Relational spirituality and quality of life 2007 to 2017: an integrative research review

There is a growing body of research that promotes spirituality as an internal locus of control in terms of regulating negative emotional states [1, 2]. These studies assert spiritual activities as helpful means of attaining self-transcendence and coping with life stressors. Chaney and Southwick [3] made such a claim in their book Resilience, describing how people overcome life’s challenges by searching for connectedness and seeking comfort in spirituality based on what is transcendent. Spirituality differs in many ways from ‘religiosity/religiousness’. The former emphasizes the personal character of spiritual transcendence in terms of the changing, developing constitutive trait and dynamic attribute one has from cradle to grave [4], whereas the latter is considered in terms of the institutionalised character of religious beliefs. In this paper, we refer to relational spirituality (RS) as the former—as an important platform for personal development that draws people to forge meaning in life through spiritual transcendence [5]. Piedmont [6] ascribes a special role to RS with regards to spiritual transcendence, arguing that it should be considered as the sixth domain of personality since it represents a broad-based motivational domain and language term (e.g., universality, prayer fulfilment, and connectedness) that capture adaptively important psychological qualities that are comparable to The Big Five personality: Neuroticism, extraversion, openness to experience, conscientiousness, and agreeableness. Several other authors have weighed in on the concept of spirituality and provided different definitions. For example, as “the personal quest for understanding answers to ultimate questions about life” [7], “an organised system of beliefs and symbols designed to facilitate closeness to the sacred” [8], an aspect of quality of life [9, 10], “as subjective belief systems that incorporate self-awareness and reference to a transcendence dimension” ([11]: 288), as a perceived relationship with a ‘divine attachment figure’ [12], and the “unique window into attachment processes in adulthood” ([13]: 917).

In examining the above definitions, it seems that RS is mostly discussed within two categories: (1) as a cognitive appraisal of existential issues and (2) as the experiential knowledge of the divine [14]. The former recognises RS in connection to the cognitive appraisal of stressors and interpersonal struggles when the individual is in a relationship with the sacred and often referred to as the ‘head-knowledge of God’ [15]. The latter focuses more on the ‘heart-knowledge of God’ [15] in its application of attachment theory and developmental psychology. Both perspectives of RS draw largely from a relational perspective [16], and will be used for guiding this review in terms of the conceptualisation of RS as implicit relational and experiential representations of the sacred that are essential to faith development, spiritual transcendence, and appraising life stressors and QoL.

QoL is used in health-related research to study life satisfaction and the extent to which an individual evaluates their holistic life experience from a subjective point of view [67]. It is a broad-ranging concept “affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment” ([75], p.1404), and covering several aspects of individual needs satisfaction that constitute aspects of life that contribute to overall experience.

QoL has much to do with individual satisfaction with key areas of life that enhance a general sense of physical and emotional well-being. Research shows that this concept is applicable for adolescents [17], women [18], migrants [19, 20], older adults [21], religious people [22], non-religious groups [23], among others. Studies have also shown that QoL has much broader implication for health care [24] and life satisfaction [25]. As a context-specific construct [26], measures of QoL are used to assess the individual evaluation of their health-related outcomes, and in recent cases, modified for assessing disease-specific QoL outcomes. These include, HIV/AIDS-targeted QoL [27], geriatric quality of life-dementia (GQOL-D) [28], QoL—alzheimer disease scale (e.g., [29]), and heart-disease specific QoL scale (e.g., [30]).

Researchers recognise QoL as a multidimensional concept in terms of its subjective, objective, and culture/spirituality components, while at the same time identifying the relationship between these aspects (e.g., [9, 25, 31, 32]). Marshall [33] and Rule [34] mention income, education, and housing as examples of objective aspects of QoL. Collinge et al. [35], along with O’Connell and Skevington [36], spirituality’ as/spirituality’ as an important aspect of QoL.

The subjective satisfaction aspect is the most researched aspect in QoL literature, as it mostly assesses physical health, psychological health, social relationship health, and environmental health (e.g., [31, 35]). While QoL is likely to be related to individual contexts, as well as to the subjective satisfaction aspects, we argue that the spiritual aspect may be related to beneficial health outcomes and should be positioned as an additional conceptualisation of RS. A similar proposition can be seen in other studies (e.g., [9, 10]), concluding that one’s spiritual well-being is an important aspect of QoL since it influences the subjective domain. The concept of QoL is continuum in nature since it considers overall life satisfaction that is connected with the individual’s physical, mental, environmental, social, and spiritual functioning. Nonetheless, QoL is constantly changing, depending on the lived experience resulting from several factors that control one’s life, especially ones related to self-transcendence and the connection to the sacred [37].

