Addiction Research & Theory

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Modeling intrinsic spirituality in gambling disorder

Belle Gavriel-Fried, Tania Moretta & Marc N. Potenza

To cite this article: Belle Gavriel-Fried, Tania Moretta & Marc N. Potenza (2019):
Modeling intrinsic spirituality in gambling disorder, Addiction Research & Theory, DOI:
10.1080/16066359.2019.1622002

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Published online: 13 Jun 2019.

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ADDICTION RESEARCH & THEORY
https://doi.org/10.1080/16066359.2019.1622002

ORIGINAL ARTICLE

Modeling intrinsic spirituality in gambling disorder

Belle Gavriel-Frieda , Tania Morettab and Marc N. Potenzac
a
The Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel; bDepartment of General Psychology, University of Padua,
Padova, Italy; cDepartments of Psychiatry, Neuroscience, and Child Study Center; Connecticut Council on Problem Gambling, Connecticut
Mental Health Center, Yale University School of Medicine, New Haven, CT, USA

ABSTRACT ARTICLE HISTORY

Background: Spirituality is related to an individual’s relationship with a Transcendent Being or Received 2 March 2019
Ultimate Reality, which may contribute to salutary human experience and serve as a motive for atti- Revised 3 May 2019
tudes and behaviors. In contrast to studies in the field of substance addictions showing that spirituality Accepted 7 May 2019
may protect against substance-use problems and disorders and is a resource that may promote recov-
KEYWORDS
ery, few studies have investigated the role of spirituality in gambling disorder, particularly ones using Intrinsic spirituality scale;
validated scales. gambling disorder;
Objectives: To probe the psychometric characteristics of the Intrinsic Spirituality Scale in individuals recovery; Israel
with gambling disorder and explore potential links between spirituality and a diagnosis of gambling
disorder and its severity, and levels of psychopathology as manifested in depression and anxiety.
Method: One-hundred-and-forty individuals over the age of 18 years with lifetime gambling disorder
from five treatment centers in Israel were assessed on the Intrinsic Spirituality Scale, diagnostic criteria
for gambling disorder, Generalized Anxiety Disorder Scale, and Patient Health Questionnaire 9
for depression.
Results: The Intrinsic Spirituality Scale showed good psychometric properties, differentiated recovered
and non-recovered individuals, and was negatively associated with severity of gambling disorder. No
significant associations were found with depression and anxiety.
Conclusion: The findings indicate that intrinsic spirituality is an important construct in Israeli individu-
als recovering from gambling disorder and highlight the importance of intrinsic spirituality in recovery
from gambling disorder. Additional research is needed to understand the underlying processes and
the extent to which the findings may extend to other groups of individuals with gambling disorder.

Introduction gambling behavior and preoccupation which generates harm

to the individual and others in their surroundings, and is
A growing interest in positive psychology and strengths-based
often related to other psychiatric symptoms and disorders
approaches, in addition to social changes that emphasize
including depression and anxiety disorders (Kessler et al.
secularism, may have led to increased attention in the concept
2008; Lorains et al. 2011; Grant and Chamberlain 2015).
of spirituality in the fields of mental health and addictions
Few quantitative studies assessing resources and treat-
(Barton and Miller 2015; Garcia et al. 2017). Spirituality
ment outcomes that enable individuals to cope with their
involves individuals’ relationships with a Transcendent Being
gambling problems and disorders or sustain recovery have
or Ultimate Reality and the way this relationship may guide
probed spirituality in relation to GD. Of these, most have
their behaviors and attitudes (Hodge 2003; Hodge et al.
not use validated scales to assess spirituality (Clark et al.
2015). Generally speaking, spirituality is negatively associated
2006; Oei and Gordon 2008). The aim of the current study
with mental illness and levels of involvement in risk behaviors
such as substance use and abuse, and positively associated is twofold: to investigate the psychometric properties of the
with many aspects of recovery from substance addictions and Intrinsic Spirituality Scale (ISS) (Hodge 2003) in individuals
other mental disorders (Hodge et al. 2007; Robinson et al. with GD, and to test for potential associations between spir-
2007; Salas-Wright et al. 2013; Dermatis and Galanter 2016; ituality and GD and its severity and levels of depression and
Beraldo et al. 2018). anxiety. The goal is to provide evidenced-based data on the
Gambling disorder (GD) is a behavioral addiction that is role of intrinsic spirituality in gambling recovery.
classified under the section of substance-related and addict-
ive disorders in the latest version of the Diagnostic and
Spirituality and addictive behaviors
Statistical Manual of Mental Disorders (5th ed.; DSM–5;
American Psychiatric Association 2013). It is characterized Spirituality may help people across developmental stages
by impaired control over gambling, persistent maladaptive make sense of difficulties and stressors and shape attitudes

