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Gender Differences in Spirituality in
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Treatment
a
Donna Leigh Bliss & Stacy S. Ekmark
a
a
University of Georgia, School of Social Work, Athens, Georgia, USA
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Alcoholism Treatment Quarterly, 31:25–37, 2013
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DOI: 10.1080/07347324.2013.746625
Gender Differences in Spirituality in Persons
in Alcohol and Drug Dependence Treatment
DONNA LEIGH BLISS, PhD and STACY S. EKMARK
Downloaded by [University of Georgia] at 09:03 17 January 2013
University of Georgia, School of Social Work, Athens, Georgia USA
Although research has begun to broadly address gender differences in alcohol and drug dependence, there is a dearth of research on gender differences in spirituality in this area, despite
the increased research emphasis on the role of spirituality in the
recovery process. This study addressed this gap by examining gender differences in five dimensions of spirituality in persons in
diverse alcohol and drug dependence treatment settings. The hypothesis that there would be gender differences in spirituality was
supported as women had higher levels of expression of cognitive orientation toward spirituality compared to men. Implications
for alcohol and drug dependence treatment and research are
discussed.
KEYWORDS Spirituality, alcohol dependence, alcoholism, drug
dependence, addiction, gender, social work
Alcohol and drug dependence is a widespread problem in the United States
that profoundly affects millions of individuals, with far-reaching effects on
society and the economy. In 2005, the number of people using illegal drugs
was estimated to be 20 million, and the number of people who abused
alcohol was estimated to be between 16 million and 20 million (National
Center on Addiction and Substance Abuse at Columbia University, 2007).
Furthermore, alcohol and drug dependence cost the nation an estimated
$220 billion in 2005—more than cancer ($196 billion) and obesity ($133 billion) (National Center on Addiction and Substance Abuse at Columbia University, 2007).
Address correspondence to Donna Leigh Bliss, PhD, University of Georgia, School of
Social Work, 305 Tucker Hall, Athens, Georgia 30602. E-mail: [email protected]
25
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26
D. L. Bliss and S. S. Ekmark
Over the past few decades there has been a substantial increase in
the scope of research on alcohol and drug dependence as its etiology and
methods of improving treatment outcomes have been looked at more closely.
One of the main criticisms of early research was that studies looked almost
exclusively at entirely male samples, and hence treatment options were
tailored toward men (Green, 2006) and were most often ill equipped to meet
women’s divergent needs (Ashley, Marsden, & Brady, 2003). Recognition of
this problem has led to an increase in research on gender differences in
alcohol and drug dependence. A rapidly growing body of research now
indicates that alcohol and drug dependence among women and the issues
that surround their dependence are different from those of men and may necessitate a ‘‘specialized set of therapeutic interventions’’ (Ashley et al., 2003,
p. 20). Because research shows that there are fundamental gender differences
in terms of alcohol and drug dependence, specialized gender-specific treatment programs have become increasingly common (Green, Polen, Lynch,
Dickinson, & Bennett, 2004; Grella, 2008).
Research on gender differences in alcohol and drug dependence can
typically be grouped into two main categories: access to treatment and
treatment outcomes. Generally, research has found that women face greater
barriers to accessing alcohol and drug dependence treatment than do men
(Green, 2006; Tuchman, 2010). Not only do women face more impediments
to treatment but research has shown that once women enter treatment, they
do so with more serious alcohol and drug problems and with more health
and social problems than do men (Marsh, Cao, & Shin, 2009). Research also
indicates that ‘‘women who are addicted have a history of over-responsibility
in their families of origin and reportedly have experienced more disruption
in their families than their male counterparts’’ caused by entering alcohol
and drug dependence treatment (Tuchman, 2010, p. 128). Additionally, the
lack of available, affordable childcare options poses a practical barrier to
many women’s access to treatment as very few alcohol and drug dependence
treatment centers have childcare programs (Green, 2006).
