New information about linkages between religious and spiritual factors and health-related outcomes continues to be reported by both the popular media and the scientific community. From a cover story in Newsweek, to a case conference in JAMA, to a clinical trial of intercessory prayer published in Lancet, there is ongoing interest in the intersection of religion and spirituality with health and health care in the United States. Such a trend reflects America’s overall fascination with spirituality—much of which lies outside of organized religion—so much so that some forecasters have projected a future view of health that places spiritual factors alongside physical, psychological, and social determinants.

This chapter provides an overview and framework for understanding the current phenomenon of spirituality and health, particularly as it relates to the care of older adults. The first section orients how religion and spirituality are defined and understood by several academic disciplines. The core part of the chapter outlines and illustrates a categorical approach to the study of spirituality that has been proposed by Bernard McGinn. The next segment briefly reviews the organization of spiritual care before the final section closes with a perspective that introduces some ideas about a spirituality of practice within a spirituality of place.

Religion and religiosity are generally understood in several ways: the totality of belief systems, an inner piety or disposition, an abstract system of ideas, and ritual practices. For communities of faith, religious doctrine and faith traditions provide a foundation for understanding the wide range of human experience in areas such as suffering, death, and relationships with God and others. The term spirituality, on the other hand, has multiple connotations and interpretations that are less easily defined; academic disciplines such as sociology, psychology, and theology have approached and conceptualized spirituality in various ways. The social work literature, for example, operationalizes spirituality as a process of making sense of self and the world. Here spirituality is proposed as a condition of asking and answering major philosophical questions: who am I, why do I exist, what is my purpose, and how do I fit in the world? Several sociological perspectives resonate with this decidedly existential orientation. Spirituality is represented as that which promotes human agency, or the power that comes from within, in addition to an ongoing search to know our deepest selves and what is held to be sacred.

A psychological perspective is often used when considering spirituality’s relationship with health or well-being, since theoretical or conceptual frameworks, which postulate a causal, mediating, or moderating relationship between variables of interest, can be employed. In this way of thinking, the characteristics of spirituality are presented as a web of plausible relationships, predominantly within the domain of well-being. The growing interest in positive psychology, for example, casts an individual’s subjective experience in an optimistic light and often depicts spirituality as providing a foundation for adjustment, growth, and reaching one’s human potential. A related approach, one that is especially relevant to older adults, considers spirituality within the framework of religiously based coping mechanisms.

The social and psychological sciences have contributed greatly to contemporary perspectives of spirituality; however, the roots of this concept lie within theological sources. Historians trace the etymology of spirituality to the spirit of God (ruah) in the Old Testament, which subsequently provided emphasis for the term “spirit” (pneuma) found in the New Testament. Despite the central place of this idiom in such foundational texts, the abstract word spiritualitas (spirituality) did not arise until the fifth century, here having a biblical meaning of a spiritual person, or one whose life is ordered or influenced by God. By the 12th century, spirituality was associated mainly with what pertained to the inner life of the soul. However, this usage of spirituality went into eclipse by the 18th and 19th centuries, largely because of Voltaire and other contemporary thinkers who wrote about spirituality in disparaging ways. The genesis of contemporary understandings regarding spirituality is linked with French Catholic writers who used the term in a devotional sense in the early part of the 20th century. As time progressed, spirituality gradually migrated into more academic and technical circles, predominantly within the Catholic tradition.

Current, generally more inclusive theological contexts consider spirituality in light of beliefs in God or a divine being, as well as the sociological, philosophical, and psychological manifestations of those beliefs. One representative viewpoint locates spirituality within the stories, practices, and beliefs that are developed within religious traditions and communities but that are ultimately carried into and worked out in ordinary and everyday life events. A more applied perspective—a white paper on professional chaplaincy—depicts spirituality as “an awareness of relationships with all creation, an appreciation of presence and purpose that includes a sense of meaning.” Such representations shed light on how most Americans can consider themselves to be religious and/or spiritual, grasping these concepts as independent, although perhaps related, qualities of what it is to be human.

McGinn provides a categorical approach to spirituality, one that is useful to clinicians and other providers seeking to understand the multiple ways in which spirituality is manifested in care settings, as well as to investigators interested in developing better ways to study it. The three approaches—historical/contextual, anthropological/social scientific, theological/normative—are collectively holistic in scope, since these seek to capture the range of human experience. As a result, these are not mutually exclusive; more than one may be operational or applicable at a given time.

Historical/Contextual

A historical/contextual approach looks at the place of spirituality within the context of a shared lived history by a defined group, community, or population. Such an approach can lend insight into the current, accelerated interest and recognition of spirituality in health care circles by examining two parallel, patient-centered movements: end-of-life care and complementary and alternative medicine. Both movements may be viewed as an impetus to rehumanize a health care system in the United States, which has become increasingly impersonal, spiritually barren, and grounded in technology. The ongoing momentum to improve end-of-life care is understandably inclusive of spiritual factors, despite the lack of consistency in how spirituality is addressed in clinical settings.

Complementary and alternative medicine has also promoted rapprochement between spirituality and health care, yet also holds a conflicted perspective on the place of spirituality within its armamentarium. Studies that have examined the prevalence and patterns of complementary and alternative medicine usage vary in their assignment of alternative spiritual interventions—such as faith healing and prayer—as either a therapeutic modality or a conventional religious or spiritual ritual that is exclusive of complementary and alternative medicine. In 1993, a widely publicized survey on unconventional therapies found that 25% of respondents acknowledged using prayer as a medical modality. A 5-year follow-up study by the same investigators documented an increase in the use of self-prayer and a prevalence of spiritual healing as a common therapy for anxiety, depression, and lung problems. In a subsequent analysis of this data set, one-third of U.S. adults surveyed were found to use prayer for health concerns, both for wellness and for illnesses characterized by painful or aggravating symptoms, nonspecific diagnoses, and limited treatment options such as depression, headaches, and back and/or neck pain. Respondents in this study who used prayer for their health concerns also reported high levels of perceived helpfulness, or efficacy.

For clinicians and other care providers, a historical/contextual approach can enhance a richer, more complete understanding of how patients view the relationship between their own spirituality, however defined, and their health and health care. Here it is important to appreciate and distinguish the various organizational and social contexts in which care is provided; care within a clinical setting is very different than care offered within a faith-based setting, or within the supportive environment of a religious or spiritual community. A historical/contextual perspective can facilitate spiritual assessments—the process of discerning an individual’s spiritual needs and determining what resources are available to meet those needs—which have recently been recommended by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) for all hospitalized patients.

Well-developed clinical skills are the soil for fruitful spiritual assessments: empathic and active listening; open-ended questioning; validating, restating, or clarifying information that the patient provides; and determining whether a directed physical or mental status examination is necessary. The 7 × 7 Model, developed by George Fitchett, is a useful tool that incorporates a multidimensional approach to a spiritual assessment, since it includes medical, psychological, and spiritual domains. The model encourages care providers to consider seven different areas: belief and meaning, vocation and obligations, experience and emotions, courage and growth, ritual and practice, community, and authority and guidance. Equally important, it provides a way for providers to effectively communicate with other spiritual caregivers, such as community clergy, hospital chaplains, family members, or other sources of spiritual support.

Anthropological/Social Scientific