The Four Domains Model: Connecting Spirituality, Health and Well-Being

: At our core, or coeur, we humans are spiritual beings. Spirituality can be viewed in a variety of ways from a traditional understanding of spirituality as an expression of religiosity, in search of the sacred, through to a humanistic view of spirituality devoid of religion. Health is also multi-faceted, with increasing evidence reporting the relationship of spirituality with physical, mental, emotional, social and vocational well-being. This paper presents spiritual health as a, if not THE, fundamental dimension of people‟s overall health and well-being, permeating and integrating all the other dimensions of health. Spiritual health is a dynamic state of being, reflected in the quality of relationships that people have in up to four domains of spiritual well-being: Personal domain where a person intra-relates with self; Communal domain, with in-depth inter-personal relationships; Environmental domain, connecting with nature; Transcendental domain, relating to some-thing or some-One beyond the human level. The Four Domains Model of Spiritual Health and Well-Being embraces all extant world-views from the ardently religious to the atheistic rationalist.

to help diagnose spiritual dis-ease, so that appropriate spiritual care might be provided to restore spiritual health [3]. This action is not only needed for individuals, but the whole world, for the survival of the human race [2].
Many and varied attempts at defining spirituality range from religious to humanistic ends of a spectrum (see Spilka, cited in [4]). "Spirituality" and "well-being" are both multifaceted constructs that are described as being elusive in nature [5][6][7], but this has not prevented people from trying to define spirituality and well-being, as well as their interrelationship, in the form of spiritual well-being (SWB).

Nature of Spirituality
Much debate about the nature of spirituality has occurred for centuries. However, writers have had difficulty in defining the concept [2,[8][9][10].
Spirituality can mean many things in popular usage, and is often understood differently by different people. While retaining a certain ambiguity, its current range of application extends from traditional institutional religion to occult practices. In general, the term appears to denote approaches to discovering, experiencing, and living out the implications of an authentic human life [11].
Twenty-four separate meanings for the word "spirit" are listed in the Oxford English Dictionary [12]. The general meaning underlying all the uses is that of an animating or vital principle which gives life, transcending the material and mechanical. It refers to the essential nature of human beings, their strength of purpose, perception, mental powers, frame of mind. ""Spiritual" may refer to higher moral qualities, with some religious connotations and higher faculties of mind" [13].
Literature on spirituality reveals several points of agreement about its nature, as well as divergent opinions, which are worth noting:

Spirituality is innate
Consensus is reported in the literature for spirituality being posited at the heart of human experience [14], and it being experienced by everyone [15]. Not only is it believed that "each individual has spiritual needs" [16], but also it is claimed that "human spirituality in a very real sense...unifies the whole person" and is "an inbuilt feature of the human species that develops from the beginning of an individual"s life (or not) depending on [prevailing] conditions" [17]. Spirituality can thus be seen as a fundamental, vital component of being human.

Spirituality is emotive
The notion of spirituality is emotive [18]. It touches people's hearts because it deals with the very essence of being. It is important for people in positions of influence to remember that they cannot be neutral, or value-free, but must try to be objective in examining the concepts of spirituality and spiritual health, especially as they relate to young people [19].

Spirituality and religion
A variety of opinion prevails on the nature of any relationship between spirituality and religion. Some people equate spirituality with religious activity, or use the words interchangeably (e.g., [20,21]), whereas others believe this assumption is not valid (e.g., [22,23]). Some people discuss commonalities between spirituality and religion, as well as differences [4]. This is another way of saying that although spirituality and religiosity are often used interchangeably, they are distinct, if overlapping, constructs. Three polarizations between views are held by behavioral scientists, differentiating spirituality and religion [24]. Some people argue that spirituality is subsumed by religion [4], whereas others see religion as one dimension of spirituality [15]. The view that "religiosity can but does not necessarily include spirituality" [25], is countered by one that claims, "Outstanding spiritual leaders developed most religions" [17]. Rather simplistically speaking, Horsburgh maintains that religion focuses on ideology and rules (of faith and belief systems) [26], whereas spirituality focuses on experience and relationships which go beyond religion [27]. This simplistic view is rejected by many [17,28,29]. In a recent study "using a large sample of American adults, analyses demonstrate that subjective spirituality and tradition-oriented religiousness are empirically highly independent" [30], suggesting divergence between the two constructs. A close inspection of the instruments used in this study is warranted to see how much faith can be placed in the findings.
"A relationship to the sacred or transcendent" [my italics] is included in one definition of spirituality [28]. Taking this broader view, Seaward asserts that spirituality involves "connection to a divine source whatever we call it" [2]. But, spirituality does not have to include "God-talk" according to Jose and Taylor [18]. A number of authors have followed this latter, humanistic line of thinking by providing attempts at defining secular spirituality as spirituality without any need for a religious/God component [31,32]. Many Christian writers raise arguments against removing religion and God from discussions of spirituality (e.g., [33,34]).
Abraham Maslow, reputed by many to be the father of humanistic psychology, and John Dewey, a founder of the philosophical school of Pragmatism, both consider spirituality to be part of a person"s being, therefore, prior to and different from religiosity [35]. Many supporters of the notion of evolutionary psychology fail to distinguish between "spiritual awareness as a natural phenomenon [i.e., innate] and religion as a belief system", which is enculturated through family, education and community [17].
This kaleidoscope of viewpoints illustrates how people"s worldviews and beliefs can influence their understanding of spirituality, a key feature in the model of spiritual health presented later in this paper.