CONTACT Belle Gavriel-Fried bellegav@tauex.tau.ac.il The Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, 69978, Israel.
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 B. GAVRIEL-FRIED ET AL.
and behaviors (Koenig 2010). A recent concept analysis of
studies conducted between 2002 and 2013 identified three
main defining attributes of spirituality in the fields of health,
psychology and sociology: transcendence, connectedness,
and meaning in life (Weathers et al. 2016). Accordingly, spir-
ituality was defined by these authors as, “a way of being in
the world in which a person feels a sense of connectedness
to self, others, and/or a higher power or nature; a sense of
meaning in life; and transcendence beyond self, everyday liv-
ing, and suffering” (Weather et al. 2016, p. 93).
Differences exist between spirituality and religiosity. While
both may relate to connections with Sacred or Transcendent
Beings, religiosity tends to emphasize the socially shared set
of practices and beliefs that are framed under organizational
and institutional settings, whereas spirituality is perceived as
a personal, intrinsic component that relates to an individual’s
relationship with God or perceived transcendence, which may
contribute to a salutary human experience (Hodge 2003,
2015; Hodge and Reynolds 2018). Contemporary definitions
have broadened the concept of spirituality to suggest it may
be included in religiosity but also extend beyond it (Hodge
2018). Thus, spirituality can exist within a religion context
but is also a distinct entity in itself. This definition thus
covers people from diverse religious backgrounds as well
on those who define themselves as non-religious or atheists
(Koenig 2008; Hodge 2018). Other conceptualizations see
religiosity and spirituality as each having independent and
overlapping components that may operate through buffering
and preventative mechanisms to promote positive health out-
comes (Garfield et al. 2013).
Some scholars in the addiction field view spirituality as a
key factor that explains the etiology of addictive behaviors
and as a resource that enhances recovery (Cook 2004). For
example, within existential theory (Frankl 1959), it has been
suggested that a lack of meaning in life and an experience
of existential vacuum might lead to frustration that is ful-
filled by addictive behaviors, whereas having high levels of
spirituality might enhance many aspects of recovery and
contribute to maintaining long-term recovery (Wolf et al.
1995; Gerwood 1998; Jarusiewicz 2000; Cook 2004; Garcia
et al. 2017).
Empirical studies, most of which have been conducted
on individuals with substance-use problems and disorders,
show a negative associations between various dimensions
of spirituality and substance use, substance addictions and
recovery (Jarusiewicz 2000; Geppert et al. 2007; Koenig
2010; Salas-Wright et al. 2013). For example, increases in
spirituality, religious practices and beliefs (such as private
spiritual and religious practices, forgiveness of the self, and
daily spiritual experience) predicted better drinking out-
comes such as abstinence and a reduction in drinking in
364 individuals with alcohol dependence over the course
of 6 and 9 months (Robinson et al. 2011). Spirituality (spir-
itual well-being, optimism and surrender) was positively
associated with indicators of recovery success (e.g. long-
term recovery and recovery-oriented behaviors) among 252
individuals from alcohol treatment settings (White et al.
2001). In acknowledgment of its importance, spirituality
was added to recovery capital as a personal dimension that
may serve as a resource to help individuals overcome sub-
stance addiction (Sterling et al. 2008).
Many studies have explored spirituality in the context of
attending and involvement in 12-step programs (Geppert
et al. 2007) that emphasize connections with a higher power
or God and view spirituality as a key component of recovery
from addictions (White et al. 2001; Morjaria and Orford
2002; Geppert et al. 2007; Kelemen et al. 2007; Kelly et al.
2009; Mustain and Helminiak 2015; Dermatis and Galanter
2016). For example, “spiritual awakening” in Alcoholics
Anonymous (AA) has been linked to decreased likelihood of
alcohol cravings in 266 AA attendees (Galanter et al. 2012).
Given the comorbidity between substance addictions and psy-
chiatric symptoms and disorders (George and Krystal 2000;
Schuckit 2006; Brook et al. 2016), studies have also reported
negative associations between a range of dimensions of spir-
ituality (such as existential well-being) and psychiatric symp-
toms including anxiety (And
o et al. 2016) and depressive
symptoms or disorders (Diaz et al. 2011; Kleftaras and
Katsogianni 2012; Horton et al. 2016) in individuals with sub-
stance-use disorders.
Despite accumulating data, studies of spirituality have
been criticized for inconsistent and varying definitions and
measurements (Cook 2004), including the use of unvalidated
and/or single-item measures (Geppert et al. 2007). Relatedly,
items referring to God may not be valid indicators of spir-
ituality in non-theistic populations (Hodge 2003) and values
such as harmony, well-being, gratefulness and the capacity
for forgiveness may also be related to or distinct from spir-
ituality (Koenig 2008). As such, the use of validated instru-
ments to assess spirituality has been advocated.
Empirical studies examining spirituality as related to GD
and recovery from GD are scarce despite data suggesting that
GD and substance-use disorders share underlying mechanisms,
vulnerability factors and treatment approaches (Petry 2015;
Goudriaan et al. 2019). Studies examining spirituality as a pro-
tective factor against gambling behavior among non-clinical
populations (Hodge et al. 2007; Chen et al. 2018) and among
individuals with gambling problems (Clark et al. 2006; Oei
and Gordon 2008) have generated seemingly inconsistent
results. Among 5179 adolescents and young adults, those who
were certain in their spiritual beliefs were more likely to gam-
ble (Chen et al. 2018). Similar findings were reported by Clark
et al. (2006) who asked 244 individuals (of whom 148 were
problem gamblers) to rate their motives to continue gambling.
One of the motives was “gambling gives me hope and oppor-
tunity for a better life”, an item that the authors interpreted
as “spirituality.” Problem gamblers were 3 times more likely
than non-problem gamblers to make this statement, which
led the authors to conclude that in some cases spirituality
may contribute to the development of gambling problems.
These finding may be explained by superstitious beliefs
and/or distorted hope related to gambling behaviors
(Ariyabuddhiphongs and Chanchalermporn 2007) that may
lead individuals to think that their beliefs in a Higher
Power may help them win.

