Substance Use & Misuse, 44:19261940 Copyright 2009 Informa Healthcare USA, Inc.

. ISSN: 1082-6084 (print); 1532-2491 (online) DOI: 10.3109/10826080802486723

Pilot Study: Spirituality and Religiosity

Do Spirituality and Religiosity Help in the Management of Cravings in Substance Abuse Treatment?
SARAH J. MASON, FRANK P. DEANE, PETER J. KELLY, AND TREVOR P. CROWE
Illawarra Institute for Mental Health and School of Psychology, University of Wollongong, Wollongong, Australia
The purpose of this study was to examine the relationship of spirituality, religiosity and self-efcacy with drug and/or alcohol cravings. A cross-sectional survey was completed by 77 male participants at an Australian Salvation Army residential rehabilitation service in 2007. The survey included questions relating to the participants drug and/or alcohol use and also measures for spirituality, religiosity, cravings, and self-efcacy. The sample included participants aged between 19 and 74 years, with more than 57% reporting a diagnosis for a mental disorder and 78% reporting polysubstance misuse with alcohol most frequently endorsed as the primary drug of concern (71%). Seventy-ve percent of the clients reported that spirituality and religious faith were useful components of the treatment program. A multivariate multiple regression analysis identied that spirituality and self-efcacy have signicant relationships with cravings. Self-efcacy mediated the relationship between spirituality and drug and/or alcohol cravings. The limitations of this study included its cross-sectional design and a sample that was drawn from a faith-based program. Future research would benet from the longitudinal examination of the relationship between spirituality, self-efcacy, and cravings; the exploration of a broader range of client-specic and interpersonal variables; and the inclusion of a control group from a secular treatment facility. Keywords Craving; religion; substance misuse; spirituality; residential; alcohol; coping; self-efcacy; relapse; spiritual well-being; recovery

Preparation of this article was supported by the Australian Rotary Health Research Fund and The Salvation Army. Address correspondence to Frank Deane, Illawarra Institute for Mental Health, Building 22, University of Wollongong, Wollongong, NSW 2522, Australia. E-mail: fdeane@uow. edu.au.

1926

Spirituality and Cravings

1927

Introduction
Self-reported experiences of craving1 for a substance whilst undergoing treatment have been linked to depression, low self-efcacy, psychological distress, and relapse (Bottlender and Soyka, 2004; Daughters, Lejuez, Kahler, Strong, and Brown, 2005; Gordon et al., 2006). A craving is dened by the Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) as a persistent desire to use a substance (American Psychiatric Association, 2000, p. 201). This classication is consistent with craving being characterized as a subjective state, where an individual experiences an intense desire to recommence past drug-taking behavior (Kozlowski and Wilkinson, 1987). Craving measures at the beginning of treatment have been found to predict relapse (e.g., Bottlender and Soyka, 2004; Gordon et al., 2006). Not only are those with higher levels of craving more likely to drop out and relapse before completing their treatment program, but also high craving at treatment completion predicted relapse at a 12-month follow-up (Bottlender and Soyka, 2004). Further, Gordon et al. (2006) found that increased craving in the week prior to discharge predicted relapse more effectively than treatment duration or levels of alcohol severity measured at admission. In contrast, factors such as self-efcacy, spirituality, and religiosity may improve substance abuse outcomes. Self-efcacy can be dened as an individuals belief that he or she can effectively cope with difcult situations (Bandura, 1986). For substance misuse, self-efcacy is considered important in preventing relapse and increasing condence in high relapse-risk situations (Greeneld et al., 2000; Ilgen, McKellar, and Tiet, 2005; Moos, 2007; Walton, Blow, Bingham, and Chermack, 2003). Self-efcacy can be measured in terms of situational condence, and through these measures research suggests that higher self-efcacy is associated with decreased relapse (Greeneld et al., 2000; Ilgen, McKellar, and Tiet, 2005). Gordon et al. (2006) also found that participants experiencing increased cravings for alcohol were less condent about the ability to refuse alcohol. The role of spirituality and religion in managing substance abuse2 has been of increasing interest to researchers (Geppert, Bogenschutz, and Miller, 2007). However, whilst spirituality and religion are related constructs, theoretically they are distinct. Spirituality is considered to be a predominantly individual experience, whereas religiosity is often thought to include individual and institutionalized components (Seidlitz et al., 2002). Religiosity is generally characterized by an involvement with a religious institution that contains prescribed theology and rituals (Seidlitz et al., 2002). In contrast, spirituality is often referred to as a subjective experience involving personal experiences with a higher power or sensing the mysteries of existence (Sussman, Nezami, and Mishra, 1997). The combined role of spirituality and self-efcacy on craving has rarely been evaluated. Spiritual well-being has been positively correlated with abstinence self-efcacy at both intake and discharge to a 3-week outpatient treatment facility (Piderman, Schneekloth,
1 The reader is reminded that cravinga concept and process , often noted in the literature, is all-too-often utilized without in any way adequately noting its dimensions ( linear, non-linear), its demands, the critical necessary conditions which are necessary for it to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether its underpinnings are theory-driven, empirically-based, individual and/or systemic stake holder- bound, based upon principles of faith or what. What is necessaryendogenously as well as exogenously for the posited craving to happen? This is necessary to clarify if the term and process is not to remain as yet another shibboleth in a eld of many stereotypes. The denitions which are often noted equate description with explanation which can be misleading. Editors note. 2 The journals style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editors note.

