The Effect of Baseline Patterns of Spiritual Coping, Forgiveness, and Gratitude on the Completion of an Alcohol Addiction Treatment Program

In this study, the widely accepted concept of spirituality and religiousness as overlapping yet distinct and distinguishable constructs has been applied (Burkhardt and Solari-Twadell 2001; Jarusiewicz 2000). According to Wong (2010), spirituality grants the individual the ability to recognize the resourcefulness of meaningful living, in this way providing the opportunity to use spirituality to transcend the detrimental effects of stressful situations. In a similar vein, Pargament et al. (2000) posit that during times of acute stress people often mobilize spiritual resources to mitigate the consequences of stressful circumstances. Analogously to the definition of religious coping (Pargament 1997), spiritual coping can be defined as the utilization of spirituality as a strategy for managing stressful life events. Such a definition of spiritual coping is not confined exclusively to religious coping, but it also includes other domains in which spirituality may be manifested—especially personal, social, and environmental ones (Burkhardt and Solari-Twadell 2001).

Conceptualizations of spiritual coping distinguish two forms: positive spiritual coping that is usually salubrious for an individual, and negative spiritual coping that is usually detrimental to health and well-being (Ano and Vasconcelles 2005; Pargament 1997). Moreover, the two forms of spiritual coping are relatively independent from each other, that is, when struggling with a certain situation, a person may resort to both of them (Charzyńska 2015; Pargament 1997).

Charzyńska (2015) proposed the conception of multidimensional spiritual coping and presented its operationalization, the Spiritual Coping Questionnaire (SCQ). SCQ encompasses four forms of positive spiritual coping: (1) personal (looking for inner peace, harmony, and serenity); (2) social (establishing deep and valuable relationships with other people); (3) environmental (searching for tranquility and peace in nature); and (4) religious (seeking support and strength from a stable relationship with God or a higher being). It also includes three forms of negative spiritual coping: (1) personal (questioning the meaning and purpose of one’s life); (2) social (focusing on the belief that people are egoistic and hypocritical); and (3) religious (questioning God’s or a higher being’s love and care for humans).

Forgiveness is one of the fundamental premises of world religions, spiritual formations, and moral systems (Webb et al. 2006; Worthington et al. 2001). Most researchers support the idea that various aspects of forgiveness can be distinguished on the basis of the method of forgiveness (e.g., offering, seeking, and feeling) and its target (e.g., self, others, deity, community, families, the universe; Toussaint and Webb 2005). The aspects of forgiveness most often studied in alcohol research involve self-forgiveness, forgiveness of others, and feeling forgiven by God. Self-forgiveness is defined as letting go of negative emotions (such as shame, guilt, or resentment) targeted at self, which are evoked by committing an act perceived by a person as morally wrong, and replacing them with more benevolent beliefs, emotions, and behaviors toward self (Hall and Fincham 2005). Forgiveness of others is understood as an intentional process involving affective, behavioral, and cognitive components, that entails the reduction of negative responses to an offender and in some cases also encompasses attempts to develop more positive and prosocial attitude toward him or her (Enright and Fitzgibbons 2015; Worthington et al. 2001). The other aspect of forgiveness—feeling forgiven by God—involves the recognition that God/a higher being has forgiven faults and other behaviors that are perceived by the individual as morally wrong (Toussaint et al. 2001).

Gratitude is another moral virtue highly related to religion and spirituality (Peterson and Seligman 2004). It is understood as a life orientation toward perceiving and appreciating good things in one’s life and the positive aspects of the world, even in difficult circumstances (Wood et al. 2008). Gratitude is often seen as being conceptually related to forgiveness (Breen et al. 2010). Indeed, both are prosocial and empathy-based virtues that enhance well-being and health by reinforcing the establishment and maintenance of long-lasting positive relationships with self, others, and God (McCullough et al. 2002; Wood et al. 2008).

