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Source: Wellness Perspectives, Summer94, Vol. 10 Issue 4, p3, 11p, 1 chart

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;
   Russell, 1984).
   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
   Item Number: 9411295982

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