1928

Mason et al.

Pankratz, Maloney, and Altchuler, 2007). A study involving telephone interviews of 130 participants 3 months after completing an inpatient alcohol misuser treatment program included measures of cravings, spirituality and self-efcacy being collected at intake, during treatment and at the end of treatment (Gordon et al., 2006). As noted, craving prior to the discharge was related to drinking relapse at 3-month follow-up. At follow-up, two distinct clusters of participants were identied, those who reported no craving to drink (59%) and those who still had craving (41%). Discriminant function analysis indicated that the active cravers were more likely to have entered treatment with lower levels of spirituality and self-efcacy for refusing alcohol and higher levels of depression (Gordon et al., 2006). The authors noted that limitations of their study were the use of a single item craving measure and a relatively homogeneous sample of white, middle-aged individuals who were primarily alcohol dependent. Some effort has been made to articulate a conceptual substance abuse behavior change model incorporating spiritual transformation processes. Neff and MacMaster (2005, p. 674) suggested that an intervention which enhances a sense of spirituality, meaning, forgiveness, and spiritual connectedness, thus motivating further engagement into program activities (i.e., enhancing social integration), may enhance social support and peer inuence processes. These authors reect upon the existential characteristics of spiritual transformation, with an emphasis on the radical (though not necessarily sudden) change in the self in relation to contact with other (including a higher power and/or their social environment) (Neff and MacMaster, 2005, p. 674). Although this model recognizes a range of faith-based interventions (e.g., acceptance, forgiveness, discipline, etc.), readiness factors and the likely inuence of social learning processes and environments, there is a suggestion that a persons initial level of spirituality is likely to be associated with social engagement, self-efcacy, and positive coping with substance use stressors such as craving. The aim of the current research is to extend prior ndings by exploring the relationship between spirituality, religiosity, and self-efcacy with cravings. A description of participants perception of the usefulness of religious and spiritual practices for helping them cope with cravings is provided. It is hypothesized that there will be a negative relationship between spiritual and religious beliefs and self-reported cravings. Self-efcacy will be negatively associated with cravings and positively related to spirituality and religiosity. Although it is unclear exactly how spirituality operates to predict craving, it is possible that spirituality may improve ones sense of condence in a range of situations (self-efcacy) and the capacity of individuals to effectively cope with cravings over the course of treatment. The researchers recognize the complexity of the intrapersonal, interpersonal, and existential factors associated with spirituality and change processes, thus it is clearly a pilot study aimed at clarifying the associations between (but a few) these variables. Nevertheless, it is hypothesized that the relationship between spirituality and cravings will be mediated by self-efcacy.

Method
The Program The study was conducted at the Lake Macquarie Recovery Service Centre (LMRSC), which is a male-only rehabilitation center for substance misusers run by The Salvation Army in New South Wales, Australia. The long-term residential program is known as the Bridge Program and lasts for 810 months with variation dependent on individual

Spirituality and Cravings Table 1 Selected demographic information (n = 77) Characteristics Diagnosis Depression Bipolar disorder Schizophrenia Drug-induced psychosis Personality disorder Other Beliefs Religious afliation Christian None Other
a

1929

n(%) 15 (19.5) 9 (11.7) 8 (10.4) 7 (9.0) 3 (3.9) 2 (2.6)

Characteristics Substances for treatmenta Alcohol Cannabis Amphetamines Ecstasy Cocaine Heroin Other

n(%) 55 (71.4) 37 (48.1) 35 (45.5) 13 (16.9) 10 (13.0) 10 (13.0) 13 (16.9)

59 (76.6) 12 (15.6) 6 (7.8)

Spiritual Religious Unsure Other

38 (49.4) 22 (28.6) 8 (10.4) 9 (11.7)

Participants could provide more than one answer, so totals may be greater than 100%.

needs. The program is abstinence-based and is primarily involved in treating problems associated with drugs and alcohol.3 As a faith-based treatment provider, spirituality is an important component of the program. This spiritual aspect of recovery is explored through involvement in 12-step program activities (e.g., Alcoholics Anonymous meetings) and regular attendance at onsite chapel services. The chapel services are Christian-based and are run through The Salvation Army church. The treatment program also includes a range of psycho-social intervention modules such as cognitive behavioral therapy, social skills training, individual and group therapy delivered with a therapeutic milieu aimed at maximizing the benets of a therapeutic community.

