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Because large numbers of people across the globe profess a belief in God and consider themselves to be religious (e.g., Dogan 2003; Gallup 1995), spirituality and religiosity are of great interest to researchers and clinicians in the social and medical sciences. The pervasive influence of these constructs in society in general, and the day-to-day lives of people in particular, make them obvious targets for scientific scrutiny. What influence do these constructs exert on our physical and psychological equilibrium? A fast-growing research literature continues to document significant empirical relations between religious and spiritual variables (i.e., spiritual constructs) and salient mental and physical health outcomes (Koenig 1997; Koenig et al. 2000; Miller and Thoresen 2003; Thoresen 1999). This interest is truly interdisciplinary in nature and generating a vast empirical literature (Dy-Liacco et al. 2003). A recent, focused PsycINFO search (September 8, 2009) on the number of times the terms quality of life (QOL) and spirituality or religion appeared in a scientific article returned over 32,000 citations. The purpose of this chapter is to provide a general review of the literature on QOL and its relations to the spiritual/religious relying mostly on research conducted in the USA. Because numerous literature reviews already exist in this area (e.g., Koenig et al. 2000; Sawatzky et al. 2005), this chapter will focus on distilling key conceptual and empirical findings rather than merely recounting all the results from this very large literature. The chapter will conclude by identifying current issues in the field relevant to researchers worldwide and outlining potentially useful directions for future research. But before beginning, it is necessary to define the key variables of this chapter: religiosity and spirituality.

Quality of Life, Spirituality, and Religiosity Defined

In examining quality of life (QOL), this chapter takes a rather broad perspective. QOL can be divided into objective (qualities associated with specific, verifiable outcomes, such as death rates) and subjective (qualities associated with personal perspectives on self-functioning, such as satisfaction with life) types of outcomes. The main focus of this report will be to examine how religious and spiritual constructs, and their measurement, are related to subjective QOL indices. The question to be addressed is, “To what extent does religious involvement and spiritual experience contribute to perceived increases in satisfaction with life and other mental health outcomes?” This perspective works out of our interest in learning how spirituality and religiosity become involved in (or moderate) the motivational struggle of individuals to create a sense of well-being and happiness in their lives. Not covered in this review is how negative aspects of spirituality (e.g., spiritual struggles, religious crises) impact these outcomes (see Piedmont et al. 2007 for one perspective on this). However, some attention will be given to how spiritual constructs relate to objective outcomes surrounding physical health. This is a result of many studies including both types of QOL indicators in their designs, and is included to give the reader some sense of the predictive value of spiritual constructs across a number of important life outcomes.

Despite widespread usage, spirituality and religiosity do not have any universally accepted definitions (e.g., Miller and Thoresen 2003). Scott (cited in Hill et al. 2000) identified 31 different definitions of religiousness and 40 for spirituality, which she classified into nine different content areas (e.g., experiences of connectedness, systems of thought or beliefs, and capacities for transcendence). Nonetheless, spirituality and religiosity are seen by many as conceptually sharing much in common (e.g., Hill and Pargament 2003), and some researchers prefer to interpret these two dimensions as being quite similar (e.g., Zinnbauer et al. 1999). Musick et al. (2000) have noted that in samples of adults, these two terms are highly related to one another. They questioned whether there is a meaningful distinction between these two constructs or if any disparities are “… simply an artifact of the wishes of researchers hoping to find such differences” (p. 80).

Nonetheless, there are those who emphasize the distinctiveness between these two constructs (e.g., Piedmont 2001; Piedmont and Leach 2002). Here, spirituality is viewed as an attribute of an individual (much like a personality trait) while religiosity is understood as encompassing more of the beliefs, rituals, and practices associated with an institution (Miller and Thoresen 1999, p. 6). Religiosity is concerned with how one’s experience of a transcendent being is shaped by, and expressed through, a community or social organization. Spirituality, on the other hand, is most concerned with one’s personal relationships to larger, transcendent realities, such as God or the Universe. Clarifying spirituality and religiosity in terms of personal versus social orientations has some value for the field and helps to promote clarity in discussing these terms. Although these concepts are highly correlated, there is empirical support for their discriminant validity (e.g., Piedmont et al. 2009). For the purposes of this report, spirituality and religiosity will be defined in this manner. Accordingly, each construct’s relationship to QOL will be examined separately.

Religiosity and QOL

One direct and simple assessment method for researching religiosity has been to correlate the frequency of religious participation with a variety of outcomes. “Frequency of Church Attendance” is perhaps the most widely used index in this area [and has been shown to be a strong predictor of physical and mental health outcomes (George et al. 2002)], although other behavioral exemplars include “Frequency of Prayer,” “Frequency of Reading Religious Literature,” and “Frequency of Watching Religious Programs.” For well over 30 years, researchers have been able to document the linkage between involvement in religious activities and other theological, attitudinal, and behavioral outcomes (see Dittes 1969 for an early overview of research in this area). Perhaps the most important are the consistent findings in the medical literature of significant relationships between involvement in religious activities and a variety of physical health outcomes, such as reduced blood pressure and less hypertension, increased immune functioning, and a reduced risk of mortality (Koenig et al. 1998; Powell et al. 2003; Seeman et al. 2003).

The facilitative effects of religious activity have also been documented with mental health outcomes as well. Koenig et al. (2000) noted in their review that despite early research (e.g., in the 1950s and 1960s) that claimed no positive effect for religion on mental health, better designed and implemented research of the last 20 years has shown quite consistent positive findings (see Koenig et al. 2000 for a comprehensive review of this literature). Religious involvement has been consistently related to greater life satisfaction, hope, optimism, and purpose in life. Koenig and Larson also noted that religious involvement has been related to a faster resolution of depressive episodes and that religious interventions helped depressed individuals recover faster than those receiving either a secular intervention or no intervention at all. In their review of the literature, Ellison and Levin (1998) noted the prospective, positive impact that religious involvement has on well-being, depression, and stress experience. Although religion may protect us from negative mental health outcomes, it does not seem to prevent physical diseases or to improve recovery time from an acute illness (see Powell et al. 2003). The benefits for religious involvement have been found for minority and elderly groups as well, suggesting that religion’s impact is universal and not a consequence of social privilege or cultural ethos. The effect of religious involvement occurs even when physical and social factors are controlled.