There has been extensive research on the impact of alcohol and drug
dependence on biology, social functioning, and psychology (Morgan, 2002);
however, over the past two decades, the social work profession has highlighted the need for examining spirituality as well, as part of a broader holistic
approach to assessing and treating alcohol and drug dependence. Social
work, as well as other helping professions, has begun to include spirituality
as a component of person-in-environment assessment (Bliss, 2009). Furthermore, the Joint Commission on Accreditation of Healthcare Organizations,
the largest and most influential healthcare accrediting body in the United
States, revised its standards in 2001 to require that spirituality be assessed in
a variety of health care settings, including some types of behavioral health
care organizations such as those that provide alcohol and drug dependence
services (Hodge, 2006; Bliss, 2009).
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Gender Differences in Spirituality
27
Fortunately, there is a growing research base that highlights the role
of spirituality in improving treatment outcomes. In a literature review of 44
empirical studies on various aspects of the relationship between spirituality
and alcohol and drug dependence, Bliss (2007) noted that 31 of these articles
examined spiritual variables as components of the recovery process. In
general, higher levels of spirituality were associated with improved treatment
outcomes such as increased abstinence and improved life functioning. Although the vast majority of the studies that Bliss (2007) reviewed addressed
the 12-Step spirituality of Alcoholics Anonymous, it is important to note
that spirituality can be assessed in many other ways and along different
dimensions including meaning and purpose in life, relationship with God or
a deity figure, personal values, locus of control, and spiritual well-being. Also,
though spirituality was found to play an important role in recovery, it was
not necessarily the only role as other factors were influential in promoting
recovery as well.
Despite the surge in research interest on spirituality and alcohol and
drug dependence in general, there has been a limited research focus on
gender differences within this relationship (Bliss, 2007). Complicating this
lack of research focus, the studies that are available regarding gender differences tend to focus more on discreet aspects of spirituality or examined
religious practices as a proxy for spirituality. For example, in a review of the
literature one study that looked at spirituality in a treatment setting examined
the affect of Qigong meditation on substance abuse treatment outcomes for
men and women and found that female participants whose meditation was
of ‘‘acceptable quality’’ reported greater reductions in cravings, anxiety, and
withdrawal symptoms than did male participants whose meditation was of
‘‘acceptable quality’’ (Chen, Comerford, Shinnick, & Ziedonis, 2010). Another study evaluated the role of religiosity on the posttreatment abstinence
outcomes of African American adults completing 3 months of substance
abuse treatment and found that women achieved significantly higher rates
of abstinence and were more likely to practice their religion posttreatment
than the men in the sample (Stewart, Koeske, & Pringle, 2007). One study
that evaluated gender-specific patterns of drug use among active stimulant
users in rural Kentucky found that spirituality and/or religiosity may have
more ‘‘influence’’ on drug using behavior for rural male stimulant users than
for females (Staton-Tindall et al., 2008).
The purpose of this study is to begin to address this gap in the research
literature by examining gender differences in alcohol and drug dependence
through the lens of spirituality that is diversely conceptualized. Given the
breadth of research that identified gender differences in various other aspects
of alcohol and drug dependence, this study tests the hypothesis that there
will be gender differences in spirituality, although the direction of these
differences are not predicted due to the limited research base on gender
differences in spirituality to support such specificity.
28
D. L. Bliss and S. S. Ekmark
METHOD
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Research Design and Sample
A cross-sectional design was used for this study. Four programs located in the
Baltimore, Maryland, and Washington, DC, metropolitan areas that offered
an array of services such as detoxification, inpatient, outpatient, methadone
maintenance, day treatment, and residential treatment agreed to participate
in this study.
Convenience sampling was used to identify potential participants. Inclusion criteria for participants were men and nonpregnant women, age 18
or older, currently in a substance abuse treatment program, had an alcohol
use disorder, and had fewer than 12 months of sobriety from alcohol use
disorders. Exclusion criteria were women or men in acute alcohol withdrawal
or who were experiencing psychiatric symptoms that impaired their ability
to comprehend and/or respond to study questions. Potential participants
were prescreened by treatment staff to determine if they were eligible to
participate in the study. This study was approved by the University of Maryland Baltimore Institutional Review Board (IRB). All participants signed an
IRB-approved informed consent form.
This study involved the author going onsite to these treatment centers
and administering a survey in groups ranging from 5 to 20 clients (N D 180),
which took about 30 minutes to complete. Clients received a $10 honorarium
for participating in the study.
