Wellness: a review of theory and measurement for counselors.
Although several authors have proposed definitions (Ardell, 1977; Clark, 1996; Dunn, 1977; Edlin, 1988; Greenberg, 1985; Jensen & Allen, 1994; Lafferty, 1979), the models contain different dimensions of wellness (focuses and number of dimensions), and an integrated definition has not been created. Clarifying the definition of wellness is difficult because of the subjective nature of the construct (Kelly, 2000) and because of the inherent value judgment about what wellness is and what it is not, and the implication that one can be either well or not well (Sarason, 2000).
There is some alignment, however, on the nature of wellness. Most authors generally agree that wellness is a multidimensional, synergistic construct (Adams et al., 1997; Ardell, 1977; Dunn, 1977; Hettler, 1980) that is represented on a continuum, not as an end state (Clark, 1996; Dunn, 1977; Lafferty, 1979; Lotion, 2000; Sarason, 2000; Sechrist, 1979; Teague, 1987). Most definitions also include the assumption that wellness is not just the absence of illness (Ardell, 1977; Edlin, 1988; Lafferty, 1979; Teague, 1987). Although there is some consensus on the nature of wellness, further progress needs to be made to better elucidate a comprehensive definition.
Considering the increased interest and emphasis on wellness in counseling, it is first necessary to review the literature to come to an agreement on the definition, conceptualization, and preferred means of assessing wellness. Increased conceptual clarity will facilitate the creation of better measures of wellness. Current wellness assessment instruments can only be as good as the conceptual frameworks upon which they are based. New wellness assessments need to reflect a comprehensive conceptualization of the construct. In this article, I review wellness theory, definitions, and assessment measures and synthesize the research into an integrated, comprehensive definition of wellness that can be the foundation of new wellness assessment measures.
Attempts to define wellness often begin with references to the World Health Organization's (1967) definition of wellness being not just the absence of illness but a state of complete physical, mental, and social well-being. Many conceptualizations of wellness include the central tenet that wellness is not just the absence of disease (Adams et al., 1997; Dunn, 1977; Edlin, 1988). Dunn, for example, emphasized wellness as a positive state, one that is beyond simply nonsickness. He defined high-level wellness as "an integrated method of functioning, which is oriented toward maximizing the potential of which the individual is capable. It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning" (Dunn, 1977, p. 4).
Beyond the absence of illness, wellness conceptualizations focus on areas of health or strength. Egbert (1980) outlined the focal areas of wellness as being an integrated personality with a clear sense of identity, a reality oriented perspective, and a clear meaning and purpose in life. Furthermore, he described wellness as including the recognition of a unifying force in one's life, the ability to cope creatively and to be inspired by hope, and the capability of creative, open relationships. Similarly, Travis and Ryan (1988) conceptualized wellness as comprising self-responsibility and love. In their meta-analysis of qualitative research on wellness, Jensen and Allen (1994) defined wellness as the subjective experience of health. They described the wellness-illness relationship as dialectical, where health, wellness, and illness are the same. For example, both wellness and illness are needed to define the other; without illness there would be no concept of wellness. Witmer and Sweeney (1992) and later Myers, Sweeney, and Witmer (2000) described a holistic model of wellness that comprises five life tasks: spirituality, self-regulation, work, friendship, and love. Those authors described the Wheel of Wellness (WOW) as having 12 spokes, or subtasks: sense of worth, sense of control, realistic beliefs, emotional awareness and coping, problem solving and creativity, sense of humor, nutrition, exercise, self-care, stress management, gender identity, and cultural identity (Myers et al., 2000). Myers, Luecht, and Sweeney (2004) described the evolution of the WoW model into the 5F-Wel, which comprises five factors (creative, coping, social, essential, and physical) and the subsequent revision of the 5F-Wel that includes the factors cognitive-emotional wellness, relational wellness, physical wellness, and spiritual wellness.
In work similar to the creation of the WoW, other researchers have explored and defined the various elements, or interrelated areas, that comprise wellness (Adams et al., 1997; Greenberg, 1985; Hettler, 1980; Lafferty, 1979; Renger et al., 2000). A comparison of these models is presented in Table 1. Depken (1994) indicated that most college health textbooks describe wellness as comprising physical, intellectual, social, emotional, and spiritual dimensions. Both Lafferty and Greenberg described wellness with the five factors used by Depken; Greenberg, however, referred to mental wellness instead of intellectual wellness. Lafferty and Greenberg both defined wellness as the integration of the five dimensions and high-level wellness as the balance among the dimensions.
Other wellness models included the factors described by Depken (1994), Lafferty (1979), and Greenberg (1985) but incorporated additional dimensions (Adams et al., 1997; Hettler, 1980; Renger et al., 2000). Hettler's (1980) wellness model comprised six dimensions: social, spiritual, physical, intellectual, emotional, and occupational. Hettler agreed with Dunn's (1977) conceptualization of wellness and stressed the process of becoming aware of wellness and actively making choices toward optimal living. Similar to the other models, Hettler's model conceptualized wellness as the integration and balance of the six dimensions.
Adams et al. (1997) conceptualized wellness similarly to Hettler (1980). However, Adams et al. did not include occupational wellness. Instead they included the additional dimension of psychological wellness, reflecting the general perception of positive outcomes in response to life's circumstances. Adams et al. labeled the six dimensions of wellness as social, spiritual, physical, intellectual, emotional, and psychological and conceptualized wellness from a systems perspective. Subsystems (i.e., dimensions) have their own elements and are integrated into a larger whole. The authors described wellness as salutogenic, or health focused, and emphasized the importance of including multiple factors such as cultural, social, and environmental influences.