The sample included 358 Polish participants receiving short-term outpatient treatment in alcohol dependence treatment centers in southern Poland. Fifteen participants returned empty questionnaires (a participation rate of 96%); thus, they were excluded from the study. Moreover, because some of the variables of interest (namely positive and negative religious coping, and feeling forgiven by God) were directly related to religiousness, the data from 20 patients (5.8%) who declared that they did not believe in God/a higher being were also excluded from further analysis.

The final sample consisted of 323 participants. Table 1 presents the sociodemographic and alcohol-related characteristics of the sample. The majority of participants were male, Roman Catholic, graduates of elementary or vocational schools, unemployed or pensioners, and in intimate relationships.

The Spiritual Coping Questionnaire (SCQ; Charzyńska 2015) was used to assess patients’ spiritual coping. Participants were presented with 32 items measuring spiritual coping in various domains and were asked to indicate what they were thinking and doing in the past four weeks when dealing with their alcohol problems. The SCQ items are divided into seven subscales, constituting two main scales: positive spiritual coping and negative spiritual coping. Positive spiritual coping is made up of four subscale domains: personal (four items; e.g., “I was trying to find sense in what happened”), social (six items, e.g., “I was compassionate toward other people’s pain”), environmental (five items, e.g., “I was seeking closeness to nature”), and religious (six items, e.g., “In my relations with God/a higher being, I was searching for strength to live”). Negative spiritual coping consists of three subscale domains: personal (four items, e.g., “I was convincing myself that my life had no sense”), social (four items, e.g., “I was convincing myself that other people were full of evil”), and religious (three items, e.g., “I was blaming God/a higher being for what happened in my life”). The participants answered using a 5-point Likert scale (1 = “very inaccurately,” 2 = “rather inaccurately,” 3 = “neither inaccurately nor accurately,” 4 = “rather accurately,” and 5 = “very accurately”). The scores for each of the seven subscales were calculated by averaging the responses to particular items. Cronbach’s alpha coefficients for the subscales of the SCQ ranged from 0.71 (negative religious coping) to 0.95 (positive religious coping).

The Forgiveness Scale (Charzyńska and Heszen 2013), which is a Polish adaptation of indices of forgiveness prepared by Toussaint et al. (2001), was used to measure forgiveness. The scale encompasses three aspects of forgiveness: self-forgiveness (two items; e.g., “I find it hard to forgive myself for some of the things I have done wrong”), forgiveness of others (five items; e.g., “I have forgiven those who have hurt me”), and feeling forgiven by God (two items; e.g., “I know that God forgives me”). The response format for the Forgiveness Scale depends on the item formulation. The participants respond using a 5-point Likert scale ranging from 1 (“strongly agree” or “never”) to 5 (“strongly disagree” or “very often”). Five items had to be recoded because they measured difficulty with self-forgiveness or inability to forgive others. The indices of particular aspects of forgiveness were calculated by averaging the responses to particular items. In the current study, self-forgiveness, forgiveness of others, and feeling forgiven by God yielded an internal consistency estimate (Cronbach’s alpha coefficient) of 0.76, 0.75, and 0.90, respectively.

The trait gratitude was measured with the Gratitude Questionnaire (GQ-6; McCullough et al. 2002; Polish adaptation by Kossakowska and Kwiatek 2014). The GQ-6 is made up of six items (e.g., “If I had to list everything that I felt grateful for, it would be a very long list”). The responses are given using a 7-point Likert scale (1 = “strongly disagree,” 2 = “disagree,” 3 = “slightly disagree,” 4 = “neutral,” 5 = “slightly agree,” 6 = “agree,” and 7 = “strongly agree”). Two items were reverse scored because they measured difficulty expressing or feeling gratitude. The level of gratitude was calculated by summing up all the responses. In this study, Cronbach’s alpha coefficient for the GQ-6 was 0.71.

Before verification of the hypotheses, Little’s Missing Completely at Random test was performed to examine whether the data were missing completely at random (Little and Rubin 1987). The expectation–maximization (EM) algorithm (Dempster et al. 1977) was used to impute missing data. In the next step of analysis, means, standard deviations, and paired comparisons, along with correlation coefficients for spiritual coping, forgiveness, gratitude, and therapy completion, were calculated.

