Physical, mental, and spiritual health: Triad of happiness and tranquility. Keynote address presented at "International Conference of Health Psychology: Issues and Challenges. Department of Psychology. GC University Lahore, Pakistan (26-28 April, 2017).

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Physical, mental, and spiritual health: Triad of happiness and tranquility
Prof. Dr. Syed Ashiq Ali Shah
Department of Psychology
Kwantlen Polytechnic University
Surrey, British Columbia
Canada
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The following definition of health was developed at the International Health Conference of 61
countries organized by the World Health Organization in 1948.
“A state of complete physical, mental, and social well-being, and not merely the absence of
disease or infirmity. The enjoyment of the highest attainable standard of health is one of the
fundamental rights of every human being, without distinction of race, religion, political beliefs or
economic and social conditions”. The WHO’s definition states that “there is no health without
mental health.”
The early definition of health in the Western countries was influenced by the ‘biomedical model’
(Kleinman, Eisenberg, & Good, 2006). This model viewed disease and ill-health as resulting
from infections, genetic or developmental abnormalities or physical injury. The treatment
focused on curing the biological aspects of the disease. According to this model distress has no
intrinsic value and so it must be dealt with medication and the technical interventions. Later,
researchers criticized the biomedical model and proposed that health and disease have
psychological and social dimensions in addition to the biological and replaced the biomedical
model with the ‘biopsychosocial’ model (Engel, 1977).
The biopsychosocial model of health incorporates three dimensions, namely, the biological (e.g.,
genetic, biological, and physiological functioning of the body), social (e.g., lifestyles and
activities, quality of relationships, living conditions such as poverty), and psychological (e.g.,
beliefs and attitudes toward health, emotions, feelings of despair, positive thinking).
Although, biopsychosocial approach of health psychology positions itself at the intersection
between biological and social factors in health and illness (Kazarian & Evans, 2001), most
theories in health psychology have been derived from mainstream psychology and have adopted
psychology’s assumptions, methods and problems somewhat uncritically (Marks, 1996). This
approach, therefore, has an individualistic bias and broadly reflects Western values. Furthermore,
although health psychology claims to reject the biomedical approach, in clinical practice it rarely
departs from traditional medical approaches (Marks, 1996).
There have been attempts to overcome these limitations by, for example, integrating health
psychology and cultural psychology (Kazarian & Evan, 2001). The advent of a critical health
psychology has recently challenged and sought to depart from the limitations of health
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psychology, and is believed to be central to an emerging cultural health psychology
(MacLachlan, 2004).
The emerging areas of cross-cultural and cultural psychology have brought to the spotlight the
importance of cultural and religious-spiritual beliefs in the physical and mental health of people.
A number of traditional Asian and African societies believe that illness is the result of
supernatural phenomena and promote prayer or other spiritual interventions that counter the
presumed disfavor of powerful forces (Boyd-Franklin, 2010; Siddiqui & Shah, 1997). There are
several important cultural beliefs among these societies which emphasize the importance of
cultural and religious practices and the role of the family and social connections in the physical
and mental health (Abu Raiya, & Pargament, 2010; Azhar, & Varma, 2000; Razali, Aminah, &
Khan, 2002). These societies assign considerable importance to maintaining harmony within the
family and the society and discourage conflict and direct confrontation.
The biopsychosocial model, like the definition of health by WHO (1948) is deficient as both
ignore the spiritual and transcendence dimension of health. In the tradition of Muslim
sociocultural system the definition of health also includes the spiritual aspect of the person and
not only the mind and body called the ‘holistic view of health’ (Shah, 2005). A holistic view of
health encompasses a state of ‘homeostasis between the mind-body and the spiritual aspects of
human beings. An imbalance or disturbance of homeostasis can result in illness and disease.
Most traditionally religious cultures also emphasize spiritual health. Health professionals from
these cultures have pointed out that while WHO definition of health includes physical, mental
and social welfare it ignores the spiritual wellbeing of individuals (Yurkovich & Lattergrass,
2008). As good diet and happy daily living are related to physical and mental health, a stable
spiritual association of the individual to the divine is a key to a peaceful soul and psyche, i.e.,
feeling connected to and in balance with the spiritual world is a foundation of both good mental
and physical health.
Mental and spiritual problems can significantly affect people’s quality of life with serious
consequences to society. The focus of this paper is on the holistic view of health which
incorporates the physical, mental and spiritual health of people within their cultural context. We
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believe that the three component of health are closely linked and they reciprocally impact one
another.
First, people with chronic physical conditions are at risk of developing poor mental health. Poor
physical health can cause worries, anxiety, depression, stress, lack of concentration and lack of
spiritual involvement.
Second, people with serious mental health conditions are at high risk of experiencing chronic
physical conditions. Poor mental health can weaken the immune system making the person
vulnerable to diseases and viral infections.
Third, lack of spiritual involvement is a risk factor for mental health problems (isolation,
hopelessness, lack of purpose and patience) and increased vulnerability to physical illness (poor
hygiene, lack of self-discipline). Spiritual decadence can disturb healthy mind-body balance
through negative thoughts and deviation from the righteous deeds.
In order to argue for holistic notion of health, we first discuss the Western definition of health
and the inconsistencies and biases in its delivery system. Then we will discuss the importance of
each component to the others and finally the reciprocal determinism of the three components.
Three Indicators of Worldwide Health
A criteria to examine health at the international level uses three indicators of health, namely, the
average life expectancy, infant mortality, and subjective well-being. Life expectancy and infant
mortality are objectively defined universal criteria. Life expectancy is the average amount of
years an individual is expected to live after her/his birth. Infant mortality is based on the number
of infant deaths per 1000 births. These two indicators of health differ from smaller to greater
extent internationally. The Western countries with higher socio-economic standing have the
longer life expectancies and lowest infant mortality rates compared to the developing or the
underdeveloped countries. Countries facing poverty and other hardships have the lowest life
expectancy and highest infant mortality rates (Matsumoto & Juang, 2017). A comparison of 223
countries in 2014 indicated the longest average life expectancy of 90 years in Monaco and the
shortest at 49 in Chad (CIA, The World Fact book, 2014). These discrepancies are attributed to
the availability or lack of resources and affluence or poverty that enable people to acquire the
resources in order to sustain optimum health. Such resources include proper nutrition and
hygiene, education, affordable housing, resources of health care which include hospitals, clinics,
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dentistry and other facilities. The poor and developing countries with low economic status do not
have the same means as other countries to be able to address important health issues such as
infectious diseases, common illnesses, injuries, and malnutrition. A large part of these
differences can be attributed to resources that ensure access to good nutrition, health care, and
treatment (Barkan, 2010). However, North-South divide or industrialized versus developing
countries is not a viable explanation for the staggering differences in life expectancy and infant
mortality but such difference also exist within highly industrialized countries which are self-
proclaimed champions of human rights and the democracy. The U. S., notoriously tops the list
where both gender and ethnicity are unevenly related to the life expectancy (Matsumoto &
Juang, 2017). Statistics show that the life expectancy for African American males is around 72
years, whereas European American females live on average till the age of 81 (National Center for
Health Statistics, 2011). African Americans also have the highest infant mortality rate in the U.