Is spirituality subjective?
Spirituality has been seen as personal, or subjective, lacking much of the objective nature considered necessary for its investigation via the scientific method [36]. But, science can neither affirm nor deny metaphysical issues, such as spirituality [37], any more than it can aesthetics. Proponents of scientism, those who exalt the scientific method to the unholy status of "science = truth", tend to dismiss spirituality, claiming it cannot be studied through current scientific methodology [9]. However, "If we can accept concepts such as self-worth, self-esteem, and self-actualization, then it should be legitimate to explore...spirituality, for these concepts are equally as intangible as spirituality" [18] . If the view is taken that the use of the five physical senses and the empirical way of knowing is the only true science, then much of logic, mathematics, reason and psychology have no place in science. To focus too much on the sensory realm, and, from a spiritual perspective, to reduce a person to mere matter, is a classic example of mistaking substance for essence [35].
In order to balance an over-emphasis on the subjectivity of spirituality, Thatcher argued that there is a "crippling price to pay for misidentification of spirituality as inwardness" and we need to go beyond the inner search to fully understand spirituality [38].

Spirituality is dynamic
"The spirit is dynamic. It must be felt before it can be conceptualized" [39]. In keeping with this view, terms like "spiritual growth" and "development" are used to express the vibrant nature of spirituality [36]. A person"s spiritual health can be perceived to be high or low. If it is static, there is neither growth nor development, nor spiritual life. The spiritual quest is like being on a journey: If you think you've arrived, you haven't yet begun, or you are dead.

Understanding spirituality
Five types of spirituality are believed to exist in the United States, namely "humanistic spirituality" with focus on human spirit with no claim to a higher power; "unmoored spirituality" focusing on energy, connection, and nature; and three types of "moored spirituality" based on Eastern religions; or Western religions with evangelical, or conservative, bases [28]. These five types of spirituality could just as easily be grouped into the three categories described as "God-oriented, worldly-oriented with an idolatrous stress on ecology or nature, or humanistic, stressing human potential or achievement" (Spilka, cited in [3]).
An attempted integration of the divergent views described spirituality as the ancient and abiding human quest for connectedness with something larger and more trustworthy than our egos-with our own souls, with one another, with the worlds of history and nature, with the invisible winds of the spirit, with the mystery of being alive [40].
This definition has many similarities to this author"s functional definition: Spirituality is concerned with a person"s awareness of the existence and experience of inner feelings and beliefs, which give purpose, meaning and value to life. Spirituality helps individuals to live at peace with themselves, to love (God and)* their neighbor, and to live in harmony with the environment. For some, spirituality involves an encounter with God, or transcendent reality, which can occur in or out of the context of organized religion, whereas for others, it involves no experience or belief in the supernatural. (NB * These words were placed in parentheses as they will be meaningless to those people who do not acknowledge a relationship with God.) [41] Although it must be kept in mind that there can be negative as well as positive expressions of spirituality [42], the focus of this paper is on positive aspects of spiritual health and well-being.

Dimensions of Health
The nature of health needs to be addressed, before investigating the relationship between spirituality and health. Even in Greek times, educators considered the total health of each individual as having a sound spiritual base [43]. Thus, "for Hippocrates, it is nature which heals, that is to say the vital force-pneuma (or spirit)-which God gives to man" [44]; whilst "healing" may be defined as "a sense of well-being that is derived from an intensified awareness of wholeness and integration among all dimensions of one"s being" [45], which includes the spiritual elements of life.
It has been suggested that there are six separate, but interrelated, dimensions that comprise human health (e.g., [2,46]). Health involves much more than physical fitness and absence of disease; it includes the mental and emotional aspects of knowing and feeling; the social dimension that comes through human interaction; the vocational domain; and, at the heart, or, very essence of being, the spiritual dimension. It is the spiritual dimension which seems to have greatest impact on overall personal health [47].

