In global health, understanding suffering is often based on indicators (profiles) or data rather than face-to-face encounters with afflicted individuals. This situation is especially true when we face chronic or hidden suffering at the individual level.

Distant compassion was first raised by Bill Foege in his 1984 lecture: he said that if we are to protect the reputation this institution has earned, we must have a plan for every task, and the prerequisite for success in this plan is direct encounter. This is an extraordinary message for global public health, which is responsible for the health of populations worldwide and not of individual persons. Safeguarding this position depends not only on program effectiveness, measurable outcomes, and epidemiological capability, but also on love and compassion—this love meaning the shared willingness and resolve of staff and personnel in the face of pain and suffering. Second, compassion requires empathy and the capacity to perceive and understand the pain and suffering of others. Raw data alone cannot sufficiently generate motivation and emotional or affective arousal. For those working at the macro-policy level of global health and public health, overcoming this emotional and affective distance is difficult. The reverse, of course, holds true for those working in difficult conditions, amid intense pain and suffering, with insufficient resources, and sometimes in the midst of danger. In these circumstances, what threatens compassion is excessive emotion or personal stress, such that reactions, rather than being affective and emotional, become harsh, antagonistic, and in some cases lead to flight from the situation and even passivity.

Third, compassion requires action. The instruments of global public health—the means through which compassion is expressed and suffering is alleviated—are often not direct and personal, as they are in clinical settings, but are inherently organizational, finding expression, for example, through large-scale plans and programs, budget allocations, financial and service grants, protocols, training, and support. Large-scale plans and programs in global health are implemented through international collaborations and partnerships. Organizational policies and global programs, while essential for transferring the resources needed to relieve the pain and suffering of the world's people, can divert the attention of health practitioners from the encounter with suffering itself. And empathy, in the midst of this, is easily sacrificed. This happens almost in the short term; many of the young people I have spoken with, after just a few years of education and service in a school of public health, have expressed disappointment and despair and have lost their desire to serve the people.

Dualistic Thinking

The second challenge in the field of global health is dualistic thinking. By this I mean seeing the world exclusively in terms of this or that, such as disease or health, death or life, and the like. This binary or dualistic classification has had a tremendous impact in the field of communicable diseases (epidemiology). At the same time, it has its own limitations. Dualistic thinking does not allow us to perceive contradiction and to resolve complex issues. Moreover, this thinking is fundamentally inconsistent with the lived experience of many in the field of global health and public health; a field in which categories and classifications such as here and there, local and global, and us and them no longer suffice.

Throughout history, reflections within religious and spiritual traditions have pointed to the value of non-dual awareness, which lies beyond binary, two-sided, black-and-white categorizations. For those trained in the epidemiological mode of thought, the concept of being non-dual makes no sense or is at least unscientific, for epidemiology is typically aligned with a Newtonian worldview. In contrast, the science of physics and studies of consciousness have moved beyond subject-object dualism in order to make empirical data meaningful.

Non-dual awareness is precisely what is necessary for global health leadership. In a 2012 lecture, Bill Foege pointed to the geographical non-duality of global health; in this regard, he said that everything is simultaneously local and global; global health has no here and there. Hunter and Fineberg (2014) recently described global public health as a vast carpet spread across the world, having an impact everywhere, in which the encounter with each individual patient is a local event, and international health institutions form a patchwork quilt of diverse entities. Therefore, for global health to fulfill its promise of eradicating suffering from all the world's people, its practitioners must encounter individual human beings face to face. These non-dual skills are taught more in the dominant traditions of the great religions and spiritual paths than in schools of medicine, nursing, and health.

The Conspiracy of Silence

One of the persistent dualities is the distinction between our inner self (that which gives life meaning and purpose) and our action in the world. Those of us who work in the health field tend to quarantine our spirituality, and we never collectively acknowledge and affirm its invigorating power. This creates an internal division, which is a silent form of inner suffering. The reason or reasons for this conspiracy of silence are not entirely clear. Given the extent of suffering and disease in the world, any emphasis on the inner life could be considered a luxury, and might distract us from the more important task of addressing global health. Global health, rooted in the science of epidemiology, is outcome-oriented and thoroughly secular. In this context, the public manifestations of personal values cannot be observed face to face. At the same time, as one of the leading theologians, Gustavo Gutiérrez (2003), has said, if we are to do fruitful work, we must drink from the wellspring of our own spirituality.

One of the themes that repeatedly arises in my conversations is the importance of a personal encounter with a specific individual, for example, during an international service-learning project or doing medical work abroad. The stories of such encounters have a profound impact on motivating, shaping, and sustaining the entire medical and health profession. When a personal encounter provides an opportunity for dialogue, the result will be far more beneficial.

The Necessity of Saving the World

The fourth challenge that emerged in my conversations and interviews is very subtle and sensitive. Therefore, identifying it requires greater care. This challenge is what Carl Jung referred to as the hidden aspect (or the shadow); this hidden aspect is the goal or mission that many health practitioners pursue in their work. One of the things global health aims to do is provide an arena for doing good on a large scale, which has a significant (and, of course, measurable) impact in delivering millions of people worldwide from suffering, pain, and distress. The skillful and systematic application of relatively simple technologies can dramatically save children from death, eradicate scourges like Guinea worm disease, and eliminate the devastating and destructive effects of diseases that threaten a billion people across the globe. Thus, global health not only seeks to awaken the motivation of compassion inherent in the consciousness arising from human maturity, but also to stir the ego's (self's) desire for meaning and identity. The comprehensive and global vision of health is a factor that compels individuals to seek the realization of their own salvation and to believe in themselves as a benevolent and caring person (as the great religious traditions require).

Linking one's personal identity and self-worth to a field as vast and expansive as global health can lead to a flurry of fervent activities in the name of serving others. If unmanaged, this will become problematic; at the same time, this work is usually justified provided there is a severe need. A monk named Thomas Merton (1965) does not refer to global health, yet he addresses this problem when he writes: expose yourself to a multitude of conflicting concerns and issues, yield to many demands and exigencies, feel committed to numerous projects, help everyone in everything to overcome the violence and adversities of the times.

But to what extent does identifying oneself with others affect the performance of health practitioners in the world? First, it can have a considerable impact on family and romantic relationships. Second, the options and the will required to climb the ladder of effectiveness in global health can be an obstacle to an individual's commitments. With such an obstacle, it is difficult to affirm the consequences of a person's actions. Attachment to a particular outcome is not compatible with a deep understanding of compassion. Rather, it causes us to fall into a kind of selfish behavior that is primarily focused on the needs of the caregiver rather than the care of the client.

Third, one of the major challenges in global health is the imbalance of power and resources between donor agents (whether government or the private sector) and recipients. Those who donate—often, priorities in medicine and health at the international level are fundamentally driven by donors, foreign policy, or other factors.

And finally, it is the intense identification of the self with the recipient that leads to an inability to cope with the unexpected, painful consequences of one's actions. Apologizing for medical errors has become very common in recent years. Unfortunately, this apology has not yet been institutionalized at the level of global health and well-being. There is no tradition in global health and well-being of apologizing for the loss of life, even as a result of benevolent interventions; a necessity that is deeply felt.

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The Nature and Assessment of Spiritual Health

Author: John W. Fisher

Translator: Ali Akhlaghi

Published in Issue 145 of the Specialized Scientific Quarterly of Wisdom and Knowledge Information

Source:

Understanding and Assessing Spiritual Health, John W. Fisher, 2009, M. de Souza et al. eds. International Handbook of Education for Spirituality.

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