S., compared to other ethnicities (National Center for Health Statistics, 2011). What causes these
differences? An American survey of young African American males indicated that 1 of 3 attends
college, 3 of 4 are drug free, 5 of 9 are employed, and 7 of 8 became fathers as teenagers
(Martin, Harris, & Jack, 2015; Snyder & Dillow, 2015). The findings of the survey further show
that 1 out of every 3 African American men ends up in the prison system (Martin et al., 2015).
The social disparities in access to education, jobs, social support, and public health care seem to
be the main reason for this gap between the African Americans and the European Americans. The
efforts of the past U.S. government to lessen this gap are being systematically eroded by the
current far right U.S. administration of Trump.
The third measure of health, the subjective well-being is an individual’s self-perceived sense of
overall happiness and life satisfaction. Subjective well-being (SWB) focuses on one’s
perceptions and self-judgments of health and well-being and encompasses a person’s feelings of
happiness and life satisfaction (Diener & Ryan, 2009). To greater extent it is more subjective
compared to the life expectancy and the infant mortality rate.
A number of findings show that those who reported higher levels of subjective wellbeing were
less susceptible to the viruses (Cohen, Doyle, Turner, Alper, & Skoner, 2003), had stronger
immune systems, fewer heart attacks, and less artery blockage than those with lower levels of
subjective wellbeing (Diener & Biswas-Diener, 2008). Other findings suggest that higher
subjective wellbeing may lead to a longer life expectancy (Diener & Chan, 2011). One major
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reason for higher subjective well-being seems to be affluence, or material wealth. The wealthy
who enjoy greater household income report greater satisfaction with their financial situation,
enjoy greater purchasing power, and are more optimistic about the future (Diener Tay, & Oishi,
2013). Again, one notices awkward contrast between the haves and have-not regarding the
subjective wellbeing. The following diagram on the relationship between the subjective
wellbeing and the gross domestic product shows that many Latin American, Asian and African
countries with considerably low GDP report higher subjective wellbeing compared to a number
of Western and former East bloc countries with higher GDP. Most of these countries are
collectivist societies characterized by close family and communal relationships which are the
major sources of belongingness, harmony and social support. Research findings also indicate that
family and social support are crucial to one’s wellbeing and happiness (Gilmour, 2012; Maton &
Wells, 1995; Shafranske, 1996). This shows that affluence, money and material resources are not
the sole factor in satisfaction and happiness. There are some other interesting contrasts among
some neighbouring countries as well. While U.S. has higher GDP than Canada both are at the
same level of subjective wellbeing. Pakistan fares less well both on the GDP and subjective
wellbeing compared to its neighbours.
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A study by Ng and Diener (2014) shows that nonmaterial factors such as feeling respected,
having social support from friends and family, and feeling satisfied with the amount of freedom
one has in life, are all related to greater subjective wellbeing across many cultures. It is important
to note that individuals are unique and the factors that influence subjective wellbeing for one
person may entirely be different for another person. The higher mean subjective wellbeing scores
of Westerners compared to the Easterners may not be enough to explain the differences between
rich and the poor nations (Liu, Chiu & Chang, 2017). Thus, in addition to having enough
material resources, our sense of autonomy and connection to others are essential to our
happiness.
The above two pictures dispel the myth about the link between affluence and the subjective
wellbeing. These pictures are rather suggestive of the relationship between our thoughts, feelings
and relationship with others and our wellbeing and happiness.
The picture on the left of a poor young road construction worker from Pakistan shows a radiating
smile on her face which seems to be coming from the depth of her heart. Despite of facing
hardships of daily life in this tender age she responds to others with a smile. The reasons for her
cheerful behvaiour may be the family and the social support she enjoys and her innocence of not
harbouring any ill feelings towards others.
The picture on the right of a billionaire and the president of U.S., the abundance of money and
power seem not to be helpful to put a smile on the face of a bigot and racist whose heart is
darkened by the evils of arrogance, hatred and xenophobia.
Impact of physical health on mental health
There’s an old saying that when you look good, you feel good, but it also seems to be medically
sound. The idea that physical activity plays a role in the management of moderate mental health
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diseases, especially depression and anxiety is becoming popular among researchers ( Biddle &
Asare, 2011). Although, people with mental illnesses, especially, depression tend to be less
physically active than non-depressed individuals, increased aerobic exercise or strength training
has been shown to reduce depressive symptoms significantly.
A review of studies on the relationship between physical activity and mental health by
Richardson, Faulkner, McDevitt, Skrinar, Hutchinson, & Piette (2005) is compelling on the
relationship between physical health and mental health. A number of studies cited in their review
found a strong relationship between physical activity and mental health in the general population
(Biddle, Fox, & Boutcher, 2000). People who have serious mental illness, including major
depression, schizophrenia, and bipolar disorder, often have poor physical health and experience
significant psychiatric, social, and cognitive disability (Childs & Griffiths, 2003). Physical
activity has the potential to improve the quality of life of people with serious mental illness
through two routes—by improving physical health and by alleviating psychiatric and social
disability.
People living with chronic physical health conditions experience depression and anxiety at twice
the rate of the general population. Co-existing mental and physical conditions can diminish
quality of life and lead to longer illness duration and worse health outcomes (Patten, 1999).
People with any chronic physical disease tend to feel more psychological distress than do healthy
people. Poor physical health is a risk factor in depression like the social and relationship
problems that are very common among chronically ill patients.
Studies have shown that exercise can act as a mood enhancer, but exercise also seems to affect
long-term mental health. A study by Melville (2011) showed that just six weeks of bicycling or
weight training eased the symptoms of women suffering from anxiety disorder. Weight training
also reduced feelings of irritability in the subjects.