In contrast, Oei and Gordon (2008) found that belief in
a higher power (measured by five items developed by
the authors) differentiated between relapsed vs. abstinent
individuals in 75 Gamblers Anonymous (GA) members.
However, although belief in a higher power predicted mem-
bership in the abstinence group, it had less relative impact
than other variables such as attending and participation in
GA meetings (Oei and Gordon 2008). Overall, the critiques
in studies which have probed the role of spirituality in sub-
stance addiction might shed light on the inconsistent find-
ings in the gambling field (e.g. different definitions, use of
invalid scales). Hence, the current study was developed to
determine factors related to intrinsic spirituality (assessed
using the Intrinsic Spirituality Scale (ISS), a previously vali-
dated scales in independent samples) as it applies to GD,
GD recovery and depression and anxiety.
The current study
The current study examined the psychometric properties of
the ISS (Hodge 2003) in individuals with GD and tested
associations between intrinsic spirituality, DSM-5 GD and
GD severity, and depression and anxiety symptoms. We
predicted lower levels of intrinsic spirituality would be
found in individuals who had not recovered from GD than
in recovered individuals, and lower levels of intrinsic spir-
ituality would be associated with higher levels of GD sever-
ity, depression and anxiety.
Method
Participants and procedure
The current study is part of a larger research project exam-
ining recovery resources in GD (Gavriel-Fried 2018; Gavriel-
Fried & Lev-el 2018). One-hundred-and-forty Jewish indi-
viduals with lifetime GD with durations of recovery of up to
5 years with no comorbid addiction to other drugs or alco-
hol (according to the DSM-5) were recruited for this study
from five treatment centers in Israel. The first appeal to
potential participants who were treated in these centers
between 2011 and 2016 was made by the administrative staff
of the treatment centers. Those who consented met indi-
vidually with the research team and completed the question-
naire on a tablet using Qualtrics software. There were no
missing data. The sample consisted of 101 men and 39
women, aged 23–77 years (M ¼ 49.15, SD ¼ 13.93). In terms
of religious backgrounds, 79 participants self-identified as
secular, 51 as traditionally Jewish (i.e. individuals who iden-
tify with the values of the Jewish faith, without strictly
observing all religious directives), and 10 as religiously
Jewish (i.e. following more faith-based practices). The mean
DSM-5 GD severity as assessed by inclusionary criteria
count in the previous 12 months was 2.56 (SD ¼ 3.10), and
67 participants declared zero past-year DSM-5 symptoms. A
combination of lifetime GD and zero past-year DSM symp-
toms is a conservative definition of recovery (Slutske et al.
2009). Individuals were compensated for their time with a
shopping 100 Israeli shekel shopping voucher (about $25).
ADDICTION RESEARCH & THEORY 3
The study was approved by the ethical committees of the
lead author’s university and the social welfare office.
Measures
Intrinsic spirituality scale
The ISS is a modified abbreviated version of the intrinsic
religion scale (Allport and Ross 1967) developed by Hodge
(2003). It measures the extent to which spirituality functions
as an individual’s master motive in life and is applicable to
theistic and non-theistic individuals, within or outside reli-
gion contexts. The scale is based on a sentence completion
format in which one sentence is presented to the respond-
ents with a different response key for each item ranging
from 0 to 10. A sample item is: “When I think of the things
that help me to grow and mature as a person, my spiritu-
ality … : (0) – “has no effect on my personal growth” and
10 – “is absolutely the most important factor in my personal
growth”. Higher scores represent higher spirituality. The
score is calculated as the mean of all items. The reliability
reported by Hodge (2003) was .96 and in the current study
was .95.
DSM-5 diagnostic criteria for GD (DSM-5, 2013)
The criteria are based on responses to 9 yes/no items refer-
ring to the past year such as, “Has made repeated unsuc-
cessful efforts to control, cut back, or stop gambling.”
Individuals were asked to respond in terms of their GD
symptoms in the previous 12 months. The answers were
summed and were calculated both as a continuum that
reflects GD severity, and as a dichotomous variable in
which those who indicted 0 GD DSM-5 symptoms were
considered recovered and those who acknowledged one or
more criteria were considered as non-recovered (Slutske
et al. 2010). The reliability of this measure was a ¼ .91.
The patient health questionnaire-9 (PHQ-9)
The PHQ-9 assesses the severity of depression using 9 items
relating to the past 2 weeks based on DSM-IV criteria for
depressive episodes (Kroenke and Spitzer 2002). Answers
range from 0 (not at all) to 3 (nearly every day). Higher
PHQ-9 scores represent greater depression. The original reli-
ability reported in 2 different samples ranged from .89 to .86
(Kroenke et al. 2001), and in this study was .84.
Generalized anxiety disorder scale (GAD-7)
This instrument measures the presence of GAD in the previ-
ous 2 weeks on 7 items (Spitzer et al. 2006). Responses
range from 0 (not at all) to 3 (nearly every day). Higher
scores represent higher anxiety levels. The reliability
reported in the original study was a ¼ .92 (Spitzer et al.
2006), and in this study was .91.
4 B. GAVRIEL-FRIED ET AL.