Spiritual Health and Well-Being
Ellison suggested that spiritual well-being "arises from an underlying state of spiritual health and is an expression of it, much like the color of one"s complexion and pulse rate are expressions of good [physical] health" [48]. Fehring, Miller and Shaw supported this view by adding, "spiritual well-being is an indication of individuals" quality of life in the spiritual dimension or simply an indication of their spiritual health" [49].
In the framework definition of spiritual well-being (SWB) proposed by the National Interfaith Coalition on Aging (NICA), in Washington DC, four main themes appeared as SWB was seen as "the affirmation of life in a relationship with God, self, community and environment that nurtures and celebrates wholeness" [50]. Literature reveals that these four sets of relationships are variously mentioned when discussing spiritual well-being (references across the last three decades include [48,[51][52][53][54][55]). These relationships can be developed into four corresponding domains of human existence, for the enhancement of spiritual health: relation with self, in the Personal domain relation with others, in the Communal domain relation with the environment, in the Environmental domain, and relation with transcendent Other, in the Transcendental domain.
Principles of Grounded Theory qualitative research methodology were used to develop detailed descriptions of these four domains of spiritual health from interviews with 98 educators from 22 secondary schools (State, Catholic and Independent) in Victoria, Australia. Up to five senior staff were interviewed in each school to elicit their views on the nature of spiritual health and its place in the school curriculum. Surveys were also collected from 23 Australian experts in fields related to SWB [41]. The following definition was derived, in which spiritual health is described as: A, if not the, fundamental dimension of people"s overall health and well-being, permeating and integrating all the other dimensions of health (i.e., physical, mental, emotional, social and vocational). Spiritual health is a dynamic state of being, shown by the extent to which people live in harmony within relationships in the following domains of spiritual well-being: Personal domain-wherein one intra-relates with oneself with regards to meaning, purpose and values in life. Self-awareness is the driving force or transcendent aspect of the human spirit in its search for identity and self-worth.
Communal domain-as shown in the quality and depth of interpersonal relationships, between self and others, relating to morality, culture and religion. These are expressed in love, forgiveness, trust, hope and faith in humanity.
Environmental domain-beyond care and nurture for the physical and biological, to a sense of awe and wonder; for some, the notion of unity with the environment. Transcendental domain-relationship of self with some-thing or some-One beyond the human level (i.e., ultimate concern, cosmic force, transcendent reality or God). This involves faith towards, adoration and worship of, the source of Mystery of the universe [41].
This definition outlines the inter-connective and dynamic nature of spiritual health, in which internal harmony depends on intentional self-development, coming from congruence between expressed and experienced meaning, purpose and values in life at the Personal level. This intentional self-development often eventuates from personal challenges, which go beyond contemplative meditation, leading to a state of bliss, perceived by some as internal harmony.
Morality, culture and religion are included in the Communal domain of spiritual health, in accord with Tillich"s view that the three interpenetrate, constituting a unity of the spirit, but "while each element is distinguishable, they are not separable" [56]. Tillich adds that separation of religion from morality and culture yields what is generally called "secular". In the work presented here, religion (with small "r") is construed as essentially a human, social activity with a focus on ideology and rules (of faith and belief systems), as distinct from a relationship with a Transcendent Other such as that envisioned in the Transcendental domain of spiritual health. It is acknowledged that the ideals of most religions would embrace relationships with both the horizontal (Communal) and vertical (Transcendental) aspects, but the two have been separated, for emphasis, in the following model. Table 1 depicts the dynamic interrelationships between the component parts of the definition of spiritual health given above. Here, each DOMAIN of spiritual health is comprised of two aspectsknowledge and inspiration. The Knowledge aspect (written in bold type under the heading for each DOMAIN) provides the cognitive framework that helps one to interpret the Inspirational or transcendent aspect of spiritual health /well-being (in italics), which is the essence and motivation of each domain of spiritual health (SH). Here we see the metaphorical "head" and "heart" working together, striving for harmony. Once achieved, this harmony is reflected in expressions of well-being, examples of which are presented at the bottom of each DOMAIN in Table 1.