To test the hypotheses, a latent profile analysis (LPA), which is one of the methods of the person-centered approach, was conducted. LPA is an extension of latent class analysis (LCA) that uses continuous variables as indicators of profile membership (Vermunt and Magidson 2005). LPA enables the grouping of individuals in relatively homogeneous subpopulations, presenting qualitatively and quantitatively distinct patterns on a set of indicators. It has been demonstrated that LPA outperforms traditional clustering procedures (e.g., K-means or hierarchical clustering; Magidson and Vermunt 2002; Meyer et al. 2013).

In the first step of LPA, models containing one to seven profiles were examined and compared using the following information criteria (Nylund et al. 2007; Tein et al. 2013): Bayesian information criterion (BIC), consistent Akaike information criterion (CAIC), and sample-size adjusted BIC (SABIC). Lower BIC, CAIC, and SABIC values indicate better model fit. To estimate the precision with which cases are assigned to profiles, the entropy value was calculated; higher entropy values (i.e., values closer to one) represent better latent profile separation (Magidson and Vermunt 2002). In addition, to provide stable and meaningful latent profile solutions several other criteria were taken into account: model parsimony (in favor of a less complex model), latent profile proportions (the smallest profile could not be made up of less than 5% of the total sample), and substantive interpretability of the profiles (Collins and Lanza 2010).

Once the best solution was determined, the participants were classified into latent profiles on the basis of their probability scores. Finally, using a Wald test, the probability scores were related to an outcome variable, that is, completion of therapy (Vermunt 2010). The calculations were performed in Latent GOLD 5.1 (submodule called Step 3 included; Vermunt and Magidson 2005) and IBM SPSS Statistics version 25 (IBM Corp. 2017).

The percentage of missing values was 0.88%. The results of the Little’s test (χ²(150) = 161.68; p > 0.05) showed that the data followed the pattern of being completely at random. Thus, in the next step a single imputation by EM algorithm (Dempster et al. 1977) was performed using the Missing Value Analysis Module in IBM SPSS version 25.0 (IBM Corp. 2017).

Table 2 presents descriptive statistics along with bivariate correlations for all study variables. In most cases, positive spiritual coping was positively associated with forgiveness of others, feeling forgiven by God, and gratitude, but not with self-forgiveness; the inverse correlations were found between negative spiritual coping and all moral virtues. Moreover, gratitude was positively related to all aspects of forgiveness. All the correlations between indicators were either weak or moderate, which suggested that they measured different psychological constructs and thus justified employing LPA. Positive spiritual coping in the personal domain turned out to be the only significant correlate of therapy completion (r = 0.16, p = 0.005).

Table 3 presents the comparison of LPA models for spiritual coping, forgiveness, and gratitude. The lowest BIC and CAIC values were noted for the five-profile solution. Although the SABIC value was the lowest for the seven-profile solution, this model was rejected due to a very low frequency for the smallest profile (3.8%), suggesting the instability of this solution. This decision was also supported by the investigation of the shape of the profiles: two pairs of the profiles in the seven-profile solution differed from each other just slightly in terms of profile conditional response means, whereas no substantial differences in the shapes of these profiles were noted. After rejecting the seven-profile solution, the five-profile and the six-profile solutions were investigated more closely. The BIC, CAIC, and SABIC values were lower for the five-profile solution than for the six-profile solution. Accordingly, the former solution was identified as best fitting the data, and the latter was rejected.