Measure
Expressions of Spirituality Inventory–Revised. The Expressions of Spirituality Inventory–Revised (ESI-R) (MacDonald, 2000a) is a five-dimension
(six items per dimension), 30-item self-administered measure of experiences,
attitudes, beliefs, and lifestyle practices concerning spirituality. The ESI-R is
scored using a 5-point Likert-type scale (0 D strongly disagree, 1 D disagree,
2 D neutral, 3 D agree, 4 D strongly agree).
The five dimensions of the ESI-R are (1) cognitive orientation toward
spirituality (pertains to the expressions of spirituality that are cognitiveperceptual in nature such as beliefs and attitudes), (2) experiential/phenomenological dimension of spirituality (concerns experiential expressions of
spirituality such as spiritual, religious, mystical, peak, transcendental, and
transpersonal experiences), (3) existential well-being (spirituality as expressed
through a sense of meaning and purpose in life), (4) paranormal beliefs
(e.g., ESP, precognition, psychokinesis), and (5) religiousness (expression of
spirituality through religious means such as religious beliefs and practices).
Each dimension is individually scored, with higher scores indicating higher
degrees of expression of the particular dimension (MacDonald, 2000a).
Gender Differences in Spirituality
29
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Although the ESI-R represents diverse expressions of spirituality rather
than assessing a single construct of spirituality, given it is revised from the
original 98-item Expressions of Spirituality Inventory, which was derived
from a factor analysis of 11 existing measures of spirituality to determine if
there was a stable factor structure that could be used to develop a model
and measure of spirituality (MacDonald, 2000b), the ESI-R does have a stable
factor structure of spirituality. MacDonald (2000a) stated the ESI-R had similar
psychometric properties and correlated with those of the 98-item version,
which was reported to have interitem reliability, factorial validity, construct
validity, and predictive validity.
RESULTS
Sample Demographic Characteristics
A sample of 180 women and men in various types of alcohol/other drug
treatment settings completed the surveys. The sample comprised slightly
more males than females. The mean age was 39.6 years (SD D 10.4). Slightly
less than two thirds identified themselves as African American, whereas
slightly less than one third stated they were White. Slightly more than one half
stated their income for the previous year was less than $10,000. Mean years
of education was 12.0 (SD D 2.12). Slightly more than one half reported
being single/never married, with slightly less than one third stating they
were separated/divorced. Outpatient treatment was the most common type
of alcohol/other drug program setting, followed by detox, and inpatient.
The mean length of current sobriety was 71.97 days (SD D 77.98). There
were no statistically significant gender differences in demographic variables,
except for gender itself as there were significantly more males than females
in the study (99 vs. 81). See Table 1 for additional information on sample
demographic characteristics.
Statistical Analysis
Given there were no statistically significant gender differences in the demographic variables and that only two categories of gender were used
(men and women), it was not necessary to use ANOVA or analysis of
covariance (ANCOVA) to test the research hypothesis as these statistical
analyses are more suited when comparisons are made between more than
two categories (ANOVA) and when covariates needed to be statistically
controlled for (ANCOVA) (Grimm & Yarnold, 2000). Therefore, t tests were
used as there were only two categories, and there were no statistically significant differences between these categories in terms of salient demographic
variables.
30
D. L. Bliss and S. S. Ekmark
TABLE 1 Sample Demographic Characteristics by Gender (N D 180)
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Type
Gender
Race/ethnicity
African American
White
Hispanic
Asian/Pacific Islander
Other
Income previous year
Less than $10,000
10,000–19,999
20,000–29,999
30,000–39,999
40,000–49,999
50,000 or more
Marital status
Single/never married
Separated/divorced
Married
Living with someone
Widowed
Type of program
Outpatient
Detox
Inpatient
Women-specific
Day support
Halfway house
Methadone maintenance
Other
Male
frequency
(%)
Female
frequency
(%)
99 (55.0)
81 (45.0)
52 (28.8)
32 (17.7)
1 (.05)
1 (.05)
8 (4.4)
53 (29.4)
24 (13.3)
1 (.05)
0 (.00)
3 (1.6)
47
15
23
6
4
4
(26.1)
(8.3)
(12.7)
(3.3)
(2.2)
(2.2)
50
12
8
5
3
3
(27.7)
(6.6)
(4.4)
(2.7)
(1.6)
(1.6)
48
31
14
3
3
(26.6)
(17.2)
(7.7)
(1.6)
(1.6)
43
28
5
4
1
(23.8)
(15.5)
(2.7)
(2.2)
(0.5)
34
27
24
0
4
4
5
1
(18.8)
(15.0)
(13.3)
(0.0)
(2.2)
(2.2)
(2.7)
(0.5)
20
12
11
21
10
4
3
0
(11.1)
(6.6)
(6.1)
(11.6)
(5.5)
(2.2)
(1.6)
(0.0)
Significance
**
NS
NS
NS
NS
Type
Mean (SD)
Mean (SD)
Significance
Years of education
Age
Length current sobriety in days
11.84 (2.26)
38.63 (10.75)
64.99 (74.52)
12.27 (1.93)
40.78 (9.86)
80.51 (81.65)
NS
NS
NS
*p < .05, **p < .01.