Renger et al. (2000) described another six-domain wellness conceptualization similar to those of Adams et al. (1997) and Hettler (1980). Renger et al. defined wellness as consisting of emotional, spiritual, physical, social, intellectual, and environmental domains. In defining each of the domains, Renger et al. stressed the importance of knowledge, attitude, perception, behavior, and skill in each of the wellness areas. Similar to Hettler, Renger et al. included the five core dimensions described by many authors (Depken, 1994) and added the sixth dimension of environmental wellness to recognize the important impact of one's surroundings. Similar to other authors, Renger et el. defined wellness as the integration and balance of the dimensions, resulting in the optimal state of being that an individual is able to achieve in relation to his or her life circumstances.
Consistency in describing the nature of wellness is seen in most of the models and definitions. First, most authors incorporated the idea that wellness is not just absence of illness as first outlined by the World Health Organization's definition of wellness (Ardell, 1977; Edlin, 1988; Lafferty, 1979; Teague, 1987). Second, wellness is described in terms of various factors that interact in a complex, integrated, and synergistic fashion (Adams et al., 1997; Ardell, 1977; Duma, 1977; Hettler, 1980). In other words, the dynamic interaction of the dimensions causes the sum of the dimensions to be greater than the whole. Each dimension is integral to the whole and no one dimension operates independently (Adams et el., 1997; Alster, 1989; Clark, 1996; Crose, Nicholas, Gobble, & Frank, 1992; Dunn, 1977; Edlin, 1988). Therefore, the wellness approach is holistic within the person and with the environment. Third, most authors outlined the necessity of balance or dynamic equilibrium among dimensions. Fourth, several models define wellness as the movement toward higher levels of wellness or optimal functioning (Ardell, 1977; Clark, 1996; Dunn, 1977; Greenberg, 1985; Hettler, 1980) and that wellness is, therefore, partially dependent on self-responsibility (Dunn, 1977; Krivoski & Piccolo, 1980; Leafgren, 1990) and one's motivation (Ardell, 1977; Clark, 1996; Dunn, 1977; Hettler, 1980). Finally, wellness is viewed as being a continuum, not as an end state (Clark, 1996; Dunn, 1977; Lafferty, 1979; Lotion, 2000; Sarason, 2000; Sechrist, 1979; Teague, 1987). Beyond the nature of the construct, several common dimensions of wellness have been described. The following sections review the dimensions of wellness included in the major theories reviewed thus far.
Hettler's (1980) definition of social wellness emphasized individuals in relation to others and to the environment. The relationship included the extent to which an individual contributes to the common welfare of the community and environment (e.g., volunteer work and community support) and the level of interdependence with others and nature (e.g., social interaction/relationships and connectedness with nature). Hettler defined a socially well individual as one living in harmony with others working toward mutual respect and cooperation. Social wellness involved the active promotion of a healthy environment and the betterment of community; effective communication and healthy relationships with others (including sexual behaviors); and a balance and integration of self with others, the community, and nature.
In comparison to Hettler (1980), Adams et al.'s (1997) conceptualization of social wellness focused more on the interaction of individuals, as opposed to the individual in relation to the larger community or environment. Social wellness, as defined by Adams et al. (1997) is the amount of support received and reciprocated and the value attached to the actions of giving and receiving support. Similar to Adams et al. (1997), Renger et al. (2000) conceptualized social wellness mainly in terms of the interaction of the individual with others. They defined social wellness as the extent to which one gets along well with others and is comfortable with expressing and willing to express one's feelings, needs, and opinions. Support, fulfilling relationships (including sexual relations), and intimacy are central concepts in this model. Similar to Hettler's definition, Renger et al. included the interaction with the social environment and the contribution to one's community.
Other authors have conceptualized social wellness. Leafgren (1990) described social wellness as contributing to one's environment to achieve common welfare, as well as the awareness of and action toward others' needs. Furthermore, he emphasized one's interdependence with nature and others, as well as one's responsibility to give back to the community and the earth. Crose et al. (1992) defined social wellness as the history of significant relationships and the quality and extent of one's social network. Relational styles and patterns were also considered an aspect of social wellness, as was one's attitude toward relationships and seeking help from others. Finally, Durlak (2000) outlined social wellness competencies as peer acceptance, altruism, attachments/bonds with others, and social skills (communication, assertiveness, conflict resolution), whereas problem areas in social wellness included peer rejection, social isolation, social anxiety, and violence/delinquency.
Following from the previous definitions, social wellness encompasses the quality and extent of interaction with others and the interdependence between the individual, others, the community, and nature. Furthermore, social wellness comprises the skills and comfort level one is able to express in the context of interpersonal interactions, as well as the motivation, action, intent, and perception of those interactions. Social wellness also includes the extent to which one gives support and how one receives support and the respect of others. In sum, social wellness is the movement toward balance and integration of the interaction between the individual, society, and nature.
Hettler (1980) conceptualized emotional wellness as a continual process that incorporates the awareness, constructive expression, and management of emotions, as well as a realistic self-assessment and positive approach to life (e.g., challenges, risks, and conflicts are viewed as healthy and as opportunities to develop further). He described emotional wellness as the awareness and acceptance of a wide range of feelings in one's self and others, as well as one's ability to constructively express, manage, and integrate feelings. He recognized that one's choices are the expression and integration of feelings, cognitions, and behaviors. An emotionally well person is flexible, open to development, able to function autonomously, and is aware of his or her limitations. Linking emotional and social wellness, Healer stated that the relationships held by an emotionally well individual are interdependent and based upon mutual commitment, respect, and trust. In sum, Hettler defined emotional wellness as a continual process that includes an awareness and management of feelings, and a positive view of self, the world, and relationships.
