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Spirituality and the science of feeling good.

Importance of Spirituality for Well-being

Spirituality is defined as a search for--and a means of reaching--something beyond human existence, creating a sense of connectedness with the world and with the unifying source of all life--an expression of a profound need of people for coherent meaning, love, and happiness in their lives. Spirituality can help people develop happiness and satisfaction with life, as well as often preventing the stresses and lifestyle imbalances that lead to physical and mental disorders. A spiritual approach to life can be particularly crucial for people facing existential crises like suicide. Given that spirituality may provide a perspective that allows people to find meaning and hope in every aspect of life, including its inevitable suffering and challenges, spirituality can help reduce vulnerability to medical disorders and enrich the quality of people's lives. (1)

Many patients complain to their physicians about a complex mixture of physical, mental, and existential problems, which are at least in part responses to stress and imbalance in their life. (2) Acute responses to stress lead to a wide variety of complaints, such as anxiety, bodily pains, and gastrointestinal problems. Chronic stress and associated imbalances in lifestyle contribute to virtually all the leading causes of disability and death around the world today. For example, people with stress and depressive disorders are more likely to suffer from heart disease, obesity, type 2 diabetes, and cancer than are people who are calm and happy. (3) In turn, depression and other diseases can lead to a vicious interplay where one exacerbates the another, leading to despair and possibly even to suicide.

Despite these facts, physicians often fail to recognize the crucial role of spirituality in helping people to develop a sense of unity and satisfaction with their life. (4) Though not always obvious, patients are often searching for answers to questions about their existence, including the meaning of life, sickness and suffering, and happiness. Such questions are often prompted by feelings of an existential vacuum (eg, emptiness and despair), but can open the door for awareness of a more liberating kind of emptiness that may bring one closer to answering such existential questions. The liberating spiritual perspective transforms one's perspective by creating an awareness of our inseparable participation in a universal unity of being, which can lead to increased well-being. (5)

Well-being is simply a calm and realistic awareness of satisfaction with one's life. (1) To be satisfied in a realistic way with life a person needs to be growing in awareness of what is good and meaningful in her life. For well-being, a person also needs to be able to adapt with serenity--that is, to adapt flexibly to whatever happens without complaint or regret. As a result of these requirements for well-being, every aspect of a human being has evolved with a strong natural affinity for spirituality, which is the only activity that can bring real meaning to lives that must face death, disease, and frequent suffering from the hard work, frustrations, rejections, mistakes, and mysteries of life. (6,7) Ultimately, only a spiritual approach can provide the means to lasting happiness, health, and satisfaction with life in the face of such adversity. (8,9)

Evolution of Spiritual Awareness

The human brain has evolved in a long series of steps over millions of years. Out of necessity, each step in this evolutionary hierarchy worked effectively for the organism to adapt and survive. As the human brain evolved it retained and modified the earlier components of its development. (10) Three major systems of learning and memory are still recognizable in a human being. The earliest system of learning to evolve was the limbic system or "emotional brain" that regulates the procedural learning of habits and skills, which we share with mammals like rats and dogs. (10) The procedural learning system leads to individual differences in emotional responses like fear, anger, disgust, and ambition.

The differences between people in their emotional style can be reliably measured by four traits of "temperament" measured by the Temperament and Character Inventory (TCI); it is useful to measure personality in ways that allow an understanding of what influences individual well-being. (11) The TCI provides a reliable tool for measuring the emotional style of a person (ie, temperament) and the higher cognitive processes that regulate emotional conflicts (ie, character).

The four TCI temperaments are called Harm Avoidance (anxious and pessimistic versus risk-taking and optimistic), Novelty Seeking (impulsive and anger-prone versus rigid and stoical), Reward Dependent (sentimental and approval seeking versus independent and aloof), and Persistent (perfectionistic and over-achieving versus lazy and under-achieving). Each emotional drive demands immediate gratification, and competing drives may be in conflict with one another. Character traits regulate these conflicts to promote well-being. The TCI character traits represent the mental expressions of the virtues of hope (ie, self-directedness), love, (ie, cooperativeness), and faith (ie, self-transcendence). Individuals who are well-developed in these three traits have the most positive emotions and the least negative emotions.

The second system to evolve was the propositional or declarative learning system of reasoning about goals and social relationships. This second system allows primates to be self-directed and cooperative in social groups. Primates are able to reason and to socialize using their "rational brain," including the prefrontal cortex. (12)

The third system of learning and memory is unique to human beings. Only human beings have episodic memories that are self-aware allowing for recollection and introspection about events throughout the course of our life from an autobiographical perspective. (13) The capacity for self-awareness does not mature until about 4 years of age, which is why human beings do not have recall of their lives before this age.

