concerns about measuring “spirituality” in research

ORIGINAL ARTICLE

Concerns About Measuring Spirituality in Research

Harold G. Koenig, MD

Abstract: Spirituality is increasingly being examined as a constructrelated to mental and physical health. The definition of spirituality,however, has been changing. Traditionally, spirituality was used todescribe the deeply religious person, but it has now expanded to includethe superficially religious person, the religious seeker, the seeker ofwell-being and happiness, and the completely secular person. Instru-ments used to measure spirituality reflect this trend. These measures areheavily contaminated with questions assessing positive character traitsor mental health: optimism, forgiveness, gratitude, meaning and pur-pose in life, peacefulness, harmony, and general well-being. Spiritual-ity, measured by indicators of good mental health, is found to becorrelated with good mental health. This research has been reported insome of the worlds top medical journals. Such associations are mean-ingless and tautological. Either spirituality should be defined andmeasured in traditional terms as a unique, uncontaminated construct, orit should be eliminated from use in academic research.

Key Words: Spirituality, religion, measurement.

(J Nerv Ment Dis 2008;196: 349355)

The term spirituality is increasingly used in research toexamine its correlation with mental or physical health. Arecent MEDLINE (OVID, 2007a) search using the word spir-ituality revealed 0 articles between 1970 and 1979, 1 articlebetween 1980 and 1989, 31 articles between 1990 and 1999, and2106 articles between 2000 and 2007. The same search usingPsycINFO (OVID, 2007b) found 5 articles between 1970 and1979, 248 articles between 1980 and 1989, 1625 between 1990and 1999, and 4353 between 2000 and 2007. Although not all ofthese articles represent original research, many of them do. Inthose studies, spirituality is measured in a variety of ways. Sinceno uniform definition of spirituality exists (Hill and Pargament,2003), it is not surprising that many different questions andinstruments are used to assess this construct.

Furthermore, the definition of spirituality has changedover the past several decades. Smith and Denton (2005) reportedthat, The very idea and language of spirituality, originallygrounded in the self-disciplining faith practices of religious

believers, including ascetics and monks, then becomes detachedfrom its moorings in historical religious traditions and is rede-fined in terms of subjective self-fulfillment (p 175). Accordingto Sheldrake (2007), the origin of the word spiritual lies in theLatin term spiritualis, which is derived from the Greek wordpneumatikos as it appears in Pauls letters to the Romans andCorinthians. After that, a spiritual person was considered some-one with whom the Spirit of God dwelt or whose life wasinfluenced by that Spirit (p 3), often referring to the clergy.Throughout most of Western history, the terms spiritual andspirituality were understood as distinctly religious.

Figures 1 to 4 illustrate how the definition of spiritualityhas changed and expanded over the years as investigatorshave examined its relationship to mental and physical health.The traditional-historical version of spirituality (Fig. 1) de-fines it as a subset of deeply religious people who havededicated their lives to the service of their religion and totheir fellow human, and whose lives exemplify the teachingsof their faith traditions. The term religion has had a relativelystable definition over the years, and as defined by psycholo-gists and sociologists of religion, is a distinct construct withmultiple dimensions, dimensions that can be measured anddistinguished from one another (Hill and Hood, 1999).

Religion, spirituality, and the secular are portrayed inFigure 1 as possible sources of human moral values, positivecharacter traits, and positive mental states such as meaning andpurpose in life, connections with others, peacefulness, harmony,well-being, and hope. The traditional-historical version of spir-ituality can be studied using the research methods of the socialand behavioral sciences. Spirituality here is distinctive frommore superficial or less devout forms of religion and fromcomplete secularity. Spiritual persons can be identified usingmeasures of religious involvement and then compared with lessreligious persons and to secular individuals with regard tomental and physical health. Spirituality is a construct completelyseparate from measures of mental or physical health.