Another study on the link between physical health and mental health by Merin and
Pachankis (2010) found that frequent recurrences of genital herpes outbreaks result in negative
affect. The study shows that frequent outbreaks reinforce a stigmatized self-schema creating
negative psychological consequences and poor coping abilities.
Many people facing physical health problems, such as heart disease, withdraw from social
interaction and social situations. However, researchers have found that patients who were
physically ill and struggling with mental health illnesses, such as depression, were twice as likely
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to avoid social interaction. Physical problems often interfere with the diagnosis, assessment and
treatment of depression. It also colours the patient’s view of his/her own physical illness (those
suffering from depression often believe their recovery is not as good as it should be), making it
more difficult to overcome the problem.
People living with the most common chronic physical conditions in Ontario also face worse
mental health than the general population (Canadian Institute for Health Information, 2008). This
study found elevated rates of mood disorders in Ontarians with diabetes, heart disease, cancer,
arthritis and asthma. An identical study by Goldberg (2010) of the Institute of Psychiatry,
London found that the rate of depression in patients with a chronic disease was three times
higher than normal.
Another study of patients with severe chronic obstructive pulmonary disease found that 22
percent of the participants had at least mild depression (Moy, Reilly, Ries, Mosenifar, Kaplan,
Lew, & Garshick, 2009). Seventeen percent were taking antidepressants. According to Moy et
al., (2009) depression which occurs together with physical illness is less well diagnosed than
depression occurring on its own. The researchers believe that depression among those with
chronic physical illnesses is likely to be missed by professionals who care for physically sick
patients. This is because of the fact that health professionals are mostly concerned with the
physical disorder which is usually the reason for the consultation, and may not be aware of the
accompanying depression.”
The rationale for the impact of physical activity on both mental and physical health among
individuals with serious mental illness is provided by Erickson, Voss, Prakash, Basak, Szabo,
Chaddock, Kim, Heo, et al., (2011) study on the relationship between the size of one’s
hippocampus and the physical fitness. The more physically fit the subjects were the larger their
hippocampus. The shrinking of the hippocampus occurs with age and affects cognitive
functioning, such as spatial memory and retention. Staying physically fit may be a way to slow
down the shrinkage of hippocampus.
These studies provide ample evidence that chronic illnesses can cause higher rates of
psychological and mental disorders such as depression. Similarly, depression may be an
antecedent for many chronic physical illnesses. This means that the relationship between chronic
physical illness and depression is reciprocal with one another.
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The impact of mental health on physical health
Mental health and physical health are linked. People living with a serious mental illness are at
higher risk of experiencing a variety of physical symptoms. Furthermore, the way that people
experience their mental illnesses can increase their susceptibility of developing poor physical
health. For example, mental illnesses can alter hormonal balances and sleep cycles (Evans,
Charney, Lewis, Golden, Gorman, Krishnan, Nemeroff, Bremner, Carney, & Coyne, 2005;
Leucht, , Henderson, Maj, & Sartorius, 2007) making the person vulnerable to a range of
physical conditions.
A mental illness may impact social and cognitive functions and decrease energy levels, which, in
turn, negatively impact the adoption of healthy behaviours. People may lack motivation to take
care of their health such as adopting unhealthy eating and sleeping habits. They may resort to
smoking or abusing substances as a consequence or response to their symptoms leading to worse
health consequences (Evans et al., 2005; Leucht et al., 2007).
The psychological or mental state of an individual can influence the physiological process of the
body. The bodily or physiological effects of psychological states are termed stress - related
psychophysiological illnesses, such as hypertension and specific headaches. The prolonged
physical symptoms may cause stress making the body weak and less resistant to fight off disease.
The stress-immune system vulnerability link is through the brain appraisal of stress by the
cerebral cortex along the HPA-axis (hypothalamus-pituitary gland-adrenal gland). The
hypothalamus activates the pituitary gland which stimulates the adrenal cortex to secrete the
stress hormones, especially, the cortisol. The high levels of cortisol in the blood over a longer
period of time suppress the disease fighting lymphocytes weakening the immune system of the
body. Stress restrains our immune functioning making us more vulnerable to viruses and
infections. Major life stress increases the risk of a respiratory infection (Pedersen, Zachariae, &
Bovbjerg, 2010). Studies also show that wound caused by injury or surgery heal more slowly in
stressed people (Kiecolt-Glaser, Loving, Stowell, Malarkey, Lemeshow, Dickinson, & Glaser,
2005). These research studies suggest that the link between stress and sickness is rather indirect.
Prolonged stress weakens the body’s immune system which cannot fight the viruses and bacteria
making the person vulnerable to diseases.
The reciprocal link between the psychological and the physiological processes of the body is the
emerging area of research called ‘psychoneuroimmunology’ which examines these mind-body
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interactions (Kiecolt-Glaser, 2009). The thoughts and feelings (psycho) influence the brain
(neuro), which influences the endocrine hormones that affect the disease-fighting immune
system. A number of studies have shown the influence of nervous and endocrine systems on the
immune system (Sternberg, 2006; Suls, Davidson, & Kaplan, 2010). A large scale Swedish study
found that the risk of colon cancer was 5.5 times greater among people with a history of
workplace stress than among those who reported no such problems. This difference was not
attributable to group differences in age, smoking, drinking, or physical characteristics (Courtney,
Longnecker, Theorell, & de Verdier, 1993). The outcomes of other studies show that people are
at increased risk for cancer within a year after experiencing depression, helplessness, or
bereavement (Chida, Hamer, Wardle, & Steptoe, 2008; Steptoe, Chida, Hamer & Wardle, 2010).
On the contrary, other studies, however, have found no link between stress and human cancer
(Coyne, Ranchor, & Palmer, 2010; Petticrew, Fraser, & Regan, 1999; Petticrew, Bell, & Hunter,
2002). These studies show that the stress-cancer link in humans is complex. Some researchers
believe that an individual’s response to a stressor is a function of a number of factors including
the type of stressor and its controllability, biological factors such as age and gender, and the
individual’s previous experience with stress (Anisman & Merali, 1999). We suggest that more
research is needed to also examine other moderating factors such as socio-cultural circumstances
of the individuals or the physical versus psychological stress to better understand the link
between stress and chronic illness.
Researchers have also found a relationship between mental health and other physical illnesses. A
series of studies documented by the Canadian Institute of Health Information (2008) underscore
a link between the mental health and some debilitating physical illnesses such as diabetes and
cancer. Diabetes rates were found to be significantly elevated among people with mental
illnesses (Dixon, Weiden, Delahanty, Goldberg, Postrado, Lucksted, & Lehman, 2000). Both
depression and schizophrenia are risk factors for the development of type 2 diabetes due to their
impact on the body’s resistance to insulin (Brown, Svenson & Beck, 2007; Coodin,
2001). People with mental illnesses also experience many of the other risk factors for diabetes,
such as obesity and high cholesterol levels.
