Spiritual Health: Definition and Theory
by Steven Hawks
Abstract: Focuses on spiritual health as an integral part of holistic
health. Characteristics of spiritual well-being and the factors that promote
it; Theoretical model of spirituality and holistic health; Maslow's hierarchy
of needs; Research, measurement and policy implications for health education.
Spiritual health, as a dimension of holistic health, has not been
adequately defined, researched, grounded in theory, or
integrated into the health education curriculum. This article
reviews the literature in relation to spiritual health and then
offers a modern definition of spiritual health that takes into
account the characteristics of spiritual well-being as well as
the factors that promote it. In addition, the theoretical
interaction of spiritual health with the other dimensions of
health is analyzed by correlating the various dimensions of
health with Maslow's hierarchy of needs. Research, measurement,
and policy implications for health education are discussed.
The health education field has undergone a transformation during the
past 50 years, from an almost exclusive emphasis on the importance of
physical health to a more balanced perspective that now promotes the
achievement of "wellness" through the pursuit of holistic health.
Toward that end, the concept of health is now generally defined as a
holistic, multi-dimensional phenomenon that includes not only
physical, but also emotional, intellectual, occupational, social, and
spiritual components (Allen & Yarian, 1981; Eberst, 1984; Greenberg,
1985; Hettler, 1979; Hoyman, 1962; Ram, 1988). A significant amount of
attention has been given to each of these dimensions of health (with
one notable exception), in terms of research, publications,
theoretical models, educational strategies and priorities, and the
amount of space occupied in personal health texts. As of yet, the
concept of spiritual health, as a major and integrated dimension of
holistic health, has not been adequately defined, researched, grounded
in theory, or integrated into the health education curriculum. If it
is true that high levels of wellness cannot be achieved without a
balance in the various dimensions of health (World Health
Organization, 1946), then there is a real need to pay more attention
to spiritual health--specifically, what it is and how it relates to
and interacts with the other dimensions of health. The purpose of this
article is to begin to systematically address these questions and then
suggest various implications for the practice of health education.
What is Spiritual Health?
It recently has been asserted in the literature that, "...there is no
single recognized definition of spiritual health" (Bensley, 1991a).
Spiritual health has been hard to define because it is thought to have
no clear structure, parameters, or measurable subcomponents (Eberst,
1984). As such it has been described as the least obvious and
measurable of the known dimensions of health (Banks, 1980). Another
barrier to interest in spirituality is that it has been considered a
taboo topic in the classroom because of its perceived closeness to
religion (Collins, Hurst, & Jacobson, 1987). Yet, there seems to have
been enough written about the concept of spiritual health to overcome
these obstacles and propose a fairly consistent, inclusive definition
of this aspect of human wellness.
Traits of spiritual health. In general, two aspects of spiritual
health have been explored in the literature: a) the internal
characteristics of those who are spiritually well, and b) the way in
which spiritual individuals expresses themselves in their external
interactions. Internally, spiritual health seems to provide the
individual with life purpose and ultimate meaning (Banks, 1980;
Hoyman, 1962; Poehler, 1982; Ram, 1988); oneness with nature and
beauty and a sense of connectedness with others (Russel, 1984); deep
concern for and commitment to something greater than self (Banks,
1980; Brown, 1978; Leean, 1988); a sense of wholeness in life
(Bellingham, Cohen, Jones, & Spaniol, 1989; Young, 1984); strong
spiritual beliefs, principles, ethics, and values (Banks, 1980; Pilch,
1988); and love, joy, peace, hope, and fulfillment (Bloomfield & Kory,
1978; Carson, Soeken, & Grimm, 1988; Chapman, 1987a).
