Open access peer-reviewed chapter
Abstract
Developed in the context of the subjective well-being movement in the 1970s, the Spiritual Well -Being Scale (SWBS) has stood the test of time. It was conceived within a theistic tradition and embodied the sense of well-being suggested in Biblical texts. The Old Testament greeting and blessing, shalom, seems to convey well the underlying concept of well-being. In this chapter we explore the empirical support and practical significance of the SWBS as a measure of well-being using the notion of biopsychosocial health as proposed by Engel and adapted by Sulmasy to include a religious/spiritual (R/S) dimension as well. Since the 1980s, thousands of studies have been completed and over 20 translations of the scale have been carried out. This chapter will concentrate on research since publication of Paloutzian, et al. Mr. Rogers used to sing, “Everything grows together because we’re all one piece.” Here our thesis is that everything goes together—biopsychosocial and spiritual—because humans function holistically. The SWBS captures this reality well. As a result, the SWBS functions as an index of well-being, an assessment instrument to identify those whose functioning is impaired, and an index of outcomes for interventions that seek to foster well-being.
Keywords
- happiness
- spiritual well-being
- biopsychosocial
- religious/spiritual
- health
1. Introduction
“Happiness is different things to different people” [1]. Happiness, joy, and subjective well-being are related but distinct concepts. Myers and Diener [2] explored happiness and showed that it is related to “three correlated but distinct factors: the relative presence of positive affect, absence of negative affect, and satisfaction with life” (p. 11). They referred to these together as subjective well-being. Myers and Diener concluded that, among other things, happy people have a meaningful religious faith. In this chapter we examine the link to religious faith or spiritual well-being as shown by research with the Spiritual Well-Being Scale (SWBS).
The SWBS is one of the most widely used measures of well-being. A recent search identified over 125,000 citations in peer-reviewed journals in the past decade. Developed by Paloutzian and Ellison [3, 4, 5], three factors contributed to the conceptual background of the SWBS: the social indicators movement of the 1960s and 1970s, the subjective quality of life studies of the 1970s, and the qualitative study of spiritual well-being by Moberg [6]. Moberg theorized that spiritual well-being involved a vertical dimension of relationship to God, and a horizontal dimension of relationship to fellow humans and the material world [6].
The SWBS consists of 20 items. Ten items include explicit references to God and comprise the Religious Well-Being Scale (RWB). The remaining 10 items measure relationship to fellow humans and the material world and comprise the Existential Well-Being Scale (EWB). The SWBS combines RWB and EWB, which are related but distinct measures. Each item is rated on a six-point continuum from
2. Psychometrics
2.1 Reliability
Reliability has been extensively examined. Internal consistencies generally range from 0.70 to 0.95 [7, 8, 9, 10]. Translations of the SWBS into other languages have found similar internal consistencies despite the challenges involved with language, cultural, and religious differences [9]. Test-retest reliabilities for intervals from 1 to 10 were 73 and above [3, 8, 10], so SWB is fairly stable though we view it as more a state than a trait. Together these data suggest that the SWBS has adequate internal consistency and test-retest reliability.
2.2 Validity
The SWBS items were constructed with content matching the horizontal and vertical dimensions proposed by Moberg [6]. After initial testing and revision, the current 20 items were selected. Expected group differences have been demonstrated e.g., [7, 8] and correlational results confirm that EWB and RWB are distinct but related e.g., [9, 11]. Scores on the SWBS are significantly related in expected directions to a number of indicators of physical, psychological, social, and religious/spiritual (R/S) functioning [7, 8, 9, 11, 12, 13, 14, 15].
Factor analytic studies have commonly found two factors e.g. [3, 12] but three factors are also reported in some samples [13]. Factor results are characteristics of samples, so this variability can be expected [10].
2.3 Norms
Bufford et al. [8] reported descriptive data on several samples, including college students, persons with mental disorders, and imprisoned convicts. Scores for these samples provide norms for interpreting SWBS scores. Negative skew and ceiling effects are reported for conservative Christian groups [8, 12, 15]. However, the scale has adequate ceiling for most purposes and sufficient range to readily identify low spiritual well-being.
2.4 Practical utility
The SWB scale has demonstrated good utility as a measure of general wellbeing, sometimes referred to as the “shalom principle” [16]; in general, RWB, EWB, and SWB correlate positively with indicators of physical, psychological, and spiritual health, and negatively with indicators of pathology. In addition to validation studies, the SWBS has been used as an independent/predictor variable and a dependent/criterion variable. The SWBS has been found to be a sensitive barometer of psychological distress [17]. It has also been used successfully as an indicator of change in several outcome studies [17, 18, 19, 20]. The primary limitation with the SWB at this time is the inability to distinguish among highly functioning individuals with strong R/S commitments [7, 9]. However, Uhder et al. [21] reported that ceiling effects are common among R/S scales.