While this literature provides consistent support for religion as a relevant factor in human mental health and well-being, a number of conceptual and empirical questions and issues remain. The key conceptual question is, “Why does religious involvement have this impact on functioning?” One answer is that being involved in a religious group may have required behavior and dietary patterns that are associated with good physical health (e.g., abstaining from smoking and drinking). Some religions may have very specific rules about health habits (e.g., Seventh-Day Adventists), and most religions teach followers to respect and care for their bodies because the body is “the temple for the soul” (George et al. 2002). Research has shown that more religiously involved individuals tend to not smoke or smoke less than nonreligious individuals (Koenig et al. 1998) or that religiously committed adolescents are less likely to exhibit delinquent behaviors (e.g., stealing personal property, using drugs, sexual promiscuity; Johnson et al. 2001). Of course, as Ellison and Levin (1998) pointed out, those who are attracted to religion may have risk-averse personalities to begin with, leading them to avoid potentially toxic behaviors and to seek the safety of supportive religious groups.

Other reasons for the value of religion could be the higher levels of social support that adherents experience. Religion certainly involves social contact in terms of formal worship services and informal “fellowship” activities (e.g., prayer groups, ministry activities) that provide individuals with opportunities for developing interpersonal contacts that can increase self-esteem, assist in managing stress, and promote positive feelings. These groups can be helpful in modeling (and reinforcing) a more positive lifestyle and for providing emotional and physical support that, according to Powell et al. (2003, p. 49), “may allay feelings of isolation, low control, and despair and improve one’s sense of self-efficacy.”

Clearly, conceptual models are needed to help articulate the pathways by which religious involvement impacts quality of life outcomes. However, it will be important that researchers demonstrate that religiosity is not mediated away by these non-spiritual mechanisms. As Hill and Pargament (2003, p. 66) argued, we must not overlook the “possibility that something inherent within the religious and spiritual experience itself contributes to or detracts from physical and mental health.” Although we will have more to say on this later in the chapter, it is important to note that to be considered ultimately useful, it will need to be shown that religiosity is not merely a stand-in variable for other variables that are themselves the causal agents for positive mental health (like social support). In other words, religiosity will need to be shown to have its own effect on mental health independent of these other variables. As a non-reducible quantity, it will need to be examined and understood in its own right (see Johnson et al. 2001 who demonstrated that religion’s impact on delinquency was independent of other related predictors, such as social control and socialization).

Empirically, an important issue to be addressed concerns the measurement of religious qualities. As Gorsuch (1988) pointed out, there was a heavy reliance on very simple, single-item measures of religiosity, the most common being religious affiliation. Such a variable is too simplistic and insensitive for useful research purposes. Merely using religious affiliation tends to lump together those who are active and involved in their faith with those who are not. Single-item measures of religious behaviors also have psychometric problems, most notably a lack of conceptual richness and limited reliability. Clearly, there is a need to use multi-item measures where both a construct’s conceptual bandwidth can be fully implemented and the psychometric utility of the scale can be measured. Numerous measures of religiosity have been developed (see Hill and Hood 1999 for a compendium of instruments), although many lack developed validity evidence. Multi-item scales, such as the Multidimensional Measurement of Religiousness/Spirituality (MMRS; Fetzer Institute/National Institute on Aging Working Group 1999) or the Religious Commitment Inventory-10 (RCI-10; Worthington et al. 2003) can help develop more sophisticated theories of what religiosity is, and what about it makes it such a useful and robust predictor of QOL outcomes.

Spirituality and QOL

Emmons and Paloutzian (2003) noted that measures of spiritual constructs have literally exploded over the past two decades possibly because they attempt to answer why numinous qualities (e.g., feelings of awe, hallowedness, and sacredness) are related to such diverse psychological outcomes. Spirituality is frequently interpreted as an internal process of the person. It represents an inner search for something transcendent or sacred. At least implicitly, most spirituality scales are measures of some internal motivation that propel individuals toward specific, identifiable goals (e.g., Emmons 1999). Cast in this light, measures of spirituality represent one psychological source underlying religious behavior that carries potential explanatory power both conceptually and empirically. In their meta-analysis of the literature on religiosity and mental health, Hackney and Sanders (2003) found that the more a spiritual measure captured intrinsic motivational styles (e.g., personal devotion versus involvement in institutional religion), the stronger the empirical link with mental health outcomes. Thus, this enhanced predictive validity suggests that measuring spirituality may be a better approach to understanding the numinous in this area.

There exists a wide range of spiritual constructs that capture diverse facets. A review of all these constructs is beyond the scope of this single chapter. However, some dimensions of spirituality have received much empirical and conceptual attention in the literature, and this section will examine these more salient constructs. Four general areas of spiritual constructs that have garnered significant interest from the field and accrued a sizable body of research are reviewed in this section.

Intrinsic-Extrinsic Religiousness

Perhaps the most well-known set of religious/spiritual constructs are the intrinsic and extrinsic religious orientations developed by Allport and Ross (1967). The Religious Orientation Scale (ROS) was developed out of Allport’s (1950) original ideas about religion and its relationship to important social attitudes, most notably prejudice. Allport understood religion to be a master motive, a psychological force that found its origins at the center of the individual and served to organize and direct the psychic system. As Allport noted (1950, p. 142):

It [religiosity] is the portion of personality that arises at the core of the life and is directed towards the infinite. It is the region of mental life that has the longest-range intentions, and for this reason is capable of conferring marked integration upon personality, engendering meaning and peace in the face of tragedy and confusion in life.

Allport made an important distinction between this “mature” motive and more “immature” religious motives that are more self-seeking and utilitarian in nature. The ROS was developed to operationalize these motives. Intrinsically religious individuals “find their master motive in religion. Other needs, strong as they may be, are regarded as of less ultimate significance, and they are, so far as possible, brought into harmony with the religious beliefs and prescriptions…it is in this sense that he lives his religion” (Allport and Ross 1967, p. 434; italics in original). As such, intrinsic religiosity represents more of spiritual quality than a religious involvement dimension. Donahue (1985) noted that intrinsic religiosity (I) relates to a number of outcomes, including being ideologically tolerant and unprejudiced, better levels of mental health, regular church attendance, and being more mature. Extrinsic religiosity (E) reflects a more utilitarian and instrumental view of religion; it is something that can be used to obtain satisfaction for other needs (e.g., security, social status, and self-justification; Allport and Ross 1967). Donahue noted that E was positively related to prejudice, dogmatism, trait anxiety, and fear of death. E captures that aspect of “religion that gives religion a bad name” (Donahue 1985, p. 416).