Adams et al.'s (1997) definition of emotional wellness was focused on the individual's self-concept or self-esteem, that is, a secure identity and positive sense of self. They detailed emotional wellness as a secure internal self-image and a positive sense of self-regard, or the extent of self-valuing. Similar to Hettler (1980) and Adams et al. (1997), Renger et al. (2000) focused on an individual's self-view. However, Renger et al. defined emotional wellness with regard to one's level of anxiety, depression, well-being, self-control, and optimism. Emotional wellness includes experiencing satisfaction, interest, and enjoyment in life, as well as having a positive anticipation of the future, or having an optimistic outlook.
Leafgren (1990) described emotional wellness as awareness and acceptance of feelings, the degree to which one feels positive about life and about oneself, and the capacity to manage feelings and corresponding behaviors. Furthermore, his conceptualization included the realistic assessment of one's limitations, as well as the ability to act autonomously and to cope with stress. Leafgren also cited another aspect of emotional wellness, specifically, the maintenance of fulfilling relationships with others. Crose et al. (1992) defined emotional wellness as focusing on coping styles and patterns, self-awareness and self-image, attitudes toward emotion and disclosure, and one's psychiatric history and use of medications.
Given the previous theories, emotional wellness is generally conceptualized as awareness and control of feelings, as well as a realistic, positive, and developmental view of the self, conflict, and life circumstances. Common themes of emotional wellness are one's attitudes and beliefs toward the self and life (e.g., a positive and realistic self-concept, identity, and amount of self-esteem) and the awareness and constructive handling of feelings. An integrated conceptualization of emotional wellness includes the capability to manage one's feelings and to act accordingly, along with the realistic assessment of one's limitations. Emotional wellness is the ability to act autonomously and cope with stress, and the capacity to have fulfilling relationships with others. In sum, emotional wellness is an awareness and acceptance of feelings, as well as a positive attitude about life, oneself, and the future.
Hettler (I 980) defined physical wellness as encompassing the degree to which one maintains and improves cardiovascular fitness, flexibility, and strength. Furthermore, he stressed the importance of maintaining a healthy diet and attempting to produce bodily balance and harmony through awareness and monitoring of body feelings, internal states, physical signs, tension patterns, and reactions. His definition also included seeking appropriate medical care and taking action to prevent and detect illnesses. In sum, Hettler's definition of physical wellness encompassed one's attention to physical self-care, activity level, nutritional needs, and use of medical services.
Adams et al. (1997) defined physical wellness as a positive perception and expectation of physical health. They focused their definition on the perception and evaluation of physical wellness as opposed to objective measures, thus making it subjective. Wellness was not discussed in behavioral terms; instead, its perceptual nature was emphasized. For example, if a person perceived that he or she was physically healthy, then he or she was considered physically well. The definition emphasized physical health but failed to further define what constitutes physical health. Renger et al. (2000) defined physical wellness as one's level of fitness and nutrition, as well as the avoidance of harmful behavior. Furthermore, like Hettler (1980), they included the perception and use of medical services. Physical wellness, as defined by Renger et al., also included the prevention and early recognition of problems.
Similar to Hettler (1980), Leafgren (1990) described physical wellness as embodying cardiovascular strength and regular physical activity, as well as a knowledge of food and the implementation of healthy dietary choices. Leafgren's definition discouraged the use of drugs, tobacco, and the excessive use of alcohol, and encouraged appropriate medical self-care and use of the medical system. Crose et al. (1992) also defined physical wellness as including medical history and medications, body awareness and image, exercise and eating behaviors, and attitudes toward physical fitness and health care. Finally, Durlak (2000) detailed physical wellness using two domains. Competencies in physical wellness included physical indices (muscle tone, cholesterol level, and blood pressure) and behaviors (eating habits and exercise levels). Problems in physical wellness incorporated various medical problems, physical injuries and disabilities, and sexually transmitted diseases.
In sum, physical wellness is the active and continuous effort to maintain the optimum level of physical activity and focus on nutrition, as well as self-care and maintaining healthy lifestyle choices (e.g., use of medical services, preventative health measures, abstinence from drugs and excessive alcohol use, safe sex practices). Physical wellness also includes the perception and expectation of wellness, as well as the acceptance of one's physical state (e.g., body image, disability). The definition focuses on an individual moving toward personal potential without comparing his or her progress with that of others, thus allowing for individual variation and circumstances. For example, an individual with a physical disability can be considered to be well by moving toward his or her own personal optimal level.
Hettler (1980) defined intellectual wellness as the degree to which one engages one's mind in creative and stimulating activities, as well as the use of resources to expand one's knowledge. The definition is focused on the acquisition, development, application, and articulation of critical thinking. Intellectual wellness is one's commitment to lifelong learning and the effort to share knowledge with others. Finally, intellectual wellness was defined by Hettler as the focusing of one's skills and abilities on achieving a more satisfying life. Adams et al. (1997) stated that the perception of being energized by an optimal amount of intellectually stimulating activity was central to intellectual wellness. Stimulating intellectual activity included mental challenges and critical reasoning, both of which require concentration. Furthermore,
Adams et al. (1997) believed that the optimal level is not too much or too little stimulation because each has adverse consequences. Similar to their definition of physical wellness, the definition of intellectual wellness was focused on the individual's perception. Renger et al. (2000) defined intellectual wellness as one's orientation and achievement toward personal growth, education and achievement, and creativity. Continual personal growth and education included attending cultural events and seeking opportunities to gain and share knowledge. Furthermore, Renger et al. stressed the importance of knowledge regarding current local and world events and an overall lifestyle that fostered learning.