Participants Participants consisted of 77 males who were currently residing in the LMRSC. The age of the participants ranged between 19 and 74 years with the average age being 37.01 years (SD = 11.10). Comorbidity of a mental illness with a substance use disorder was a common factor for the residents in the LMRSC. This included 57.1% of the residents self-reporting a previous diagnosis for a mental disorder, with the highest prevalence of mood (31%) or psychotic-type disorders (19%; see Table 1). The primary drug of concern was alcohol (71.4%).
3 Treatment can be briey and usefully dened as a planned, goal directed change process, of necessary quality, appropriateness and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutualhelp based (AA,NA, etc.) and self-help (natural recovery) models. There are no unique models or techniques used with substance usersof whatever typeswhich arent also used with nonsubstance users. In the West, with the relatively new ideology of harm reduction and the even newer Quality of Life (QOL) treatment-driven model there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Editors note.

1930 Measures

Mason et al.

Background Information. Basic background information was obtained from the participants in order to maintain condentiality and decrease acquiescence, deference or social threat (Kleinig, 2004). The questions included asking the participants about their age and if English was their preferred language. Questions were also asked regarding prior drug use and treatment history. The items were adapted from the Brief Treatment Outcome Measure (BTOM; Lawrinson, Copeland, and Indig, 2005). This included the type(s) of substance(s) that had been used in the last 12 months, the substance(s) for which they were seeking treatment, and the length (years) of substance use related problems. In each question the participant could endorse more than one response from a list. Treatment history items included prior treatment sought for their current problematic substance use, prior access to a residential rehabilitation treatment service and previous access to self-help groups such as AA and NA. Participants were also asked if they had ever received treatment for a mental health problem, and if they had they were asked to specify their diagnosis. Desires for Alcohol Questionnaire (DAQ; Clark, 1994). The short form of the DAQ is an 8item questionnaire that loads on three factors known as negative reinforcement, mild desire, and strong desire (Kavanagh, May, and Andrade, in press). Three questions that loaded on the strong desire factor were used in this current study (e.g., My desire to drink and/or use drugs now seems overwhelming). The questions for the DAQ were modied to reect both drug and alcohol cravings. Reliability analyses for the DAQ were conducted on the three factors for the original 36-item version of the DAQ. An internal consistency for the strong desires and intentions to use alcohol factor revealed a Cronbach alpha of 0.97 (Love, James, and Willner, 1998). In the present study, the Cronbach alpha was 0.79. Obsessive Compulsive Drinking Scale (OCDS; Anton, Moak, and Latham, 1995). Similar to the DAQ, the OCDS also measures cravings associated with alcohol. The OCDS consists of two subscales and is 14-items in length. The compulsive subscale was not used for the current study, as the compulsive aspects associated with drinking behavior were not relevant for the participants whilst they were residing in a rehabilitation center. The Obsessive Drinking Sub-Scale (ODS) contained the rst six items of the OCDS and measured thoughts and cravings associated with drinking. A previous study also used the obsessive subscale and found it to be a good predictor of alcohol cravings and drinking behaviors for the previous week of treatment (Flannery et al., 2001). The ODS scale was also modied for this study in order to assess cravings associated with both drugs and alcohol (e.g., How much distress or disturbance do these ideas, thoughts, impulses, or images related to drinking or using drugs cause you when youre not drinking or using drugs?). The OCDS was found to have good reliability with an internal consistency in the range of 0.840.87 (Anton et al., 1995). The internal consistency for the obsessive thoughts subscale was also good with an alpha of 0.85 (Anton et al., 1995). In the present study, the Cronbach alpha was 0.86. Drug Taking Condence Questionnaire (DTCQ; Sklar, Annis, and Turner, 1999). This is an 8-item self-report questionnaire that measures a persons self-efcacy in terms of resisting the urge to drink alcohol or take drugs in specic high relapse-risk situations. The scale was used in this current study to determine the extent participants utilized self-efcacy as a means of coping with recovery. This was calculated by asking participants to rate their condence in different high relapse-risk situations on a scale from 0% to 100%. The scores were then averaged to form an overall condence percentage. The construct validity of the DTCQ