Based on this theoretical and empirical background, RS may be perceived as a relational dynamic and an implicit relational representation (e.g., [16]) that highlights a perspective which seeks to understand the human need for an object of devotion and spiritual functioning, guiding the quest for meaning and attachment to the sacred (e.g., [16, 38, 39]), in terms of its association with QoL. This relational perspective is largely drawn from the works of object relations theorists (e.g., [40‐42]), and recently, RS has been theorized from an attachment theoretical perspective [16]. Although the original thesis on attachment proposed by Bowlby [43] largely assumed an evolutionary perspective and its manifestation in parent-child relationships, he also noted that attachment processes may have a broad implication for psychological development throughout a person’s life. Cicirelli [44] studied lifespan attachment developments among older adults, with empirical evidence supporting a strong sense of attachment to God among older adults. Other studies (e.g., [16, 37, 45]) have proposed an idea of a RS that can be interpreted in terms of an attachment-based model, one defined as a perceived relationship with the sacred. Granqvist and Kirkpatrick [13] refer to this as the maturational aspect of attachment development resulting from the increased ability in core specific cognitive tasks such as processing speed (e.g., [46]), voluntary response suppression (e.g., [47]), and working memory (e.g., [48]), which are usually immature in childhood [49].

Several studies (e.g., [13, 16, 50]) have integrated the principles of Bowlby’s [43] attachment theory into the study of religious and spiritual development. Aspects of RS as an attachment-based model of spiritual development have been reported in studies (e.g., [37]) suggesting that attachment relational variables consistently emerge as predictors of various outcome variables that match spiritual and psychological well-being. For example, Augustyn et al. [37] report that RS (through spiritual practices such as prayer, awareness of God, spiritual meaning, and forgiveness) strengthens the link between spiritual well-being and psychological outcomes. Bradshaw and Kent [22] report that RS in terms of an attachment connection to the sacred strengthens the relationship between prayer and psychological outcomes. However, Sloan et al. [51, 52] have criticized empirical studies’ claim of health benefits associated with religiosity, arguing that about 83% of the studies making such claims were methodologically flawed and misrepresented data; thus, there is no empirical basis for asserting that religious involvement is related to positive health outcomes. Miller and Thoresen [53] have argued that the consistency of empirical reports on the effects of spirituality on health-related outcomes point toward salutary effects. Other studies (e.g., [54, 55]) have linked adverse effects to beliefs in a punitive divine figure, extrinsic religiousness, and upholding a religious moral standard.

Recent literature reviews (e.g., [56, 57]) have shown evidence of positive links between spirituality/religiosity and QoL, albeit these studies were mostly limited to organizational religious affiliation among elderly adults in South America (e.g., [56]) and how religious participation correlates to mental disorders (e.g., [57]). These two reviews found empirical support for the association between several aspects of religiosity and health and mental health outcomes. For example, Bonelli and Koenig’s [57] review provides evidence to show that religious involvement is associated with better mental health outcomes in 72.1% of the studies, while Abdala et al. [56] concluded, based on the positive association in 75% of the studies, that the religious affiliation of elderly South Americans is associated with better outcomes of quality of life. However, it seems that the conceptualisation used in these studies differ from that offered in our proposed study in terms of our definitions of RS and QoL. There appears to be no recent review study which appraises RS as (1) a domain of QoL that relates to spiritual functioning, and (2) a relational dynamic in terms of the relationship connection with a symbolic sacred object or figure, either through spiritual transcendence, prayer fulfilment, attachment to God, or other implicit relational conduits. In addition, while much has been done in promoting RS as an aspect of QoL, little is known about the broader perspective regarding the association between RS and QoL in disease-specific medical-health research. With debate around the salutary effects of RS on health outcomes, this paper contributes to the ongoing debate on how RS functioning is associated with perceptions of QoL. This study will thus: (1) review recent available data that identify and appraise the links between RS and QoL; (2) determine how RS is perceived/positioned in relation to QoL; (3) identify emerging themes emerging from the association between RS and QoL and (4) discuss the results and implications of the association between RS and QoL.