Socio-demographic questionnaires severity to be significantly and positively associated with

Information on gender, age, and self-perceived religiosity
(measured on ordinal scale ranging from 1 – secular to 4
Orthodox Jewish) was collected.
Data analysis
All analyses were performed using R software (Team 2016)
and the Lavaan package (Rosseel 2012). Descriptive statistics
(i.e. means, standard deviations, skewness) were calculated.
Linear model analysis considering group (recovered and non-
recovered) as a predictor was performed to compare intrinsic
spirituality between groups. Pearson’s correlation coefficients
were calculated to assess associations between intrinsic spir-
ituality, age, gender, and religiosity. The only significant
correlation was between intrinsic spirituality and religiosity
(r(140) ¼ 0.47, p < .001); therefore, religiosity was included
as a covariate of intrinsic spirituality. Pearson’s correlation
coefficients were also employed to assess the strengths of the
relationships between intrinsic spirituality, GD severity,
depression and anxiety as well as gender and age.
First, a confirmatory factor analysis (CFA) was conducted
on the ISS scale, and then a structural equation model (SEM)
analysis was performed to test the hypothesized relationships
of intrinsic spirituality (controlling for religiosity) to both GD
severity and psychopathology (depression and anxiety) by the
maximum likelihood (ML) estimator. In order to create
three indicators each for intrinsic spirituality, DSM-5 GD,
and depression and anxiety, an item-parceling strategy was
employed using the loadings as a guide. Hence, groups of two
items or more were aggregated through summing or averag-
ing into subsets, which in turn were treated as indicators of
the latent construct (Little et al. 2002). Internal consistencies
of the ISS were assessed using Cronbach’s a. Goodness-of-fit
was evaluated using the following indices (Schermelleh-Engel
et al. 2003): Chi square (v2), Comparative Fit Index (CFI;
values greater than 0.95 were considered as indicating good
fit), Tucker Lewis index (TLI; values greater than 0.95 were
considered as indicating acceptable fit), and Root Mean
Square Error of Approximation (RMSEA; values higher than
.10 were considered not acceptable).
Results
Descriptive statistics
Descriptive statistics including Pearson’s correlations are
reported in Table 1. Pearson correlations revealed GD
depression and anxiety. Depression was found to be signifi-
cantly and positively associated with anxiety. Intrinsic spir-
ituality was not associated with GD severity, depression,
or anxiety.
Confirmatory factor analyses (CFAs)
The CFA was specified considering intrinsic spirituality as
the only factor. The CFA provided an acceptable fit to the
observed data (v2(9) ¼ 23.176, p ¼ .006; CFI ¼ 0.98; TLI ¼
0.97; RMSEA ¼ 0.106 90%CI ¼ 0.05, 0.16). Good internal
consistency was also observed (a ¼ 0.95). All factor loadings
were significant (p < .001) and ranged from 0.82 to 0.92.
Differences between recovered and non-recovered
individuals
Linear model analysis revealed higher scores in the recov-
ered relative to the non-recovered group for intrinsic spiritu-
ality (recovered, 6.61 ± 2.94; non-recovered, 5.29 ± 3.10;
t ¼ 2.57, p ¼ .011, R2 ¼.04).
Relationships between intrinsic spirituality and GD
severity and depression and anxiety
To examine the hypothesized relationships among the latent
constructs, the SEM was tested using the ML estimator. The
tested model and the estimated standardized beta coefficients
(b) are shown in Figure 1.
The structural model showed an acceptable fit to the data
(v2(57) ¼ 139.497, p < .001; CFI ¼ 0.94; TLI ¼ 0.92; RMSEA
¼ 0.10, 90%CI ¼ 0.08, 0.12). Intrinsic spirituality negatively
predicted GD severity (p ¼ .030; b ¼ 0.193) (Figure 1). In
contrast to our hypotheses, intrinsic spirituality did not stat-
istically predict depression (p ¼ .652; b ¼ 0.04) or anxiety
(p ¼ .706; b ¼ 0.03). Overall, the tested model account for
5% of the variance in GD severity, 2% of the variance in
depression, and 1% of the variance in anxiety.
Discussion
This study applied the ISS, which measures the extent to
which spirituality is considered a key motive governing
individuals’ behaviors and decisions in many areas of life, in
individuals with a lifetime gambling disorder. The scale dem-
onstrated good psychometric properties and distinguished