Spirituality and Cravings

1931

was supported by positive correlations with measures of condence and motivation to quit drinking or using drugs and negative correlations with a measure of difculty in quitting drugs and alcohol (Sklar and Turner, 1999). Also the DTCQ had a Cronbach alpha coefcient of 0.89 (Sklar and Turner, 1999). In the present study, the Cronbach alpha was 0.90. Religious Background and Behaviors (RBB; Connors, Tonigan, and Miller, 1996). This is a 13-item self-report questionnaire that measures an individuals afliation with religious practices and its associated behaviors (Connors et al., 1996). Example items include asking whether the respondents consider themselves spiritual, religious, atheist, agnostic, or unsure. Also participants were asked to report how much time was spent in religious activities such as prayer or attending a worship service. The RBB has a good internal consistency with a Cronbachs alpha of 0.86 (Connors et al., 1996). In the present study, the Cronbach alpha was 0.82. The RBB has been frequently used as a measure of religiosity with its most notable use as a measure of religious beliefs for project MATCH, a multisite clinical trial of treatment centers for alcohol misuse (Project MATCH Research Group, 1993). Nondrug Use Spirituality Index (NUSI; Sussman, Skara, de Calice, Hoffman, and Dent, 2005). Participants were provided a denition of spirituality at the beginning of this section. The statement was Spirituality can be dened as personal beliefs and practices that lead to a sense of connection with the divine or energies in life (Seidlitz et al., 2002). This NUSI is a 7-item questionnaire that aims to measure an individuals perceived level of spirituality, participation in spiritual groups, and engagement in spiritual practices (Sussman, Skara, de Calice, Hoffman, and Dent, 2005). The NUSI has satisfactory internal reliability with an alpha coefcient of 0.80 (Sussman, Skara, Rodriguez, and Pokhrel, 2006). In the present study the Cronbach alpha was 0.86. Spirituality in Treatment (SIT). A measure of the perceived helpfulness of spirituality was developed for the present study in order to determine the extent spirituality is utilized by individuals undergoing a spiritual-based treatment. Items 1, 2 and 3 were adapted from the Perceived Helpfulness of Spirituality scale (Arnold, Avants, Margolin, and Marcotte, 2002). The SIT involves six items that are rated on a 5-point scale ranging from 1 (not at all) to 5 (extremely). The items include questions regarding the helpfulness of spirituality and religious faith, in treatment, in increasing the feelings of hopefulness, in coping with cravings, helping with recovery, nishing treatment and preventing relapse. A reliability analysis found a Cronbach alpha of 0.95 for the current study. Procedure The research protocols received ethical review and approval from the University of Wollongong Human Ethics Committee and The Salvation Army. The participants were informed of the research by The Salvation Army staff in group meetings, held at the treatment facility, 2 weeks preceding the data collection period and again in a routine morning meeting on the day of research data collection. These briengs included a discussion regarding the potential benets the study offered in relation to improving treatment program components and delivery strategies. On all occasions, the voluntary nature of participation was emphasized and participants were given the option of placing a blank survey in the envelopes if they did not wish to participate. This process, particularly letting potential participants know about the study 2 weeks prior to data collection, allowed ample time for participants to consider participation without undue pressure. It also ensured that informed consent was

1932

Mason et al.

obtained and the feelings of obligation to participate were minimized (Kleinig, 2004). All residents on site attended a large group meeting for the purpose of this research. Research staff from the University of Wollongong (an experienced addictions clinician/researcher and an honors student) briefed the participants on the nature of the study and once again reinforced the voluntary nature of the research. The questionnaire was distributed to all the participants. The LMRSC staff and the researchers were present while the questionnaire was completed to answer the questions by the participants. It took the participants approximately 30 min to complete the questionnaire. All but three of the residents agreed to participate and completed the survey. An additional two participants responses were not included as they were receiving treatment for gambling problems alone.

Results
The average time spent in the LMRSC at the time of assessment was 114.03 days (SD = 91.70). For many of the residents this was not the rst time they had accessed treatment for their problematic substance use with 64.9% acknowledging past attempts at treatment. Based on participants self-report, the length of problematic substance use in an individuals lifetime ranged between 3 and 50 years, with the average time being 18.15 years (SD = 9.03). It was also found that 82.2% of the participants were experiencing problematic substance use before the age of 21. The average age (M ) of problem onset was 18.59 years (SD = 9.35; Median = 16 years). Most of the participants were polysubstance users, with 77.9% reporting the use of more than one substance in the past 12 months and 58.4% receiving treatment for polysubstance misuse. Additional descriptive information about the participants drug use, mental health history, religious afliations, and beliefs can be found in Table 1. To examine individuals attitudes toward the inclusion of spirituality and religious faith in treatment, the measure of Spirituality in Treatment (SIT) was included. The frequencies displayed in Table 2 indicate that spirituality and religious faith were useful for over 75% of participants for various treatment foci. Spirituality and religious faith were perceived as the most useful when the participants nish treatment. Exploration of assumption violations for anticipated analyses found skewed data for a number of variables that did not meet the normality assumption. Transformations were conducted on both craving scales (DAQ and OCDS) and the spirituality scale data (NUSI) (following the guidelines of Tabachnik and Fidell, 2007). The transformations included calculating the square root for the craving subscales DAQ and OCDS. For the NUSI spirituality scale, it was necessary to reect and square root the data. The transformations Table 2 Frequency scores for spirituality in treatment (SIT) measure (n = 74) Item Help with treatment completion Helpfulness of spirituality and religion in treatment Help with recovery Help prevent relapse Help with feelings of hopefulness Help cope with your cravings Mean 3.81 3.72 3.65 3.65 3.58 3.34 SD 1.17 1.26 1.22 1.30 1.39 1.35 n(%) 64 (86.5) 61 (82.4) 62 (83.8) 60 (81.1) 59 (79.7) 56 (75.7)

Note: Mean Scores are from 5-point scale with 1 = Not at all and 5 = Extremely. Frequency calculated for scores rated from 3 = Moderately to 5 = Extremely.

Spirituality and Cravings

1933

Table 3 Pearsons correlations between cravings, self-efcacy, religiosity and spirituality 1 1 2 3 4 5 Craving (DAQ)a Craving (OCDS Self-efcacyb Religiositya Spiritualityc .50 .42 .17 .30 2 .51 .10 .15

.21 .33

.69

Note: Correlation is signicant at p < .01 (2-tailed); (2-tailed). a n = 77; b n = 76; c n = 74.