Leafgren (1990) defined intellectual wellness similarly to Hettler (1980) in that his theory encompassed creative and stimulating activities, as well as the use of available resources to expand, improve, and share knowledge and skills. He outlined that stimulation can come from reading, attending cultural events, studying, traveling, and the exposure to media. Crose et al. (1992) defined intellectual wellness as one's education and learning history, mental status, cognitive style and flexibility, and attitude towards learning. Similar to intellectual wellness, Durlak's (2000) description of the academic domain of adjustment included developing talents and abilities, learning how to learn, and developing higher order thinking skills. Furthermore, he described the problem areas to include underachievement, test anxiety, and school dropouts.
Integrating the previous conceptualizations, intellectual wellness can be defined as the perception of, and motivation for, one's optimal level of stimulating intellectual activity. The optimal level of activity is achieved by the continual acquisition, use, sharing, and application of knowledge in a creative and critical fashion for the personal growth of the individual and for the betterment of society.
Nettler (1980) defined spiritual wellness as a worldview that gives unity and goals to thoughts and actions, as well as the process of seeking meaning, purpose in existence, and understanding of one's place in the universe. Spiritual wellness also included the appreciation of the depth and expanse of life and of the universe along with the acceptance and recognition of the transcendence of the unknown. Furthermore, spiritual wellness is focused on inner and relational harmony with others and the universe, as well as the search for a universal value system.
Adams et al. (1997) defined spiritual wellness as a positive perception of meaning and purpose in life, as well as recognition and acceptance of a unifying and integrating force between mind and body. Adams, Bezner, Drabbs, Zambarano, and Steinhardt (2000) expanded the definition of spiritual wellness by including a sense of meaning and purpose in life; connectedness to the self, the environment, or a higher power; and the belief in a unifying life force. Furthermore, they detailed how optimism and a sense of coherence act as mediators in the relationship between experiences and perceived wellness.
Renger et al. (2000) similarly defined spiritual wellness as finding a basic purpose in life and the pursuit of a fulfilling life; the ability to give and receive love, joy, and peace; and one's willingness to help others. Just as the other definitions did, Renger et al.'s definition emphasized the relational nature between the self, others, and the universe, as well as the creation of meaning and the definition of one's identity in relationship to others and the universe.
Several other authors have offered conceptualizations of spiritual wellness. For example, Leafgren (1990) defined spiritual wellness as seeing meaning and purpose in life and the appreciation of the expanse of life and the forces that exist in nature. Furthermore, Leafgren described spiritual wellness as including values and ethics that were gained through involvement in religious groups, through other people, or through nature. Crose et al. (1992) defined the components of spiritual wellness as religious and spiritual history, life satisfaction, purpose and meaning of life, beliefs about death, and attitudes toward the relational aspects of living. Additionally, Ingersoll (1994, 1998) and Westgate (1996) defined spiritual wellness in terms of holistic dimensions. Ingersoll (1998) described spirituality with 10 dimensions: conception of the absolute or divine, meaning, connectedness, mystery, sense of freedom, experience-ritual-practice, forgiveness, hope, knowledge-learning, and present centeredness. Westgate proposed four spiritual wellness dimensions: meaning in life, intrinsic values, transcendence, and spiritual community.
Of all the wellness dimensions reviewed thus far, spiritual wellness is the most well-defined and explored in the literature. Not only do authors focus on spiritual wellness, but many authors have explored definitions of spiritual well-being (Ellison, 1983) and spiritual health (Banks, 1980; Bensley, 1991; Eberst, 1984). Although the definitions reviewed are only a sampling, the key aspects of spiritual wellness are evident: a continual process of finding meaning and purpose in life in relation to others and the universe; the self in relation to others, the community, nature, the universe, and some higher power; shared community and experience; and the creation of personal values and beliefs (Adams et al., 1997; Healer, 1980; Leafgren, 1990; Renger et al., 2000). Considering the previous definitions, spiritual wellness is the innate and continual process of finding meaning and purpose in life, while accepting and transcending one's place in the complex and interrelated universe. Spiritual wellness is a shared connection or community with others, nature, the universe, and a higher power. Additionally, spiritual wellness is the development of values and a personal belief system.
Psychological wellness, as defined by Adams et al. (1997), is the individual's sense of optimism that he or she will experience positive outcomes resulting from the events and experiences of life. Of the wellness models reviewed, Adams et al.'s (1997) model is the only one that included the psychological dimension. However, it seems that both psychological and emotional wellness are conceptually similar. Hettler's (1980) definition of emotional wellness (i.e., a realistic self-assessment and positive view of the self, the world, and relationships wherein challenges, risks, and conflicts are viewed as opportunities to further develop) is very similar to Adams et al.'s (1997) definition of psychological wellness. Similarly, Leafgren (1990) and Renger et al. (2000) defined emotional wellness as including optimism and a positive approach to life. Given the similarities of Adams et al.'s (1997) conceptualization of psychological wellness and other authors' ideas about emotional wellness, psychological wellness can be viewed as closely related to or a possible aspect of emotional wellness.