Table 1. Descriptive statistics and intercorrelations (n ¼ 140).

Descriptive Statistics Pearson’s correlations
Mean sd range skew 1 2 3 4 5 6 7
1. Gender (39 females) – – – – 1
2. Age 49.16 13.93 54 0.11 0.49 1
3. Religiosity – – – – 0.01 0.04 1
4. Intrinsic spirituality 5.92 3.08 10 0.56 0.01 0.02 0.47 1
5. GD severity 2.56 3.10 9 0.81 0.06 0.02 0.02 0.13 1
6. Anxiety 4.76 5.44 21 1.36 0.05 0.08 0.09 0.06 0.40 1
7. Depression 5.99 5.69 24 1.19 0.02 0.15 0.08 0.00 0.49 0.82 1
p < .001.

Figure 1. Structural equation model of the relationship between intrinsic spiritually and gambling disorder (GD) severity, depression and anxiety with standardiza-
tion parameters. Asterisks indicates paths that were statically significant at p < .001.
between recovered and non-recovered individuals. Individuals
with low levels of intrinsic spirituality also demonstrated
higher levels of GD severity in a SEM.
The findings resonate with those from previous studies of
individuals with substance-use disorders that have reported
spirituality as a protective factor from addictive behaviors
and as a promotor of recovery (Koski-Jannes and Turner
1999; Jarusiewicz 2000; Geppert et al. 2007; Koenig 2010;
Salas-Wright et al. 2013). The results thus suggest that spir-
ituality should be considered as an important factor that
may operate similarly in GD as in substance-use disorders
(Petry 2015; Goudriaan et al. 2019), and suggests a role for
spirituality in interventions for GD. The good psychometric
indices of the ISS in a clinical sample of individuals with
lifetime GD suggest it may be an effective tool to assess spir-
ituality in populations with GD, and as such could be
applied in future studies in the field.
Interestingly, and in contrast to predictions, spirituality
was not associated to depression and anxiety. This runs
counter to previous findings in individuals with substance-
use disorders in which associations were observed (Diaz
et al. 2011; And
o et al. 2016; Horton et al. 2016). One meth-
odological reason could be related to the use of different
scales to measure different aspects of spirituality. Another
consideration involves differences in timeframes (in this
study, 2 weeks for anxiety and depression whereas GD
recovery was assessed over 12 months). From a clinical per-
spective, the findings suggest that spirituality may be a
resource in GD, despite comorbid depression and/or anxiety
symptoms. As the clinical sample investigated here included
people who were being treated mainly for GD, spiritual
resources may have been engaged relatively early in treat-
ment to cope with GD-related problems. More studies
should be conducted to investigate a role for spirituality
over time in treatment of individuals with GD, including
with respect to co-occurring psychiatric symptomatology.
In practical terms, the findings suggest that spirituality-
related factors could be beneficially integrated into treatment
and research of GD. Therapists could encourage their
patients to explore spiritual elements that might facilitate
ADDICTION RESEARCH & THEORY 5
their growth and recovery, and, like many do, encourage
them to participate in 12-step programs in addition to con-
ventional treatment approaches. However, differences in def-
initions of spirituality should be considered. In terms of
gambling research, given seemingly contradictory findings
which view spirituality both as a potential risk and protect-
ive factor, future studies should investigate spirituality in
relation to types of gambling (Friedland 1998), and consider
other factors that might moderate links between spirituality
and gambling behaviors.
This study has limitations related to its cross-sectional
design that preclude causal inferences. Furthermore, partici-
pants completed self-report questionnaires without cross-
references to other resources. Spirituality is a multidimen-
sional construct that includes many kinds of practices and
beliefs (Weathers et al. 2016). As intrinsic spirituality only
explained 5% of the variance in GD severity, it is possible
that other measures assessing more diverse elements of spir-
ituality may have captured more of the variance. Moreover,
some of the reported RMSEA values were slightly above the
stated cutoff value of .10. However, it has been suggested
that models with a small sample sizes (for example, less than
200 individuals) may have RMSEA values that can falsely
indicate a poor model fit (Taasobshirazi and Wang 2016).
Future studies involving larger samples should be under-
taken to further examine this fit index. Finally, this study
was conducted in Israel and included solely Jewish individu-
als. While the observations that Israel is predominantly secu-
lar (Ruah-Midbar 2012) and only 7.14% of our participants
defined themselves as more highly religious may suggest that
the findings can be generalized to other Western secular
populations, direct investigation of this possibility is war-
ranted. Regardless, more studies should be conducted on
other populations in different cultural contexts.
Despite limitations, this study validated the ISS in indi-
viduals with GD and points to a role for intrinsic spirituality
in GD recovery. As such, it paves the way for future studies
that should examine more dimensions of spirituality and
spirituality in different sub-populations of individuals with
GD and investigate possible mechanisms between spirituality
6 B. GAVRIEL-FRIED ET AL.
and GD, gambling behaviors and co-occurring disorders
over time.
Funding
This study was supported by a seed grant awarded to Dr. Belle
Gavriel-Fried by the National Center for Responsible Gaming
(NCRG) in 2017. Dr. Potenza’s involvement was supported by the
National Center for Responsible Gaming, the Connecticut Council
on Problem Gambling, and the Connecticut Department of Mental
Health and Addiction Services.
ORCID
Belle Gavriel-Fried http://orcid.org/0000-0001-5528-5339
Tania Moretta http://orcid.org/0000-0002-4734-1545
Marc N. Potenza http://orcid.org/0000-0002-6323-1354
References
Allport GW, Ross JM. 1967. Personal religious orientation and preju-
dice. J Pers Soc Psychol. 5(4):432.
American Psychiatric Association (APA). 2013. Diagnostic and statis-
tical manual of mental disorders. 5th ed. Washington, DC:
American Psychiatric Association Press.
And