The modern version of spirituality (Fig. 2) understandsit as including religion but expanding beyond it. As the termspirituality has been used more widely in pluralistic healthcare settings, the goal has been to apply it to persons fromdiverse religious backgrounds and to those with no religiousbackground. This creates a new category of spiritual but notreligious individuals. What this means and how to differen-tiate it from those who are both religious and spiritual, however,is less clear. This view of spirituality, while more nebulous thanthe traditional-historical version, is also valid from a researchstandpoint, since such a conceptualization allows for comparisonof the mental and physical health of those who are spiritual and

Department of Psychiatry and Behavioral Sciences, and Department ofMedicine, Duke University Medical Center, Geriatric Research, Educa-tion and Clinical Center, VA Medical Center, Durham, North Carolina.

Send reprint requests to Harold G. Koenig, MD, Box 3400, Duke UniversityMedical Center, Durham, NC 27710. E-mail: [email protected].

Copyright 2008 by Lippincott Williams & WilkinsISSN: 0022-3018/08/19605-0349DOI: 10.1097/NMD.0b013e31816ff796

The Journal of Nervous and Mental Disease Volume 196, Number 5, May 2008 349

religious, those who are spiritual but not religious, and thosewho are completely secular. Because of the more nebulousnature of this category, persons who are spiritual but not reli-gious are difficult to identify, other than by simply asking themhow they would categorize themselves (spiritual but not reli-gious, religious but not spiritual, both religious and spiritual, orneither). Spirituality in this sense has also been described as asearch for the sacred, which may occur outside of an estab-lished religious tradition (Pargament, 1999).

The tautological version of spirituality (Fig. 3) is similar tothe modern version, but extends out even further to includepositive mental health and human values as part of its definition.This concept of spirituality includes not only indicators oftraditional religiousness or a search for the sacred, but alsopositive psychological states: purpose and meaning in life, con-nectedness with others (quality of social support), peacefulness,harmony, and well-being. I call this the tautological versionbecause by including indicators of mental health in the definitionof spirituality, this assures a positive correlation between spiri-

tuality and mental health. Rather than conduct research todetermine whether spirituality is related to mental health, thismodel solves the problem by defining spirituality from the verystart in terms of mental health. Research that documents anassociation between spirituality defined this way and positivemental health, is meaningless since constructs measured with thesame or similar items will always be correlated with one another.Of particular concern is that defining spirituality as positivehuman traits or good mental health completely eliminates thepossibility of identifying circumstances in which spiritual aware-ness or the spiritual quest is associated with turmoil, unhappi-ness, and perhaps mental and physical morbidity.

The fourth and latest version of spirituality (Fig. 4) in-cludes not only religion and positive indicators of mental healthas part of its definition, but also the secular. In this model,everyone is spiritual including atheists and agnostics. Since thereis no one left to compare this all-inclusive category of spiritualindividuals with, research is impossible and relationships withmental or physical health cannot be studied. While useless in

Spirituality

Religion

Source

Secular

Mental Health Physical Health

Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide

CardiovascularDisease

Cancer

Mortality

Psyc

hone

uroi

mm

un

olo

gy

vs. Well-being

Positive Negative

FIGURE 1. Traditional-historical version.

Spirituality

Religion

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psyc

hone

uroi

mm

un

olo

gy

vs. Well-being

Positive Negative

FIGURE 2. Modern version.

Koenig The Journal of Nervous and Mental Disease Volume 196, Number 5, May 2008

2008 Lippincott Williams & Wilkins350

terms of research, however, this version of spirituality has greatclinical utility, as I will discuss later in this article.