Correlation is signicant at p < .05

resulted in improved distributions that approximated normality. For ease of expression, the original names of variables are used. Pearsons bivariate correlations between the variables are displayed in Table 3 A statistically signicant inverse relationship was found between cravings and spirituality (r = .30). There were positive correlations found between spirituality and selfefcacy (r = .33), and spirituality and religiosity (r = .69). Self-efcacy was negatively correlated with cravings (r = .42). Based on the hypothesis that there will be a negative relationship between spiritual and religious beliefs and self-reported cravings, a multivariate multiple regression analysis was conducted. The results indicate that spirituality has a signicant inuence on cravings ( = .33, p = .04). However, there was no signicant effect for the inuence of religiosity on cravings ( = .05, p = .75). The R 2 suggests that spirituality and religion account for 8.9% of the variance in cravings. It was further hypothesized that self-efcacy will be negatively associated with cravings. It was found that self-efcacy had a signicant inuence on cravings ( = .34, p = .01). The Sobel test was used to examine the hypothesis that self-efcacy mediates the relationship between spirituality and craving (Sobel, 1982). The conrmation is based on all the conditions being met for mediation and a signicant result on the Sobel test (Baron and Kenny, 1986). An interactive program that calculated the Sobel statistic was accessed from Preacher and Leonardelli (2003). The mediator model is demonstrated in Figure 1. The values on each path are standardized coefcients ( ) and the values in parentheses are standardized partial regression coefcients from multiple regression equations that include the other variable with a direct effect on the dependent variable (see Holmbeck, 2002).

Figure 1. Mediation model for associations between spirituality and cravings as mediated by self-efcacy. = p < 0.00; = p < 0.01; = p < 0.05.

1934

Mason et al.

The effect of mediation can be established based on three criteria outlined by Baron and Kenny (1986). In the regression analyses (1) spirituality must affect self-efcacy, (2) spirituality must affect cravings, and (3) self-efcacy must affect cravings. For perfect mediation, spirituality should have no effect on cravings when controlled for self-efcacy. For the rst condition, spirituality predicted self-efcacy ( = .33 p = .01). The R 2 indicated that 10.7% of the variance in self-efcacy was being explained by spirituality. For the second condition, spirituality predicted cravings ( = .30, p = .01). The R 2 resulted in 8.7% of the variance in cravings being explained by spirituality. Within a covariate analysis, spirituality decreased in signicance ( = .17, p = .14), whilst a signicant relationship was found between self-efcacy and cravings ( = .35, p = .00). The inclusion of self-efcacy into the regression equation increased the explained variance to 19.3%. Results from the Sobel test conrmed the mediation model (with a test statistic of 2.00, p = .05). This indicates that self-efcacy is mediating the relationship between spirituality and cravings, such that as spirituality and self-efcacy increase, cravings decrease.

Discussion
The current study explored the relationships between spirituality, religiosity, self-efcacy, and cravings. Spirituality and religion are often utilized and researched as the same construct, but there is evidence to suggest while they may be related, they are also distinct constructs (Pardini, Plante, Sherman, and Stump, 2000; Seidlitz et al., 2002). The results from this study established an association between spirituality and religiosity. However, further analysis conrmed the suggestion that spirituality and religiosity are also distinct, based on their unique relationships with other constructs. Spirituality had signicant associations with cravings and self-efcacy, whereas these were not found to be signicant for religiosity. Similarly, in prior studies, when spirituality and religiosity were measured separately, different outcomes were found for each construct (Arnold et al., 2002; Galanter, 2006; Webb, Robinson, Brower, and Zucker, 2006). In the present study, spirituality is related to cravings in such a manner that as spirituality increases, cravings decrease. These ndings extend those of Gordon et al. (2006) by not only including a multi-item measure of spirituality and a more diverse patient sample, but also by including religiosity in the analysis. The results suggest that religiosity was not related to cravings. Research on the inuence of self-efcacy in treatment has also found that increased self-efcacy is a signicant predictor of drinking outcome (Long, Williams, Midgley, and Hollin, 2000) and is negatively associated with cravings (Loeber, Croissant, Heinz, Mann, and Flor, 2006; Gordon et al., 2006). In the current study, the hypothesis that spirituality is positively correlated with self-efcacy is conrmed. Spiritual well-being has also previously been signicantly associated with abstinence self-efcacy (Piderman et al., 2007). It was also hypothesized that self-efcacy would mediate the relationship between spirituality and cravings. This hypothesis was based on the evidence that higher spirituality was associated with lower cravings (Gordon et al., 2006) and higher self-efcacy was related to lower cravings (Walton et al., 2003). The results from the current study conrmed that self-efcacy mediates the relationship between spirituality and cravings. This suggests that spirituality leads to an increase in self-efcacy, which in turn relates to a decrease in cravings. However, it should be noted that the increase of spirituality and self-efcacy and its association with cravings could be attributed to other personal characteristics, strengths, or weaknesses that may affect the individuals ability to adapt to

Spirituality and Cravings

1935

relevant components of their treatment, e.g., afliation with treatment assumptions, treatment readiness and expectations, resilience and attitudinal factors may affect the strength of this association. The participants were also asked questions related to the usefulness of spirituality in treatment to help manage situations such as their recovery, cravings, and relapse. More than 75% of the participants considered spirituality useful in increasing the feelings of hopefulness and also helping to cope with cravings. Over 80% of the participants also considered spirituality would be helpful in the maintenance of recovery, completion of the treatment program, and help to prevent the relapse. The participants in this treatment center appeared to consider the inclusion of spiritual and religious components as a useful aspect of substance abuse treatment.