People with serious mental illnesses often experience high blood pressure and elevated levels of
stress hormones and epinephrine (adrenaline) which increase the heart rate. These physical
changes interfere with cardiovascular function and significantly elevate the risk of developing
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heart disease among people with mental illnesses (Larson, Owens, Ford & Eaton, 2001).
Similarly, people with serious mental illnesses also experience higher rates of many other risk
factors for heart disease, such as poor nutrition, lack of access to preventive health screenings,
and obesity. In Canada, women with depression are 80 percent more likely to experience heart
disease than women without depression (Johansen, 1999). This is attributed to both biological
and social factors. Similarly, people with mental illnesses have up to a three times greater
likelihood of having a stroke (Hackett & Anderson, 2005).
A number of other researches show that people with serious mental illness may also be at higher
risk of premature mortality than the general population (Brown, Inskip, Barraclough, 2000;
Joukamaa, Heliovaara, Knekt, Aromaa, Raitasalo, & Lehtinen, 2001). On average, people with
severe mental illness die ten to 15 years earlier than the general population. Although, some of
the excess mortality is due to suicide and accidental death, ischemic heart disease is a common
cause of excess mortality in this population (Lawrence, Holman, Jablensky, & Hobbsi, 2003). An
Australian study which followed the users of psychiatric services between 1980 and 1998, age-
adjusted ischemic heart disease mortality ratios were 1.9 (95 percent confidence interval, 1.8 to
2) for those who used psychiatric services compared with the general population (Lawrence, et
al., 2003). In another study of more than 38,000 persons who were under treatment in the
Department of Veterans Affairs health system, of those with schizophrenia, 19 percent, or almost
one in five, also had a diagnosis of diabetes (Sernyak, Leslie, Alarcon, Losonczy, & Rosenheck,
2002). However, because of the increased risk of obesity, diabetes and cardiovascular disease
associated with the use of antipsychotic drugs such as clozapine, olanzapine and quetiapine
researchers believe that the outcome of this study may be due partly to the association between
atypical antipsychotic and diabetes (Lean & Pajonk, 2003; Sernyak, et al., 2002).
Psychosocial and cultural Influences on physical and mental health
There is a growing awareness among psychologist on the role of socio-cultural factors in the
maintenance of physical and mental health. The empirical evidence indicates that sociocultural
determinants of health impact both chronic physical conditions and mental health. The role of
culture in the physical and mental health of people has been documented in the fifth revision of
DSM. The latest version of DSM-V which was released on May 18, 2013, the section on culture-
bound syndromes has been revised and replaced by three concepts: (1) cultural syndromes of
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distress and patterns of symptoms that tend to cluster together for individuals belonging to
specific cultural groups and communities; (2) cultural idioms of distress, i.e., the ways that
cultural groups and communities communicate and express their distressing thoughts,
behaviours, and emotions; and (3) cultural explanations of distress, which are the beliefs of
cultural groups and communities about the causes of the distress, symptoms, or illness.
According to Matsumoto and Juang (2017) the cultural syndromes of distress or culture-specific
syndromes refer to a group of symptoms that consistently occur together for people in certain
cultures and communities. In other words, how cultural groups and communities explain why
symptoms are occurring. More specifically, the concepts of cultural syndromes, cultural idioms
of distress, and cultural explanations represent cultural concepts of distress. Cultural concepts of
distress is a broader and more comprehensive construct than the DSM-IV TR’s category of
culture-bound syndromes. The main idea of cultural concepts of distress is to develop a broader
understanding of all psychological disorders, not just those which are specific to a particular
culture.
An example of the second concept in DSM-V pertaining to the ‘cultural idioms of distress’ (the
ways cultural groups express their distressing thoughts) may be the peculiarity of meaning
assigned to a physical or psychological disorder by a layperson in a specific culture. A physical or
a psychological disorder may be pan-cultural but its expression may depend on the common lexical
categories used in the folk language of that culture (Siddiqui & Shah, 1997). Although, diarrhoea
is a common disease of gastro-intestinal infection and is universal, it’s labelling and expression
varies across cultures. In Canada, the popular term used for diarrhoea is ‘stomach flu’, whereas it is
called ‘loose motions’ in layperson’s language in Pakistan.
DSM-V, like its previous version, includes a number of culture bound symptoms of distress such
as amok, zar, baksbat, susto, latah, koro, whakama, witiko, fajin-kyofusho, and pibloktoq. Amok
is prevalent in some Southeast Asian countries, Malaysia, Indonesia and Philippines and has
been observed mostly in men. The primary causes of amok are stress, sleep deprivation, personal
loss, and alcohol consumption because of which the person experiences extreme anger and
homicidal aggression (Haque, 2008). Although, it is regarded as a culture specific syndrome it
may occur in other cultures as well but may not be identified as amok. The incidences of mass
shootings in schools and public places in the U.S. typically resemble the symptoms of Amok but
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not labelled as Amok (Hagan, Podlogar & Joiner, 2015). Ironically, the labelling of Amok in
U.S., depends upon the type of person committing the mass killing; if it is perpetrated by a white
supremacist then the person is labelled as ‘mentally sick’ but if it is done by a brown guy,
especially a Muslim, the person is called a ‘terrorist’.
‘Zar’ is observed among Northern and Eastern Africans and Middle-Eastern countries
particularly in Iran and Egypt. Zar is believed to be because of the possession of the person by
the spirits (Mianji & Semnani, 2015). A person experiencing this disorder would have a sudden
change in consciousness, and/or shouting, banging head against the wall, crying, and laughing
(Mianji & Semnani, 2015). ‘Latah’ is observed in women in Malaysia and includes hysteria and
echolalia (uncontrollable and immediate repetition of words spoken by another person). ‘Fajin-
kyofusho’ is found in Japan which combines social anxiety with one’s appearance with a
readiness to blush and a fear of eye contact. ‘Whakama’ is a New Zealand Maori (native
Polynesian population) construct that includes shame, self-abasement (humbleness, degrade,
humiliation), feelings of inferiority, inadequacy, self-doubt, shyness, excessive modesty and
withdrawal. ‘Witiko’ is a disorder that has been identified in Algonquin Indians in Ontario,
Canada and involves the belief that individual is possessed by Witiko spirit which is a man eating
monster. The person may show cannibalistic tendencies along with suicidal thoughts to avoid
acting on cannibalistic urges. ‘Koro’ is commonly found among Southeast Asian men (Malaysian
Chinese). The symptoms resemble to excessive anxiety and fear that penis is retracting into the
body which may result in impotence and ultimately death. ‘Sinking heart’ is a condition of
distress found among some cultures in Pakistan and India. The person experiences physical
sensations in the heart or chest. The symptoms are thought to be caused by excessive heat,
exhaustion, worry, or social failure. It has some characteristics of depression but also resembles a
cardiovascular disease. ‘Pibloktoq’ is a type of Arctic hysteria found among the Inuit of Artic
Canada. All these disorders are examples of culture specific symptoms and occur among people
belonging to a specific culture. Their understanding, explanation and the symptoms make sense
within the context of those specific cultures and might not be applicable to other societies and
people.