Table 4 and Fig. 1 present five profiles identified by LPA. Almost one third of the patients belonged to Profile 1, which was labeled “both moderately positive and negative dimensions of spirituality.” These participants had moderate levels of all indicators: both positive (i.e., positive spiritual coping, forgiveness, gratitude) and negative ones (i.e., negative spiritual coping). Profile 2 (21.0%; “moderately positive dimensions of spirituality”) was composed of patients with moderate levels of positive spiritual coping and moral values, and a relatively low level of negative spiritual coping. Profile 3 (20.2%; “predominantly negative dimensions of spirituality”) grouped patients with low levels of positive spiritual coping (except for positive religious coping), forgiveness, and gratitude, and a high level of negative spiritual coping in all domains. Profile 4 (14.0%; “mixed dimensions of spirituality with the lowest positive religious coping”) was made up of patients with a low level of positive spiritual coping, especially positive religious coping, a relatively high level of self-forgiveness, moderate levels of forgiveness of others, feeling forgiven by God, and gratitude, and a low level of negative spiritual coping. The least numerous Profile 5 (11.6%; “highly positive dimensions of spirituality”) consisted of persons with high levels of positive spiritual coping and all moral virtues accompanied by a low level of negative spiritual coping.

From 323 participants of this study, an alcohol addiction therapy program was completed by 170 persons (52.6%), including 117 men (50.9% of all men) and 53 women (57.0% of all women). The Wald test showed that completion of therapy was significantly related to the latent profile membership (Wald = 14.15; p = 0.007). The completion rates for each profile were as follows: 0.538 for Profile 1 (“both moderately positive and negative dimensions of spirituality”), 0.584 for Profile 2 (“moderately positive dimensions of spirituality”), 0.482 for Profile 3 (“predominantly negative dimensions of spirituality”), 0.301 for Profile 4 (“mixed dimensions of spirituality with the lowest positive religious coping”), and 0.738 for Profile 5 (“highly positive dimensions of spirituality”). Patients in Profile 4 were less likely to complete therapy compared to patients in Profile 1 (Wald = 5.83; p = 0.016), Profile 2 (Wald = 7.07; p = 0.0079), and Profile 5 (Wald = 12.75; p < 0.001). The difference between the members of Profile 4 and Profile 3 was also noted but it did not achieve a statistically significant level of p < 0.05 (Wald = 2.99; p = 0.084). Moreover, patients in Profile 5 completed therapy more often not only than patients in Profile 4, but also than patients in Profile 1 (Wald = 3.89; p = 0.049) and Profile 3 (Wald = 5.41; p = 0.030).

The sample of patients of alcohol addiction therapy turned out to be heterogeneous in terms of spiritual coping, forgiveness, and gratitude, which is indicated by five established profiles with different qualitative and quantitative characteristics. Importantly, persons who belonged to different profiles also differed in terms of the rates of treatment completion. Hence, not only do present findings lend strong support to the multidimensional nature of spirituality, but they also, and primarily, indicate that various baseline dimensions of spirituality impact the completion of alcohol addiction therapy to different extents.

As expected, LPA identified the profile with high levels of positive spiritual coping, forgiveness, and gratitude, and a low level of negative spiritual coping (Profile 5). This profile had the greatest probability of completing treatment (0.738), which confirms, consistent with the previous studies (Chen 2017; Laudet and White 2008; Medlock et al. 2017; Pardini et al. 2000; Webb et al. 2006), that spiritual coping, forgiveness, and gratitude build personal and social resources that support recovery from alcohol dependence.

The profile with moderate levels of both positive and negative spiritual variables (Profile 1) turned out to be the most numerous. Approximately one third of persons entering alcohol addiction therapy resorted to both positive and negative dimensions of spirituality. For persons addicted to alcohol, the time periods immediately before and after admission into treatment often bring acute stress as the individual has to deal with the consequences of heavy drinking and psychosocial problems (Puffer et al. 2012). As a consequence, the time periods around early recovery from alcohol dependence seem to stimulate the patients’ use of spirituality to cope with stress, in both positive and negative ways.

In this context, it is important to take a closer look at the results of comparison of Profiles 1 and 5. According to the findings, Profile 1 (“both moderately positive and negative dimensions of spirituality”) had a lower probability of completing alcohol addiction therapy than Profile 5 (“highly positive dimensions of spirituality”). This means that resorting to negative spiritual coping when facing stress—even if positive spiritual resources are used simultaneously—decreases the completion rates for alcohol addiction treatment. This is consistent with the results of previous studies, which noted the detrimental effects of negative religious coping on the outcomes of substance abuse treatment (Puffer et al. 2012; Robinson et al. 2011). The tendency to engage in maladaptive spiritual coping may be associated with a sense of hopelessness about one’s ability to change and other negative affective states that lead to increased alcohol cravings and thus heighten the risk for relapse (Giordano et al. 2015; Medlock et al. 2017).