2.5 SWBS and Shalom
In modern Hebrew,
3. Biological well-being
3.1 Inflammatory bowel disease
A study conducted by Cotton et al. [22] reviewed how children with inflammatory bowel disease compared to those without this disorder with regard to their spiritual well-being and mental state. A total of 155 inflammatory bowel disease patients completed the SWBS, Children’s Depression Inventory, and Pediatric Quality of Life Inventory. They found that pediatric patients with IBD had similar levels of religious and existential well-being to those without IBD. However, children with IBD considered spiritual well-being to be more influential on their mental health than healthy individuals did.
3.2 Immunosuppressive treatment
This cross-sectional and descriptive study conducted by Gunes et al. [23] looked at the relationship between SWB and patient’s self-reported adherence to immunosuppressive therapy following a liver transplant. Following their surgery, 131 patients completed the SWBS, patient information form, and Immunosuppressive Therapy Adherence Scale (ITAS). They found that individuals who had college degrees had lower SWBS scores, while those 65 years of age or older reported higher SWBS scores and lower treatment adherence. However, a regression analysis found a substantial positive relationship between total SWBS scores and adherence to immunosuppressive therapy. In conclusion, SWB predicted better treatment adherence.
3.3 Breast cancer
In a descriptive study of women with breast cancer, Nakane and Koch [24] examined the role of faith in coping with their diagnosis, enduring their treatment, and improving their overall experience. Participants completed the SWBS and an interview. The data showed that 67% of participants considered their faith to be an important component of their medical treatment. Participants scored an average of 92% (M = 111.5) on the SWBS. The data were analyzed according to the RWB which resulted in a 100% (M = 60) score among all participants. The participants scored care 85% (M = 51) on the EWB. The study concluded that incorporating faith in cancer care can be beneficial. Particularly, these patients reported that their faith played the most important role in their treatment and positively affected their experience.
3.4 Multiple sclerosis
A cross-sectional and correlational study conducted by Shaygannejad [25] looked at the relationship between SWBS and social support in patients with multiple sclerosis. The Perceived Social Support Inventory and the SWBS were completed by 120 patients. The average score on the SWBS was 87% (M = 104.4) while the perceived social support was 61%. They reported a correlation between the SWBS and perception of social support, particularly for the emotional dimension, which proved to have a greater connection with spiritual well-being than the other two dimensions of social support.
3.5 Coronary artery disease
De Eston Armond et al. [26] conducted a case-control study involving 88 adults; 42 of these individuals were cases and 46 were controls. They gathered demographic information from participants and administered the SWBS. Data analyses did not show a significant difference between the two groups when comparing levels of SWBS and there was no correlation between coronary artery disease and SWB, RWB, and EWB. Both groups demonstrated high scores on RWB, but there was a significant difference in variability between the “case” and “control” groups on EWB. This may be due to lack of clear differentiation between the two groups. This outcome could be related to study design or an SWBS limitation rather than an actual indicator that SWB is not related to coping with coronary artery disease.
Ramesh et al. [27] examined SWBS, worry and anger among 327 patients with coronary artery disease (CAD). SWBS was negatively related to CAD severity, while worry and angry rumination were positively related. They concluded that worry and anger moderated the relationship of spiritual well-being to CAD.
Mashhadimalek et al. [28] examined the association of heart rate variability (HRV), considered a barometer of health, and SWBS among a sample of 31 of Farsi-speaking Muslims. They used cluster analysis to form to groups that differed in SWBS scores. No differences were found in selected HRV indices during the resting phase, but the group with higher SWBS scores differed significantly on selected HRV indices while reading the Quran, indicating increased parasympathetic arousal. Other measures showed the increase in parasympathetic arousal was associated with pleasure and joy. They concluded these findings are consistent with other findings that support a link between R/S and happiness; the HRV findings suggest health gains.
3.6 Traumatic brain injury
Sekely et al. [29] explored how spiritual well-being influenced recovery in individuals who sustained a traumatic brain injury (TBI). Specifically, the study looked at how SWB influenced depressive and anxious symptoms following a TBI. After a neuropsychological evaluation to confirm their functioning, 83 participants completed the SWBS, Beck Depression Inventory II, and The Beck Anxiety Inventory. They found that there was a negative correlation between the BDI-II score and the EWB score as well as the BAI score and the EWB score [28]. They concluded that EWB may protect TBI patients from anxious and depressive symptoms.