As regards the influence of sociocultural influences on the physical and mental health, the
research conducted by Steptoe, O’Donnell, Marmot & Wardle (2008) in the U.K., has found
links between a number of psychosocial and cultural factors such as negative life events, stress,
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bereavement, unemployment and health problems such as common cold, heart disease and
mortality. Specifically, these studies found linkage between unemployment and mortality,
cardiovascular disease and cancer; between negative life events and gastrointestinal disorders;
between bereavement and lymphocyte functions; between pessimistic explanatory styles and
physical illnesses; between positive mood and heart rate and blood pressure; and between
psychological well-being and mortality (Chida & Steptoe, 2008; Dockray & Steptoe, 2010;
Steptoe, Dockray, & Wardle, 2009; Steptoe, Hamer, & Chida, 2007). The studies also indicate
that individuals with few social supports tend to have poorer health. Current reviews show that
feeling lonely is linked to a host of health problems (Hawkley & Cacioppo, 2010; Steptoe &
Kivimaki, 2013).̈
In a Statistics Canada study conducted by Gilmour (2012) the link between psychosocial factors
and health of Canadian seniors was examined. Individuals self-reported their level of social
interaction and their level of health. Overall, the study found that individuals with more social
interaction built into their life reported better physical health. The study also found that younger
seniors (65-74) were more likely to report better health.
Research also shows that the disadvantaged socio-cultural circumstances of the minorities may
impact their wellbeing and health. An important psychosocial factor which has been found to
contribute to health problems in the case of ethnic minorities is perceived racism and
discrimination. One significant health disparity is the shorter life expectancy for African
Americans versus other ethnic groups in the U.S. This difference is assumed to be linked to
stress-related health outcomes such as high blood pressure (hypertension) due to racism and
discrimination (Brondolo, Rieppi, Kelly, & Gerin, 2003; Krieger, 1999; Mays, Cochran, &
Barnes, 2007). Studies show a link between perceived racism and poorer physical health (such as
a greater incidence of cardiovascular disease) and premature biological aging among African
Americans (Chae, Nuru-Jeter, Adler, Brody, Lin, Blackburn, & Epel, 2014; Mays et al., 2007).
The cultural values that emphasize group belongingness and interdependence may play a role in
promoting health. For example, people who live in collectivistic cultures may enjoy stronger and
deeper social ties with others than do people in individualistic cultures. These social relationships
are regarded a “buffer” against the stress of living, reducing the risk of cardiovascular disease.
People living in individualistic cultures may not have access to the same types of social
relationships; therefore, they may have less of a buffer against stress and are more susceptible to
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heart disease. Triandis, Bontempo, Villareal, Asai, & Lucca (1988) have suggested that culture,
specifically, social support is a major ingredient in mediating stress, which affects health. The
findings of Matsumoto and Fletcher (1996), however, suggest a much more complex picture.
Although, collectivistic cultures were associated with lower rates of cardiovascular diseases, they
were also associated with death from infectious and parasitic diseases and cerebrovascular
diseases.
Even the difference between one’s personal values and attitudes and the individual’s perception
of society’s values may produce stress and disease. Matsumoto, Kouznetsova, Ray, Ratzlaff,
Biehl, & Raroque (1999) asked participants about personal values, society’s values, coping
mechanisms and health. Discrepancy scores were computed. The higher the discrepancy between
personal and perceived society’s values, the more coping mechanisms were needed from the
participants and the higher the prevalence of diseases. In another study, participants were asked
to describe an emotional experience, and how well this experience matched the country’s
emotional profile was assessed (De Leersnyder, Mesquita, Kim, Eom, & Choi, 2014). It was
found that, the better the fit between the individual’s emotional profile and the society’s
emotional profile, the healthier the participant was.
Another factor related to health and disease may be the cultural beliefs about vaccinations.
Todorova (2014) has observed that vaccinations are effective at eradicating infectious diseases.
However, some cultures or groups are more prone to rejecting vaccines either because of their
religious beliefs or their suspicions about the side effects of the vaccinations which increases
their vulnerability to infectious diseases. In some parts of Pakistan there is a wide spread belief
among people that there is some hidden agenda behind these vaccinations because of which
many parents resist the attempts to vaccinate their children against polio.
Since each country has its own unique way of dealing with health care, there are certain factors
that determine how well a country’s health care distribution systems works. For instance, the
access to advanced technology and healthcare resources in developed countries plays a crucial
role in the delivery of health care services when compared to developing countries that do not
have access to as many resources. In addition, some countries like Canada provide free
healthcare for its citizens, whereas Canada’s neighbour, America does not offer its citizens free
health care, which is why an individual’s socio-economic status plays a huge role in getting
16

health care in the U.S. Hence, the poor who cannot afford healthcare services may not be able to
get adequate treatment which may make them vulnerable to diseases (Grant, 2013).
The role of religion and spirituality in physical and mental health
A large number of studies have revealed a correlation between religiosity and health. Religiously
active people tend to live longer than those who are not religiously active. A research review of
more than 1500 studies has revealed connections between spirituality and health and healing
(Koenig King, & Carson, 2011). Some of these studies have found positive impact of religion on
a number of determinants of physical health suggesting that religion can positively influence
physical health (Wallace & Forman, 1998), opportunity to receive support (Maton & Wells,
1995; Shafranske, 1992; 1996), ability to show resiliency in the face of risk factors (Werner &
Smith, 1989), and coping (Donelson, 1999; Dubow, Pargament, Boxer, & Tarakeshwar, 1999).