o B, Almos PZ, N
emeth VL, Kov
acs I, Feh
er-Cs
ok
as A, Demeter I,
R
ozsa S, Urb
an R, Kurgyis E, Szikszay P, et al. 2016. Spirituality
mediates state anxiety but not trait anxiety and depression in alcohol
recovery. J Subst Use. 21(4):344–348.
Ariyabuddhiphongs V, Chanchalermporn N. 2007. A test of social cog-
nitive theory reciprocal and sequential effects: hope, superstitious
belief and environmental factors among lottery gamblers in
Thailand. J Gambl Stud. 23(2):201–214.
Barton YA, Miller L. 2015. Spirituality and positive psychology go hand
in hand: An investigation of multiple empirically derived profiles
and related protective benefits. J Relig Health. 54(3):829–843.
Beraldo L, Gil F, Ventriglio A, Torales J, Goncalves P, Bhugra D,
Castaldelli-Maia J. 2018. Spirituality, religiosity and addiction recov-
ery: current perspectives. Curr Drug Abuse Rev. 11(1):26–32.
Brook JS, Zhang C, Rubenstone E, Primack BA, Brook DW. 2016.
Comorbid trajectories of substance use as predictors of antisocial
personality disorder, major depressive episode, and generalized anx-
iety disorder. Addict Behav. 62:114–121.
Chen F, Berchtold A, Barrense-Dias Y, Suris J-C. 2018. Spiritual belief
and its link with potentially addictive behaviors in a youth sample
in Switzerland. Int J Adolesc Med Health. DOI:10.1515/ijamh-2018-
0070
Clark D, Tse S, Abbott M, Townsend S, Kingi P, Manaia W. 2006.
Religion, spirituality and associations with problem gambling. N Z J
Psychol. 35(2):77.
Cook CC. 2004. Addiction and spirituality. Addiction. 99(5):539–551.
Dermatis H, Galanter M. 2016. The role of twelve-step-related spiritual-
ity in addiction recovery. J Relig Health. 55(2):510–521.
Diaz N, Horton EG, Green D, McIlveen J, Weiner M, Mullaney D.
2011. Relationship between spirituality and depressive symptoms
among inpatient individuals who abuse substances. Couns Values.
56(1-2):43–56.
Frankl VE. 1959. The spiritual dimension in existential analysis and
logotherapy. J Individual Psychol. 15(2):157.
Friedland N. 1998. Games of luck and games of chance: the effect of
luck-versus chance-orientation on gambling decisions. J Behav Decis
Making. 11(3):161–179.
Galanter M, Dermatis H, Santucci C. 2012. Young people in alcoholics
anonymous: the role of spiritual orientation and AA member affili-
ation. J Addict Dis. 31(2):173–182.
Garcia SDO, Babarro JM, Romero MDLPT. 2017. Spiritus contra spiri-
tum: including spirituality in addiction treatments for recovery, a
systematic review. Univ J Psychol. 5(2):66–87.
Garfield CF, Isacco A, Sahker E. 2013. Religion and spirituality as
important components of men’s health and wellness: an analytic
review. Am J Lifestyle Med. 7(1):27–37.
Gavriel-Fried B. 2018. The crucial role of recovery capital in individuals
with a gambling disorder. J Behav Addict. 7(3):792–799.
Gavriel-Fried B, Lev-el N. 2018. Mapping and conceptualizing recovery
capital of recovered gamblers. Am J Orthopsychiatry. DOI:10.1037/
ort0000382
George TP, Krystal JH. 2000. Comorbidity of psychiatric and substance
abuse disorders. Curr Opin Psychiatry. 13(3):327–331.
Geppert C, Geppert C, Bogenschutz MP, Geppert C, Bogenschutz MP,
Miller WR, Miller WR. 2007. Development of a bibliography on reli-