The Studys Limitations

The results from this study should be viewed cautiously due to several limitations. The most important limitation relates to the cross-sectional design of the study. Based on this limitation, causality cannot be determined between the variables examined in this study. Additionally, the measures used within the study relied on self-report. We do not have measures of the actual behaviors (e.g., monitoring the number of chapel sessions attended) or measure cravings in the presence of the individuals drug of choice, where we might capture more immediate cravings. Another potential limitation was that it was conducted within a faith-based treatment center. Based on the exploratory nature of this study, this was deemed necessary in order to investigate the relations between spirituality and other variables that may be relevant to substance abuse treatment. It is also possible that individuals with strong spiritual beliefs may be more comfortable and accepted in faithbased programs compared to those who do not subscribe to such beliefs. This may be an additional moderating variable that in turn impacts on self-efcacy and expectations that the program will help their recovery. These additional intervening variables are likely to interact to have an impact on cravings and recovery. The implications of such considerations are that the more open a program is to a range of religious and spiritual beliefs, the more likely it will connect with a greater proportion of clients who seek help.

Future Needed Research

Future research on these variables may be enhanced with the inclusion of a control group that further looks at the participants receiving treatment for substance misuse in a secular treatment facility. Also all the participants in this study were male as the rehabilitation center is a male-only facility. The research examining gender differences for substance abuse has found no differences for males and females in relation to self-efcacy, coping, and relapse rates (Walitzer and Dearing, 2006). However, further research may be required to determine whether gender differences occur with regard to spirituality, self-efcacy, and the experience of cravings. Given that the cross-sectional research conrmed the hypothesized relationships, future research should now examine the longitudinal development of spirituality, self-efcacy, and craving intensity. Better understanding of the sequential changes in these variables, and potentially the inclusion of other variables, during treatment will hopefully guide the development of future substance abuse treatment programs.

1936 Declaration of Interest

Mason et al.

The authors report no conict of interest. The authors alone are responsible for the content and writing of the article.

RESUM E
tude est dexaminer la relation entre spiritualit Lobjectif de cette e e, religiosit e, autoefcacit e, et l etat de manque entra n e par labus de drogues ou dalcool. Une enqu ete t de pr evalence a e e r ealis ee aupr` es de 77 participants de sexe masculin dans un service de r ehabilitation dun centre dh ebergement de lArm ee du Salut. Lenqu ete comprenait des questions concernant la consommation de drogues ou dalcool des participants et une valuation de leur spiritualit tait compos e e, religiosit e et auto-efcacit e. L echantillon e e g de participants a es entre 19 et 74 ans, dont plus de 57 % ont indiqu e avoir fait lobjet dun diagnostic pour troubles mentaux et 78 % ont admis un abus de plusieurs substances toxiques, lalcool repr esentant la principale substance dans 71 % des cas. 75 % des partici l pants ont indiqu e que la spiritualit e et la foi religieuse constituaient des e ements b en eques ` plusieurs variables a du programme de traitement. Une analyse de r egression multiple a tat de lexistence de relations importantes entre la spiritualit fait e e et lauto-efcacit e, et tude comprennent son caract` l etat de manque. Les limitations de cette e ere transversal et tudi t e ait e e choisi uniquement aupr` es dun programme bas e sur le fait que l echantillon e la foi. Des recherches futures pourraient b en ecier dun examen longitudinal de la relation entre spiritualit e et auto-efcacit e, et l etat de manque, lexploration dun plus grand ventail de variables propres au participant et interpersonnelles, et linclusion dun groupe e de comparaison issu dun centre de traitement non-religieux.

RESUMEN
El prop osito del presente estudio fue examinar la relaci on entre la espiritualidad, la religiosidad y la auto-ecacia y las apetencias de drogas y/o alcohol. Se llev o a cabo un sondeo entre 77 participantes varones en un centro de rehabilitaci on residencial del Ej ercito de la Salvaci on en Australia durante el a no 2007. La encuesta inclu a preguntas relacionadas con el uso de drogas y/o alcohol de parte de los participantes, y adem as med a la espiritualidad, la religiosidad, las apetencias y la auto-ecacia. El sondeo inclu a participantes de entre 19 y 47 a nos, de los cuales m as del 57% inform o de un diagn ostico de trastorno mental y el 78 inform o del mal uso poli-sustancial, con el alcohol indicado m as frecuentemente como la primera sustancia preocupante (71%). El setenta y cinco por ciento de los clientes tiles en su programa indicaron que la espiritualidad y la fe religiosa eran componentes u de tratamiento. Un an alisis de regresi on m ultiple multivariante identic o que la espiritualidad y la auto-ecacia tienen relaciones signicativas con las apetencias. El auto-ecacia mediaba la relaci on entre la espiritualidad y las apetencias de drogas y/o alcohol. Las limitaciones del presente estudio inclu an su dise no transversal y un sondeo que se tomaba exclusivamente de un programa basado en la fe. Investigaciones futuras se beneciar an del estudio longitudinal de la relaci on entre la espiritualidad, la auto-ecacia y las apetencias, de la exploraci on de una gama m as amplia de variables interpersonales y espec cas al cliente, adem as de la inclusi on de un grupo de control tomado de un centro de tratamiento secular.