A WHO study found less likelihood of suicidal thoughts and suicidal attempts among people
having a religious belongingness (Sisask, V rnik, Kolves, Bertolote, Bolhari, Botega, ӓ
Fleischmann, Vijayakumar, & Wassermann, 2010). To be part of a religious community provides
social relationships and regulations (moral guidelines). These studies demonstrate that religion
may serve as a psychological and social resource for coping with adverse life circumstances.
The research by Zullig, Ward and (2006) examined the mediating role of self-perceived health
between perceived spirituality, religiosity, and life satisfaction among a stratified sample of
college students, while controlling for gender. The outcome indicated that students who
described themselves as spiritual or religious consistently reported greater self-perceived health
which, according to the researchers, likely influenced life satisfaction for both men and women.
Results of this research also support that religious and spiritual engagement influences life
satisfaction which in turn impacts physical and mental health
Another research by Powell, Shahabi and Thoresen (2003) has examined association between
religion or spirituality and mortality, morbidity, disability, or recovery from illness. The outcome
of the research indicated a consistent, prospective, and often graded reduction in risk of mortality
in healthy participants who were religiously active. The researchers believe that religion and
spirituality protect against cardiovascular disease because they encourage a healthy lifestyle.
However, there was no evidence that religion or spirituality slows the advancement of cancer or
improves recovery from acute illness.
17

A study by Rippentrop, Altmaier, Chen, Found and Keffala (2005) operationalized
religion/spirituality as a multidimensional factor in order to better understand the relationship
between religion/spirituality and physical health and mental health in 122 patients with chronic
musculoskeletal pain. The outcome of the study indicated that those who were experiencing
worst physical health were more likely to engage in private religious activities, perhaps as a way
to cope with their poor health. Some fundamental religious beliefs such as forgiveness, daily
spiritual experiences, religious support, and self-rankings of religious/spiritual intensity
significantly predicted mental health status.
An Australian review on the association between religious involvement and mortality risk
suggests a strong association between religious attendance and mortality, with higher levels of
attendance predictive of a strong, consistent and often graded reduction in mortality risk
(Williams & Sternthal, 2007). The study also suggests that health practices, social ties and
feelings of strength to cope with stress and adversity are important pathways by which religion
can affect health.
Researchers have also examined some other variables which are assumed to safeguard
religiously active people from stress and enhance their well-being. These benefits may flow from
a stable, coherent worldview, a sense of hope for the long-term future, feelings of ultimate
acceptance, and the relaxed meditation of prayer. These variables might also help to explain
some other findings among the religiously active, such as healthier immune functioning, fewer
hospital admissions, and, for AIDS patients, fewer stress hormones and longer survival (Ironson,
Solomon, Balbin, O’Cleirigh, George, Kumar, Larson, & Woods, 2002; Koenig & Larson, 2001;
Lutgendorf, Russell, Ullrich, Harris & Wallace, 2004).
How can one make sense of relationship between religious involvement/belongingness and
physical and mental health? There may be multitude of explanations for this link. First, religion
promotes self-control (McCullough & Willoughby, 2009). Religiously active people, therefore,
tend to have healthier lifestyles; they smoke and drink much less (Koenig & Vaillant, 2009; Park,
2007). One Gallup survey of 550,000 Americans found that 15 percent of the very religious were
smokers, as were 28 percent of those nonreligious (Newport, Argrawal, & Witters, 2010). In
American studies, too, about 75 percent of the longevity difference remained when researchers
controlled for unhealthy behaviours, such as inactivity and smoking (Musick, Herzog, & House,
1999). Second, could social support explain the religious factor (Ai, Park, Huang, Rodgers &
18

Tice, 2007; George, Ellison, & Larson, 2002)? In the three major Middle Eastern religions such
as Judaism, Christianity and Islam, religious involvement is a communal experience. Religious
belongingness provides ample opportunity to the social support network. Religiously active
people are there for one another when misfortune strikes. Moreover, religion encourages
marriage, another predictor of health and longevity. But even after controlling for social support,
gender, unhealthy behaviours, and preexisting health problems, the mortality studies still find
that religiously engaged people tend to live longer (Chida, Steptoe, & Powell 2009).
A comprehensive research review on the relationship between religious beliefs and practices
have identified hysteria, neurosis, and psychotic delusions as covariates of religious beliefs
(Koenig, 2009). The research review by Koenig (2009) has analysed the relation between
religion and/or spirituality, and mental health, focusing on depression, suicide, anxiety,
psychosis, and substance abuse. While the review consistently identified religious beliefs and
practices as strong sources of comfort, hope, and meaning, they were also, in some cases, found
to be intricately interlinked with neurotic and psychotic disorders.
Some authors assert that the links between religion and spirituality and health determined in
some previous empirical studies were unclear (Hill & Pargament, 2003). They point out that
religion and spirituality, in these studies, were measured by global indices (e.g., frequency of
church attendance, self-rated religiousness and spirituality) that do not specify how or why
religion and spirituality affect health. Hill and Pargament (2003) have also identified efforts by
some researchers who attempted to explain the concepts and measures of religion and spirituality
and how these were theoretically and functionally connected to health.
Our research in the Pakistani context has also demonstrated a link between spirituality and
mental health in the area of depression (Siddiqui & Shah, 1997). The majority of the depressed
individuals were found to exhibit feeling of guilt which manifested in terms of being punished for
some negative deeds. These feelings of guilt were embedded in the depressed individuals’
perception of transgression of religious laws rather than the social mores as assumed by the
Western psychologists. The depressed individuals’ self-perceptions were also dominated by the
thoughts that their prayers were not being answered. This reflects the person’s thinking in religious
context that God is no more granting her/his prayers. The unambiguous relation of the feelings of
guilt to perceived transgression of divine laws highlights the importance of religion to mental
health in the Pakistani society (Siddiqui & Shah, 1997). This may explain, to some extent, why
19

people in villages still go to the faith healers and shrines to seek relief from physical and mental
ailments. Alternatively, the lack of infrastructure and health facilities in the villages may create
feelings of deprivation and frustration perpetuating the century old beliefs and practices in the
absence of modern health care facilities. Moreover, the authoritarian and oppressive social
structure in the rural areas may inculcate a sense of lack of control and helplessness maintaining
the status quo (Siddiqui & Shah, 1997). Our findings also show that the highly depressed, unlike
the Caucasians, did not have suicidal ideation but expressed their desperation in an indigenous
form of death wish. The wish to be dead rather than to think of committing suicide is reflection of
the religious beliefs that suicide is not permissible in Islam as God granted life and He, the Exalted,
is the only one to take it.