In accordance with expectations, LPA yielded a profile with relatively low levels of positive spiritual coping, forgiveness, and gratitude along with a high level of negative spiritual coping (Profile 3). However, quite surprisingly, members of another profile (Profile 4, “mixed dimensions of spirituality with the lowest positive religious coping”) turned out to have the highest probability of dropping out from therapy. This result suggests that a very low level of positive religious coping may significantly hamper completion of treatment, even if a person rarely uses negative spiritual coping and has mostly average levels of forgiveness and gratitude. Not resorting to religious sources when coping with alcohol dependence–related stress may limit patients’ chances to experience the numerous benefits of positive religious coping, such as providing a meaningful personal framework; enhancing self-efficacy, optimism, and hope; serving as a buffer against depression; or mitigating alcohol cravings (Giordano et al. 2015; Medlock et al. 2017).

It should be mentioned in this context that members of Profile 4 had a higher level of self-forgiveness compared to Profiles 1–3 (Table 4). A substantial number of studies have demonstrated positive relationships between self-forgiveness and treatment outcomes among alcohol-dependent persons (Robinson et al. 2011; Webb et al. 2006). Furthermore, there is robust evidence that self-forgiveness may be the most important aspect of forgiveness in the treatment of alcohol dependence (Webb et al. 2011). However, there is also some evidence that higher baseline self-forgiveness may be associated with higher probability of dropping out from drug and alcohol treatment programs (Deane et al. 2012). A high baseline level of self-forgiveness may in fact indicate the occurrence of the ego-defensive process called pseudo self-forgiveness which should be clearly differentiated from genuine self-forgiveness. Pseudo self-forgiveness takes place when a person does not accept personal responsibility for the wrongdoing or refuses to acknowledge that the offending behavior was wrong (Hall and Fincham 2005). The possibility of the occurrence of pseudo self-forgiveness among members of Profile 4 is supported by a low level of negative spiritual coping in a personal domain noted in this group, compared to members of Profiles 1–3. Overall, the combination of a very low baseline level of positive religious coping accompanied by a relatively high baseline level of self-forgiveness seems crucial to explain the lowest rates of treatment completion noted in this profile. Religious coping is sometimes used by persons with high levels of self-blame and self-resentment to mitigate negative emotions toward self (Wasserman et al. 2013). This mechanism does not seem to work for members of Profile 4 who may perceive using religious sources of coping as unnecessary. These patients are likely to maintain the illusion of self-reliance because of which they can deny loss of control over their alcohol use (Chen 2017). The topic of the relationships between self-forgiveness, pseudo self-forgiveness, and positive religious coping among alcohol-dependent persons needs further investigation.

The results of the current study have some practical implications that are worth discussing. As noted, less than 12.0% of the sample (i.e., Profile 5) of 323 participants who declared a belief in God/a higher being presented a pattern of spiritual coping, aspects of forgiveness, and gratitude that was highly supportive of therapy completion. This finding indicates a need to routinely measure the initial levels of these variables during admission to alcohol addiction treatment to build a robust basis for subsequent practice. This is in accordance with the recommendations of many scholars and clinicians (Grim and Grim 2019; Hodge 2001) as well as with professional guidelines for therapists (e.g., Association for Spiritual, Ethical, and Religious Values in Counseling 2009) and codes of ethics (e.g., American Counseling Association 2014). However, although many mental health professionals have acknowledged the benefits of incorporating clients’ spirituality in treatment, it is still not a standard practice in therapy. In practice, usually little time and effort is devoted to addressing this topic during treatment (Cornish et al. 2012), even though many patients express the wish for incorporating their spiritual beliefs into the therapeutic enterprise (Dermatis et al. 2004). With regard to alcohol addiction treatment, therapists usually limit themselves to encouraging patients to attend AA meetings (Miller 2013). This reluctance to include spirituality in practice has various reasons, including insufficient knowledge, lack of experience, fears, or ethical concerns (Cornish et al. 2012). This is why specialized training courses and workshops concerning spirituality should be offered to alcohol addiction therapists. Professional training would help them to gain knowledge and competencies needed to take full advantage of patients’ spiritual resources and to prevent the risk of relapse related to the spiritual struggle faced by some patients.