Measures of SpiritualityInstruments used to measure spirituality that exist today

assess it in terms of religious beliefs and practices, in terms ofpositive mental health/human values, or both. The growinginclusion of positive psychological indicators in spiritual mea-sures is worrisome (Fig. 3). According to this approach, as notedearlier, spirituality is defined and measured in terms of meaningand purpose in life, social connectedness, peacefulness, har-mony, well-being, contentment, and comfort. Gratefulness, ca-pacity to forgive, self-discipline, and other positive human val-ues may also be included as indicators of spirituality. However,persons with poor mental health (those who are depressed,anxious, distressed, or disturbed) experience these positive psy-

chological emotions and states less often than mentally healthyindividuals. Defining spirituality in this way assures that thosewho are spiritual will be mentally healthy, and excludes thosewho are mentally ill from this desirable classification.

Some commonly used measures of spirituality todayillustrate this point. These scales were reviewed in the Hand-book of Religion and Health, which was the result of anexhaustive review of the literature, and included a chapter onmeasurement tools used to assess religion and spirituality(Koenig et al., 2001, pp 505507).

Functional Assessment of Chronic Illness Therapy-SpiritualWell-Being (FACIT-SP): The FACIT-SP is the most commonlyused measure of spirituality in studies today involving cancerpatients (Brady et al., 1999). It has literally become the standardmeasure of spirituality in this population. One reason for this is

Spirituality

Religion

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psyc

hone

uroi

mm

unol

ogy

Well-being

Positive Negative

FIGURE 4. Modern clinical version (not for re-search).

Spirituality

Religion

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psyc

hone

uroi

mm

unol

ogy

vs.

Well-being

Positive Negative

FIGURE 3. Modern-tautological version.

The Journal of Nervous and Mental Disease Volume 196, Number 5, May 2008 Measuring Spirituality in Research

2008 Lippincott Williams & Wilkins 351

because a version of the FACIT, the Functional Assessment ofCancer Therapy (Cella et al., 1993), is the most widely usedmeasure of quality of life and functioning in cancer patients and hasbeen used in hundreds of studies worldwide (FACIT, 2007). Eventhe National Cancer Institute endorses the FACIT-SP as one of thestandard measures of spirituality in cancer patients (NCI, 2007).The FACIT-SP consists of 12 statements to which agreement israted, and includes such items as I feel peaceful, I have a reasonfor living, I feel a sense of purpose inmy life, I am able to reachdown deep in myself for comfort, I feel a sense of harmonywithin myself, and I know whatever happens with my illness,things will be okay. Not surprisingly, spirituality measured in thisway will correlate with good mental health.

Daily Spiritual Experiences Scale (DES): The DES isincreasingly being used as a measure of spirituality in studies ofmental and physical health (Underwood and Teresi, 2002). Arecent PsycINFO (2007) search identified at least 17 studiesusing this measure, the majority of which were conducted in thepast 2 years. The DES is a subscale of the Fetzer InstitutesMultidimensional Measure of Religiousness and Spirituality(below). The DES consists of 16 items rated in terms of fre-quency, and includes statements such as, I feel deep inner peaceor harmony, I am spiritually touched by the beauty of cre-ation, I feel thankful in my blessings, I feel a selfless caringfor others, and I accept others even when they do things I thinkare wrong. Again, this measure assesses a very broad conceptof spirituality and is contaminated by measures of peacefulness,harmony, and other positive experiences that patients with se-vere depression or anxiety seldom feel.

Spiritual Well-Being (SWB) Scale: The SWB scale devel-oped by Paloutzian and Ellison (1982) is perhaps the mostwidely used spiritual well-being scale used today to assessspirituality. A recent PsycINFO (2007) search uncovered 182articles (most of them research studies) that cite this measure.The SWB scale consists of 20 items, 10 measuring existentialwell-being and 10 assessing religious well-being. The ques-tions assessing existential well-being tap general psychologicalwell-being. For example, here are some of the items that makeup the scale: I feel that life is a positive experience, I feelunsettled about my future (reverse scored), I feel very fulfilledand satisfied with life, I dont enjoy much about life (reversescored), and I feel that life is full of conflict and unhappiness(reverse scored). Unless existential well-being and religiouswell-being subscales are analyzed separately and results distin-guished, the associations reported between SWB and mentalhealth can be quite misleading. Until now, this issue has beenlargely under the radar screen. However, researchers are increas-ingly questioning the appropriateness of categorizing positivemental health states such as existential well-being as spiritual(Salandar, 2006; Tsuang et al., 2007; Krause, 2008).