As majority of research on relationship between religion and health has heavily borrowed the
correlational paradigm the skeptical researchers remind us that correlations can leave many
factors uncontrolled (Sloan, 2005; Sloan & Bagiella 2002). An example to highlight the problem
of correlational research may be the link between religion and longevity: women are more
religiously active than men, and women outlive men by at least five years. Does religious
involvement merely reflect this gender-longevity link? One 8-year study by the National
Institutes of Health, for example, followed 92,395 women, ages 50 to 79. Even after controlling
for many factors, women attending religious services weekly or more experienced an
approximately 20 percent reduced risk of death during the study period (Schnall, Wassertheil-
Smoller, Swencionis, Zemon, Tinker, O’Sullivan, Van Horn & Goodwin, 2010). But the
association between religious involvement and life expectancy is also found among men
(Benjamins, Ellison & Rogers, 2010; McCullough & Laurenceau, 2005; McCullough &
Willoughby, 2009).
A 28-year study that followed 5286 Californians found that, after controlling for age, gender,
ethnicity, and education, frequent religious attenders were 36 percent less likely to have died in
any year. In another 8-year controlled study of more than 20,000 people (Hummer, Rogers, Nam,
& Ellison, 1999), this effect resulted in a life expectancy of 83 years for frequent attenders at
religious services and 75 years for infrequent attenders. These correlational findings do not
indicate that non-attenders can add 8 years to their lives if they start attending services and
change nothing. But the findings do indicate that religious involvement is a predictor of health
and longevity, just as nonsmoking and exercise are.
20

This means that correlational findings are vulnerable to a host of different interpretations because
of the issue of third variable/s and it is not possible to control all possible covariates of religiosity
(Hackney & Sanders, 2003; Koenig, 2012; Moreira-Almeida, Lotufo Neto, & Koenig, 2006). An
understandable reason for the use of correlational techniques in the area of religiosity and health
seems to be the nature of the variables which are difficult to examine with the experimental
methods (Murken & Shah, 2002). The religious variables cannot be manipulated because of the
ethical, moral and religious reasons, nor can a control group be used because of the moral and
religious concerns (Murken & Shah, 2002). One cannot instruct one group of people to abandon
religious practices and the other to involve themselves in the same for a specific period of time
and then compare the two on some dependent variable of health and wellbeing. Obviously, the
areas of spirituality/religion and health are not only the areas in psychology which use the
correlational method, other fields of psychology which have excessively used the correlational
model are personality and mental ability testing (Murken & Shah, 2002). Technically, the
coefficient of determination (r2) explains the common variance between the two variables and
provides similar information like other effect size statistics. Further, a review of the studies on
the relationship between religiosity and health by Hill and Pargament (2003) provides more
insight into the explanations and the improved methods used by various researchers in this area.
Holistic model: Integrating biological, social, psychological and spiritual dimension.
The early psychology of the 20th century confined itself to the negative and pathological aspects of
man initiated by Freud’s view of human nature as ‘bad’. The two important events which left their
mark on Freud’s view of human nature were the sexual repression of women during the Victorian
era and the aggressive hostilities of World War I which devastated Europe. The materialistic,
soulless and selfish image of man advocated by Freud was also shared by behaviourism’s scientific
obsession and its dehumanizing conception of man.
Ironically, the founders of behaviourism were not the first to bring psychology to the fold of
sciences. The establishment of first experimental laboratory by Wilhelm Wundt in 1879 at the
University of Leipzig in Germany and the contributions of Gustav Fechner put psychology (then the
study of soul) along the scientific lines. Wundt declared that new psychology should be a science
modelled after sciences like physics and chemistry. The main goal of Wundt’s efforts was to make
psychology an independent discipline rather than a branch of philosophy or physiology. The interest
of German psychologists in studying human perceptual thresholds culminated in the area of
21

‘psychophysics. Later, the emergence of ‘behaviourism in North America furthered Wundt’s idea of
making psychology a scientific discipline. The founders of behaviourism, Watson, Thorndike and
Skinner, applied the learning principles developed through animal experiments to human beings
putting psychology on the path to a secular ethnocentric-reductionist paradigm and logical inference
(Murken & Shah, 2002). Although, the humanistic revolt against the psychoanalytic and
behaviourist models corrected the distorted image of humans that basic human nature was not bad
but ‘good’, nevertheless, it occupied humans with self-concerns and perpetuated individualistic
ideology undermining the social-collectivist aspect of human beings. These lopsided interests of
pioneers of behviourism and humanism and their views of human psychology misled the researchers
over a century into the positivistic theory driven research that ignored the basic inborn nature of
humans called ‘Fitrah’ (Shah, 2005). Fitrah is the inborn spiritual aspect of humans that guides them
in developing good moral behaviour and avoiding evil tendencies (Mohammed, 1998).
Later, the secular positivistic view of man culminated in the notion of ‘value free’ or ‘value
neutral in the area of mental health and its delivery i.e., psychotherapy. The secular view of
psychotherapy to deliver value free mental services was equally a delusion of human mind as no
such thing called ‘value free’ could be imaginable in human relations and social interaction.
Elsewhere, we have argued that “value free” or “value neutral” does not exist because secularism
is a value which negates religious and moral values but passively promotes materialistic and
hedonistic tendencies (Shah, 2005). Our criticism of ‘value free’ is shared by other Canadian
researchers as well who likewise reject the misguided notion of so called ‘value free’: “Of note is
the fact that atheism itself is a belief system, as it is often associated with beliefs in science and
logical positivism, and atheism is also potentially associated with the belief and value that
spiritual and religious matters are nonessential, unhelpful, or even harmful to mental health”
(Moss & Dobson, 2006, p. 285).
There are multitudes of these values that have given rise to an individualistic society undermining
the family and social cohesion while instilling a sense of individual freedom in the mind of Western
man (Shah, 2005). Mesmerized by the crowd action of a group of Western psychologists practicing
the so called ‘liberation psychotherapy’ (Rice, 1996), the individuals feel free to follow their own
wishes and desires liberating themselves from the family, social, moral and religious obligations
(Shah, 2005).
The outcome of the secular value free view of human nature was an attempt to exclude the truth
22

claims of religion from the scientific inquiry because the explanations about the efficacy of
religion concerning mental health were not based on psychological theories and research using
genuine empirical methods (Khalili, Murken, Reich, Shah, & Vahabzadeh, 2002).