Unlike Adams et al. (1997) and Renger et al. (2000), Hettler (1980) included occupational wellness in his theory and defined it as the level of satisfaction and enrichment gained by one's work and the extent to which one's occupation allows for the expression of one's values. Furthermore, occupational wellness includes the contribution of one's unique skills and talents to the community in rewarding, meaningful ways through paid and unpaid work, as well as the balance between occupational and other commitments.
Both Leafgren (1990) and Crose et al. (1992) also discussed occupational wellness. Leafgren stated that occupational wellness is one's attitude about work and the amount of personal satisfaction and enrichment one gains from one's work. Similarly, Crose et al. included in their definition one's attitude toward work and leisure, as well as one's work history, patterns and balance between vocational, avocational and leisure activities, and vocational goals. Integrating the previous conceptualizations, occupational wellness is the extent to which one can express individual values and gain personal satisfaction and enrichment from paid and non-paid work; one's attitude toward work and ability to balance several roles; and the ways in which one can use skills and abilities to contribute to the community.
Hettler's (1980) contribution of occupational wellness expanded wellness theory to include an aspect of the environment, one's occupation. However, Hettler's model and definition lacked an emphasis on what can be traditionally considered environmental concerns (e.g., pollution, conservation, and nature). Renger et al. (2000) included environmental wellness as a separate dimension and defined it to include the impact on and balance between home and work life, as well as an individual's relationship with nature and community resources. For example, steps taken to improve pollution or participation in a community clean-up effort were considered an aspect of environmental wellness. Therefore, Renger et al. conceptualized environmental wellness as a broad dimension that looked at the nature of an individual's reciprocal interaction with the environment (e.g., home, work, the community, and nature).
Considering the previous conceptualizations, environmental wellness is the balance between home and work life, as well as the recognition of the individual's impact on that environment. It is the reciprocal relationship between the environment and the individual in various roles and the individual's relationship with nature and community resources. It includes one's effort to improve the environment and community, as well as the extent of the control one has over that environment. In sum, environmental wellness focuses on the nature of an individual's reciprocal interaction with the environment (e.g., home, work, the community, and nature).
A review of the theories and definitions of wellness demonstrated that several models include five similar components: emotional, intellectual, physical, social, and spiritual wellness. Although the definition of each dimension may vary slightly in each model, the ideas presented in each model can be integrated into comprehensive definitions for each dimension. The dimensions less frequently cited in the literature (e.g., psychological, occupational) can be considered separate dimensions or they can be integrated within core dimensions. As discussed, Adams et al.'s (1997) definition of psychological wellness seems to be similar to the emotional dimension of other models. Therefore, inclusion of psychological wellness as a separate wellness dimension is not necessary. The ideas about psychological wellness presented by Adams et al. (1997) can be considered an aspect of emotional wellness.
Unlike psychological wellness, occupational wellness as defined by Hettler (1980) and environmental wellness described by Renger et al. (2000) were distinct enough from the other dimensions to merit leaving them as two individual dimensions. The decision that environmental wellness should be a separate dimension is supported when considering the importance of exploring the relationship between the person and the environment (Depken, 1994). Furthermore, the central role that one's occupation plays in one's life and identity (Dorn, 1992) supports the decision of having occupational wellness as a separate dimension. Therefore, it follows that a comprehensive model of wellness needs to have environmental wellness and occupational wellness as separate dimensions.
Finally, the placement of spiritual wellness within wellness models has been explored in the literature (Benjamin & Looby, 1998; Chandler, Holden, & Kolander, 1992). Spiritual wellness can be considered a separate dimension just like the others or a central dimension that encompasses all the other dimensions. Spiritual wellness is an important dimension, but the role it plays in wellness is not clearly defined. Furthermore, exploration of the structure of wellness is needed before determining the role of spiritual wellness. Therefore, spiritual wellness will be considered as a separate and equal dimension.
The proposed holistic model of wellness will, therefore, comprise seven dimensions: social, emotional, physical, intellectual, spiritual, occupational, and environmental. Each of the seven dimensions will be defined by the integrated definition that resulted from the review and synthesis of the existing theories in the literature. The structure of the proposed model represents the major wellness dimensions discussed in the literature. As was the case in past theories, in the current model wellness is conceptualized as a synergistic and multidimensional construct that is represented on a continuum, not as an end state.
* Measurement of Wellness
Several of the reviewed theories have been the foundation of instruments that measure wellness (Adams et el., 1997; Hettler, 1980; Myers et el., 2004; Renger et el., 2000; Sweeney & Myers, 2003). The varied definitions and models of wellness yield various means of assessing the construct. The resulting wellness measures are reviewed in the following sections.
Life Assessment Questionnaire
The Wellness Inventory of the Life Assessment Questionnaire (LAQ; National Wellness Institute, 1983) was developed to measure the six wellness dimensions outlined by Hettler (1980): social, spiritual, physical, intellectual, emotional, and occupational. The LAQ contains 100 items that are measured on a 5-point Likert scale, with lower scores meaning lower levels of wellness. Initial psychometric data have been collected on the LAQ. As noted by Palombi (1992), neither the manual nor information on the samples used to create the instrument is available.