gion, spirituality and addictions. Drug Alcohol Rev. 26(4):389–395.
Gerwood JB. 1998. The existential vacuum in treating substance-related
disorders. Psychol Rep. 83(3_suppl):1394–1394.
Goudriaan AE, van den Brink W, van Holst RJ. 2019. Gambling dis-
order and substance-related disorders: similarities and differences.
In Heinz A, Romanszuk-Seiferth N, Potenza MN, editors. Gambling
disorder. Cham: Springer; p. 247–269.
Grant JE, Chamberlain SR. 2015. Gambling disorder and its relation-
ship with substance use disorders: implications for nosological revi-
sions and treatment. Am J Addict. 24(2):126–131.
Hodge DR. 2003. The intrinsic spirituality scale: a new six-item instru-
ment for assessing the salience of spirituality as a motivational
construct. J Soc Serv Res. 30(1):41–61.
Hodge DR. 2015. Spirituality and religion among the general public:
implications for social work discourse. Soc Work. 60(3):219–227.
Hodge DR. 2018. The evolution of spirituality and religion in inter-
national social work discourse: Strengths and limitations of the
contemporary understanding. J Relig Spirituality Soc Work Soc
Thought. 37(1):3–23.
Hodge DR, Andereck K, Montoya H. 2007. The protective influence of
spiritual-religious lifestyle profiles on tobacco use, alcohol use, and
gambling. Soc Work Res. 31(4):211–219.
Hodge DR, Reynolds C. 2018. Spirituality among people with disabil-
ities: a nationally representative study of spiritual and religious pro-
files. Health Social Work. DOI:10.1093/hsw/hly035
Hodge DR, Zidan T, Husain A. 2015. Validation of the Intrinsic
Spirituality Scale (ISS) with muslims. Psychol Assess. 27(4):1264–1272.
Horton EG, Luna N, Malloy T. 2016. Associations between spirituality,
meaning in life, and depressive disorders among a sample of indi-
viduals in treatment for substance-use disorders. J Spirituality
Mental Health. 18(4):283–299.
Jarusiewicz B. 2000. Spirituality and addiction: relationship to recovery
and relapse. Alcohol Treat Q. 18(4):99–109.
Kelemen G, Erdos MB, Madacsy J. 2007. Voices of sobriety: exploring
the process of recovery through patient testimonials. Addict Res
Theor. 15(2):127–140.
Kelly JF, Magill M, Stout RL. 2009. How do people recover from alco-
hol dependence? A systematic review of the research on mechanisms
of behavior change in alcoholics anonymous. Addict Res Theor.
17(3):236–259.
Kessler RC, Hwang I, LaBrie R, Petukhova M, Sampson NA, Winters
KC, Shaffer HJ. 2008. DSM-IV pathological gambling in the National
Comorbidity Survey Replication. Psychol Med. 38(9):1351–1360.
Kleftaras G, Katsogianni I. 2012. Spirituality, meaning in life, and
depressive symptomatology in individuals with alcohol dependence.
J Spirituality Mental Health. 14(4):268–288.
Koenig HG. 2008. Concerns about measuring “spirituality” in research.
The Journal of Nervous and Mental Disease. 196(5):349–355.
Koenig HG. 2010. Spirituality and mental health. Int J Appl Psychoanal
Stud. 7(2):116–122.
Koski-J€annes A, Turner N. 1999. Factors influencing recovery from
different addictions. Addict Res. 7(6):469–492.
Kroenke K, Spitzer RL. 2002. The PHQ-9: a new depression diagnostic
and severity measure. Psychiatr Annal. 32(9):509–515.