Research using the ROS has shown it to have a number of psychometric issues. First, although I and E were originally conceptualized to be opposite poles of the same dimension, empirically, they turn out to be independent of one another. Second, the E dimension has also been shown to capture two distinct facets: social (involved in religion for interpersonal contact) and personal (using religion for personal needs and security). Third, there were concerns about the level of language in the scale, making it unsuitable for less educated samples. As such, a number of different revisions to this scale have occurred. There is the “Age-Universal version” (Gorsuch and Venable 1983) that is appropriate for use with individuals as young as fifth grade and another version, the “I/E-Revised” (Gorsuch and McPherson 1989), that aims to provide a more stable assessment of the two E facets. Trimble (1997) noted that over 150 research studies have been done using various versions of these instruments, making the ROS perhaps the most researched scale to date. Although the ROS has been shown early on to be a good predictor of prejudice and religious attitudes, later work has demonstrated that the I/E domains correlated with important psychosocial outcomes such as sexual attitudes (Haerich 1992), altruism (Trimble 1997), purpose in life (Batson et al. 1993), and mental health (Ventis 1995).

The value of the ROS is that it takes a multidimensional approach to understanding religiousness that captures both its positive and negative aspects. The mutual orthogonality of the I and E dimensions makes possible a fourfold typological classification of one’s religious orientation. Individuals can be classified as being “high” or “low” on each of these two dimensions. Those high on I and low on E are considered “intrinsics,” while those high on E and low on I are “extrinsics.” Those high on both domains are referred to as “indiscriminately pro-religious” and those low on both are “nonreligious.” This typology appreciates the interactional nature of these two dimensions and enables one to decompose curvilinear effects into more conceptually manageable pieces. It enables a more precise evaluation of the spiritual motivations underlying various social behaviors. Although a relatively “old” instrument in the field, the ROS (and its variants) continues to have relevance for research in this area.

Religious Coping

As noted above, Allport (1950) believed that spirituality represented a core aspect of human personality, one that organized and directed the agentic flow of behavior. Spirituality is a way by which individuals create a sense of purpose and meaning for their lives (Frankl 1966; Piedmont 2001, 2004a). Thus, it is particularly interesting and conceptually valuable to examine the role of spirituality in the coping process. Stress, disease, and loss threaten our basic sense of psychological integrity and physical mortality, and they present the strongest challenges to our world view. Does spirituality mitigate the potentially dysphoric effects of negative life events? If so, what is it about spirituality that keeps the fabric of our inner worlds intact in the face of such disequilibria? These are the questions that research on spiritual coping attempts to answer. In the process, such research hopes to demonstrate the resiliency that high levels of spirituality provide.

One of the most frequently employed measures of spiritual coping is the Religious Problem Solving Scale (RPSS; Pargament et al. 1988). The RPSS identifies three religiously based problem-solving styles. These are: the deferring, where the individual defers the responsibility of problem-solving to God; the self-directing, in which it is the individual’s responsibility to solve problems; and the collaborative, in which the responsibility for the problem-solving process is held jointly by the individual and God (Hill and Hood 1999 provide a review of this instrument). Research has provided support for the utility of the scale. The factor structure has been shown to generalize well to religious samples (e.g., Fox et al. 1998), although it has not always been recovered in general adult samples (e.g., Nairn and Merluzzi 2003). Nonetheless, research has shown that the RPSS does predict important outcomes such as burnout (Rodgerson and Piedmont 1998) and positive adjustment to cancer (Nairn and Merluzzi 2003). Most importantly, these studies have also shown that the predictive effects of the RPSS were not completely mediated by other potential predictors, such as personality and self-efficacy.

Although this work helped to document the importance of religion in the coping process, it was not sufficient for identifying which specific components of spirituality were involved in coping. Further, there was also a need to recognize specifically that religion could have both positive and negative effects on coping and QOL. As such, Pargament developed another measure of religious coping, the RCOPE (Pargament et al. 2000), that includes very specific coping behaviors. As Pargament et al. noted, “It is not enough to know that an individual prays, attends church, or watches religious television. Measures of religious coping should specify how the individual is making use of religion to understand and deal with stressors” (2000, p. 521, italics in original). The RCOPE contains five content domains: meaning, control, comfort/spirituality, intimacy/spirituality, and life transformation. Each domain has from 3 to 6 subscales that contain very specific coping behaviors that are both positive (e.g., “Sought God’s love and care,” “Tried to build a strong relationship with a higher power”) and negative (e.g., “Wondered if God really cared,” “Felt punished by God for my lack of devotion”). The goal of the scale was to identify those elements of religious coping helpful in managing stress and those that may hinder positive adaptation.

Ano and Vasconcelles (2005) provided a meta-­analysis of research using this multifaceted approach to religious coping. They found in their analysis of 49 studies (containing 105 effects) that positive coping techniques were indeed related to positive psychological adjustment and that negative religious coping behaviors were related to negative outcomes ­(cumulative effect sizes were.33 and.22, respectively). Although no effort was made to assess potential mediation effects, these results show the RCOPE to have a small-to-medium predictive effect. Lewis et al. (2005) showed that the short form of the RCOPE significantly predicted happiness even after controlling for levels of intrinsic religiosity. Thus, religious coping may have something to contribute to QOL over and above general measures of spirituality. Certainly more research is warranted on this scale, but it does provide a significant enhancement to our thinking about religion’s effect on behavior—that there exists the possibility that certain aspects of religiosity can exert a negative influence on adaptation.