DeStefano and Richardson (1992), with a predominately Caucasian sample of college freshman, found low to moderate correlations between the subscales except for the correlation between Emotional Awareness and Emotional Management (r =.77). Palombi (1992), in reviewing the only two prior studies on the LAQ, reported previous findings of an overall alpha coefficient of .76 and test-retest reliabilities of the subscales ranged from .57 to .87, with a 2-week time interval. In the second study reviewed, Palombi reported that the subscale test retest reliabilities ranged from .81 to .94 (no time interval reported) and internal consistency reliabilities ranged from .67 to .94. In her evaluation of the LAQ with a college sample of users of counseling services and matched nonusers, Palombi reported that the intercorrelations among the total score and subscale scores ranged from .42 to .68. She also found that the alpha coefficient of the total score was .93 and that all but two of the alphas for the subscales were above .74. The two exceptions were Physical Fitness (.64) and Self-Care (.68). Palombi concluded from the results that the LAQ might be measuring a unidimensional construct. DeStefano and Richardson, using factor analysis, found the LAQ to have three dimensions and compared the LAQ with objective measures of physical health (e.g., pulse, weight loss). They reported little support for external validity of the LAQ in relation to specific indictors of health and that the LAQ scores related more highly with individuals' perceptions of wellness.
Perceived Wellness Survey
The Perceived Wellness Survey (PWS; Adams et el., 1997) was developed as a health focused, multidimensional measure of perceived wellness in the following domains: social, spiritual, physical, intellectual, emotional, and psychological (Adams et el., 1997). The PWS contains six items in each of the six domains, for a total of 36 items. Respondents score each item on a 6-point Likert scale that ranges from 1 (very strongly disagree) to 6 (very strongly agree). Higher scale scores indicate higher levels of wellness. The sample (N = 558) used to create the instrument, as further described in Adams et el. (1997), comprised employees from two major companies, as well as college students in a health education class, and was ethnically diverse. See Adams et el. (1997) and Harari, Waehler, and Rogers (2005) for a more complete summary of the scale's development and description.
In pilot studies, the PWS showed convergent validity correlations with conceptually related instruments (e.g., measuring well-being, social support, and self-esteem) ranging from .37 to .56 (Adams et el., 1997). Adams et el. (1997) reported that the total scale internal consistency was .91, and 90% of the items had an item to total scale correlation greater than .30. However, only four of the six subscales demonstrated adequate internal consistency (alpha > .70), with the internal consistency estimates for each of the subscales ranging from .64 (Intellectual and Social) to .81 (Physical). Similar total scale internal consistency results were seen in subsequent administrations of the instrument (Adams et el., 2000). More recently, Harari et al. (2005) explored the psychometric properties of the PWS. They also found that the internal consistency for the PWS for the total score was .91 for the full scale and for a revised 33-item scale. Harari et el. found no support for the existence of separate subscale dimensions of the PWS hypothesized by Adams et el. (1997) and concluded that the PWS is not an adequate measure of the Perceived Wellness Model.
Optimal Living Profile (OkP)
The OLP (Renger et al., 2000) was created for a private commercial wellness organization (Canyon Ranch) to represent the Total Person Concept, as defined by Canyon Ranch, which included the six dimensions of emotional, spiritual, physical, social, intellectual, and environmental wellness. The scale consists of 135 items measured on two different 5-point Likert scales depending on the item wording. The 5-point Likert scales ranged from 1 (strongly agree) to 5 (strongly disagree) or from 1 (very frequently) to 5 (almost never). The samples used in creating the scale comprised participants and non-participants of Canyon Ranch's Life Enhancement Program, as well as college students. The researchers did not report other specific information about the samples.
The OLP demonstrated adequate reliability and validity (Renger et al., 2000). Cronbach's alpha estimates for each subscale ranged from .78 (Environmental Wellness) to .95 (Emotional Wellness). Test-retest correlations coefficients for the subscale scores ranged from .53 (Physical Wellness) to .86 (Intellectual Wellness). Additionally, content validity was supported by outside reviewers and concurrent validity was supported by comparing OLP scale with interview data. Divergent validity was addressed by removing items that correlated more highly with another dimension than the one they were supposed to measure. Beyond the initial studies on the OLP, future research is needed to gather psychometric data on the instrument and to explore if the proposed OLP wellness dimensions emerge.
Wellness Evaluation of Life Inventory (WEL) and Successors
The WEL (Myers et al., 1998) was designed to measure the five life tasks and the subtasks of the Wheel of Wellness. The scale has gone through several revisions since its creation. The most recent version, the WEL-S, comprises 120 items scored on a 5-point Likert scale, ranging from strongly agree (1) to strongly disagree (5). Hattie, Myers, and Sweeney (2004) reported Cronbach alpha estimates for each of the 12 subtasks ranging from .61 (leisure) to .89 (love). Myers et al. (2004) reported that test-retest reliability coefficients ranged from .68 for cultural identity to .88 for nutrition. Furthermore, they found that internal consistency ranged from .60 (realistic beliefs) to .94 (friendship).
The 5F-Wel (initially referred to as the WEL-J; Myers & Sweeney, 1999) measures the Indivisible Self wellness model (IS-WEL). The 5F-Wel comprises 91 items (73 attitudinal and behavioral statements and 18 additional experimental items). Responses are recorded on a 5-point Likert scale, from strongly agree (1) to strongly disagree (5). Myers et al. (2004) described how the scale scores are computed for the five factors (creative, coping, social, essential, and physical) as well as for the 17 third-order factors and the higher order wellness factor (sum of all scores). Myers et al. (2004) further described the revision of the 5F-Wel to the 4F-Wel with the four factors of cognitive-emotional wellness, relational wellness, physical wellness, and spiritual wellness. Psychometric data are still being collected for the 5F-Wel and the 4F-Wel.
