Keywords

1 Defining Health and Its Components

According to the principles of the World Health Organization (WHO 1946), “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Since this definition, which has been strikingly disruptive to that time, an increasing amount of articles have been published concerned with a non-included health phenomenon on WHO definition, religiosity/spirituality (R/S), and its impacts in physical, mental and social health (Damiano et al. 2016; Koenig 2012; Lucchetti and Lucchetti 2014).

This paradigm change on health research, which will be discussed throughout this book, allowed some health specialists to even propose the inclusion of spirituality on health definition (Larson 1996; Chuengsatiansup 2003; Chirico 2016), expanding the concept to a state of complete physical, mental, social, and spiritual well-being and not merely the absence of disease or infirmity. Furthermore, following this proposal, the World Health Organization Quality of Life Group (WHOQOL group), developed a sub-scale of the WHOQOL questionnaire, proposing spirituality as a core component of quality of life (WHOQOL-SRPB Group 2006).

Nevertheless, albeit this growing number of research concerned to investigate R/S and its impact on health, and the increased attention given by the World Health Organization to spirituality, religiousness, and personal beliefs, there are still criticisms toward the inclusion of R/S on health definition and even on medical research (Sloan et al. 1999). The lack of consensus of spirituality definition might play an important role on these divergences toward the R/S area, and a standard conceptualization of spirituality as well as a better understanding of potential differences between spirituality and other aspects of health (mental and social) are crucial to the development of R/S area on science (and consequently on clinical practice).

Therefore, the main goal of this chapter is to review the different definitions of spirituality according to the medical literature, trying to differentiate it to other components of health, such as mental and social aspects. To reach this goal, it is imperative to prior define religion and religiosity in order to build the conceptual framework of spirituality.

2 Conceptualizing Religion and Religiosity

Religion has been one of the most important aspects of either modern or ancient societies, whose etymology comes from the Latin word religio, derivation of relinquere, which means to leave, to abandon; religare, to connect again; or relegere, to pay attention to the details. (Azevedo 2010).

It is impossible to talk about religion without citing the important contribution of the sociologist Émile Durkheim (1858–1917). Studying the elementary aspects of religious life (1912), Durkheim defined religion as “an unified system of beliefs and practices relative to sacred things, that is to say, things set apart and forbidden-beliefs and practices which unite into one single moral community called a church, all those who adhere to them.”

Recently, other social scientists, based on Durkheim’s definition, developed further concepts of religion. According to Sherkat (2014), “Religions are social groups that produce and maintain explanations about the meaning and purpose of life, and many humans value explanations about such important matters. These explanations go beyond the natural world, invoking some supernatural leap of faith.” Others authors, such as Max Weber (1922), prefer don’t give any definition of religion and even question if giving any definition is possible.

In health research, important authors support the religion conceptualization given above. Michael B. King and Harold G. Koenig (2009) defines religion as “an organized system of beliefs, practices, rituals, and symbols designed a) to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality) and b) to foster an understanding of one’s relationship and responsibility to others in living together in a community”.

But what these concepts share in common? First, all concepts claim to a social aspect of religion. In other words, all authors postulate that to do religion is mandatory to share the same personal beliefs and practices into a group, not being sufficient to feel your own supreme power, or have your practices individually. Second, a moral aspect given and shared by religious beliefs. And last but not least, a supernatural or transcendent belief (except by Durkheim).

Furthermore, Koenig et al. (1997), intending to increase our understanding about R/S area and also to facilitate our analysis of potential researches, developed an idea of religiosity, which Lucchetti et al. (2010), reviewing the first edition of the Handbook of Religion and Health (Koenig et al. 2012), postulated as “the degree which an individual believes, follows, and practices a religion”. The same author (Koenig and Büssing 2010) divided religiosity into three major dimensions: organizational religious activity (ORA) (the frequency that someone goes to the church, temple or religious meetings), non-organizational religious activity (NORA) (involves private religious activities such as prayer, meditation or bible study), and intrinsic religiosity (IR) (having religion behind every aspects of one’s life).

Hence, religion, despite largely practiced, has different meanings and sub-areas, which are really important to understand prior studying spirituality. Thus, on next topic, we will discuss the many possible definitions of spirituality, trying to give to the reader the autonomy to understand and choose those that most fit to him.

3 Defining Spirituality

One of the most important criticisms of spirituality researches is the lack of a standard definition. Defining spirituality is so difficult that many authors have written papers only to discuss and propose its best definition (King and Koenig 2009; Hill and Pargament 2003; Tanyi 2002; Gall et al. 2011; Reinert and Koenig 2013). Previous research has suggested that lay people see spirituality way different than theologians (Cour and Götke 2012), which may influence researches and their interpretation to this phenomenon.

To understand researches that ask patients about the importance of spirituality to their lives (Hilbers et al. 2010), or if they want that the health care provider addresses their spiritual needs (MacLean et al. 2003), or also ask a physician if they think is important to address patients’ spiritual needs (Lucchetti et al. 2016), it is crucial to understand and know if the researcher provided a standard definition of spirituality to their sample, or also if the sample gave the researcher their own definition of spirituality. For example, people who understand spirituality as synonym of religion might see with much more rejection the idea of sharing one’s spiritual beliefs and/or issues with his/her health care provider and vice versa.