Overall, the area of stress and coping provides an interesting context for examining the role of religion and spirituality in daily life. Efforts at charting this influence focus on specific actions, behaviors, and attitudes that are religiously oriented. What is most engaging is the openness to consider the negative aspects of religion and spirituality. What form(s) of the spiritual is (are) associated with impaired functioning? If spirituality does create a durable sense of personal meaning, then in addition to understanding how a positive spiritual orientation creates cohesiveness under stress circumstances, we need also to consider how a negative spirituality can create a sense of personal meaning that can maintain a dysfunctional style of life even under adaptive circumstances (see, e.g., Stifler et al. 1993).

Spiritual Transcendence

For Piedmont (1999, 2001), spiritual transcendence represents a universal human capacity to stand outside of one’s own immediate existence and to view life from a broader, more integrative whole. To varying degrees, we begin to realize that there is a larger meaning and purpose to life. Because spirituality is concerned with how individuals create ultimate meaning for their lives, it is not surprising that some see it as a central organizing aspect of personality (Allport 1950; Batson et al. 1993) and as such, should be related to a variety of constructs that impact the quality and satisfaction people derive for their lives.

The Spiritual Transcendence Scale (STS), which is a part of the Assessment of Spirituality and Religious Sentiments (ASPIRES) scale (Piedmont 2004a), was developed to conceptualize spirituality as a motivational aspect of the individual. Rather than viewing spirituality as a cognitive schema (Beit-Hallahmi 1989; Worthington et al. 1996), a way of being (Elkins 1988), or way of understanding (Wong 1998), the STS defines spirituality as a nonspecific affective force that drives, directs, and selects behaviors (Piedmont 2004a). As an intrinsic source of motivation, spirituality would be a relatively stable construct over time and would impel individuals toward identifiable goals (Emmons 1999). Spirituality would operate in ways consistent with other motivational traits, such as extraversion, power, affiliation, and conscientiousness.

The STS scale comprises three correlated facets, labeled Connectedness (feelings of belongingness to a larger human reality that cuts across generations and groups), Prayer Fulfillment (the ability to create a personal space that enables one to feel a positive connection to some larger reality), and Universality (the belief in a larger meaning and purpose to life). These facet scales evidence differential patterns of relationships to a variety of psychosocial outcomes in both normal and clinical samples (Piedmont 2001, 2004b).

There are three important findings concerning the STS that are relevant for this discussion. First, as a motivational variable, the STS has shown itself related to a wide number of important outcomes such as well-being, life satisfaction, coping ability, interpersonal style, and psychological growth and maturity (Piedmont 2001) as well as being relevant to predicting levels of burnout and job satisfaction among clergy (Golden et al. 2004). Bartlett et al. (2003) demonstrated the predictive value of spiritual transcendence for predicting well-being among chronic arthritis sufferers. The STS scales have also been shown to predict coping ability and improvement in both substance abuse (Piedmont 2004b) and gambling (Walsh 2001) samples. Most importantly, Piedmont (2006) has shown that the predictive effects of the STS were not mediated by other relevant predictors, like personality, nor were they product of some methodological artifact due to correlated method error. Thus, spiritual transcendence makes a unique predictive contribution to our understanding of how individuals manage the many stressors in their lives.

Second, the STS was developed to capture an aspect of spirituality that was nondenominational in nature and that captured a universal aspect of human functioning. It is hypothesized that spiritual transcendence is an intrinsic, and unique, aspect of humanity. As such, the STS should be a relevant predictor of outcomes for individuals across both religious groups and cultures. A growing body of research is demonstrating the utility of the STS as a generalizable construct.

Goodman et al. (2005) gave the ST scales to a sample of conservative, reformed, and orthodox Jews. She found the ST scales to be reliable in all three samples and to significantly predict outcomes. Piedmont and Leach (2002) gave the ST scales and elements of the religiosity scale (in English) to an Indian sample of Hindus, Muslims, and Christians. The ST scales evidenced alpha reliabilities comparable to those found in the USA. Further, the ST scales were found to evidence significant incremental validity over the FFM personality domains in predicting emotional well-being and psychological maturity. Cho (2004) translated the ST items into Korean and distributed the form to middle-aged married couples. The ST scales were found to significantly predict fear of intimacy. Wilson (2004) gave the ST scales in English to a sample of aboriginal Canadians who were receiving inpatient treatment for alcoholism. The ST scales were found to be quite reliable, and the overall score correlated significantly with other measures of spirituality and ethnic identity. Piedmont (2007) translated the ST scales into Tagalog, a native language of the Philippines. Alpha reliabilities were comparable with American samples, save Connectedness, which was much lower in both the self- and observer-rating versions. However, test-retest reliabilities were found to be very high for all scales. The ST scales were also found to evidence significant incremental validity over the FFM personality domains in predicting measures of well-being, life satisfaction, and world view, among others. Finally, Rican and Janosova (2010) translated the ASPIRES into Czech and administered it to a large sample of secular Czech youth who largely reject organized religion. Here, again, the factor structure, independence from established personality measures, and incremental validity were found to hold. These findings are evidence that the STS represents a universal quality of human behavior and that the model of spirituality represented by the STS has relevance across cultures, religions, and languages.

Third, as a motivational variable, spirituality needs to be considered as a causal input into one’s psychological system. In other words, levels of spirituality will have a direct impact on how other aspects of one’s inner world will function. Increasing levels of spirituality will bring about a corresponding improvement in feelings of well-being, coping ability, and life satisfaction. Little research has been done on causal modeling spiritual constructs, but that which has been accomplished supports the causal precedence of spirituality (e.g., Dowling et al. 2004). Dy-Liacco et al. (2005) examined a variety of causal models using the STS, religiosity, world view, and well-being. They found the best empirical support for those models that used the STS as the predictor of these constructs. Piedmont et al. (2009), using SEM, examined the STS in relation to measures of well-being and psychological growth (e.g., self-actualization and purpose in life). Two models were examined, one where spirituality was viewed as a product of these constructs (i.e., happy, mature people also had a better sense of spirituality) and the other where spirituality was the predictor (i.e., a more developed sense of personal meaning and connection with a transcendence reality led to higher levels of psychological maturity and personal well-being). Again, the best empirical support was found for those models that viewed spirituality as the causal predictor.