A Model of Spiritual Health
In this model, people"s worldviews are seen to filter the knowledge aspects of spiritual health, while their beliefs filter the inspirational aspects. A key feature of this model is the partially distinct nature of, yet interrelation between, the "knowledge" and "inspirational" aspects of each of the four domains of spiritual well-being.
The quality, or rightness, of the relationship that a person has with themselves, with others, with nature and/or with God constitutes a person's spiritual well-being in those four domains. An individual's spiritual health is indicated by the combined effect of spiritual well-being in each of the domains that are embraced by the individual. Spiritual health is thus enhanced by developing positive relationships in each domain, and can be increased by embracing more domains. The notion of progressive synergism is proposed here to help explain the interrelationship between the four domains of spiritual well-being. As the levels of spiritual well-being in the domains are combined, the result is more than the sum of the quality of relationships in the individual domains. Progressive synergism implies that the more embracing domains of spiritual well-being not only build on, but also build up, the ones they include.
When relationships are not right, or are absent, we lack wholeness, or health; spiritual disease can grip our hearts. The quality of relationships in each of the domains will vary over time, or even be non-existent, depending on circumstances, effort and the personal worldview and beliefs of the person. Not many people hold the view that they are sole contributors to their own spiritual health (relationship in the Personal domain only); most at least include relationships with others in their world-view of spiritual well-being. The notion of progressive synergism implies that development of the Personal relationships (related to meaning, purpose and values for life) is precursor to, but also enhanced by, the development of the Communal relationships (of morality, culture and religion).
Ideally, a person"s unity with the environment builds on, and builds up, their Personal and Communal relationships. Cultural differences apply here. Many people from Western societies do not hold the same view of environment as other people groups, for example First Nations people and adherents to many Eastern religions. Westerners are more likely to have some awareness of environmental concerns rather than the deep connection or a sense of wonder and oneness with the environment that is evidenced in some non-Western cultures.
The relationship of a person with a Transcendent Other embraces relationships in the other three domains. For example, from a theistic point of view, a strong faith in God should enhance all the other relationships for SWB, reflecting Macquarrie"s assertion, "As persons go out from or beyond themselves, the spiritual dimension of their lives is deepened, they become more truly themselves and they grow in likeness to God" (cited in [57]).
People known as Rationalists would be willing to embrace the knowledge aspects of "spiritual" well-being, but not the inspirational aspects. These people would hold atheistic or agnostic worldviews.
Just as spiritual health is a dynamic entity, it is similarly through the challenges of life that the veracity and viability of a person"s worldview and beliefs will be tested, together with the quality of their relationships in the domains of SWB considered to be important. Spiritual health will be enhanced or emaciated. When we have ways of assessing the current state of a person"s spiritual health, as clinician, friend, counselor, parent, or teacher, we have a basis from which to help nurture relationships appropriately, to enhance our own, and others", spiritual well-being.

Final Comments
The four domains model of spiritual health and well-being purports to provide a clear conceptual framework which embraces the diversity of views expressed in discussions of spirituality in the general populace. SWB is the expression of the underlying state of spiritual health of a person. As such, spiritual health, spiritual well-being and the composite, spiritual health and well-being, all encompass the same field of enquiry, namely the quality of relationships people have with themselves (Personal domain), with others (Communal domain), with the environment (Environmental domain) and/or with a Transcendent Other (Transcendental domain).
Spiritual well-being should not be confused with positive psychologists" notion of psychological well-being. Although these two aspects of well-being are inter-related, psychological well-being focuses on headspace (i.e., study of the psyche or mind). The four domains model asserts that spiritual well-being encompasses the psychological/cognitive, or knowledge, component of each domain, but goes beyond the head to the very heart or core of a person through in-depth relationships (what is referred to here as inspiration). For example, a few labels of Ryff"s Psychological Well-Being scales [58] bear resemblance to some detail in the 4D Model of SH/WB (spiritual health/well-being), but there are different emphases in the content of each factor. It is also worth noting that the factorial validity of Ryff"s scales has been questioned because of considerable cross-loading of items on a variety of factors [59][60][61]. Empirical studies on a spiritual well-being questionnaire, called SHALOM [62], have provided evidence to support the factorial independence of SWB from personality [63], and mental, physical and emotional well-being [64]. SHALOM was based on the 4D model of SH/WB.

Applications of the 4D model to measurement of SH/WB
This 4D model has been employed as the theoretical foundation for a number of empirical studies, investigating spiritual health and well-being of youth in the U.K. [65], and Australia [66]. Approximately 190 available spirituality and spiritual health and well-being measures were critiqued against the four domains model [67]. That work showed the extent to which available spiritual well-being questionnaires address the quality of relationships in each of the four domains. Very few instruments were found to provide a balance of items across the four domains. This four domains model of SH/WB also provided the base for the development of well-balanced SWB measures, namely Spiritual Health in Four Domains Index [68], teachers" SWB [69], the Spiritual Well-Being Questionnaire/SHALOM for adolescents and adults [63,70], and Feeling Good, Living Life, a spiritual well-being questionnaire for primary school children [71]. The model also gave significant structure to the Quality Of Life Influences Survey, which integrated resilience theory with the four domains model of SH/WB to assess the level of support that young people gain from home, school, church and the wider community in nurturing relationships which enhance their SWB [67,72].