4. Psychological well-being
Through the Triangle of Well-being and Resilience model, Dr. Dan Siegel [30] demonstrates how our mind, brain, and relationships are part of a flowing system, and are consistently and continuously responding to new experiences. We as humans, function holistically, so anything that affects us, affects our whole self. Our psychological well-being is linked to all other facets of our whole self, including physical health, social endeavors, and spirituality. Dr. Carol Ryff was a pioneer in psychological well-being, focusing on well-being beyond medical or biological descriptions. Ryff [31] developed the Six-factor Model of Psychological Well-Being.
The Six-factors of Dr. Ryff’s model include self-acceptance, personal growth, purpose in life, positive relations with others, environmental mastery, and autonomy. Lindfors et al. found that Ryff’s model was relevant cross-culturally, and data supports the use of a six-factor model [32]. The six relevant factors of psychological well-being described by Ryff [31] give context to parts of a person’s life that could also impact or overlap other areas of well-being, such as spirituality. Ryff’s multidimensional construct of well-being builds on such concepts such as
As explained below, spirituality and religiosity are often primary sources of a person’s well-being, and the factors of spirituality tie into all other aspects of well-being, including biopsychosocial well-being and what that means from a religious or spiritual perspective.
Wnuk and Marcinkowski [34] proposed that well-being is multidimensional, echoing Ryff [31]. They found that the meaning of life and hope were directly related to psychological well-being in terms of cognitive and emotional measures, however, only in positive directions. They hypothesized that religiosity, including finding the meaning of life and improving hope, might show a positive influence on psychological well-being [33]. They also found that psychological well-being and its relationship with meaning of life, an aspect of religiosity, played a major role in their participants’ quality of life.
As previously discussed, spirituality, health-related behaviors, and psychological well-being all intersect. Bożek et al. [33] found that these three particular aspects of life were significantly related in the realm of acquired education. Acquired education in this instance means the subconscious process of retaining knowledge. They found that spirituality and health-related behaviors were linked to psychological well-being and spirituality associations with psychological well-being were stronger in the students who were studying aspects of the human mind and spirit. High levels of psychological well-being are associated with a “lower risk of depression, a lower possibility of displaying risk behavior, a decreased immune cell expression of a conserved transcriptional response to adversity” ([32], para. 7).
Kamitsis and Francis [35] completed a study to determine how engaging with nature influences psychological health, as well as the role that spirituality plays in the relationship between nature and psychological health. Through surveys, the authors found that “nature exposure and connectedness to nature were positively associated with psychological wellbeing and greater reported spirituality,” which supports previous research ([35], p. 139). The results of this study show how people experience nature, and the impact that connecting with nature can have on spiritual and psychological well-being. It is important to study treatment options involving engagement with nature to determine their effectiveness in increasing spiritual and psychological well-being.
When thinking about psychological health and well-being, trauma and traumatic experiences can play a major role in how someone processes or moves towards a more psychologically healthy state of mind. Park [36] completed a study among 436 college students to determine predictors of three aspects of spirituality, including faith, meaning and peace, and relationships among those spiritual well-being aspects and psychological adjustment after experiencing a traumatic event. The results of their study showed that different patterns of coping with a person’s trauma predict different components of spiritual well-being. Park [36] also found that each of the three aspects of spiritual well-being, faith, meaning, and peace, particularly the latter two, were correlated with psychological adjustment.
The current research puts a rather large emphasis on the relationship between spiritual well-being and psychological well-being. Implications for future research include studying the intersecting relationships among physical, psychological, social well-being and spiritual well-being.
5. Social well-being
5.1 SWB, social support, and suicidality
Gaskin-Wasson et al. [37] explored the relationship between spiritual well-being, depression, suicidality, and interpersonal needs in a sample of African American females who had experienced a suicide attempt and intimate partner violence within the last year. SWB was negatively associated with suicidality, depression, and thwarted interpersonal needs. Thwarted belongingness significantly mediated the relationship between SWB and depression. Results suggest SWB protects against depression and suicidality.
In a sample of 176 adolescents in low-income and marginalized families in Malaysia, Ibrahim et al. [38] found higher levels of RWB, EWB, family support, and friend support were associated with lower levels of suicidal ideation. Lower levels of SWB, RWB, and family support also predicted an adolescent was more likely to report suicidal ideation, suggesting both social and spiritual well-being protect against suicidal ideation.