Forgiveness and Gratitude and QOL

The field of positive psychology focuses on people’s strengths rather than their weaknesses, on building the best things in life rather than repairing the worst, and on fulfilling the lives of normal people rather than healing the wounded. In their groundbreaking book, Peterson and Seligman (2004) focused on those character strengths and virtues that are believed to be the bedrock of the human condition. For the purposes of this chapter, we will focus only on two: forgiveness and gratitude. Although it is certainly possible to experience forgiveness and gratitude without any professed religious affiliation, the inner experience of forgiveness and gratitude would appear to be a relevant correlate to any definition of spirituality. Almost all well-known spiritual teachers from many traditions emphasize forgiveness and gratitude as key virtues to be cultivated (e.g., Rye et al. 2001).

Forgiveness

The research on forgiveness to date indicates that the more forgiving a person has been, the less negative affect (e.g., depression, anger, anxiety), and the higher levels of well-being, quality of life, and life satisfaction experienced (Friedman 2010; Friedman and Toussaint 2006; Toussaint and Friedman 2008; Toussaint and Webb 2005; see also Worthington 2005 for an overall review). However, there are many types of forgiveness (e.g., forgiveness of self, forgiveness of others, forgiveness of circumstances or situations, forgiveness of God, asking for forgiveness), and each appears to have somewhat different effects on QOL outcomes. It is important in examining this literature to consider how these factors moderate the findings. For example, Toussaint et al. (2001) found in a national probability sample that forgiving oneself and others was positively related to life satisfaction, but seeking forgiveness was negatively related to life satisfaction. Krause and Ellison (2003) found that forgiving others was positively related in older adults to life satisfaction and negatively related to depressive affect, depressive somatic symptoms, and death anxiety. On the other hand, being forgiven by God had no relationship to depressive somatic symptoms and was a significantly weaker correlate of these outcomes. Thus, the type of forgiveness serves as a salient moderator of forgiveness’ effect.

Another distinction to consider is whether a scale captures state or trait forgiveness. State measures of forgiveness deal with forgiveness of a particular person or situation. Changes in these state measures may enhance quality of life variables without necessarily enhancing either a general disposition to forgiveness or enhancing spirituality. Changes in trait or dispositional measures of forgiveness may enhance both quality of life and level of spirituality if the change is substantial. In those studies where both types of measures were included, they showed different results. For example, state forgiveness but not trait forgiveness positively related to existential well-being (Rye et al. 2001), while in a study by McCullough et al. (2001), state forgiveness was not related to life satisfaction cross-sectionally or longitudinally. In a series of studies using the Heartland Forgiveness Scale (Thompson et al. 2005), a trait measure of forgiveness, the researchers distinguished between forgiveness of self, forgiveness of others, and forgiveness of circumstances. The results indicated that high levels of dispositional forgiveness were predictive of low depression, anger, and anxiety and increased satisfaction with life. However, when controlling for each type of forgiveness, they found that forgiveness of self accounted for unique variance in depression, anxiety, and satisfaction with life but not in anger. Forgiveness of others (circumstances) accounted for unique variance in anger. Forgiveness of circumstances predicted all four aspects of psychological well-being (depression, anxiety, anger, and life satisfaction) above and beyond the prediction by self and other forgiveness. These researchers concluded that forgiveness of self and situations appeared to be more strongly related to aspects of psychological well-being than forgiveness of others.

Forgiveness as currently studied is operationalized as a multidimensional construct, and research has shown that different types of measures have very different patterns of correlation with external QOL criteria. Findings are, on the surface, inconsistent, but it is clear that many factors, such as age, health status, race, and type of instrument, moderate the observed effects. Also, a comprehensive theory of forgiveness is needed that can relate these different forgiveness constructs together (see Jampolsky 1999 and the Foundation for Inner Peace 1975 for non-dualistic approaches to forgiveness theory). Finally, it should be noted that most existing measures of forgiveness are secular in orientation. Only one subscale of the RCOPE (summarized above) measures forgiveness, through an explicit assessment of appeals to either God or spiritual helpers to aid in forgiving or release of resentments. Further research needs to be done that compares the role of spiritually oriented measures with secular scales to understand better conceptual differences and to examine the relative predictive validity of QOL outcomes.

Gratitude

Gratitude, like forgiveness, has been studied extensively in recent years and can be considered both an inner experience and an attitude. Emmons and McCullough (2003, 2004) have shown that people with a strong disposition to gratitude have the capacity to be empathetic and to take the perspective of others. Grateful people are also considered to be more generous and helpful by people in their social networks (McCullough et al. 2002). In addition, McCullough et al. indicated that those who regularly engaged in religious activities such as prayer and reading religious materials were more likely to be grateful, to acknowledge a belief in the interconnectedness of life, and to possess a commitment and responsibility to others.

In recent series of studies by Emmons and colleagues (Emmons and McCullough 2003, 2004) employing the Gratitude Questionnaire-6 (GQ6; a brief six-item measure of gratitude), they indicated that grateful people reported higher levels of positive emotions, life satisfaction, vitality and optimism, and lower levels of depression and stress (see also Watkins et al. 2003; Watkins 2004). Interestingly, this research found that measures of negative affect such as anxiety and irritability did not correlate with measures of gratitude. This has led some to conclude that the disposition toward gratitude appears to increase pleasant feelings more than it diminishes unpleasant emotions (Emmons and McCullough 2003, 2004).

Watkins et al. (2003) indicated that there was a positive correlation between gratitude and internal locus of control, divine control, and intrinsic religious orientation and a negative correlation with extrinsic religious orientation. They interpret this to mean that grateful people are more likely to feel in control of their destiny through the actions of a divine entity that is interested in their well-being. McCullough et al. (2002) found small but significant correlations between self and informant’s ratings of gratitude with self-transcendence, importance of religion, frequency of religious attendance, religious friends, reading scripture, prayer, and relationship with God (correlations ranged from.16 to.32). Both sets of authors indicated that there is a negative relationship between gratitude and narcissism. Clearly, gratitude has very strong associations with spiritual and religious motivations and behaviors. However, much of this research has been done with college students, thereby limiting the generalizability of their findings.