In terms of their external interactions, spiritually well individuals
express themselves through trust, honesty, integrity, altruism,
compassion, and service (Banks, 1980; Chapman, 1987a; Poehler, 1982;
Russell, 1984). In addition, they regularly commune with or have some
sort of personal relationship and experience with a higher power or
larger reality that transcends an observable physical reality (Banks,
1980; Elkins, Hedstron, Hughes, Leaf, & Saunders, 1988; Leean, 1988;
Factors leading to spiritual health. Most of what has been written
about spiritual health concentrates on the internal and external
characteristics of the spiritually healthy person described above,
rather than on the factors that lead to spiritual health. In looking
for the factors that lead to the characteristics of spiritual health
described above, it appears to this author that three criteria must be
met: a) a well-defined worldview or belief system that provides
purpose, meaning, and motivation to life; b) selflessness,
connectedness with, and concern for others; and c) high levels of
personal faith and commitment in relation to the worldview and belief
It seems that spiritually well individuals must have a well-defined
worldview that explains reality for them and offers a coherent belief
system. The worldview does not have to be a religious one, but it must
nevertheless answer such basic existential questions as "where did I
come from," "why am I here," "which path will lead to meaning and
fulfillment in my life," and "what will happen to me after I die"
(Brower, 1984). Generally, these questions are answered within the
context of a higher power or larger reality. By answering these
questions, the spiritual worldview provides a sense of meaning and
purpose to existence in general, and, further, offers a path for
personal fulfillment (a dream, cause, or mission) at the individual
level. This road to fulfillment and meaning then outlines rules of
conduct, values, and a sense of moral ethics and beliefs.
The themes of compassion, selflessness, integrity, honesty, and
connectedness with others occur in most discussions of spirituality
(Banks, 1980; Elkins et al., 1988; Poehler, 1982; Russell, 1984). As
such, another criteria for a spiritually sound worldview is that the
path to meaning which it advocates should involve some degree of
selflessness, service to others, and a sense of connectedness with
others. Since the alternative to a worldview based on selflessness
would be one based on self-gratification, the importance of making
selflessness a criteria for spiritual health becomes clear. Namely,
individuals who organize their lives around self-gratification and
pleasure seeking are more prone to addictions, mood disorders, and a
profound sense of emptiness and unhappiness, all of which are
antithetical to the characteristics of spiritual health as outlined
above. In support of this position, research has found a negative
relationship between spiritual well-being and such self-oriented
constructs as individualism, success orientation, and personal freedom
(Ellison, 1983). On the other hand, connectedness with others has been
linked to several positive health outcomes (House, Landis, & Umberson,
1988; Kaplan et al., 1988).
Finally, in order for a worldview to have a positive impact on an
individual's spiritual well-being, the individual must have a deep
sense of belief (or faith) and hope that the worldview does, in fact,
accurately depict reality. Without that sense of belief, faith, and
hope, the level of commitment and motivation necessary to follow the
path prescribed by the worldview would never be attained, especially
since the worldview, as suggested above, must advocate selflessness,
compassion, concern for others, sacrifice, etc. Once faith, hope, and
commitment are in place, pursuit of meaning and purpose along the path
outlined by the worldview can lead the individual to personal
fulfillment, self-esteem, connectedness with others, and high levels
of spiritual health.
Toward a definition of spiritual health. A short, but comprehensive
definition of spiritual health that takes into account the
characteristics and criteria discussed above might be: "A high level
of faith, hope, and commitment in relation to a well-defined worldview
or belief system that provides a sense of meaning and purpose to
existence in general, and that offers an ethical path to personal
fulfillment which includes connectedness with self, others, and a
higher power or larger reality."
In addition to meeting the criteria outlined above, this definition
meets the criteria set forth by Chapman (1986) for a modern definition
of spiritual health: (a) the definition does not attempt to answer
highly complex and personal questions, (b) it is practical and relates
to health, (c) it is sensitive to the scope of other areas of
specialization in the field of health promotion, (d) it provides a
foundation for the development of an appropriate science base
surrounding the practical use of spiritual health program
interventions, and (e) it is flexible enough to provide opportunity
for inclusion of new ideas and concepts concerning health and
well-being. Finally, this definition is consistent with constructs
that undergird the most common measures of spiritual health and
maturity, including a) personal commitment as manifested in living, b)
personal commitment as manifested in belief, and c) loving
relationships with others (Bassett et al., 1991).
Spiritual Health as an Integral Part of Holistic Health
The correlation between Maslow's (1970) hierarchy of needs and the
dimensions of health provides a theoretical framework that supports
the definition of spiritual health offered above and that describes
how spiritual health relates to and interacts with the other
dimensions of health. While the correlation between the five
dimensions of health and Maslow's hierarchy may not be absolute, the
comparison leads to interesting insights (see Figure 1).