Travis (1981) developed the Wellness Inventory (WI), which contains 120 questions that measure 12 dimensions labeled self-responsibility and love, breathing, sensing, eating, moving, feeling, thinking, playing and working, communication, sex, finding meaning, and transcending. The items are scored on a 5-point Likert scale ranging from 1 (no) to 5 (yes always). Lower scores on the inventory represent lower levels of wellness. Palombi (1992) reported internal consistency of the total score of the WI as .93 and that the coefficient alphas of eight of the 12 subscales were above .74. Palombi reported that, similar to the LAQ, the WI might be measuring a unidimensional construct.
Owen (1999) reviewed the psychometric properties of TestWell (National Wellness Institute, 1992), a wellness inventory designed to tap Hettler's (1980) dimensions of wellness. TestWell contains 100 items, scored on a 5-point Likert scale. Owen reported that TestWell had a split-half reliability of .87; 8 of the 10 subscales had coefficient alphas over .71, and the total reliability was .92.
* Integrating Theory and Measurement
Despite the extensive literature on the definition of wellness and the development of several scales, there has been little empirical exploration of the structure and dimensions of wellness. Most of the theories previously reviewed are conceptual; they have not been adequately empirically validated beyond testing the psychometric properties of the instruments designed to measure them. However, two models, the Wheel of Wellness and the IS-WEL model (Myers et al., 2004; Sweeney & Myers, 2003) have received more empirical attention in the literature.
The lack of empirical evaluation of the theories is noted in Harari et al. (2005) and explained as being due, in part, to the limited appropriate psychometric measures to test the theories. Several wellness instruments exist that are based on the individual wellness theories; however, the instruments can only be evaluated in terms of how well they measure the model they were created to represent. In the case of all the instruments reviewed, typically only the psychometric properties of the instruments themselves have been investigated. Therefore, most of the current research is not exploring the nature of wellness because exploring properties of the instruments is not analogous to exploring the dimensions of wellness. Research needs to emphasize integrating wellness theory and defining the dimensional structure. Only after a comprehensive model and definitions are elucidated can better assessments be created. In sum, better wellness inventories will only result from an integrated theory and better understanding of the dimensional structure of wellness.
Authors agree that wellness inventories are needed (Adams et al., 1997; Renger et al., 2000) and note the difficulties in adequately capturing such a complex concept as wellness (Harari et al., 2005; Kelly, 2000). In order to succeed at creating better means of assessing wellness, it is important to understand the difficulties related to the measurement of such a fluid construct. The measurement of wellness is complicated because of its subjective and personal nature, as well as the uncertainty regarding whether wellness is best represented with individual dimensions or as one unified construct (Harari et al., 2005). Given the complexity of the construct, researchers must consider what is the best means to assess wellness. As evident from the wellness inventories reviewed, the majority, if not all, of the instruments currently available are quantitative, self-assessments. Researchers have commented on the limited nature of quantitative measures and the loss of rich background data when relying solely on them. For example, Lotion (2000) advocated for the use of more qualitative assessments to capture the depth of wellness and to move away from categorizing "well" versus "not well." Perhaps some of the difficulty in capturing wellness is related to the incongruence between the nature of wellness and the current quantitative measures. A qualitative measure based on a comprehensive model of wellness would better represent the multidimensional nature of wellness. Using qualitative methods may be an ideal way to help clarify the wellness construct, to assess individuals' levels of wellness, and to structure counseling interventions.
Therefore, theory is the place to start if researchers want to refine the conceptualization of wellness and ways of measurement. Researchers need to again ask the question "what is wellness?" and comprehensive definitions and models need to be developed. This review is the first of many steps to help understand the wellness construct and to create improved means to measure wellness. With a comprehensive definition of wellness proposed, the dimensional structure of wellness needs to be explored, and superior assessments need to be created.
* Implications for Counseling and Assessment
The increased focus on wellness in the literature and the creation of better measurements will also undoubtedly have an impact on practitioners. Superior assessments will facilitate practitioner's use of wellness theory in working with clients. Practitioners can center treatment on the core dimensions of wellness. For example, practitioners may choose to use wellness models as a means of structuring therapy, a road map to explore areas of improvement for clients. The proposed wellness model can be used to guide counselor's work with clients. For example, counselors can structure individual sessions or the entire course of therapy around wellness themes and explore each of the wellness dimensions with clients.
When using wellness in counseling, counselors should first educate clients on its multidimensional, synergistic nature. Furthermore, counselors need to stress the idea that optimal functioning is not just the absence of illness. After introducing the general ideas of wellness, counselors can explore each of the dimensions with clients, who will benefit from considering how each wellness dimension relates to their experiences and goals. For each dimension, clients should brainstorm examples of specific actions or values that foster wellness. For example, walking daily can be a targeted behavior to foster physical wellness or joining a club can increase social wellness. When examples are created for each dimension, clients will have a better understanding of what constitutes each dimension and will be able to assess their levels of wellness. At this point, it may be helpful to have clients make a bar graph representing their assessed levels of wellness on a scale of 1 to 10 for each dimension to allow for visual comparisons across dimensions. Such a visual representation will help clients decide what dimensions of wellness they want to focus on in counseling and will facilitate clients' movement toward more optimal levels of wellness. Furthermore, clients should explore specific behaviors representing each dimension that they would like to improve. Once the dimensions to be improved upon are identified, the client can create specific goals and objectives. Goals need to be specific and measurable, as well as reasonably attainable. When setting goals, it is also important to identify and discuss any possible roadblocks to reaching the set goals. Discussing roadblocks with clients helps them anticipate and thus prepare for obstacles, setting them up for success. Finally, as clients create goals, it is important to focus on only one or two goals at a time because progress toward one goal will have an impact on several areas of functioning given the synergistic nature of wellness.