Toussaint and Friedman (2008) showed in a sample of psychotherapy clients strong significant correlations (most rs  >  .50) between both gratitude and measures of well-being, quality of life, life satisfaction, positive affect, positive beliefs, cognitive balance, affective balance, optimism, self-worth, hope, and happiness. However, Friedman also found moderate-to-strong negative correlations between gratitude and various measures of negative affect, especially depression, anger, anxiety, and vulnerability (rs ranging from  −.40 to  −.70). Perhaps for those who might benefit most from a gratuitous perspective, the associations may be equally strong for positive and negative psychological affects.

Summary

Positive psychology represents a more secular approach to addressing human kind’s ultimate sense of self. Although spiritual and positive psychological constructs have much in common, research is needed to better understand how these two sets of constructs overlap with each other. To what extent do they represent redundant concepts? What unique insights do they contribute? As this short review noted, there exists quite a bit of variability in the predictiveness of forgiveness and gratitude. Especially regarding the former, much more conceptual and empirical work needs to be done that examines the various aspects of forgiveness (e.g., forgiveness of others versus forgiveness of self) and their personological implications. Gratitude represents a more circumscribed construct that can be easily measured. However, its relationship with QOL needs to be examined across more demographically diverse samples.

Current Issues

There should be little doubt, given this review, that spiritual constructs are relevant dimensions for understanding a wide range of salient mental and physical health outcomes. Certainly, current scales can adequately measure spirituality and religiosity. What is particularly exciting about this research is that spirituality and religiosity represent psychological aspects of the individual not contained in the models and measures employed by traditional physical and social scientists. Thus, a consideration of one’s spirituality represents an entirely new dimension of the person that has the potential for significantly changing how we think about ourselves and, most importantly, for identifying new pathways for making interventions into peoples’ lives. To accomplish this will require much more work. As the field struggles to exploit its potential, there are numerous challenges to its growth. This section will outline four issues that the field is currently struggling with and will need to be addressed.

Defining the Basic Constructs of the Field

The current data suggest that religiosity and spirituality, although highly related, are not interchangeable constructs. Although the field has had difficulty in defining these concepts, with some believing that a single overall definition is impossible, or inappropriate (e.g., Hill, et al. 2000), the basic scientific need for accurate description and definition of spiritual constructs still remains. If religiosity and spirituality are such complex phenomena that they defy concise description, then they offer little hope for truly expanding our understanding of people. As Hill et al. (2000, p. 65) noted,

Without a clearer conception of what these terms mean, it may be difficult to know with any precision or reliability what researchers attribute to them. Also, communication within the social scientific study of these constructs and across other disciplines may be impaired by a lack of common understanding and clinical agreement. Finally, without common definitions within psychological as well as sociological research, it becomes difficult to draw general conclusions from various studies. Therefore, these definitions are in dire need of empirical grounding and improved operationalization.

In their review of the literature on spirituality and QOL, Sawatzky et al. (2005) empirically documented this problem by showing that although there are many spirituality scales that carry the same or similar names, they are assessing very different qualities. It is critical for the field to find ways to operationalize these constructs in order to promote consistency and understanding (e.g., Sperry 2005). Koenig (2008), an active researcher in the field of spirituality and health, has provided an overview of some of these definitional issues and the impact they have on the field’s development. He asserted that if the field cannot create a unique, clear construct, the use of religious and spiritual constructs should be eliminated from research altogether.

Measurement Properties of Scales

The field is plagued by a lack of substantial validity information for many of the assessment instruments that are available (e.g., Gorsuch 1984; Slater et al. 1994). A perusal of the compendium of measures of religiosity presented by Hill and Hood (1999) shows that of the 126 instruments presented, 40 (32%) provide no psychometric data beyond the original study. Thus, many measures are developed, but there is little follow-through in the scientific community to develop these instruments.

Ideally, empirical parameters need to be developed for defining what is and is not spiritual. To do so would require an evaluation of spiritual constructs within larger personality models, like the Five-Factor Model of Personality (FFM; Digman 1990; McCrae and John 1992). The FFM represents a comprehensive, empirically developed, taxonomy of traditionally defined personality dimensions. Locating spiritual scales within the context of this model would help to determine the extent to which the scale captures already established personality dynamics and to what extent it represents something different. MacDonald (2000) provides a good example of this type of research. He jointly factor analyzed a number of putative spiritual scales along with markers of the FFM domains. He was able to recover the five personality dimensions, but his results also indicated that many of the spiritual and religious scales defined additional factors independent of the personality domains. Perhaps one way to define what is spiritual is to demonstrate that a scale is independent of personality and correlated to those qualities that constitute this independent dimension (see also Piedmont 2001; Piedmont et al. 2009).

Methodological Issues

There is no doubt that spiritual constructs have important relationships with a variety of physical and mental QOL indicators. However, these findings do not go unchallenged. Sloan and colleagues have criticized this research on the basis of numerous methodological and statistical shortcomings (Sloan and Bagiella 2002; Sloan et al. 2001). One of the concerns centers on the lack of evidence documenting the predictive power of religious and spiritual variables over and above other established constructs, like social support. This failure to demonstrate incremental predictive validity for spiritual and religious constructs raises important concerns about their construct validity (see Joiner et al. 2002). The question arises as to what degree spiritual constructs are merely the “religification” (Van Wicklin 1990) of already existing personality constructs. As Buss (2002) noted, “Religious phenomena may simply parasitize existing evolved mechanisms or represent byproducts of them” (p. 203).

Still other criticisms have centered on the empirical robustness of the findings. Sloan et al. also argued that these mostly zero-order relationships fail to control for the multiple comparisons that are performed in such studies, thus increasing the likelihood for Type I errors. Smith (2001) argued that the observed relationships with health outcomes may be artifactual—the product of a singular reliance on self-report data. For him, correlated method error (e.g., acquiescence, social desirability) may be responsible for the findings.