Physical health. Physical health is generally defined in terms of body
composition, muscular strength and endurance, cardiorespiratory
fitness, and flexibility--most of which are closely associated with
Maslow's physical needs for proper nutrition, activity, shelter, and
protection from the environment. Until basic physical needs are met,
and some level of physical health is attained, it is difficult to
progress toward higher levels of health. Not only is physical health,
at least in part, a prerequisite for wellness in other dimensions of
health, but high levels of physical wellness also significantly
enhance the other dimensions of health (Hales & Hales, 1985). As such,
it serves as a foundation for achieving wellness in the other
dimensions of health.
Intellectual health. Before intellectual health--the ability to
reason, analyze, evaluate, create, and make rational decisions--can
flourish, it could be argued that individuals must feel that their
environment is safe, secure, and protected. Otherwise, worry and
anxiety would diminish the development of these abilities. Once
achieved, intellectual health becomes the primary tool for developing
meaningful social relationships, evaluating worldviews, comprehending
and choosing spiritual beliefs, and achieving emotional health.
Social health. Social health is achieved when an individual feels
genuine love, acceptance, and a sense of belonging within a larger
social unit. There is a direct correlation between the concept of
spiritual health and Maslow's concept of love and acceptance needs. As
with physical and safety needs, ideally, this dimension of health is
nurtured during infancy and childhood within the context of a loving
family. Positive social health then becomes crucial for the future
development of spiritual health as it is within the context of the
family and other social institutions that a spiritual worldview is
usually learned and adopted. In turn, once a full sense of spiritual
well-being has been developed, it is the path advocated by the
spiritual worldview that defines proper social relations with others.
Until the need for belonging and acceptance has been met, it is
difficult to achieve spiritual and emotional health.
Spiritual health. The relationship between spiritual health and
Maslow's concept of self-esteem is also insightful. As suggested
above, spiritual health is based on faith in a worldview that
advocates a certain path to fulfillment. This path embodies the
values, beliefs, and behaviors necessary to achieve meaning within the
worldview. Self-esteem occurs when the individual lives in close
harmony with the value system that results from a strong sense of
faith and spirituality. According to Maslow, love and acceptance are
the prerequisites to self-esteem. Based on the proposed model, it
could be further argued that a strong sense of spiritual health and a
commitment to a spiritually based value system are also prerequisites
to the development of self-esteem. In support of the proposed
relationship between spiritual health and self-esteem, it has been
reported in the research literature that there is a positive
correlation between spiritual well-being and self-esteem (Ellison,
1983). As such, self-esteem seems to derive from an internal locus of
control (living in harmony with spiritual values), and is not
dependent on such external constructs as physical appearance, talent,
socioeconomic status, or power. Any attempt to achieve long-term self
esteem through a pursuit of these external factors will, accordingly,
Emotional health. Finally, high levels of emotional health as
described in the literature are consistent with Maslow's concept of
self-actualization. Emotional health is generally defined as the
ability to feel and express the full range of human emotions, give and
receive love, achieve a sense of fulfillment and purpose in life, and
develop psychological hardiness (seeing change as a challenge instead
of a threat, and developing strong levels of personal commitment and
coping skills). Those with peak emotional health find beauty and
connectedness in life, tolerance and acceptance of others, and full
acceptance of self. Similarly, Maslow's self-actualization occurs as
individuals achieve their full potential as human beings as manifested
through fulfilling relationships, the full development and expression
of talents and abilities, and a sense of fulfillment and purpose in
life (Maslow, 1970). As described above and as advocated elsewhere,
spiritual health (and the path it advocates) may serve as a starting
point for the development of emotional health, self-renewal, and
self-actualization (Leichtman & Japikse, 1983). Not surprisingly,
recent reports in the research literature have found significant
positive correlations between spiritual well-being and hardiness
(Carson & Green, 1992), coping ability (Maton, 1989), and marital
adjustment (Roth, 1988), key indicators of emotional health and
self-actualization. At the same time, an inverse relationship between
spiritual well-being and excess anxiety, a sign of negative emotional
health, has been reported (Kaczorowski, 1988).