Spirituality and Cravings

1937

THE AUTHORS

Sarah Mason (BSc, Hons) completed an honors degree in psychology at the University of Wollongong. Her research interests include examining the relationship between spirituality, religiosity, and cravings in relation to substance use. She hopes to complete the training in clinical psychology and pursue her research interests through completing a PhD.

Frank Deane Ph.D., is Director of the Illawarra Institute for Mental health and Professor in the School of Psychology at the University of Wollongong. He trained as a Clinical Psychologist at Massey University and currently teaches in the clinical psychology programs at the University of Wollongong. He has previously worked in clinical and academic positions in New Zealand and the USA. He has research interests in help-seeking for mental health, drug and alcohol consumption-related problems, service utilization and effectiveness, and the role of homework in treatment.

Peter J. Kelly Ph.D., is an Associate Research Fellow with the Illawarra Institute for Mental Health at the University of Wollongong, Australia. He is a Clinical Psychologist and has considerable experience working clinically within the drug and alcohol user eld. He is currently coordinating a large multistate study examining the treatment outcomes for the individuals attending residential rehabilitation programs and works part-time in private practice.

1938

Mason et al. Trevor Crowe Ph.D., is a Research Fellow with the Illawarra Institute for Mental Health at the University of Wollongong, Australia. He co-coordinates the High Support stream of the Australian Integrated Mental Health Initiative, which evaluates a recovery-oriented training program for the mental health clinicians. He also coordinates several substance misuse and mental health comorbidityfocused research and training projects. Trevor is a Psychologist, Psychotherapist and Certied Addictions Counselor with over 18 years clinical experience. He has particular interests in research and clinical work with the people suffering from comorbid mental health and substance misuse related problems.

Glossary
Craving: A subjective state where an individual experiences an intense desire to use a substance. Religiosity: Refers to religious beliefs and practices that are associated with a formal or institutionalized religious doctrine. Self-efcacy: Subjective perception that one has both the condence and skills to engage in a particular behavior. Spirituality: A subjective experience involving personal experiences with a higher power or sensing the mysteries of existence. It has also been referred to as a search for existential meaning that is not always conned to the context of a formal religious doctrine.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). (Text Revision). Washington, DC: Author. Anton, R. F., Moak, D. H., Latham, P. (1995). The obsessive compulsive drinking scale: a self-rated instrument for the quantication of thoughts about alcohol and drinking behavior. Alcoholism: Clinical and Experimental Research, 19:9299. Arnold, R. M., Avants, S. K., Margolin, A., Marcotte, D. (2002). Patient attitudes concerning the inclusion of spirituality into addiction treatment. Journal of Substance Abuse Treatment, 23:319 326. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. New Jersey: Prentice Hall. Baron, R. M., Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51(6):11731182. Bottlender, M., Soyka, M. (2004). Impact of craving on alcohol relapse during, and 12 months following, outpatient treatment. Alcohol & Alcoholism, 39:357361. Clark, D. (1994). Craving for alcohol. Journal of Psychopharmacology, 9:73. Connors, G. J., Tonigan, J. S., Miller, W. R. (1996). A measure of religious background and behaviour for use in behaviour change research. Journal of Addictive Behaviors, 10:9096. Daughters, S. B., Lejuez, C. W., Kahler, C. W., Strong, D. R., Brown, R. A. (2005). Psychological distress tolerance and duration of most recent abstinence attempt among residential treatmentseeking substance abusers. Psychology of Addictive Behaviours, 19(2):208211.

