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Seeking for the Divine , . . has been a major aspiration and force in
all cultures and periods of history, yet it has been virtually ignored by
traditional psychology. . . . Regular people with ordinary problems who
are also on a spiritual path . . . are looking for therapists who will honor
their seeking for something sacred and who can respect their whole
being-in
its psychological and spiritual fullness-rather
than
belittling or minimizing their spiritual seeking, as much of traditional
psychotherapy has historically done.
(Cortright, 1997, pp. 13-14)
psychological, environmental, and behavioral dimensions of illness. In addressing chronic health problems that account for a majority of medical
visits, however, the limitations of a technological model have become obvious (Thoresen & Eagleston, 1985; Thoresen & Hoffman Goldberg,
1998).
The shortcomings of a technological approach are similarly apparent
in addressing psychological and behavioral problems, most of which are
continuously distributed rather than falling into discrete diseases or disorders. Multiple interrelated causes are common. Furthermore, comparative
treatment outcome studies often fail to reveal one superior therapeutic
approach (Orlinsky & Howard, 1986). Even attempts to match treatments
differentially to client characteristics have met with relatively little success
(e.g., Project MATCH Research Group, 1997). Health outcomes are influenced by a broad array of factors beyond the particular treatment delivered
(Moos, Finney, & Cronkite, 1990).
WHAT IS HEALTH?
How are you? If one reflects on a thorough answer to this question,
rather than regarding it as a routine greeting, it opens up the complexity
of health and well-being. There are many possible answers. Some of them
reflect the absence of aversive states: OK, not bad. Yet, as wisdom is not
merely the absence of ignorance, nor courage the absence of fear, so health
is surely more than a lack of disease. A large component of health is
subjective, which is what differentiates disease (a biomedical concept) from
illness (subjective feeling states such as weakness, pain, or nausea). People
may experience illness in the absence of detectable disease (a common
problem in medical care) and can experience wellness despite terminal
disease. Even a single continuum, ranging from perfect health to death,
fails to capture the richness of experienced wellness.
Health is better conceived of as a latent construct like personality,
character, or happiness, a complex multidimensional construct underlying
a broad array of observable phenomena. The number of component dimensions is a subject of both discussion and study. For illustrative purposes,
we propose that health could be conceptualized in three broad domains:
suffering, function, and coherence (cf. Antonovsky, 1979). The first of
these does typically define health by the absence of an experience, the
other two by presence. Suffering is one consensual form of unhealth and is
a common reason for seeking help. Such suffering may take a variety of
forms, including physical pain, anxiety, depression, or distress. Yet, in a
larger sense, we have known many healthy people who have lived with
chronic pain or who exuded health even as they approached death from
disease (e.g, Albom, 1997). The continuum of suffering, from none to
WHAT IS SPIRITUALITY?
For at least as long as history has been recorded, humankind has
assumed that reality is not limited to the material, sensory world. Belief in
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MILLER A N D T H O R E S E N
material existence. In such an individualistic perspective, each person (regardless of religious involvement) defines his or her own spirituality, which
might center on material experiences such as mountain biking at dusk,
quiet contemplation of nature, reflection on the direction of ones life, and
a feeling of intimate connection with loved ones (e.g., Spirituality in
Silicon Valley, 1998). Clearly, spirituality and religion are not the same.
Religion and religiosity can, in fact, interfere with a persons spiritual
growth. Some teachings warn that the spiritual purpose of religious practice
can be lost in obsessional piety or in political and economic agendas that
focus on power and prestige. Spirituality, then, can be defined apart from
religion, and the relationships between the two become a matter for empirical study. Before leaving this point, though, it is worthwhile to note
that this sharp distinction between spirituality and religion that some currently make has not always been emphasized. When William James (1902/
1985) wrote the book, The Varieties of Religious Experience, a century ago,
he was clearly describing the broader domain that is now called spirituality.
So what are the dimensions of this multidimensional space of spirituality? These are a matter of both debate and scientific study. For the
present purposes, we propose three broad measurement domains: practice,
belief, and experience. In so doing, we acknowledge that others have described a larger number of dimensions. Glock and Stark (1965), for example, described four elements or domains, all of which are associated with
the context of religion: the experiential, the ritualistic, the intellectual,
and the consequentiai. Capps, Rambo, and Ransohoff (1976) offered a
somewhat different breakdown of six spiritual dimensions within religion:
the mythological, ritual, experiential, dispositional, social, and directional.
The three domains that we describe here-spiritual practices, beliefs, and
experiences-are meant to characterize spirituality more generally, whether
inside or outside the context of religion. These broad domains are consistent with a psychosocial perspective that is sensitive to cultural, ethnic,
socioeconomic, and religious differences. Each domain, such as practices,
can encompass a wide range of constructs and variables. Each is amenable
to a variety of qualitative and quantitative assessment approaches (e.g.,
biographical and autobiographical material, narrative interviews, physiological measures, self-report questionnaires).
The first of these three dimensions is perhaps the easiest to measure
because it focuses on overt observable behavior (e.g., Connors, Tonigan,
& Miller, 1996). People can be described by the extent to which they
engage in spiritual practices such as prayer, fasting, meditation, and contemplation. Also included here would be participation in specifically religious activities such as worship, dance, scriptural study, singing, confession,
offerings, and public prayer.
The second domain of spiritual beliefs is large, and its content varies
SPlRlTUALlTY AND HEALTH
with culture (Smith, 1994). Directly pertinent here are beliefs about transcendence (e.g., soul, afterlife), deity, and the reality of a spiritual dimension beyond sensory and intellectual knowledge. Personal morality and endorsed values are also part of this domain (Rokeach, 1973). Transcending
the me factor (i.e., I, me, my, mine) in personal values has been a common quest in many religions (Bracke & Thoresen, 1996; Easwaren, 1989).