Toward the end of the 20th century psychology discovered the importance of positive approach to
human psychology focusing on human virtues and values (Seligman, 2002). The other pioneers
of psycho-spirituality in the West were psychiatrists Peck (1990) and Schmidt (1987). They
were among the torch bearers to speak out in support of spiritual growth of the individuals.
Schmidt (1987) became interested in the influence of religion and spirituality on mental health
after unsuccessfully using Western psychotherapy to treat the clients in Brunei. When he
included the religious and spiritual practices into therapy the clients responded positively (Badri,
2000).
Peck (1990) criticized Western psychology and psychiatry for trying to mimic sciences by
allowing a neutral stand towards human evil and in denial of the soul. He disagreed with the
clinicians’ approach of not mentioning the human soul and spirituality in their framework. Peck
(1990) pointed out that the prevalence and increasing incidence of anxiety and depression in our
modern world was the result of the failure on the part of psychologists to build moral aspects of
personality and to highlight the importance of delaying gratification (Metcalfe & Mischel, 1999;
Mischel, 1974; Mischel, Ebbesen, & Raskoff Zeiss, 1972)). Many of his ideas and critical
discourse seems to be inspired by the writings of the early Muslim Sufi scholars. As a matter of
fact he has acknowledged using Islamic and other religious sources but has used the Western
style to make his ideas more appealing and acceptable to the Western professionals.
The contemporary researchers have acknowledged the importance of religion and spirituality in
psychological care and have suggested to incorporate it into the biopsychosocial framework
which is used by the psychologists. The biopsychosocial perspective involves the recognition
that patients’ problems are multifaceted, and have biological, psychological, and social aspects
(Bakal, 1999). This conceptualization of health involves recognition of how physical health is
intricately associated with attitudes, thoughts, feelings, and behaviours. This shift in the thinking
of psychologists has led to the expansion of biopsychosocial model into the biopsychosocial-
spiritual model (Sulmasy, 2002). This model does not take a dualistic approach to mind and
body, but instead proposes that the biological, the psychological, the social, and the spiritual
23

elements are part of the whole. Each factor interacts with and affects other aspects of the person.
Thus, one’s thinking, feelings, and coping with an illness may influence bodily symptoms, illness
progression, and even ultimate prognosis.
From the perspective of biopsychosocial-spiritual model, spirituality is viewed as the sense of
meaning and life purpose that one has (Daaleman & VandeCreek, 2000). Antonovsky (1987;
1994) has suggested that this construct of meaningfulness is one of the most important
“resistance resources” in comprehending and managing difficult life circumstances, such as the
diagnosis of a terminal illness. This sense of meaningfulness enables an individual to utilize
active coping strategies to deal with the adverse life circumstances.
Although the terms spirituality and religion are often used interchangeably, some authors believe
that they are not synonymous because of the controversy over the extent of their overlap or
differentiation in the current definitions (Hill, Pargament, Hood, McCullough, Swyers, Larson et
al., 2000). Traditional definitions often failed to distinguish spirituality from religiousness.
However, some researchers have suggested to treat spirituality and religion as polarized, with
religion being the more narrowly defined construct of the two (Zinnbauer, Pargament, & Scott,
1999).
Spirituality comes from the Latin word “spiritus,” which refers to a nonmaterial life force within
the body. The spiritual quest involves the search for existential meaning, whether in the context
of a well-defined religious tradition or not. This pursuit may, or may not, involve a supernatural
component, hence, it has been defined as the ways in which people understand and seek
transcendent meaning and value (Sulmasy, 2002). Another attempt to differentiate spirituality
from religion views spirituality in terms of more individual experiences with respect to the
meaning of life and a personal relationship with God (Hill, Pargament, Hood, McCullough,
Swyers, Larson, & Zinnbauer, 2000). A number of other terms used for spirituality are
“personal,” “transcendent,” and “relatedness” which view spirituality as being fluid and dynamic
in nature (Zinnbauer, Pargament, & Scott, 1999).
The word religion also has its roots in Latin, i.e., “religare,” which means to bind together. Some
authors have argued that religion is associated with rigid social structures and institutions
(Pargament, 1997). The proponents of this viewpoint argue that religion is rather socially
organized as it emphasizes the development of the humans on the institutional elements, such as
dogma, doctrines, and organization (Zinnbauer et al., 1999). According to this view, religion
24

tends to be a more static entity, associated with tradition. However, some other definitions view
religion as both the outward demonstrable practice of spiritual understanding and the collective
framework of beliefs, values, codes of conduct, and rituals specific to a particular group of
believers, a more orthodox form of spirituality (Strang & Strang, 2001). According to Sulmasy
(2002) although not everyone has a religion, anyone who is seeking for ultimate meaning has
spirituality. This is why the issues surrounding meaning, value, and relationship are particularly
important for a client irrespective of his or her religious history.
Islam perceives spirituality, morality and religion as inseparable and interrelated entities. Spirituality
is not only about an individual’s relationship with the Creator; it also includes a communal
dimension. The relationship between man and his Creator is the root of the moral attitude of man
towards his fellowmen. Spiritual ethics speak about the power of self-control that enable an
individual to manage emotions thus handling feelings in a proper way.
Our understanding of relationship between spiritual, mental and physical health envisages the
application of psychological principles to understand human behaviour within the framework of
spiritual worldview. We believe that human psychology, in addition to biological and
psychological dimensions, has a spiritual dimension that requires a non-materialistic and non-
secular approach to address the issues pertaining to human behaviour. In our view, the primary
emphasis in understanding the health of people should be to focus on the problems of people
with psychological understanding that takes due care of their spiritual needs.
A healthy body has a healthy mind; an old truism. However, there is a close association between
the mental, physical, and spiritual health; the closely bonded components of the whole: a holistic
system. Physically and mentally healthy people are the assets of the society. The spiritual health
is the basic foundation of morality of the society.
We conceptualize the physical, mental and spiritual dimensions of health as part of one system.
These dimensions may have their unique contributions to the overall health of an individual but
cannot be viewed separately from each other. However, the relative contribution and emphasis of
these dimensions in the health of an individual may be determined by the socio-cultural
background and the personal circumstance of an individual. Hence, we propose in the following
a holistic model of health which envisages a reciprocal relationship between the physical, mental
and spiritual dimensions of health which are embedded within a specific socio-cultural context.
25

The diagram shows the relationship of three components of health, i.e., physical, mental and
spiritual to the overall health and happiness of an individual. The diagram also shows the
importance of social context and the cultural factors that define and moderate the relationship of
these three components of health to the wellbeing of an individual.
26

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