5.2 SWB, social support, and depression
In a study conducted in Iran during the COVID-19 pandemic, Sharif Nia et al. [39] analyzed the relationship between spiritual well-being, social support, financial stress, and depressive symptoms. SWB and social support were negatively related to depression levels. Social support indirectly impacted depression through SWB and financial distress, with effects of 12.08% and 13.62% respectively. The effect of SWB on depression accounted for 56.69% of the variance and the effect of SWB on financial distress was 22.09% of the variance. Akbari et al. [40] explored the relationship between social support, SWB, and post-partum depression within mothers in Iran; a comparison group of non-depressed post-partum mothers was utilized. In a sample of 44 mothers with diagnoses of post-partum depression, 73.3% reported perceptions of low social support and 22.7% reported high scores on the SWBS. Among the non-depressed group, 72.4% reported perceptions of high social support and 58% reported high scores on the SWBS. Results across both studies indicate SWB and perception of social support contributed to protecting against depression amid life transition, demonstrating fewer depressive symptoms among participants during a global pandemic and in mothers with post-partum depression.
5.3 SWB and social aspects of health
Soleimani et al. [41] explored the relationship between SWB and death anxiety in survivors of acute myocardial infarction (AMI). Higher levels of social support were positively associated with RWB, EWB, and total SWB. AMI patients with more perceived social support and higher levels of SWB reported less death anxiety. Patients who were single had higher levels of death anxiety than married patients, but SWB was associated with reduced death anxiety among both unmarried and married patients. Results suggest SWB and social support could be considered protective factors for coping with death anxiety and related stress among patients with AMI, and may be most vital for those who are single or lack the additional social support associated with marriage.
5.4 SWB and social health among elders
Mahammadi et al. [42] explored the relationship between spiritual well-being, social health, and capacity for self-care in a sample of elders in community health centers in Iran. Elders with higher levels of social health and SWB had a greater capacity for self-care, with SWB, RWB, and social health predicting self-care capacity. Social health had the highest share in predicting self-care capacity and EWB had no significant effect. Among a sample of elderly residents in China, Chen et al. [43] demonstrated greater levels of perceived social support and fewer depressive symptoms predicted higher levels of SWB. Further, SWB was not directly associated with functional ability, yet perceived social support and depression mediated the relationship between SWB and functional ability. Results from both studies suggest that higher levels of SWB and social support can positively impact personal well-being among elderly populations.
5.5 SWB and social environment
Among a sample of low-income African American mothers, Lamis et al. [44] explored whether EWB and RWB were moderators for neighborhood disorder and parenting stress. EWB predicted greater income, being employed, having a home, and lower probability of receiving treatment for psychiatric conditions. Higher levels of EWB and RWB were also related to fewer reports of experiencing recent interpersonal violence. Neighborhood disorder was positively related to parenting distress, but those with higher scores on EWB and RWB reported less parenting distress. There was also a significant interaction between EWB and neighborhood disorder. Mothers who reported low levels of EWB reported greater levels of parenting stress regardless of neighborhood disorder, while those who reported high levels of neighborhood disorder also reported high levels of parenting distress despite reporting medium or high levels of EWB. High EWB may be an important protective factor against parenting distress in the presence of social disorder, but does not preclude distress in the face of more serious neighborhood disorder.
6. Religious/spiritual well-being
Paloutzian et al. [10] argued that the inclusion of patient’s spiritual well-being (SWB) in healthcare policy is an essential component to a comprehensive program of patient care. Since then, the body of research interested in examining a modern holistic view of the human being has grown to further embrace a spiritual dimension. Of particular interest to the current work, in the last decade researchers have emphasized exploration of the spiritual dimensions of health and its meanings and propose that inclusion of the biopsychosocial-spiritual model in medical practice may have profound effects on patient health, disease, treatments, and cure [45]. As the modern humanistic view of health gains momentum in healthcare, the interest gives way to development of ancillary analyses of patient care experiences including patient-provider relationships, patient subjective experience, and patient decision-making [44]. In this section, we assess the latest movement of the empowerment of patients through inclusion of patient SWB in a variety of healthcare settings. Additionally, we examine whether clinicians’ perception of transcendence, or their level of SWB, will enable them to better impact and understand their clients.
As research around spirituality and its influence on overall health expands, it is salient to examine the willingness or resistance of clinicians and patients to incorporate this dimension into their practice. In one experiment, Saad et al. [45] posed the challenge of translating all phrases from the Physician’s Pledge on the Declaration of Geneva to a spiritual dimension; following a full translation, researchers found spirituality as a dominant aspect of high standard medical training and clinical practice. As noted by the World Psychiatric Association [46], high-quality physician care is significantly associated to better mental health. This continuum of patient care can be perceived as a transformation of modern medicine due to understanding and inclusion of the human spiritual dimension. Oxhandler and Parrish [47] compared five helping professions’ (3500 licensed clinicians) views and behaviors regarding integration of clients’ religion and spirituality (R/S) in clinical practice. They found positive attitudes and no variability across professions, indicating helping professionals’ openness to spiritual integration in clinical settings.