There were statistically significant differences in gender in terms of
cognitive orientation toward spirituality (t D 2.56, df D 178, p D .011).
Women had a mean score of 19.04 (SD D 4.92) and men had a mean score
of 17.1 (SD D 4.8). There were no statistically significant gender differences
in religiousness (t D 1.52, df D 178, p D .129), paranormal beliefs (t D 1.38,
df D 178, p D .169), experiential/phenomenological dimension of spirituality
(t D 1.09, df D 178, p D .277), and in existential well-being (t D .369, df D
178, p D .713). See Table 2 for additional information on gender differences
in the five ESI-R dimensions of spirituality.
31
Gender Differences in Spirituality
TABLE 2 Gender Differences in Five Expressions of Spirituality Inventory–Revised (ESI-R)
Dimensions of Spirituality (N D 180)
Male
Female
Dimension
Mean
SD
Mean
SD
Significance
Cognitive orientation
Religiousness
Paranormal beliefs
Experiential/phenomenological
Existential well-being
17.2
17.6
8.7
11.6
11.5
4.8
4.9
4.4
5.2
4.9
19.04
18.7
7.8
12.5
11.2
4.9
4.5
4.2
5.4
5.7
.011
.129
.169
.277
.713
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Note. Scores for each ESI-R dimension can range from 0 to 24, with higher scores indicating greater
expression of a particular dimension.
Internal Consistency Reliability and Intercorrelations
among ESI-R Dimensions
Cronbach’s alpha for the five dimensions of the ESI-R in this study was .67,
which is slightly less than the ideal minimum of .70 (de Vaus, 2002). A
subsequent analysis of intercorrelations among the five dimensions of the
ESI-R indicated that cognitive orientation toward spirituality dimension and
experiential/phenomenological dimension of spirituality were significantly
correlated with three other ESI-R dimensions. Existential well-being and
religiousness were significantly correlated with two other ESI-R dimensions,
whereas paranormal beliefs was significantly correlated with one other ESI-R
dimension. See Table 3 for additional information on intercorrelations among
ESI-R dimensions.
TABLE 3 Correlations among the Five Dimensions of the Expressions of Spirituality Inventory–Revised
Cognitive
orientation
Cognitive orientation
Correlation
Significance (Sig.)
Experiential/
phenomenological
Correlation
Sig.
Existential well-being
Correlation
Sig.
Paranormal beliefs
Correlation
Sig.
Religiousness
Correlation
Sig.
Pearson
—
—
Pearson
.506
.001
Pearson
.317
.001
Pearson
.086
.252
Pearson
.794
.001
Experiential/
phenomenological
Existential
well-being
Paranormal
beliefs
Religiousness
.506
.001
.317
.001
.086
.252
.794
.001
—
—
.118
.114
.285
.001
.381
.001
.118
.114
—
—
.158
.035
.141
.058
.285
.001
.158
.035
—
—
.068
.366
.381
.001
.141
.058
.068
.366
—
32
D. L. Bliss and S. S. Ekmark
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DISCUSSION
The hypothesis of this study was supported as gender differences in cognitive
orientation toward spirituality were found with women having higher levels
of expression compared to men. Although this finding is not unexpected in
light of the research literature on gender differences in various aspects of
alcohol and drug dependence, the paucity of research on gender differences
in spirituality in this population necessitates the need for a broader review of
gender differences in cognitive functioning and emotional expressiveness to
assist in the interpretation of the study finding that women had higher levels
of expression of cognitive orientation toward spirituality compared to men.
