Bailly et al. (Reference Bailly2018) examined the trajectory of spirituality in a cohort of 567 non-institutionalized older adults living in Tours, France, during a period of five years. The measurements for spirituality (Daily Spiritual Experience Scale, DES), social support (Satisfaction with Social Support subscale of the Duke Social Support Index), and accommodative tendencies (Flexible Goal Adjustment) were longitudinally collected at three time points (2007, 2009, and 2012). The results of the study confirmed some expected observations, such as higher levels of spirituality among religious older adults when compared with the ones without religion, and older women reporting higher levels of spirituality than older men. But the most interesting finding was the observation that the measured levels of spirituality among older adults remained stable during this five-year period. Based on a growing number of studies and theories of aging suggesting that the levels of spirituality increases during a person's lifetime, one would expect an increase in the levels of spirituality along the study follow-up. The authors, however, interpreted the stable level of spirituality informed by the participants as having already reached a relatively high mean rating score of spirituality at baseline. From the beginning of the trail, many participants expressed self-contentment and reported having found meaning in their lives. Moreover, the responders had, in general, more years of education than expected for people in their age group, lived at home independently with a good self-health evaluation, had relatively fewer diseases, and a good perception of financial satisfaction; these characteristics perhaps make this group not representative of the French general population in the same age bracket.
One of the factors related to changes in attitudes leading to a spiritual transcendence is the transformation of the environment and/or health status. Most of the publications on spirituality investigate the relationship with health and the levels of spirituality in the context of a patient's disease. As the authors rightly commented, more than age per se, it may be the way age-related changes in health functioning, social losses, and approaching death are dealt with that could be one of the relevant factors for the development of spirituality among older adults. For example, the respondents of this study continue having a relatively stable daily routine and modus vivendi and presumably even in difficult times.
Spirituality and health (mental and physical) is a fascinating area that started to develop as a scientific field only at the beginning of the XXI century (Koenig, Reference Koenig2008). Bailly's original cohort is an example of it. Their cohort started in 2001, with evaluations every two years, but only included the measuring of spirituality, in 2007, missing these measurements in the assessment waves of 2001, 2003, and 2005. The growing interest in this area is illustrated by the increasing number of publications reporting a positive correlation between spirituality and better outcomes in prevention, healing, and coping with diseases. At the same time, we still know very little about the mechanisms that underlie these interactions.
Another important point raised by Bailly and her coauthors concerns the definition of spirituality. The traditional–historical meaning defines a “spiritual person” as a deeply religious individual, but in the last 20–30 years the definition of spirituality became quite a broad and diffuse term that differs according to the individual user, and may signify, for instance, the superficially religious person, the religious seeker, the seeker of well-being and happiness, or the completely secular person (Koenig, Reference Koenig2008). As a consequence of this “polymorphic” characterization of spirituality, there is little agreement today within the academic community upon a common definition for spirituality. A number of scales, indexes, and questionnaires have been developed to measure spirituality in research. However, those measurements from research data reflect different concepts and therefore lead to different valuations with limited overlap between them, making the comparison of the results of two independent studies many times very difficult or even impossible. As an example, the DES used by Bailly et al. in this paper measures a very broad concept of spirituality, which includes measures of peacefulness, harmony, and other positive experiences. However, with this definition, an individual with depression or anxiety who rarely has such feelings of harmony and peacefulness would have difficulties to identify with it. Again, when the authors compare their results with another rare longitudinal study (Wink and Dillon, Reference Wink and Dillon2003), they found out that both studies used a distinct method for measuring the levels of spirituality and, therefore, the results are not readily comparable. Wink and Dillon (Reference Wink and Dillon2003) used answers to open-ended questions for spirituality, which were then coded between 1 and 5, and later those ratings were validated against the Religion Index for Psychiatric Research.
The current problem that arises from not having a consensus definition for spirituality could be compared to the difficulties that researchers had to classify psychiatric disorders before the development of operational criteria in psychiatry, in the 1960’s and 1970’s, when it was difficult to compare the results of clinical studies in a variety of psychiatric disorders. Such a methodological development is also required in the field of spirituality. However, there is an advantage from the clinical perspective to use a broad concept of spirituality, since it also expands eligibility, i.e. every person is more or less spiritual – including atheists. Patients can define whatever spirituality means to them and the health worker will address it according to each patient's definition. Nonetheless, the use of this universal characterization would make research on the relationship between spirituality and health very difficult, since all participants will be spiritual (but to different degrees) (Peteet et al., Reference Peteet, Zaben and Koenig2018). An alternative definition of the term spirituality to be used in research, according to Koenig, would be to apply it only to a subgroup of deeply religious people: the ones who have dedicated their lives to the service of their religion and to their fellow humans, and whose lives exemplify the teachings of their faith and traditions (Koenig, Reference Koenig2008). This narrow definition would lead to the exclusion of those groups of people who still consider themselves spiritual but do not lead such spiritually dedicated lives. To include the term religion, on the other hand, has its advantages: is a more distinct construct with multiple dimensions, which that can be measured and distinguished from one another; here is very little disagreement between investigators on the definition of this term.
In conclusion, the need for more studies is clear, especially to understand the effects and mechanisms of action/relationship of spirituality and health/well-being. Despite there being few methodologically sound studies – particularly, longitudinal ones like the study presented here by Bailly et al. – it would be very welcome (and challenging) for investigators to reach a common denomination for spirituality, i.e. to have a consensual agreement in order to establish a set of core or minimal standardized measurements of spirituality to be used in future research, enabling the comparison of results across different groups, settings, and cultures. In this way, it would be possible to shorten the time and lessen the resources to identify the possible mechanisms of action of this proposal.