Self-awareness allows human beings to grow in awareness of what influences our body, our emotions, our thoughts, and even the initial perspectives that are present before we formulate words with our rational brain or automatic emotional responses with our emotional brain. The emergence of the modem human brain was characterized by the development of a capacity for art, science, and spirituality. About 60,000 years ago, modern man developed the self-awareness to begin to bury his dead in a ritualistic way symbolic of awareness of a source of life that exists beyond space and time. (14)

The Path to Well-being

The emotional brain and the rational brain both have a strong affinity for spirituality. As a result, human beings have a natural tendency toward growing in self-awareness. People have the capacity to become self-aware of their emotional reactions and relationships to one another by means of limbic-cortical communication, such as the Papez circuit that connects the anterior cingulate cortex with the hypothalamus, thalamus, and hippocampus. (15) The anterior cingulate cortex provides a key interface for the regulation of emotional drives, cognition, and motor behavior. (16) The size of the anterior cingulate cortex and its functional connectivity with cortical and limbic structures is strongly moderated by temperament traits, particularly Harm Avoidance. (17-19) Emotional stress can precipitate overactive emotional responses at the expense of higher cortical processes, thereby short-circuiting or hijacking the function of the rational and self-aware parts of the brain. As a result, a person cannot grow in self-awareness when overly fearful, angry, or suicidal. Therefore, helping people to relax allows them to let go of struggles with themselves and others and then to grow. If a person is severely suicidal or psychotic, it is usually necessary to begin with somatic treatments to restore reality testing and self-acceptance; only then will the patient be able to begin to reflect and to meditate in a state of calm self-acceptance that allows for growth in awareness. A strong sense of self-awareness reduces the vulnerability to future episodes of depression.

There are three major stages of self-awareness along the path to well-being, as summarized in Table 1. (1) The absence of self-awareness occurs in severe personality disorders and psychoses in which there is little or no insightful awareness of the preverbal outlook or beliefs and interpretations that automatically lead to emotional drives and actions. Lacking self-awareness, people act on their immediate likes and dislikes which is usually described as an immature or a "child-like" ego state.

The first stage of self-awareness is typical of most adults today. Ordinary adult cognition involves a capacity to delay gratification to attain personal goals but which remains egocentric with frequent distress when attachments and desires are frustrated. Hence the average person can function well under good conditions, but may frequently experience problems under stress. At this stage a person is able to make a choice to relax and let go of their negative emotions, thereby setting the stage for acceptance of reality and movement to higher stages of coherent understanding.

The second stage of self-aware consciousness is typical of adults when they operate like "good parents." Good parents are allocentric in perspective--that is, they are "other-centered" and capable of calmly considering the perspective and needs of their children and of other people in a balanced way that leads to satisfaction and harmony. This state is experienced when a person is able to observe their own subconscious thoughts and consider the thought processes of others in a similar way. Hence, the second stage is described as "meta-cognitive" awareness, mindfulness, or "mentalizing." The ability of the mind to observe itself allows for more flexibility in action by reducing dichotomous thinking. (20) At this stage, a person is able to observe herself and others for understanding, without judging or blaming.

The third stage of self-awareness is called contemplation because it is direct perception of one's initial perspective--that is, the preverbal outlook or schemas that direct one's attention and which provide the framework that organizes our expectations, attitudes, and interpretation of events. Direct awareness of our outlook allows the enlarging of consciousness by accessing previously unconscious material, thereby letting go of wishful thinking and allowing the impartial questioning of basic assumptions and core beliefs about life, such as "I am helpless," "I am unlovable," or "Faith is an illusion."

Character develops through growth in self-awareness as we try to find meaning and satisfaction by learning ever-more coherent perspectives on our life. Extensive empirical work has shown that movement through these stages of development can be described and quantified in terms of steps in character development or psychosocial development. (21) Differences between individuals in their level of self-awareness can also be reliably measured in terms of character traits. I have called the TCI character traits Self-Directedness (responsible and purposeful versus blaming and aimless), Cooperativeness (tolerant and kind versus prejudiced and revengeful), and Self-Transcendent (intuitive and spiritual versus conventional and skeptical) (see Self-Directedness and Cooperativeness are traits that can be measured in other primates, but Self-Transcendence is a spiritual trait unique to human beings. Empirical studies in the general population show that the individuals who are above average in all three TCI character traits have the highest levels of positive emotions and the lowest levels of negative emotions of all possible character configurations. A spiritual perspective allows us to see that we live our lives in division, split between contradictory desires that create conflict and dissatisfaction. Growing in awareness of this division helps a person to transcend problems and to rediscover a sense of unity.

Fortunately, it is possible to help people develop in well-being, as indicated by measures of positive emotionality, character, and virtues. Growth in well-being reduces vulnerability to depressive relapses and recurrences. (2) I have developed an exercise, called the "Silence of the Mind" meditation with explicit instructions to take people through each of the stages of awareness (1) (see pages 84-95). For those who are interested in growing in self-awareness, a useful set of tools are publicly available through a nonprofit DVD series called "The Happy Life--Voyages to Well-Being," (22) which provides reflections, meditations, and other exercises to help a person become more self-aware and happy (see A booklet and workbook are also provided to facilitate growing in awareness about lifestyle choices that affect various aspects of well-being, including healthcare, diet, exercise, sleep, recreational activities, and spirituality. These materials can be used in self-help or as adjuncts to other mental health treatment depending on the individual. They do not offer spiritual direction, but rather encourage each person to remember his or her own inner life because it can be a priceless source of support in difficult moments.