When working with persons with alcohol dependence, individual treatment plans should expand on issues related to spiritual potential and deficits. Knowledge of the specific configuration of dimensions of spirituality for a given patient would make it possible to develop focused clinical interventions aimed at modifying specific spiritual variables, adjusted to the needs and expectations of the patient, and his or her current situation, in this way providing integrated holistic care (Medlock et al. 2017; Puffer et al. 2012; Grim and Grim 2019; Wong 2010). Several recommendations for modifying positive and negative religious coping have already been made in the literature and include, among others, combining spiritual issues with a cognitive-behavioral framework by encouraging positive religious coping thoughts and challenging negative ones, changing attachment styles and God-related images, or simply making more referrals to 12-step support groups (Grim and Grim 2019; Moriarty et al. 2006).

To the best of the author’s knowledge, this is the first study to explore the configurations of baseline dimensions of spirituality and their associations with the rates of successful completion of alcohol addiction treatment. Despite a number of strengths, it has some limitations in need of acknowledgment and consideration. One group of limitations pertains to sample characteristics. Although the sample was quite large and heterogeneous in terms of sociodemographic and alcohol-related variables, the study involved only those individuals who participated in an outpatient group therapy. Thus, the results should not be generalized to other contexts, such as inpatient treatment. Moreover, because of the religious character of some of the variables measured, only data from patients who declared a belief in God or another higher being were included in the analyses, which may limit the generalizability of the research findings to some extent. However, it should be noted that the rate of exclusion due to being non-religious was low (5.8%).

Another limitation stems from the measures used in the study. First, the indexes of self-forgiveness and feeling forgiven by God consisted of only two items, which could have made it difficult to capture intra- and interindividual variability of the scores. Nevertheless, these indexes turned out to be sufficient to observe the differences between the profiles; also, the reliability indexes for these measures were acceptable in this study. Second, gratitude was operationalized as a general disposition only. It is recommended that future studies include different aspects of gratitude (e.g., gratitude toward God, gratitude toward therapists, gratitude for sobriety) to determine how they are related to treatment completion.

In the current study, the completion of therapy was regarded as the only outcome of interest. No other clinically relevant variables (e.g., abstinence self-efficacy, alcohol cravings, quality of life) were taken into account. In addition, this study measured the completion rates for short-term therapy and did not monitor patients’ alcohol-related behaviors for a longer period of time. Thus, future studies should apply longer follow-up intervals to examine whether baseline configurations of spiritual coping, forgiveness, and gratitude are important for long-term abstinence.

Finally, when interpreting the results, the specific cultural context in which this study was conducted should be taken into account. Poland is a religiously homogeneous country; more than 90% of Poles declare themselves to be religious, with most identifying as Roman Catholic (Central Statistical Office 2018; Zarzycka 2009). Thus, for most Poles, spirituality manifests in a traditional religious form. It has been noted that living in a religious culture may influence the importance of religious variables in the context of recovery from alcohol dependence (Webb et al. 2011). Polish people may be more likely to use religious resources when struggling with stressful situations—such as beginning alcohol addiction therapy—compared to persons living in more secular countries (Strobbe et al. 2013). Moreover, in some countries, a group of people who declare themselves to be spiritual but not religious has been growing substantially (Fuller and Parsons 2018). Further research is therefore required to examine the role of dimensions of spirituality in treatment completion in more spiritually and religiously diverse countries than Poland.