Spirituality and Cravings

1939

Flannery, B. A., Roberts, A. J., Cooney, N., Swift, R. M., Anton, R. F., Rohsenow, D. J. (2001). The role of craving in alcohol use, dependence, and treatment. Alcoholism: Clinical and Experimental Research, 25(2):299308. Galanter, M. (2006). Spirituality and addiction: a research and clinical perspective. American Journal of Addictions, 15:286292. Geppert, C., Bogenschutz, M. P., Miller, W. R. (2007). Development of a bibliography on religion, spirituality and addictions. Drug and Alcohol Review, 26:389395. Gordon, S. M., Sterling, R., Siatkowski, C., Raively, K., Weinstein, S., Hill, P. C. (2006). Inpatient desire to drink as a predictor of relapse to alcohol use following treatment. American Journal of Addictions, 15:242245. Greeneld, S. F., Hufford, M. R., Vagge, L. M., Muenz, L. R., Costello, M. E., Weiss, R. D. (2000). The relationship of self-efcacy expectancies to relapse among alcohol dependent men and women: a prospective study. Journal of Studies on Alcohol, 61:345351. Holmbeck, G. N. (2002). Post-hoc probing of signicant moderational and mediational effects in studies of pediatric populations. Journal of Pediatric Psychology, 27(1):8796. Ilgen, M., McKellar, J., Tiet, Q. (2005). Abstinence self-efcacy and abstinence 1 year after substance use disorder treatment. Journal of Consulting and Clinical Psychology, 73(6):11751180. Kavanagh, D. J., May, J., Andrade, J. (in press). Tests of the elaborated intrusion theory of craving and desire: intrusive thoughts, craving, imagery and negative mood during treatment for an alcohol disorder. British Journal of Clinical Psychology. Kleinig, J. (2004). Ethical issues in substance use intervention. Substance Use & Misuse, 39:369398. Kozlowski, L. T., Wilkinson, D. A. (1987). Use and misuse of the concept of craving by alcohol, tobacco, and drug researchers. British Journal of Addiction, 82:3136. Lawrinson, P., Copeland, J., Indig, D. (2005). Development and validation of a brief instrument for routine outcome monitoring in opioid maintenance pharmacotherapy services: the brief treatment outcome measure (BTOM). Drug and Alcohol Dependence, 80:125133. Loeber, S., Croissant, B., Heinz, A., Mann, K., Flor, H. (2006). Cue exposure in the treatment of alcohol dependence: effects on drinking outcome, craving and self-efcacy. British Journal of Social & Clinical Psychology, 45(4):515529. Long, C. G., Williams, M., Midgley, M., Hollin, C. R. (2000). Within-program factors as predictors of drinking outcome following cognitive behavioral treatment. Addictive Behaviors, 25(4):573 578. Love, A., James, D., Willner, P. (1998). A comparison of two alcohol craving questionnaires. Addiction, 93(7):10911102. Moos, R. H. (2007). Theory-based processes that promote the remission of substance use disorders. Clinical Psychology Review, 27:537551. Pardini, D. A., Plante, T. G., Sherman, A., Stump, J. E. (2000). Religious faith and spirituality in substance abuse recovery: determining the mental health benets. Journal of Substance Abuse Treatment, 19:347354. Piderman, K. M., Schneekloth, T. D., Pankratz, S., Maloney, S. D., Altchuler, S. I. (2007). Spirituality in alcoholics during treatment. The American Journal on Addictions, 16:231237. Preacher, K. J., Leonardelli, G. J. (2003). Calculation for the Sobel test: An interactive calculation tool for mediation tests. Retrieved July 3, 2007, from http://www.psych.ku.edu/ preacher/sobel/sobel.htm Project MATCH Research Group. (1993). Project MATCH: rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 17:11301145. Seidlitz, L., Abernethy, A. D., Duberstein, P. R., Evinger, J. S., Chang, T. H., Lewis, B. L. (2002). Development of the spiritual transcendence index. Journal for the Scientic Study of Religion, 41:439453. Sklar, S. M., Annis, H. M., Turner, N. E. (1999). Group comparisons of coping self-efcacy between alcohol and cocaine abusers seeking treatment. Psychology of Addictive Behaviors, 13(2):123 133.

1940

Mason et al.

Sklar, S. M., Turner, N. E. (1999). A brief measure for the assessment of coping self-efcacy among alcohol and other drug users. Addiction, 94(5):723729. Sobel, M. E. (1982). Asymptotic intervals for indirect effects in structural equations models. In S. Leinhart (Ed.), Sociological methodology 1982 (pp. 290312). San Francisco: Jossey-Bass. Sussman, S., Nezami, E., Mishra, S. (1997). On operationalizing spiritual experience for health research and practice. Alternative Theories in Clinical Practice, 4:120125. Sussman, S., Skara, S., de Calice, P., Hoffman, B., Dent, C. W. (2005). Spirituality as a 1-year prospective predictor of violence perpetration and drug use among youth at continuation high schools. Journal of Applied Social Psychology, 35(1):8099. Sussman, S., Skara, S., Rodriguez, Y., Pokhrel, P. (2006). Non drug use- and drug use-specic spirituality as one-year predictors of drug use among high-risk youth. Substance Use & Misuse, 41:18011816. Tabachnick, B. G., Fidell, L. S. (2007). Using multivariate statistics (5th ed.). Allyn and Bacon: Boston. Walitzer, K. S., Dearing, R. L. (2006). Gender differences in alcohol and substance use relapse. Clinical Psychology Review, 26:128148. Walton, M. A., Blow, F. C., Bingham, R., Chermack, S. T. (2003). Individual and social/environmental predictors of alcohol and drug use 2 years following substance abuse treatment. Addictive Behaviors, 28(4):627642. Webb, J. R., Robinson, E. A., Brower, K. J., Zucker, R. A., (2006). Forgiveness and alcohol problems among people entering substance abuse treatment. Journal of Addictive Diseases, 25(3):5566.

Copyright of Substance Use & Misuse is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.