Three other issues need to be considered when examining studies in this area. The first concerns the magnitude of effect often noted between religious/spiritual constructs and measures of QOL, which are clearly low to moderate in magnitude. In a meta-analytic study on the relationship between spirituality and QOL, Sawatzky et al. (2005) found an overall relationship of r  =  .34 (CI:.28–.40). In another meta-analysis of religious coping’s relations to psychological adjustment, Ano and Vasconcelles (2005) found effects of.33 for positive religious coping (CI:.30–.35) and.22 for negative religious coping (CI:.19–.24). These findings mirror still others that examined spirituality in national and cross-national samples (e.g., Diener and Clifton 2002; Ferriss 2002). Small-to-moderate effect sizes do not diminish the importance of spiritual constructs to understanding QOL outcomes; however, it should remind researchers that these constructs are not going to single-handedly answer all our questions about QOL.

A second, related issue concerns the impact of spirituality on QOL outcomes across various cultures. Most research in this report has focused on various US samples. However, it needs to be determined whether these effects can generalize globally. Diener and Clifton (2002) examined the relationship between religiosity and well-being in both US and international probability samples. Aside from observing mostly small associations, they did note that religiosity’s effect did vary across communist versus noncommunist countries, with the former evidencing no associations. Clearly, cultural and societal conditions impact the benefits of religion and research needs to understand the complex role that context plays in how people experience spirituality (see Tarakeshwar et al. 2003).

The third issue concerns the potential problem of criterion contamination. Measures of spirituality that have been shown to correlate with QOL outcomes may contain items that are themselves QOL-related. As such, any observed association has less to do with the role of spirituality as a predictor than the correlation being the result of a statistical artifact; the two scales correlate because they share similar items. For example, the Spiritual Well-Being Scale (Paloutzian and Ellison 1991) is noted as being one of the most widely used scales for research and clinical purposes (Boivin et al. 1999). It contains items such as “I feel that life is a positive experience,” “I feel very fulfilled and satisfied with life,” and “I feel good about my future,” all of which are themselves indicators of a positive QOL. Therefore, it is not surprising that this measure can correlate very strongly with self-reported measures of satisfaction with life and QOL (e.g., r  >  .50; Matheis et al. 2006).

These are core issues that the field needs to address. Science demands that its models be parsimonious and that our constructs represent reliable effects. These criticisms here of mediation, small effect size, cultural relativity, statistical conclusion invalidity, and correlated method error are serious hurdles that must be jumped before the wider social and physical sciences will recognize spiritual constructs as substantive constructs. Piedmont (2006) conducted a series of Structural Equation Model (SEM) analyses in American and Philippine samples to examine exactly these issues. He found that spirituality was not mediated by personality in predicting a variety of QOL outcomes, including well-being, psychological maturity, and world view. These findings were observed with both self-report and observer rating data, and across two relatively distinct cultural groups. Researchers interested in examining religious and spiritual effects need to routinely control for potential mediators, such as the personality dimensions of the FFM which are also important predictors of QOL outcomes (see Piedmont 2001).

Identifying Causal Pathways

A key empirical question that is emerging in the field concerns the causal relationships between them and other psychological constructs. As Hackney and Sanders (2003) discussed in their meta-analysis, although most studies frame their emphasis in terms of the effects of spirituality and religiousness on various outcomes, the correlational nature of these studies leaves open the possibility that good QOL predisposes people to spiritual and religious involvement rather than the other way around. This is an important issue that speaks to the ultimate value of the spiritual constructs. If one’s spiritual orientation develops out of one’s sense of personhood, then it is one’s level of psychological adjustment that forms the experiences of the transcendent. Thus, unhappy people will tend to have unhappy relationships with the transcendent. Like any other behavior, relationships with some ultimate reality are reflections of more basic psychological dynamics. From this perspective, spiritual constructs are merely the reflection of already established psychological constructs (e.g., Joiner et al. 2002), or are just a conduit or method by which individuals are able to activate other psychological mechanisms that are adaptive (e.g., Fredrickson 2002).

However, if spirituality and religiosity are “inputs” into our psychological system, then they become important conduits through which growth and maturity can be focused. In this scenario, the quality of one’s relationship to the transcendent has important implications for our own psychological sense of stability (Piedmont 2005). Therefore, disturbances in our relationship to the transcendent would have serious repercussions for the rest of our mental world. Demonstrating the causal precedence of spiritual constructs would enable their use as explanatory constructs in larger models of QOL. If religious and spiritual constructs do play a significant role in driving adaptation and growth, then this creates the possibility for a whole new class of potential therapeutic strategies based on these types of dynamics (e.g., Murray-Swank 2003; Piedmont 2004b). At a minimum, it would demand that any model of human behavior must include spiritual constructs if that model were to be comprehensive (Piedmont et al. 2009).

Directions for Future Research

We believe that this is an exciting time to be involved in research on spirituality and religiosity and its linkages to important life outcomes, such as QOL. Never has there been more interest in the field than now. There are a variety of measures, a growing (interdisciplinary) empirical literature, and openness in the scientific community to examine the possible contribution of spirituality. As noted above, there certainly are methodological and conceptual issues confronting researchers in this area as they struggle to document the relevance of spirituality and religiosity. However, we would like to say a few words about the directions the field should move toward as the scientific discussion evolves.

Theoretical Models

Having demonstrated that spiritual constructs have something important to say about QOL, it is now important to begin to integrate these findings within larger mainstream models of well-being, coping ability, personality development, and mental/physical health (to name but a few). We need to develop a conceptual depth to our understanding of spirituality that is consistent with current theoretical models of human functioning. Future work will have to begin to identify: (a) how spiritual and religious variables develop and are expressed over the life course; (b) those factors, both internal and environmental, that influence the expression of religious sentiments and spiritual motivations; and (c) the pathways by which spiritual and religious constructs impact, and are impacted by, psychological processes and dynamics. Peterson and Seligman (2004) attempted to integrate spirituality within a larger psychological model of character strengths and virtues. Such a process helps to elaborate the types of properties spirituality has and the role it plays in the psychic life of the individual. Paloutzian and Park (2005) provide another effort to outline how spirituality can be integrated into psychological study at all different levels, from the neurological to the intra-psychic to the organizational and social. There are many levels of analysis where a consideration of the spiritual and religious can be included. Such conceptual developments are needed.