MultidimensionalMeasure of Religiousness/Spirituality:TheFetzer Institutes Multidimensional Measure of Religiousness/Spirituality is rapidly becoming the standard measure of reli-giousness/spirituality in the spirituality and health field overall,

given its comprehensive nature (Fetzer Institute, 1999). Therealso exist national norms for the short version of this instrument(Idler et al., 2003). Among its spirituality subscales are meaning,values, and forgiveness subscales. The meaning subscale in-cludes items such as, The meaning in my life comes fromfeeling connected to other living things, and Knowing that Iam a part of something greater than myself gives meaning to mylife. The values subscale includes items such as equality, innerharmony, social power, freedom, and self-discipline, each ratedon a scale from not important to supremely important. Theforgiveness subscale has statements such as, It is easy for me toadmit that I am wrong, I believe that when people say theyforgive me for something I did they really mean it, I am ableto make up pretty easily with friends who have hurt me in someway, I have forgiven those who hurt me, and so forth.

In summary, these positive traits could very well be theoutcome or the results of spirituality. However, should theybe part of the definition itself? One cannot assume that onlyspiritual people experience meaning and purpose in life, havehigh values, or forgive others (or experience peace, harmony,and care deeply for others). Indeed, completely secular per-sons and atheists may experience these things as frequently ormore frequently than so called spiritual persons. Spiritual-ity cannot claim a priori these positive human traits as itsinherent right. This is for scientific research to establish orrefute, and that research is impossible to conduct if spiritu-ality is defined by these traits ahead of time.

Published ResearchSince it is not widely known that many measures of

spirituality are contaminated with positive psychological traits orhuman experiences (i.e., items tapping good mental health),reviewers of medical and psychiatric journals may allow publi-cation of research studies with findings that are meaningless ortautological. I provide several examples below where spiritualitywas measured using the FACIT-SP, the SWB scale, the DSEscale, or the SRPB scale, and correlations with good mentalhealth were the primary research findings.

In a study published in The Lancet, McClain and col-leagues (2003) used the FACIT-SP to examine 160 palliativecare cancer patients with a life expectancy of 3 months or less.They reported that spiritual well-being (total FACIT-SP score)was highly and significantly correlated with less desire for ahastened death, less hopelessness, and less suicidal ideation.They concluded that spiritual well-being may offer protectionagainst end-of-life despair. However, what exactly did theseinvestigators find? They found that patients who reported thatthey felt peaceful, had a reason for living, had a sense of purposeand meaning, and felt a sense of harmony and comfort were lesslikely to be suicidal, hopeless, or experience despair. Is that notobvious? Are such findings reportable in one of the worlds topmedical journals? Similar research using the FACIT-SP hasbeen conducted in cancer and noncancer patients and publishedin well-known medical (Bekelman et al., 2007; Daugherty et al.,2005; Mrus et al., 2006), psychiatric (Nelson et al., 2002;Peterman et al., 2002), and quality of life (Kobayashi et al.,2005) journals.



In a study published in the American Journal of Psy-chiatry, Tsuang et al. (2002) and other researchers at Harvardexamined the relationship between spiritual well-being and anumber of personality, emotional, and substance abuse out-comes. They found that the existential well-being subscale ofthe Spiritual Well-Being scale was significantly associatedwith 7 of 11 dimensions of personality and was significantlynegatively associated with alcohol abuse or dependence. Corre-lations with the religious well-being subscale, however, weremuch less impressive. Although these investigators correctlyreported results for each subscale separately, the existentialwell-being subscale was still considered a dimension of theoverall concept of spiritual well-being. Again, is it surprisingthat existential well-being (measured using items assessing lifesatisfaction, fulfillment, enjoyment, low life conflict, and happi-ness) is inversely correlated with negative personality traits,emotional distress, and substance abuse? What kind of usefulinformation do such correlations really provide? To do themjustice, this research group later noted similar concerns aboutdefinitions as I address here, cautioning researchers about usingconstructs of personal well-being as indicators of spirituality(Tsuang et al., 2007).