Implications for Health Education
If spiritual health is a meaningful dimension of health, as argued in
this paper, then it becomes important to a) measure spiritual
well-being in a humanistic, non-religious way as defined above; b)
conduct research that establishes relationships between spiritual
well-being and other pertinent variables; and c) develop health
education interventions that can enhance spirituality.
Measurement. As a starting point, two scales have been identified in
the professional literature that show promise as valid measures of
spiritual well-being as defined in this paper (Elkins et al., 1988;
Ellison, 1983, 1991). Both scales measure purpose and meaning in life;
connectedness with self, others, and a higher power or larger reality;
and levels of commitment and faith in relation to personal belief
systems. The Spiritual Well-Being Scale (Ellison, 1983, 1991) has been
used extensively and has documented validity and reliability.
Research. Using valid, reliable instruments, the future research
agenda for spiritual health should include attempts to better
understand relationships between spiritual well-being and other
positive psychological variables such as self-esteem, psychological
hardiness, emotional maturity, resiliency, and coping ability. In
addition, research should be conducted that can identify socially
conditioned factors that might influence spiritual well being, such as
family structure, parenting style, religiosity, cultural influences,
socioeconomic status, education level, etc.
Applications. Once spiritual well-being is better understood, programs
for enhancing spiritual health can be developed, implemented, and
evaluated. Programs might build on the foundation currently being
developed in the area of mind/body medicine and include such
interventions as group support (Spiegel, 1993), mindfulness meditation
(Kabat-Zinn, Lipworth, Burney, & Sellers, 1986), and guided imagery
(Ornish et al., 1990).
According to the model in Figure 1, there is a reciprocal,
corresponding relationship between the five dimensions of health and
Maslow's hierarchy of needs. Just as Maslow's model is hierarchical,
perhaps there is a loose hierarchy within the dimensions of health
with physical and intellectual health serving as the functional tools
necessary to develop high levels of wellness in the social, spiritual,
and emotional dimensions. The process in not strictly unidirectional,
however, as wellness in these higher dimensions, in turn, enhances
physical and intellectual health. Within this model, spiritual health
becomes a central component. It is developed within the context of
social relationships and then serves as the path to emotional
development and self-actualization. Without spiritual health, the
highest levels of human development cannot be achieved.
There is growing evidence that spiritual health exerts a major
influence on the other dimensions of health (Goodloe & Arreola, 1992).
Accordingly, several authors have forcefully argued that a need exists
for spiritual health education in a variety of settings, including:
the worksite (Bensley, 1991b; Chapman, 1986, 1987a, 1987b), the
university (Reichle, Vantrease, & Fink, 1989; Richardson & Nolan,
1984), the school system (Hoyman, 1962; Jose, 1987; Osman & Russell,
1979), the community (Fahlberg & Fahlberg, 1991; Goodloe & Arreola,
1992; Seaward, 1991), and the primary care setting (Aldridge, 1991;
McKee & Chappel, 1992). An important task that remains is to overcome
the barriers to spiritual health education, including the lack of
definition and theory. As a move in that direction, this article has
proposed a working definition of spiritual health and a theoretical
framework that explains the relationship between spiritual health and
the other dimensions of health.
Given the above discussion, it is not surprising that some authors
have concluded that spiritual health is "...the source of all other
dimensions, and that spirituality is the over-arching umbrella
covering all of the other aspects of health, representing the essence
of who and what the individual is" (Kolander & Chandler, 1990). The
way is open for the ongoing development of spiritual health teaching
methods that can be implemented into comprehensive health education
and health promotion programs and evaluated in light of the definition
and theory offered in this article.
Figure 1. A Theoretical Model of Spirituality and Holistic Health
Five Dimensions of Health
Maslow's Hierarchy of Needs
Emotional <<>>Self Actualization
Spiritual <<>> Self-Esteem
Social <<>> Love, Acceptance
Intellectual <<>> Safety, Security
Physical<<>> Food, Shelter
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By Steven Hawks, Utah State University
Steven Hawks is an Assistant Professor of Health Education in the
Department of Health, Physical Education and Recreation at Utah State
University, Logan, Utah 84322-7000.
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Source: Wellness Perspectives, Summer94, Vol. 10 Issue 4, p3, 11p, 1
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