All selected studies have been summarised in Table 1, showing evidence of positive (***), indirect (#*), negative association (**), and lack of association (#) between RS and QoL. A total of 132,053 participants were involved across the 20 selected studies. In particular, 70% of the studies were conducted with participants suffering from one form of mental or physical health-related challenge which included: 499 terminally ill elderly persons [62], 362 Muslim patients undergoing haemodialysis [63], 111 individuals with dementia [29], 44 couples (dyads) following a first-time cardiac event [30], 294 patients following an open-heart surgery [64], 63 outpatients with schizophrenia [65], 1024 older American adults [22], 8344 Norwegian cancer patients [66], 481 terminally ill cancer patients [67], 198 HIV/AIDS infected patients [27], 678 military veterans with PTSD [68], 8405 cancer survivors [69], 75 ALS patients and their caregivers (dyads) [70], and 162 Iranian women with breast cancer [71]. The remaining 30% were conducted with other study populations, including 87 college students [72], 1287 older Jews in Europe [73], 208 Jewish men and women [74], 274 older Koreans living alone in Chuncheon [28], 107, 683 older adults in a national health survey [75], and 1774 American adults [76].

All the 20 studies selected for the review employed quantitative research designs, while one study adopted a mixed-methods design (i.e., [29]). With the exception of a few prospective cohort studies (e.g., [22, 62, 67, 75]), for the most part a cross-sectional design was used.

Among the most important findings has been the fairly consistent positive correlation between RS and QoL. This finding contrasts with the classical thesis which underestimates the continuing social influence of religion on healthcare, as religion can sometime be perceived as involving moral restrictions that contribute to guilt and, hence, negative emotions that predispose to depression and poor QoL [57]. As presented in Tables 1 and 2, our review of the association between QoL and RS reveals the following:

These findings highlight the significance of RS as an important component for negotiating day-to-day QoL. While most of the studies identify RS as a form of coping strategy with health benefits, in 75% of the reviewed studies (*** and #*), others showed the role of perceived social support in enhancing the effects of RS on QoL via caregivers who are religious [29], being part of a faith community [64], or seeking spiritual support and collaborative religious coping through community prayer services [65]. Psychosocial activities that include practices of RS became a helpful coping recourse for achieving better QoL and played a major role in the way participants experienced spirituality and negotiated their QoL.

The role of prayer in moderating the effects of RS is also noteworthy in the IR (e.g. [22, 64, 75]). Prayer was often used by the participants as a spiritual conduit for assessing the sacred and an important aspect of RS, with studies referring to ‘prayer’ as a form of religious coping behaviour. Overall, prayer was the most commonly used aspect of religious coping behaviour among older adults, and was positively associated with cognitive, behavioural and psychological changes.

However, religious coping behaviour may not be used as a coping therapy in every context, as demonstrated in studies conducted within the illness context (e.g., Miller et al.; [29, 30, 71, 75]), secular context (e.g., [66]), and religious context (e.g., [28, 73]), which highlight this shift in perspective. First, we see this shift in health-specific studies (except for [74]) reporting on a variety of patients (e.g., dementia, cardiac arrest, and breast cancer patients), which found that RS was not related to physical health QoL. This suggests that even though RS may have provided comfort, it does not necessarily change the physical health status of the patients. Second, we also found that the same applies for participants in the secular Norwegian context (e.g., [66]) whose RS did not translate to better health outcomes.

Third, another study (e.g., [28]) also support that the effects of RS on QoL is context-driven, and may be different depending on individual religious background, or how RS is practiced as in the case of Jewish participants (i.e., [73]) whose integration into the Synagogue community was a significant predictor of better physical health than their prayer life. Moon and Kim reported that spirituality accounted for the variance in QoL among Korean Protestants and Catholics, but not for the Buddhist sample. One interpretation given for this result was that “Buddhists usually attend religious meetings less regularly than Protestant or Catholics” ([28]: 298), and that Buddhists had lower RS outcomes than Protestants and Catholics. These different perspectives suggest varying accounts of the salutary effects of RS on QoL, which seem to vary based on the individual’s social context. In other words, even though RS may have provided symbolic beneficial experiences (e.g., a sense of meaning, social support, and spiritual connection) that are good for negotiating QoL, these health benefits can also be because of other sources such as the social context that affect the spiritual role. To better understand the role of RS on health outcomes, we need to consider the “ways in which culture influences religion’s expression of the spiritual” ([77]: S54).