Research on gender differences in aspects of cognitive functioning lends
support for the validity of the finding that women had higher levels of expressions of spirituality that are cognitive-perceptual in nature such as spiritual
beliefs and attitudes compared to men. For example, gender differences
in cognitive processing have been closely analyzed in psychological and
neuropsychological literature (e.g., Ardila, Rosselli, Matute, & Inozemtseva,
2011; Hedges & Nowell, 1995; Kimura, 1999; Weiss, Kemmlera, Deisenhammerb, Fleischhackera, & Delazer, 2003). Cognitive processing, including core
cognitive abilities such as verbal, visuospatial, and quantitative abilities, has
been shown to differ between males and females (Halpern et al., 2007). As
cited in Ardila et al., three major differences in cognitive abilities between
men and women have generally been reported ‘‘(a) higher verbal abilities,
favoring women; (b) higher spatial abilities, favoring men; and (c) higher
arithmetical abilities, also favoring men,’’ although differences in calculation
abilities have, in some cases, been interpreted as a result of men’s stronger
spatial abilities (Benbow, 1988; Geary, 1996); thus, the three differences
described could be reduced to only two (Ardila et al., 2011, p. 984).
Similarly, the expression of these cognitive beliefs and attitudes is consistent with research that shows that women consistently report being more
emotionally expressive than men (Bronstein, Briones, Brooks, & Cowan,
1996). For example, studies have found that women talk about emotions
more than men and use more emotion words than men (Goldschmidt &
Weller, 2000). Furthermore, in many studies women have self-reported ‘‘more
intense experience of emotions than men, more intense expression, and
greater comfort with and tendency to seek out emotional experiences’’ (Grossman & Wood, 2003, p. 1010). Women have been shown to experience greater
emotional intensity of positive and negative emotions, such as happiness and
anger, respectively, as well as experiencing such intensity of emotion across
the life span from early childhood to adulthood (Aldrich & Tenenbaum,
2006; Grossman & Wood, 1993). Furthermore, the hypothesis that emotional
expression, recognition, and experiences may differ dramatically for males
and females is implicit in almost every theory of emotional development
(Brody, 1985).
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Gender Differences in Spirituality
33
Finally, another plausible explanation for the finding that women experience greater expression in cognitive orientation toward spirituality than
men is that women differ from men in terms of religious expression (Miller &
Stark, 2002). Research has shown that men and women throughout different
religions ‘‘appear to construct their religious experiences and/or engagement
in contrasting ways, men being more active, that is, oriented to action, and
women more affective in their expression or understanding of their own
religiousness’’ (Sullins, 2006, p. 847). The affective dimension of religiosity,
which includes measures such as ‘‘frequency of prayer, the subjective experience of comfort and strength in religion, or self-assessed intensity of religious
identity,’’ consistently shows a greater difference between men and women
than those measures that express the more active dimension of religion, such
as church attendance, membership, or volunteerism (Sullins, 2006, p. 847).
Implications for Alcohol and Drug Dependence
Treatment and Research
The findings from this study that women were more expressive of spiritual
beliefs and attitudes compared to men has important implications for alcohol
and drug dependence treatment for women and men. For women, treatment
should be structured to provide opportunities for women to learn how to use
the expression of their spiritual attitudes and beliefs in a manner that supports
their recovery needs. Of particular importance is the need for treatment
providers to help women translate these attitudes and beliefs into specific
behaviors and practices that promote recovery. Just as the specific treatment
needs of women has led to the creation of gender-specific treatment programs, mixed-gender treatment settings need to offer the flexibility in the
provision of treatment services to more effectively target how women can
better utilize spirituality in their recovery efforts.