More Sophisticated Statistical Models

The development of better theories will help to identify the many relevant variables that need to be considered when conducting research in this area. As such, research will need to implement multivariate designs that will be able to address more sophisticated questions about incremental validity, mediation, and construct dimensionality (e.g., Dy-Liacco et al. 2005; Piedmont 2006). Unfortunately, the field has an over reliance on cross-sectional, correlational data. Batson (1997, p. 6) has argued, “In research methods, the psychology of religion is about 30 years behind other areas of psychology.” Few studies adjust for Type I error due to multiple comparisons, statistically control for other relevant mediators, or apply multivariate or SEM techniques to model building/testing questions. There is a very strong reliance on correlational-type data (Dy-Liacco et al. 2003). To move forward, the field will need to employ more sophisticated analytic techniques (including more experiments) that will examine more complex conceptual questions related to systems and processes.

Longitudinal and Cross-Observer Data

What is the role and impact of spiritual and religious constructs over the life span? How does a spiritual orientation develop? When does it develop? How does it become expressed over time? These are important questions that need to be answered. Few research studies take such a perspective, although there are exceptions (see, e.g., Pargament et al. 2004; Wink and Dillon 2003). As people age, does what constitutes spirituality change? Do we need different scales to measures spirituality at different age ranges? Piedmont (1999) has hypothesized that spiritual transcendence increases as people get older, a result of a more active concern over personal mortality. He provided data showing a significant age effect, and also that different aspects of spirituality were relevant for younger as opposed to older individuals (Piedmont 2004a, b). Brennan and Mroczek (2002) described statistical procedures (i.e., latent growth curve and individual growth curve analyses) for examining changes in spirituality over time at both the aggregate and individual levels. These statistical techniques can be helpful in charting the natural developmental changes that may occur on spiritual dimensions. It also needs to be determined whether different spiritual constructs have similar or different trajectories over the life span.

Related to the use of longitudinal data is the need to include other sources of information beyond mere self-report, specifically, the need to include observer ratings in studies of spiritual and religious constructs. As noted above, the almost singular reliance on self-report data raises questions of acquiescence effects and correlated method error as explanations for observed findings. It is important that the fields develop and validate observer rater versions of their self-report instruments (see Piedmont 2004a). In this manner, ratings of individuals’ spirituality can be obtained from knowledgeable others (e.g., parents, spouses, close friends, etc.). Showing that these observer ratings of spirituality converge with self-rated scores would overcome these two criticisms. More importantly, showing significant convergence between self- and observer-rated scores of spirituality provides evidence of consensual validation for the spiritual construct. Such cross-observer convergence demonstrates that people share an understanding of what “spirituality” means and can identify dispositions, behaviors, and goals toward which this construct directs the individual. Without such agreement, spiritual and religious constructs must be viewed as solipsistic aspects of the individual—labels applied to idiosyncratic aspects of the person that may have limited interpretive and predictive value.

Cross-Cultural and Multi-faith Approaches

It has long been known that the majority of measures designed to assess spirituality are rooted in Christian-based perspectives (Gorsuch 1984; Slater et al. 2001), reflecting mostly a mainline Protestant orientation (Gorsuch and Miller 1999). Although Christianity may be the mainstream faith orientation in America, it certainly does not represent, nor speak for, other faith traditions. Piedmont and Leach (2002) have noted that this lack of theological pluralism undermines both the scientific endeavor to understand the basic elements of spirituality and efforts to develop a comprehensive model of spiritual development and experience that would have ecological validity.

Although there is clear value for understanding the spiritual and religious dynamics of specific religious groups and cultures (Moberg 2002), there is a twofold value for attempting to understand what is common across different groups. First, it needs to be known to what extent spirituality is an innate aspect of the individual. Does spirituality represent a fundamental motivational aspect of the individual that orients him or her to specific types of outcomes? Or is spirituality really a specific, context-dependent response to organized religion? (Also implied in this question is the more fundamental etiological question, “What came first, religion or spirituality?” See Piedmont et al. (2009) for an empirical analysis of this question.) If spirituality is a motivation, then there should be some basic qualities of spirituality that are consistent across all spiritually mature individuals regardless of their religious affiliation. We can see support for this proposition with only a casual perusal of history; individuals such as Jesus (a Jew), Buddha (an Eastern Philosopher), Gandhi (a Hindu), and Mother Teresa (a Catholic) all share many of the same qualities and dispositions, yet they come from very different time periods and different faith backgrounds. What is this basic quality, and how does it come to influence behavior? What resources does it provide for coping, adapting, and thriving?

The second advantage of cross-cultural and cross-faith research is that it will begin to show that spiritual constructs are a universal aspect of the human experience. More than that, spirituality may represent a uniquely human quality. Only our species evidences any concern for, sensitivity to, or celebration of the sacred. There are no animal models for spirituality. Every human culture across history has reserved a significant place for religious and spiritual endeavors. The little cross-cultural research that has been done (e.g., Cho 2004; Piedmont 2007) has indicated that broad concepts of spirituality generalize well to different faiths and cultures. In fact, many of the spiritual concepts used in research in the USA and Europe have been found in other languages that do not share a common etymological root with English. This is evidence that all cultures are led toward and encounter similar spiritual realities.

Finally, very little research has been conducted on spiritual masters or teachers from a variety of spiritual or religious traditions around the world. This would appear to be essential if we are to understand the highest and best there is in spirituality and religiosity, especially if we are to see it as a major strength and virtue. Most research to date has been done with college students, adolescents, normal adults, and the elderly, many of whom except for the college students are in some state of distress, illness, or injury. Such an approach may shed new insights into spirituality and its related dynamics. Perhaps what may be the ultimate gift from the study of spirituality would be the identification of those core, common, qualities that unite all people in a common quest for understanding the human experience and its ultimate meaning.

Conclusions

Despite the many issues and challenges facing the field of religious and spiritual research, it is hoped that these data persuasively demonstrate the value of such constructs for understanding people and the quality of their lives. Spiritual constructs do have something to add to scientific models of human behavior. The information contained in spiritual variables is non-redundant with extent constructs in the social and physical sciences. The spiritual domain represents a new, untapped “frontier” of insights into people that science needs to exploit. Such efforts would open the door to potentially new types of paradigms for conceptualizing our inner worlds and for developing positive, durable interventions that address the central existential (and personality-organizing) questions of personal meaning and ultimate purpose.