Remember that spirituality is the search for something beyond human existence and which connects individuals with the world and with all of life. Recognition of our connectedness with all life reminds us of our obligation to try to continue to live so that we can learn the art of living well. This spiritual perspective allows us to grow in self-awareness so that we can see that we often live our lives in division, split between contradictory desires that create conflict and dissatisfaction. Growing in awareness of this division will help a person to transcend his or her problems and to rediscover a sense of unity.


1. Cloninger CR. Feeling Good: The Science of Well Being. New York, Oxford University Press, 2004.

2. Cloninger CR. The science of well-being: an integrated approach to mental health and its disorders. World Psychiatry 2006;5:71-76.

3. Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis 2005;2:A14.

4. Cloninger CR. Fostering spirituality and well-being in clinical practice. Psychiatr Ann 2006;36:156-167.

5. Cloninger CR. Completing the psychobiological architecture of human personality development: temperament, character, & coherence. In: Staudinger UM, Lindenberger UER, eds. Understanding Human Development: Dialogues with Lifespan Psychology. Boston, Kluwer Academic Publishers, 2003, pp 159-182.

6. Frankl VE. The Unheard Cry for Meaning: Psychotherapy and Humanism. New York, Pocket Books, 1978.

7. Jung CG. The Integration of the Personality. New York, Farrar & Rinehart, Inc, 1939.

8. Cloninger CR. Book review of Peterson and Seligman's Character and Human Virtues. Am J Psychiatry 2005;162:820-821.

9. Plante TG, Sherman AC. eds. Faith and Health: Psychological Perspectives. New York, Guilford Press, 2001.

10. MacLean PD. The Triune Brain in Evolution: Role in Paleocerebral Functions. New York, Plenum Press, 1990.

11. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry 1993;50:975-990.

12. Cloninger CR. The genetic structure of personality and learning: a phylogenetic model. Clin Genet 1994;46:124-137.

13. Povinelli DJ, Giambrone S. Reasoning about beliefs: a human specialization? Child Dev 2001;72:691-695.

14. Mithen S. The Prehistory of the Mind: The Cognitive Origins of Art, Religion, and Science. London, Thames and Hudson, Ltd., 1996.

15. Papez JW. A proposed mechanism of emotion. Arch Neurol Psychiatry 1937;38:725-743.

16. Paus T. Primate anterior cingulate cortex: where motor control, drive and cognition interface. Nat Rev Neurosci 2001;2:417-424.

17. Paulus MP, Rogalsky C, Simmons A, et al. Increased activation in the right insula during risk-taking decision making is related to harm avoidance and neuroticism. Neuroimage 2003;19:1439-1448.

18. Pezawas L, Mcyer-Lindenberg A, Drabant EM, et al. 5-HTTLPR polymorphism impacts human cingulated-amygdala interactions: a genetic susceptibility mechanism for depression. Nat Neurosci 2005;8:828-834.

19. Pujol J, Lopez A, Deus J, et al. Anatomical variability of the anterior cingulate gyrus and basic dimensions of human personality. Neuroimage 2002;15:847-855.

20. Teasdale JD, Moore RG, Hayhurst H, et al. Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psychol 2002;70:275-287.

21. Vaillant GE, Milofsky E. Natural history of male psychological health: IX. Empirical evidence for Erikson's model of the life cycle. Am J Psychiatry 1980;137:1348-1359.

22. Cloninger CR. The Happy Life: Voyages to Well-Being. St. Louis, Anthropaideia Foundation, 2006.

C. Robert Cloninger, MD

From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO.

Reprint requests to C. Robert Cloninger. MD, Wallace Renard Professor of Psychiatry, Genetics, and Psychology, Washington University School of Medicine, Department of Psychiatry. Campus Box 8134, 660 South Euclid Avenue, St. Louis, MO 63110. Email:
Table. Three stages of self-awareness on the path to well-being

Stage Description Psychological characteristics

0 Unaware Immature, seeking immediate gratification
 ("child-like" ego-state)
1 Average adult Purposeful but egocentric, able to delay
 cognition gratification, but has frequent negative
 emotions (anxiety, anger, disgust)
 ("adult" ego-state)
2 Meta-cognition Mature and allocentric, mindful (aware of
 own subconscious thinking), calm and
 patient, so able to supervise conflicts
 and relationships ("parental" ego-state)
3 Contemplation Effortless calm, impartial awareness, wise,
 creative, and loving, able to access what
 was previously
Unconscious As needed without effort or distress
 ("state of well-being")
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Title Annotation:Special Section: Spirituality/Medicine Interface Project
Author:Cloninger, C. Robert
Publication:Southern Medical Journal
Date:Jul 1, 2007
Previous Article:Spirituality and depression: a look at the evidence.
Next Article:Depression and suicide in children and adolescents: a spiritual perspective.

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