Kroenke K, Spitzer RL, Williams JB. 2001. The PHQ-9: validity of a
brief depression severity measure. J Gen Intern Med. 16(9):606–613.
Little TD, Cunningham WA, Shahar G, Widaman KF. 2002. To parcel or
not to parcel: Exploring the question, weighing the merits. Struct
Equation Model. 9(2):151–173.
Lorains FK, Cowlishaw S, Thomas SA. 2011. Prevalence of comorbid
disorders in problem and pathological gambling: systematic review
and meta-analysis of population surveys. Addiction. 106(3):490–498.
Morjaria A, Orford J. 2002. The role of religion and spirituality in
recovery from drink problems: a qualititative study of alcoholics
anonymous members and South Asian men. Addict Res Theor.
10(3):225–256.
Mustain JR, Helminiak DA. 2015. Understanding spirituality in recov-
ery from addiction: reintegrating the psyche to release the human
spirit. Addict Res Theor. 23(5):364–371.
Oei TP, Gordon LM. 2008. Psychosocial factors related to gambling
abstinence and relapse in members of gamblers anonymous. J
Gambl Stud. 24(1):91–105.
Petry N. 2015. Behavioral Addictions: DSM-5V R and Beyond. New
York: Oxford University Press.
Robinson EA, Cranford JA, Webb JR, Brower KJ. 2007. Six-month
changes in spirituality, religiousness, and heavy drinking in a treat-
ment-seeking sample. J Stud Alcohol Drugs. 68(2):282–290.
Robinson EA, Krentzman AR, Webb JR, Brower KJ. 2011. Six-month
changes in spirituality and religiousness in alcoholics predict drink-
ing outcomes at nine months. J Stud Alcohol Drugs. 72(4):660–668.
Rosseel Y. 2012. Lavaan: An R package for structural equation model-
ing and more. Version 0.5–12 (BETA). J Stat Software. 48:1–36.
Ruah-Midbar M. 2012. Current Jewish spiritualities in Israel: a new
age. Mod Jud. 32(1):102–124.
Salas-Wright CP, Olate R, Vaughn MG. 2013. Religious coping, spiritu-
ality, and substance use and abuse among youth in high-risk
ADDICTION RESEARCH & THEORY 7
communities in San Salvador, El Salvador. Subst Use Misuse. 48(9):
769–783.
Schermelleh-Engel K, Moosbrugger H, M€ uller H. 2003. Evaluating the
fit of structural equation models: tests of significance and descriptive
goodness-of-fit measures. Methods Psychol Res Online. 8(2):23–74.
Schuckit MA. 2006. Comorbidity between substance use disorders and
psychiatric conditions. Addiction. 101:76–88.
Slutske WS, Blaszczynski A, Martin NG. 2009. Sex differences in the
rates of recovery, treatment-seeking, and natural recovery in patho-
logical gambling: results from an Australian community-based twin
survey. Twin Res Hum Genet. 12(5):425–432.
Slutske WS, Piasecki TM, Blaszczynski A, Martin NG. 2010. Pathological
gambling recovery in the absence of abstinence. Addiction. 105(12):
2169–2175.
Spitzer RL, Kroenke K, Williams JB, L€ owe B. 2006. A brief measure
for assessing generalized anxiety disorder: the GAD. Arch Intern
Med. 166(10):1092–1097.
Sterling R, Slusher C, Weinstein S. 2008. Measuring recovery capital
and determining its relationship to outcome in an alcohol dependent
sample. Am J Drug and Alcohol Abuse. 34(5):603–610.
Taasoobshirazi G, Wang S. 2016. The performance of the SRMR,
RMSEA, CFI, and TLI: An examination of sample size, path size,
and degrees of freedom. J Appl Quant Methods. 11(3):31–40.
Team RDC. 2016. R: a language and environment for statistical com-
puting. Austria, Vienna: R Foundation for Statistical Computing.
Weathers E, McCarthy G, Coffey, A. (2016). Concept analysis of spir-
ituality: an evolutionary approach. Nurs Forum. 51:79–96.
White JM, Wampler RS, Fischer JL. 2001. Indicators of spiritual devel-
opment in recovery from alcohol and other drug problems. Alcohol
Treat Q. 19(1):19–35.
Wolf Y, Katz S, Nachson I. 1995. Meaning of life as perceived by
drug-abusing people. Int J Offender Ther Comp Criminol. 39(2):
121–137.