In another recent study, published in the Journal ofNervous and Mental Disease, spirituality (measured by the 6item short version of the DSE scale) was inversely associatedwith depressive symptoms, mediated by optimism, social sup-port, and volunteering (Mofidi et al., 2007). Since 1 of the 6items of the DSE was, I feel deep inner peace or harmony,how should one interpret the results? How many depressedpeople feel deep inner peace and harmony? What does aninverse relationship between spirituality measured in this wayand depression mean? Again, the contamination of spiritualitymeasures with items assessing mental health make it difficult tointerpret associations between spirituality and mental health.

In some secular areas of the world where religion hasbecome less popular, the term spirituality has been gutted ofmost of its religious content and has been redefined in terms ofhuman values or mental health (Koenig, 2007a; Moreira-Alme-dia and Koenig, 2006). This represents another example ofspirituality research that examines associations with mentalhealth and quality of life without considering how using con-taminated measures affects results. For example, to address thewhole person, the World Health Organizations new Qualityof Life (WHOQOL) measure includes a subscale to measurespirituality, religion and personal beliefs (WHOQOL-SRPB).Investigators used this subscale to conduct research on associa-tions between spirituality and mental health in a sample of 5087persons in 18 countries, and the results of the study werepublished in Social Sciences and Medicine (Saxena, 2006). Letus consider the dimensions that make up the WHOQOL-SRPBmeasure. Of the 8 dimensions assessed, 5 measure (1) meaningin life, (2) awe, (3) wholeness and integration, (4) inner peace,serenity, and harmony, and (5) hope and optimism. Again, is itsurprising that the investigators found that their SRPB measurecorrelated strongly with the psychological and mental healthdimensions of quality of life?

Whether or not to include personal beliefs in the mea-surement of spirituality is a difficult decision. Unless personal

beliefs are specifically religious or in some way about thetranscendent or sacred, it is not obvious why they should becalled spiritual. Should the boundaries of spirituality be broad-ened in research studies to include the full range of personalbeliefs that subjects may have? There are many personal beliefsthat have nothing to do with the sacred or the transcendent andit can be confusing to use the language of spirituality to describeall beliefs, including beliefs in flying saucers, alien abductions,or the like.

Relationships With Physical HealthIf spirituality is related to physical health, as some studies

show (Koenig et al., 2001), then one mechanism by which sucheffects occur is probably because of the influence of mentalhealth on physical health (i.e., the mind-body relationship)(Koenig and Cohen, 2002). Contaminating spirituality measureswith positive psychological traits or indicators of good mentalhealth can also influence findings between spirituality and phys-ical health. For example, investigators reported that spiritualityas measured by the WHOQOL-SRPB above was significantlycorrelated with better physical health (Saxena, 2006). However,if spirituality is defined as good mental health, then associationsreported between spirituality and physical health may simply bebecause of the effects of good mental health and have nothing todo with anything distinctively spiritual.

Definitions of HealthJust as spirituality has been measured using indicators

of good health, there have likewise been attempts to includea spiritual component to definitions of health (Larson, 1996;Vader, 2006). Since research findings have linked religiousinvolvement to better health, health practices, and medicaldecision-making, it may be appropriate to include spiritualityin discussions related to providing whole person health care.However, including religious or spiritual factors in measuresof health itself (where health is an outcome to be studied)makes research between spirituality and health difficult tointerpret for the same reasons that research using contami-nated measures of spirituality is problematic. For meaningfulscientific research to be conducted, definitions and categori-zations of spirituality, mental health, and physical health musteach be clear, distinct, and nonoverlapping.