In another study, researchers examined whether patients wanted their doctors to talk about spirituality. Data from a systemic search in 10 databases including 54 studies and 12,327 patients were used. From their results, Best and Olver [48] concluded that over half the sample thought it was appropriate for the doctor to inquire about spiritual needs, and a majority of the sample expressed interest in discussion of R/S in medical consultations. Salient to note, interest increased with education, personal religiosity, private insurance, less intensity of spiritual interaction, and increased severity of patient illness. These findings suggested that while patients may be initially resistant to inclusion of spirituality in treatment, they are curious about its effects and may be more willing to engage in a casual inquiry regarding R/S.
While it is apparent that modern healthcare has adopted a shift to emphasize spirituality in treatment, we are curious about the personality traits of individuals who incorporate R/S into their lives, and how this may be applied to overall health and happiness. Particularly, we question whether the character of a clinician can affect the outcome of a patient, and how a clinician’s character is influenced by SWB. Beauvais et al. [49] examined the relationship between emotional intelligence (EI) and SWB in nursing students using the Mayer–Salovey–Caruso Emotional Intelligence Test (MSCEIT) and the Spiritual Well-Being Scale (SWBS). Results indicated relationships between managing emotion and spiritual and existential well-being. As the definition of EI has been broadened to identifying the feelings of self and others, findings suggest that higher scores on the SWBS indicated higher EI, or what some might call
Research by Hosseini et al. [50] incorporated the SWBS to address relationships between psychological hardiness and general/spiritual health and burnout among 312 medical science staff participants. Findings demonstrated that the hardiness variable had a highly significant relationship with spiritual health, meaning that increases in one were associated with increases in the other. These data can be extrapolated from the original idea behind SWB as a need for transcendence; people connected to their spirituality can engage in meaning-making of their experiences, which can provide beneficial effects on coping with difficult events and therefore, increased psychological hardiness. Also notable in this study was the burnout decrease/hardiness increase correlation. If clinicians can avoid burnout, their patients will surely benefit from longevity of treatment and clinician genuineness and competence.
In a recent survey, Levin [51] collected data from the 2010 Baylor Religion Survey from 1714 participants to investigate the prevalence and religious predictors of healing prayer use among US adults. Interestingly, results show that over 75% of adult Americans have prayed for the healing of others and over half have participated in prayer groups [50]. In support of these findings, Pew Research Center [52] gathered data that suggested over 90% of Americans believe in a Higher Power, and over half pray daily, many times for their own and others’ healing. Integration of analyses from statistics such as these and various research suggests that humans crave, or are at least curious about spirituality and transcendence, and perceive beneficial effects from some level of SWB. With each adverse circumstance we experience, verifiable mechanisms of change can only encourage healing to a certain extent. Recent research provides promising evidence that clinicians and patients alike identify R/S as a significant factor beyond tangible measures of health that contribute to overall well-being.
Engel [53] showed that differentiation-of-self mediated the relationship between spiritual dwelling and RWB for negative affect but not for positive affect. They concluded that spiritual dwelling fosters well-being through regulation of negative affect.
7. Conclusion
Shalom is found in the biblical texts of Exodus 21–22. In Israel today, when you greet someone or say goodbye, you say, Shalom. You are literally saying, “may you be full of well-being” or, “may health and prosperity be upon you.” This brief review of the SWBS as a measure of the underlying concept of spiritual well-being provides general support for the thesis that R/S well-being in many ways is consistent with the wishes and blessing associated with shalom. Supporting Engel and Sulmasy [53, 54], persons who score higher on the SWBS tend to cope better with medical adversity such as terminal cancer, experience better psychological health and are less likely to experience mental distress, have better social connections and less social strain, and function in ways that empower them to be a support and resource for those who suffer in these ways. While limited data bears on the direction of causality, there is some indication that spiritual well-being tends to play a causal role in these relationships.
Does spiritual well-being lead to happiness? Not necessarily. First, many of these findings lack the safeguards to ensure causal relationships, though a few findings meet that standard e.g. [18, 19, 55]. Second, spiritual well-being is a broader more experiential and existential quality rather than “the relative presence of positive affect, absence of negative affect, and satisfaction with life” used to define happiness. But the experience of holistic biopsychosocial and spiritual well-being [53, 54] is likely to be associated with a sense of calm, peace, satisfaction, contentment and abundance. At times these are likely to also be accompanied with happiness as well. And R/S engagement is generally associated with these experiences.
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