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Bailly et al. (Reference Bailly2018) examined the trajectory of spirituality in a cohort of 567 non-institutionalized older adults living in Tours, France, during a period of five years. The measurements for spirituality (Daily Spiritual Experience Scale, DES), social support (Satisfaction with Social Support subscale of the Duke Social Support Index), and accommodative tendencies (Flexible Goal Adjustment) were longitudinally collected at three time points (2007, 2009, and 2012). The results of the study confirmed some expected observations, such as higher levels of spirituality among religious older adults when compared with the ones without religion, and older women reporting higher levels of spirituality than older men. But the most interesting finding was the observation that the measured levels of spirituality among older adults remained stable during this five-year period. Based on a growing number of studies and theories of aging suggesting that the levels of spirituality increases during a person's lifetime, one would expect an increase in the levels of spirituality along the study follow-up. The authors, however, interpreted the stable level of spirituality informed by the participants as having already reached a relatively high mean rating score of spirituality at baseline. From the beginning of the trail, many participants expressed self-contentment and reported having found meaning in their lives. Moreover, the responders had, in general, more years of education than expected for people in their age group, lived at home independently with a good self-health evaluation, had relatively fewer diseases, and a good perception of financial satisfaction; these characteristics perhaps make this group not representative of the French general population in the same age bracket.
One of the factors related to changes in attitudes leading to a spiritual transcendence is the transformation of the environment and/or health status. Most of the publications on spirituality investigate the relationship with health and the levels of spirituality in the context of a patient's disease. As the authors rightly commented, more than age per se, it may be the way age-related changes in health functioning, social losses, and approaching death are dealt with that could be one of the relevant factors for the development of spirituality among older adults. For example, the respondents of this study continue having a relatively stable daily routine and modus vivendi and presumably even in difficult times.
Spirituality and health (mental and physical) is a fascinating area that started to develop as a scientific field only at the beginning of the XXI century (Koenig, Reference Koenig2008). Bailly's original cohort is an example of it. Their cohort started in 2001, with evaluations every two years, but only included the measuring of spirituality, in 2007, missing these measurements in the assessment waves of 2001, 2003, and 2005. The growing interest in this area is illustrated by the increasing number of publications reporting a positive correlation between spirituality and better outcomes in prevention, healing, and coping with diseases. At the same time, we still know very little about the mechanisms that underlie these interactions.
Another important point raised by Bailly and her coauthors concerns the definition of spirituality. The traditional–historical meaning defines a “spiritual person” as a deeply religious individual, but in the last 20–30 years the definition of spirituality became quite a broad and diffuse term that differs according to the individual user, and may signify, for instance, the superficially religious person, the religious seeker, the seeker of well-being and happiness, or the completely secular person (Koenig, Reference Koenig2008). As a consequence of this “polymorphic” characterization of spirituality, there is little agreement today within the academic community upon a common definition for spirituality. A number of scales, indexes, and questionnaires have been developed to measure spirituality in research. However, those measurements from research data reflect different concepts and therefore lead to different valuations with limited overlap between them, making the comparison of the results of two independent studies many times very difficult or even impossible. As an example, the DES used by Bailly et al. in this paper measures a very broad concept of spirituality, which includes measures of peacefulness, harmony, and other positive experiences. However, with this definition, an individual with depression or anxiety who rarely has such feelings of harmony and peacefulness would have difficulties to identify with it. Again, when the authors compare their results with another rare longitudinal study (Wink and Dillon, Reference Wink and Dillon2003), they found out that both studies used a distinct method for measuring the levels of spirituality and, therefore, the results are not readily comparable. Wink and Dillon (Reference Wink and Dillon2003) used answers to open-ended questions for spirituality, which were then coded between 1 and 5, and later those ratings were validated against the Religion Index for Psychiatric Research.
The current problem that arises from not having a consensus definition for spirituality could be compared to the difficulties that researchers had to classify psychiatric disorders before the development of operational criteria in psychiatry, in the 1960’s and 1970’s, when it was difficult to compare the results of clinical studies in a variety of psychiatric disorders. Such a methodological development is also required in the field of spirituality. However, there is an advantage from the clinical perspective to use a broad concept of spirituality, since it also expands eligibility, i.e. every person is more or less spiritual – including atheists. Patients can define whatever spirituality means to them and the health worker will address it according to each patient's definition. Nonetheless, the use of this universal characterization would make research on the relationship between spirituality and health very difficult, since all participants will be spiritual (but to different degrees) (Peteet et al., Reference Peteet, Zaben and Koenig2018). An alternative definition of the term spirituality to be used in research, according to Koenig, would be to apply it only to a subgroup of deeply religious people: the ones who have dedicated their lives to the service of their religion and to their fellow humans, and whose lives exemplify the teachings of their faith and traditions (Koenig, Reference Koenig2008). This narrow definition would lead to the exclusion of those groups of people who still consider themselves spiritual but do not lead such spiritually dedicated lives. To include the term religion, on the other hand, has its advantages: is a more distinct construct with multiple dimensions, which that can be measured and distinguished from one another; here is very little disagreement between investigators on the definition of this term.
In conclusion, the need for more studies is clear, especially to understand the effects and mechanisms of action/relationship of spirituality and health/well-being. Despite there being few methodologically sound studies – particularly, longitudinal ones like the study presented here by Bailly et al. – it would be very welcome (and challenging) for investigators to reach a common denomination for spirituality, i.e. to have a consensual agreement in order to establish a set of core or minimal standardized measurements of spirituality to be used in future research, enabling the comparison of results across different groups, settings, and cultures. In this way, it would be possible to shorten the time and lessen the resources to identify the possible mechanisms of action of this proposal.