Exploring each dimension of wellness can be done both in and outside of sessions. In session, the exploration and generation of examples and goals can be a verbal exchange or can be visual by recording clients' ideas about each dimension on butcher paper or a white board so that clients can "see" their levels of wellness. An option combining both in and outside session activities would be to discuss the dimensions in session and then have clients identify representative behaviors between sessions. This "homework" could be facilitated by providing clients with definitions of the wellness dimensions and asking them to list behaviors. Clients then could assess how much they perform the specific behaviors they listed and bring their lists to the next session. Together, counselors and clients could create specific goals and discuss possible roadblocks.
Additionally, practitioners can use wellness themes in group therapy. The central idea that wellness is beyond the absence of illness (Ardell, 1977; Edlin, 1988; Lafferty, 1979; Teague, 1987) positions wellness as an important theme for a therapy group that could focus on coping with chronic pain or illness. In any type of group, wellness dimensions could be the focus of each session or couple of sessions. Participants could brainstorm actions that relate to the dimensions as a group and then individually assess their personal levels of wellness. The group would also facilitate goal setting, with other members sharing ideas and giving input.
Similar to working with individual clients and groups, the proposed wellness model can also be used as a format for psychoeducational programs, as well as in training or workshops in business settings. The techniques described with counseling can be applied in noncounseling settings. For example, programming could include an overview of the concept of wellness, the dimensions, and the nature of the construct. Like the group therapy suggestions, participants could brainstorm ideas about each of the dimensions and then do activities to assess their current functioning. Exploration of how social and other dimensions of wellness can be improved in a business or classroom would also likely be beneficial. Clearly, therapy clients, as well as individuals and groups in educational and business settings, can also benefit from an exploration of wellness and identification of target wellness behaviors.
Besides affecting practice, a comprehensive definition of wellness will further strengthen the movement supporting wellness as the paradigm of counseling and continue to unify the field, while serving as a catalyst for increased exploration of the structure of wellness. With a clearer understanding of wellness, better assessments can be created and tested. Improved means of measuring wellness will also facilitate the exploration of the structure of wellness. Practitioners and researchers alike will benefit from a comprehensive definition of wellness and from improved wellness assessments.
Given the importance of the wellness construct in counseling, the existing wellness research, and the proposed comprehensive definition, the following steps are suggested in the effort to elucidate the concept of wellness. First, definitions and dimensions proposed in this article need to be further explored and supported. Second, the dimensional structure of wellness needs to be clarified. Finally, current wellness assessments need to be reviewed and revised to fit a more comprehensive conceptualization of wellness. Wellness theorists must ask whether the current quantitative assessments are the best means of measuring such a personal, fluid, and multidimensional construct. Perhaps, qualitative assessments, or a combination of qualitative and quantitative, would better capture such a complex construct. Researchers need to explore qualitative ways of assessing wellness and create new and varied means of measuring wellness. Use of better wellness assessments will assist in further exploring and confirming the structure of wellness. The increased activity and focus will strengthen wellness as central to counseling and foster increased attention on the emphasis on optimal functioning as opposed to illness and the medical model.
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Lauren J. Roscoe, Department of Psychology, Southern Illinois University, Carbondale. Lauren J. Roscoe is now at Psychology Division, Western Oregon University. This article is based on a part of Lauren J. Roscoe's doctoral dissertation at Southern Illinois University, Carbondale. The author thanks Tamina Toray and Eric Cooley for providing feedback on a previous version of the article.
Correspondence concerning this article should be addressed to Lauren J. Roscoe, Psychology Division, Western Oregon University, 326 Todd Hall, Monmouth, OR 97361 (e-mail: firstname.lastname@example.org).
TABLE 1 Components of Wellness Theory Models Dimension Model Source Social Emotional Physical 1. Lafferty (1979) X X X 2. Hettler (1980) X X X 3. Greenberg (1985) X X X 4. Leafgren (1990) X X X 5. Crose et al. (1992) X X X 6. Depken (1994) X X X 7. Adams et al. (1997) X X X 8. Renger et al. (2000) X X X 9. Durlak (2000) X X Dimension Model Source Intellectual Spiritual Psychological 1. Lafferty (1979) X X 2. Hettler (1980) X X 3. Greenberg (1985) X X 4. Leafgren (1990) X X 5. Crose et al. (1992) X X 6. Depken (1994) X X 7. Adams et al. (1997) X X X 8. Renger et al. (2000) X X 9. Durlak (2000) X (a) Dimension Model Source Occupational Environmental 1. Lafferty (1979) 2. Hettler (1980) X 3. Greenberg (1985) 4. Leafgren (1990) X 5. Crose et al. (1992) X 6. Depken (1994) 7. Adams et al. (1997) 8. Renger et al. (2000) X 9. Durlak (2000) Note. The following are brief summaries of the samples used to generate each theory: 1, 3, 5, and 6 = theoretical models not based on a sample; 2 = college students in residence halls, students using health services; 4 = theoretical model based on men's health, no specific sample cited; 7 = (n = 558), employees from two companies and college students, ethnically diverse; 8 = participants in wellness program and college students, no other sample information given; 9 = theoretical model based on adolescent wellness, no specific sample cited. (a) Academic.
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|Title Annotation:||Assessment & Diagnosis|
|Author:||Roscoe, Lauren J.|
|Publication:||Journal of Counseling and Development|
|Article Type:||Clinical report|
|Date:||Mar 22, 2009|
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