Furthermore, when defining spirituality one has to understand its etymology. According to the Oxford Living Dictionary, the word “spirit” derives from Latin spiritus, which has several meanings, such as “breathe”, “breathe of a god”, “inspiration, breathe of life”, “the vital principal in man and animals” or “supernatural immaterial creature” (Online Etymology Dictionary). These multiple definitions might be due to the Christian distinction between “soul” (immaterial) and “spirit” (seat of emotions), probably caused by Greek and Hebrew different ancient words. The word spirit branched into two other concepts: spiritual and spirituality, which originality meant “the quality of being spiritual” or “the fact or condition of being a spirit” (Online Etymology Dictionary). Therefore, historically, the word spirit (and spirituality) has always been intrinsically attached to religion beliefs (such as soul, God, immateriality).

Nevertheless, with the greatest improvement and diffusion of science and the development of new religion movements (churches, cults and sects), and also with the increasing of the percentage of population self defining “spiritual but not religious” (Sherkat 2014), some non-religious and also religious groups claimed that spirituality must be set apart of religion. According to them, many people, nowadays, find their spiritual meaning outside religion, outside the organizational and/or non-organizational aspects of religion. Therefore, currently, researchers who study the field of “spirituality/religiosity and health” works (mainly) with two distinct definitions: one more inclusive (comprehensive) and the other narrow (or religious) concept.

3.1 Inclusive Definitions

During the years of 2012–2013, the George Washington Institute for Spiritual Health and the Caritas Internationalis, organized two conferences that, among many objectives, sought to create a standard definition of spirituality, improving the definition written in 2009 (Puchalski et al. 2009). After both conferences, a comprehensive definition was created in order to solve many problems concerning the cultural issues regarding this concept. According to the organizers (led by Christina Puchalski), “Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.” (Puchalski et al. 2014).

This broad definition brings important contribution to the area. According to this definition, religion is not anymore an indissociable aspect of spirituality. Contrariwise, spirituality is seen as much broader, including meaning, purpose, and the relationship with family, society, nature, etc. Based on this definition, a person who finds meaning raising their children, or an alpinist who finds purpose climbing a mountain have a potential of being strongly spiritual. Some pundits have done some criticisms to this definition, and we will present below their reasons to criticize it.

3.2 Narrow Definitions

When analyzing the last 15–20 years (Lucchetti and Lucchetti 2014), Harold Koenig appears as one of the most prominent authors on R/S and health area. Certainly, he is the most important researcher who criticizes those most comprehensive definitions given by some health researchers recently (as shown above). According to him, defining spirituality as a meaning and purpose in life, peacefulness, connectedness to others, gratitude, forgiveness, existential well-being, etc. (King and Koenig 2009; Tanyi 2002) can be criticized because, besides including everyone (not only transcendental people) as spiritual, these virtues are synonym of good mental health, and not something distinct of it (Koenig 2013).

Albeit this wide definition is important to clinical encounter, it might be an important issue for researches. Correlate a good mental health variable (spirituality) with other mental health variables (depression, anxiety, etc.) might be a tautological bias, and should be avoided (Koenig 2013). To solve this issue, Pargament (1999) proposed a definition which a more substantial belief: the sacred. According to him, spirituality might be defined as “a search for the sacred”.

Koenig (2012), based on Pargament’s concept of spirituality, gave his own definition: “Spirituality is distinguished from all other things—humanism, values, morals, and mental health—by its connection to that which is sacred, the transcendent. The transcendent is that which is outside of the self, and yet also within the self—and in Western traditions is called God, Allah, HaShem, or a Higher Power, and in Eastern traditions may be called Brahman, manifestations of Brahman, Buddha, Dao, or ultimate truth/reality. Spirituality is intimately connected to the supernatural, the mystical, and to organized religion, although also extends beyond organized religion (and begins before it). Spirituality includes both a search for the transcendent and the discovery of the transcendent and so involves traveling along the path that leads from non-consideration to questioning to either staunch nonbelief or belief, and if belief, then ultimately to devotion and finally, surrender. Thus, our definition of spirituality is very similar to religion and there is clearly overlap.”

Therefore, according to Koenig (2012, 1013), being spiritual is being devoutly and intrinsically religious. It is differentiated from religion because the last is organized and must be practiced in community. Spirituality, however, is an intrinsic trait, that only a set of presuppositions and beliefs in aspects beyond our world (transcendent, sacred) might enhance and develop (Smith 1998).

3.3 Openness to Spirituality

When analyzing health literature, not only the spirituality itself but the degree which the health practitioner/student is opened to patients’ spirituality seems to have a great importance. This concept (openness to spirituality) is quite new in medical literature. It has been introduced by DiLalla et al. (2004), and can be defined as “the degree to which a health practitioner is open to and respect patients’ spirituality”. (Damiano et al. 2017) To give an example, in a recent study done by our research group, openness to spirituality appeared to moderate empathy in a sample of medical students. (Damiano et al. 2017) However, more studies should be done to indicate in what levels a higher opened to spirituality health practitioner might influence patients’ health.

4 Future Directions

Undoubtedly, defining spirituality and religiosity is key for understanding their role in clinical practice and its impact in health outcomes. Although there is lack of consensus for a broader or strict spirituality definition, when dealing with routine clinical management we should overcome any of these issues and address spirituality with our patients. How? Seeing our patient (or ourselves) as unique, a singular individual, and customize spiritual need for each patient at each clinical encounter.

In research, further studies are necessary to clarify unknown aspects for a better understanding of the role of religion and spirituality in health. Epidemiological research has to be done addressing cross-cultural aspects regarding how including the divine, and sacred aspects of spirituality and how it can influence mental and general health outcomes. In addition, other psychological constructs possibly related to spiritualty (such as meaning in life, transcendence, peace, support, optimism, pessimism, faith, etc.) should be further studied.