Research Versus Clinical CareThe purpose of research is to place individuals in separate

categories, which can then be compared in terms of well-definedhealth outcomes. The goal is to be reductionistic and exclusive.This enables the identification of distinct characteristics of indi-viduals that impact various health states. Such an approach,however, is not always necessary in the clinical application ofthe research findings especially in the area we are discussing.

Rather than be exclusive as necessary in conductingresearch, the clinician needs to use terms that are inclusive(Koenig, 2007b). In a pluralistic healthcare system wherepatients may have different religious backgrounds or no religion,a wide assortment of personal beliefs, and come from differentcultures, health professionals must communicate in a languagethat is welcoming and supportive. The dialogue must begin



somewhere, and all patients must feel that they have an equalplace at the table.

For these reasons, a broad, nebulous and diffuse termsuch as spirituality is ideal. Here, spirituality is a sufficientlyvague term that patients can define for themselves. For somepatients, it will mean a connection with nature, relationshipswith loved ones, the high experienced from psychedelic drugs,or the fulfillment of human potential; for other patients, it willmean their religious beliefs and relationships within a faithcommunity (Fig. 4). No one is left out or discriminated against.

LimitationsFirst, this discussion is limited by the fact that I am not

a theologian or religious scholar. My training is primarily asa mental health researcher and epidemiologist. Thus, someassumptions and generalizations regarding the terms religionand spirituality may be overly broad. More complex discus-sion of these issues from a theological viewpoint is possibleand needs to be done (Shulman and Meador, 2002). This shouldnot, however, invalidate methodological concerns about the wayspirituality is currently being measured in research studies today.

Second, I have discussed the definition of spirituality asa distinct category. Another way to view spirituality is in termsof degrees. If that view is taken (as I recommend for clinicalsettings), then everyone could be considered spiritual. Althoughthis approach is perhaps closer to reality, I would argue that froma research perspective the categorical approach to definitions isnecessary (at least initially) to try to identify and box in aconstruct, and distinguish it from other constructs. A similarcategorical approach is taken in definitions of psychiatric disor-ders in DSM-IV.

RecommendationsThe above discussion has implications for research on

religion, spirituality, and health. If the primary research questionunder study is, Do deeply religious persons experience bettermental and physical health than do less religious or completelysecular individuals, and does religion cause that better health?then I have 2 recommendations.

The first is that measures of spirituality not be used thatare contaminated with items that clearly tap positive psycho-logical, mental health, or human characteristics. The corol-lary for measures of general health is also recommendedhealth measures should not be contaminated with items tappingspirituality. This will allow the examination of relationshipsbetween religion, spirituality, and health without confusion.

Second, the term spirituality should be measured usingquestions about public and private religious beliefs, practices,rituals, ceremonies, attitudes, degree of commitment, andlevel of motivation, that are appropriate to the faith traditionsof the subjects under study. The reasoning here is that afterremoving questions related to mental health, positive charac-ter traits, and nonspecific personal beliefs, all that one is leftwith is religion. Even the simple category, spiritual but notreligious is probably too vague since we really dont knowwhat that means, which makes interpretation of research find-ings difficult. Religion can be understood as a multidimensionalconstruct, and some of those measurable dimensions includemystical experiences (as with Hoods Mysticism scale) (Hood,

1975) and the search for a connection with the sacred/transcen-dent (as in Batsons Religious Quest scale) (Batson et al., 1993).Religious language (spirituality or that of the spirit), however,should not be used to describe purely secular, psychological orhumanistic concepts.

ACKNOWLEDGMENTSThe author thanks Keith G. Meador, MD, ThM, for his

intellectual and theological contributions to this manuscript.

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concerns about measuring “spirituality” in research

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