Fortunately, the increased research interest in spirituality has identified
a wide array of specific behaviors and practices that treatment providers
can offer to promote spiritual growth in women. For example, Canda and
Furman (1999) provided a detailed discussion of spiritually sensitive practice
skills and techniques that practitioners can use ranging from creating a
spiritual development time line and narrative to focused relaxing and guided
visualization (p. 291). Hodge (2003) discussed how spiritual assessment tools
including spiritual histories, life maps, ecomaps, genograms, and ecograms
can be used to provide more effective client-centered services. Finally, in
Spiritually Oriented Social Work Practice, Derezotes (2006) provided a practical, theoretical framework for spiritually oriented social work practice that
can be used to help facilitate spiritual development in traditional social work
populations such as women.
At the same time, the fact that men were found to have lower expressions of spiritual beliefs and attitudes does not necessarily mean this is not an
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34
D. L. Bliss and S. S. Ekmark
important area to focus on in men’s recovery. Instead, societal expectations
of the gender role of men may inhibit this expression in a manner that
can hinder their recovery efforts (Green et al., 2004; Grella, 2008). Rather
than presume that spirituality is somehow of less importance to men in the
recovery efforts, treatment providers would be well advised to more robustly
help men identify their spiritual beliefs and attitudes, and as with women,
learn how to translate them into specific behaviors that promote recovery.
As with any research that explores new terrain, this study does have
limitations that suggest caution in the interpretation of the study findings.
First, spirituality is a multidimensional construct that can be assessed in many
ways. It is possible that other measures of aspects of spirituality may lead to
different results. As such, the ESI-R should not be considered the definitive
measure of spirituality, despite the comprehensive manner in which the
measure was developed from 11 other measures of spirituality. Second,
despite the number of significant correlations among the various dimensions
of the ESI-R, when analyzed as a function of gender, only one of the five
dimensions of spirituality had statistically significant differences between
males and females. This does raise the possibility that the results of this
study were not necessarily clinically significant as it would be reasonable
to presume that if one dimension of spirituality was significantly different
in terms of gender, the same might be true for other dimensions as well
given the number of significant intercorrelations. Third, the Cronbach’s alpha
of .67 was less than the ideal minimum of .70 for exploratory research,
which raises questions about the reliability of the ESI-R. However, some
researchers have questioned the utility of the coefficient alpha as an ideal
indicator of reliability and have suggested that other indicators of reliability
may be considered (DeVellis, 2012). Although this can be controversial to
some researchers given the wide use and acceptance of the Cronbach’s alpha
as an indicator of reliability, such an alternative perspective does allow for
the tentative acceptance of the reliability of the ESI-R in this study despite it
not reaching the .70 threshold, while still calling for a cautious interpretation
of the findings and the need for additional psychometric research on the
ESI-R.
Despite these limitations, this study highlighted an important, yet underexplored area that has implications for alcohol and drug dependence
treatment. As treatment providers continue to include spirituality as part of a
more holistic framework for assessing and treating clients, providers will also
need to encourage clients to continue with their spiritual development after
discharge. However, while many treatment providers support, and perhaps
require participation in 12-Step groups such as Alcoholics Anonymous, which
has an explicitly spiritual focus, it is important to note that given how broadly
spirituality can be conceptualized, the existence of other support groups that
can also facilitate spiritual growth including secular recovery support groups
such as SMART Recovery, Secular Organization for Sobriety, LifeRing, and
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Gender Differences in Spirituality
35
Secular Recovery, explicitly religious alternatives such as Celebrate Recovery, and gender-specific and secular recovery groups such as Women for
Sobriety.
Clearly, gender differences in diverse aspects of alcohol and drug dependence will continue to be an important area of research in the identification
of ways to differentially provide treatment services based on gender in the
hope of improving treatment outcomes. As the role of spirituality in the
recovery process continues to be an area of focus, further research is needed
on examining gender differences using other measures of spirituality as the
ESI-R examined only five dimensions of spirituality. For example, in a review
of the literature on the relationship between spirituality and alcohol and
drug dependence, Bliss (2007) found that spirituality is a multidimensional
construct that can be assessed in many ways and along different dimensions
including meaning and purpose in life, relationship with God or a deity
figure, personal values, locus of control, and spiritual well-being, to name but
a few. Pursuing this line of research could pave the way for the development
of more spirituality-based treatment interventions that could be differentially
targeted toward women and men with the intention of improving treatment
outcomes for those afflicted with alcohol and drug dependence problems.
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