This IR has shown the discrepancies in themes used to describe RS and QoL over the last 10 years. Table 2 shows the different themes associated with all the studies, although the various conceptualisations still point to some sort of relational dynamics that involve attachment to the sacred and aspects of spiritual functioning. Of the 20 studies identified, none exclusively used the term “relational spirituality”, even though the conceptualisations bear semblance with our definitions of RS. The specific terms used in describing RS in most of the studies are “religion”, “religiosity”, “faith”, “spirituality”, “complementary therapy”, “private prayer”, “religious coping”, “attachment to God”, “seeking God’s help”, “Jewish spirituality”, and “images of God.” In using these terms, most of the studies failed to clearly define RS as a relational dynamic that deals with attachment to the sacred. Instead, they used measures and categorical variables that assess aspects of RS that involve intrinsic aspects, such as meditation, prayer, and attachment to a higher power. Conceptually, RS continues to change while retaining the relational dynamic of its tradition.

At present, an attachment-based model of RS, though achieved through prayer and other religious-related activities with others and positive perceptions of the divine, seems to be the overriding theme in studies examining RS and QoL over the past 10 years. God image representations and trust/mistrust in God as seen in the works of Krause et al. [76] and Krumrai et al. [74] also re-emphasize similar relational perspectives, along with other studies which demonstrate a similar attachment-religion connection. These conceptualisations are likely because of the operation of Bowlby’s [43] proposed internal working models of attachment which, even though developed during the early years of life, remain active in one’s lifespan attachment development [44] and determine the extent to which a potential object of attachment is experienced, even in the RS context (e.g., [13, 16, 37]).

Long [78] found a significant correlation between measures of attachment to God RS, parental bonding, and religious coping. The ability to regulate emotional states in RS contexts due to the internal working model of the attachment system may be the very key to unfolding spiritual coping model for negotiating QoL when drawn to the sacred. The direct and/or indirect associations with QoL suggest the activation of a spiritual coping model that helps in relational processes and in dealing with stressful life situations, based on the connection to what is transcendent. The idea of the transcendent can take different directions, as shown in our IR as spiritual functioning, forgiving self, forging a meaningful relationship with others, and building a sense of attachment to God. This framework of a spiritual coping model is more active in the third aspect in terms of the association between RS and QoL.

The limitations across these 20 studies include the following: mostly focused on older adults with younger people unrepresented; mostly quantitative design which lacks in-depth perspectives capture; mostly cross-sectional studies with limited causality examination; lack of QoL specific measures; and the use of categorical rather than continuous operationalization of RS and QoL.

Although study findings show evidence of the links between RS and QoL in medical-health research for the last decade, we were unable to retrieve some studies related to RS and QoL during our initial literature search due to indexing problems and date of publication. After conducting a manual search of related articles reporting on the links between RS and QoL, we found some related studies (e.g., [16, 37, 79‐83]), but were not able to report them because they were either not indexed in the selected databases (i.e., PubMed, ScienceDirect, and PsycINFO), using a different conceptualisation of QoL (e.g., levels of emotional distress), or were published after our deadline of literature search (i.e., March 2017). However, the results from these “missing” studies also support the salutary effects of an attachment-based model of RS on levels of psychological wellbeing. We are confident that the studies selected for this IR are good representatives of relevant studies published within the past 10 years demonstrating how RS has been perceived/positioned in relation to QoL.

The findings from this review have broad implications for the role of RS in relation to QoL in medical-health contexts. Existing models of RS coping are better understood by integrating spiritually-based perspectives that include identifying aspects of faith and individual life that may be understood as a contextual ‘biopsychosocial spirituality’ [64]. Greater awareness of the importance of RS among healthcare professionals may improve cultural competence in healthcare services and community support in addressing patient’s spirituality, and strengthen collaborative relationship between healthcare and faith-based organizations. Further research on the relation between RS and QoL should be conducted across different population and health contexts.