The concept of God (where one is present) is an interesting dimension
here (e.g., whether the nature, image, and intentions of a supreme being
are seen as being fundamentally loving, indifferent, or punitive toward
humankind).
The third domain, spiritual experience, offers perhaps the greatest
challenges for valid measurement, yet it is fundamental to an understanding
of spirituality. Many would regard this experiential dimension as the fundamental and defining nature of spirituality (Helminiak, 1996). Such experiences might be roughly divided into routine, everyday encounters of
the transcendent or sacred, versus exceptional spiritual and mystical experiences (although this distinction will break down for some whose daily
reality is mystical). At least two perplexing problems of definition emerge.
The first is the problem of defining which experiences are spiritual. Among
individuals who have had sudden, dramatic, and transforming life experiences, for example, some describe them in spiritual language and others do
not (Miller & CdeBaca, 1994). Believers and nonbelievers may have essentially parallel experiences, but they differ in the understanding of their
meaning and nature. A second challenge is empirical description of the
experiences themselves. Whether they are labeled as spiritual, there appears to be a relatively common topography to certain numinous phenomena including mystical (Bucke, 1923; Oates, 1973), transformational
(Loder, 1981; Miller & CdeBaca, 1994), and near-death experiences (Kellehear, 1996).
Before moving on, we acknowledge that this scientific way of thinking
and speaking about spirituality will seem strange to many readers. Those
who equate spirituality with the experiential dimension may prefer phenomenological metaphors to operational definitions. To speak of spiritual
behavior appears to reduce spirituality to nothing more than behavior.
This is not our intention. Words are unquestionably inadequate to fully
describe so complex a phenomenon, and, being defined in distinction from
material reality, spirituality is particularly difficult to define. Other complex
constructs such as personality can similarly be described as having at least
three dimensions-behavioral,
cognitive, and experiential-none
of
which (or their sum) fully characterizes the phenomena to which the word
personality refers. The upcoming discussion of spiritual variables may likewise
be jarring both to those who prefer a phenomenological and purely subjective approach to spirituality and to behavioral scientists for whom the
term may seem a scientific oxymoron. Yet, we believe that it is important
to include clients spirituality in treatment, and clinical practice is increasingly guided by the fruits of scientific method (e.g., empirically validated
treatments). We contend that these are compatible and complementary
frames of reference, with each offering perspectives that can enhance and
enrich the other.
It is also wise to be aware of psychotherapy issues that may be especially important or problematic for clients who are committed to a particular religious perspective. Assertiveness training, for example, may raise
special issues for some Christian and Islamic clients, for whom assertion
can be confused with aggressiveness and appear to conflict with central
religious teachings about humility and turning the other cheek. Helpful
writings by clinicians with expertise in both psychology and religion are
available. Such individuals have thought through issues, such as assertiveness and forgiveness, from the perspective of clinical practice (e.g., Augsberger, 1979; Rayburn, 1985; Sanders & Maloney, 1985; Thoresen, Harris,
and Luskin, in press). Part 111 of this book focuses particularly on such
border-crossing issues.
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them, thereby rendering them more accessible (and effective) to clients for
whom spirituality is of central importance (Johnson & Ridley, 1992; Worthington, 1988).
A number of major health intervention studies have already incorporated what is essentially spiritual material (e.g., Friedman et al., 1986;
Nowinski, Baker, & Carroll, 1992; Omish et al., 1990; Spiegel, Kaplan,
Kraemer, & Gottheil, 1989). Spirituality related themes raised in these
contexts have included the sense of direction, meaning, and purpose in
life; feelings of connectedness with oneself, with others, and with God or
a higher power; clarifying what is trivial and what is truly vital in life;
reducing self-critical and hostile cognitions; and fostering love, compassion,
and forgiveness (Thoresen, 1998; Thoresen, Luskin, & Harris, 1998). Such
concerns may not have been labeled as spiritual-they are often referred
to as personal values or philosophy of life issues-but their spiritual relevance seems clear. To illustrate, in the Recurrent Coronary Prevention
Program (Friedman et al., 1986), coronary patients in the psychosocial
treatment were asked to practice listening with their heart to others, to
verbally express their love and compassion for others, and to spend time
alone in experiencing nature. Each week they were also asked to reflect on
spiritually related quotations, such as It is only with the heart that one
can see rightly. What is essential is invisible to the eye (St. Exupery, 1943,
p. 9). Rarely have such themes been central, however, and they often have
been given little or no emphasis. Equally rare has been a careful assessment
of client spiritual and religious factors to study their impact on health
outcomes within the context of intervention research.
What if a client should ask, What are your religious beliefs? It is a
fair question, and an open summary of your pertinent beliefs and values
can be an appropriate response (see chap. 7 in this book). Often, however,
the underlying concem is more general and is similar to that of the client
who asks a younger-looking clinician, Just how old are you? What may
be most needed is your reassurance that even if there are areas where your
values and beliefs may differ, you will respect the clients beliefs, and such
differences ordinarily do not impede working together effectively (Malony,
1985). You can also indicate that should either of you find that this becomes a problem, you would make an appropriate referral.
SUMMARY
Spiritual well-being is an important and too often overlooked dimension of health. Much is already known. Spiritual and religious involvement
is not only common but is often important in clients lives and has been
generally linked to positive health outcomes. A clients spiritual perspectives may be relevant in understanding his or her problems and useful in
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