Donna Leigh Bliss a & Stacy S. Ekmark a a University of Georgia, School of Social Work, Athens, Georgia, USA

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1 This article was downloaded by: [University of Georgia] On: 17 January 2013, At: 09:03 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Alcoholism Treatment Quarterly Publication details, including instructions for authors and subscription information: Gender Differences in Spirituality in Persons in Alcohol and Drug Dependence Treatment Donna Leigh Bliss a & Stacy S. Ekmark a a University of Georgia, School of Social Work, Athens, Georgia, USA Version of record first published: 17 Jan To cite this article: Donna Leigh Bliss & Stacy S. Ekmark (2013): Gender Differences in Spirituality in Persons in Alcohol and Drug Dependence Treatment, Alcoholism Treatment Quarterly, 31:1, To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 Alcoholism Treatment Quarterly, 31:25 37, 2013 Copyright Taylor & Francis Group, LLC ISSN: print/ online DOI: / Gender Differences in Spirituality in Persons in Alcohol and Drug Dependence Treatment DONNA LEIGH BLISS, PhD and STACY S. EKMARK University of Georgia, School of Social Work, Athens, Georgia USA Although research has begun to broadly address gender differences in alcohol and drug dependence, there is a dearth of research on gender differences in spirituality in this area, despite the increased research emphasis on the role of spirituality in the recovery process. This study addressed this gap by examining gender differences in five dimensions of spirituality in persons in diverse alcohol and drug dependence treatment settings. The hypothesis that there would be gender differences in spirituality was supported as women had higher levels of expression of cognitive orientation toward spirituality compared to men. Implications for alcohol and drug dependence treatment and research are discussed. KEYWORDS Spirituality, alcohol dependence, alcoholism, drug dependence, addiction, gender, social work Alcohol and drug dependence is a widespread problem in the United States that profoundly affects millions of individuals, with far-reaching effects on society and the economy. In 2005, the number of people using illegal drugs was estimated to be 20 million, and the number of people who abused alcohol was estimated to be between 16 million and 20 million (National Center on Addiction and Substance Abuse at Columbia University, 2007). Furthermore, alcohol and drug dependence cost the nation an estimated $220 billion in 2005 more than cancer ($196 billion) and obesity ($133 billion) (National Center on Addiction and Substance Abuse at Columbia University, 2007). Address correspondence to Donna Leigh Bliss, PhD, University of Georgia, School of Social Work, 305 Tucker Hall, Athens, Georgia dlbliss@uga.edu 25

3 26 D. L. Bliss and S. S. Ekmark Over the past few decades there has been a substantial increase in the scope of research on alcohol and drug dependence as its etiology and methods of improving treatment outcomes have been looked at more closely. One of the main criticisms of early research was that studies looked almost exclusively at entirely male samples, and hence treatment options were tailored toward men (Green, 2006) and were most often ill equipped to meet women s divergent needs (Ashley, Marsden, & Brady, 2003). Recognition of this problem has led to an increase in research on gender differences in alcohol and drug dependence. A rapidly growing body of research now indicates that alcohol and drug dependence among women and the issues that surround their dependence are different from those of men and may necessitate a specialized set of therapeutic interventions (Ashley et al., 2003, p. 20). Because research shows that there are fundamental gender differences in terms of alcohol and drug dependence, specialized gender-specific treatment programs have become increasingly common (Green, Polen, Lynch, Dickinson, & Bennett, 2004; Grella, 2008). Research on gender differences in alcohol and drug dependence can typically be grouped into two main categories: access to treatment and treatment outcomes. Generally, research has found that women face greater barriers to accessing alcohol and drug dependence treatment than do men (Green, 2006; Tuchman, 2010). Not only do women face more impediments to treatment but research has shown that once women enter treatment, they do so with more serious alcohol and drug problems and with more health and social problems than do men (Marsh, Cao, & Shin, 2009). Research also indicates that women who are addicted have a history of over-responsibility in their families of origin and reportedly have experienced more disruption in their families than their male counterparts caused by entering alcohol and drug dependence treatment (Tuchman, 2010, p. 128). Additionally, the lack of available, affordable childcare options poses a practical barrier to many women s access to treatment as very few alcohol and drug dependence treatment centers have childcare programs (Green, 2006). There has been extensive research on the impact of alcohol and drug dependence on biology, social functioning, and psychology (Morgan, 2002); however, over the past two decades, the social work profession has highlighted the need for examining spirituality as well, as part of a broader holistic approach to assessing and treating alcohol and drug dependence. Social work, as well as other helping professions, has begun to include spirituality as a component of person-in-environment assessment (Bliss, 2009). Furthermore, the Joint Commission on Accreditation of Healthcare Organizations, the largest and most influential healthcare accrediting body in the United States, revised its standards in 2001 to require that spirituality be assessed in a variety of health care settings, including some types of behavioral health care organizations such as those that provide alcohol and drug dependence services (Hodge, 2006; Bliss, 2009).

4 Gender Differences in Spirituality 27 Fortunately, there is a growing research base that highlights the role of spirituality in improving treatment outcomes. In a literature review of 44 empirical studies on various aspects of the relationship between spirituality and alcohol and drug dependence, Bliss (2007) noted that 31 of these articles examined spiritual variables as components of the recovery process. In general, higher levels of spirituality were associated with improved treatment outcomes such as increased abstinence and improved life functioning. Although the vast majority of the studies that Bliss (2007) reviewed addressed the 12-Step spirituality of Alcoholics Anonymous, it is important to note that spirituality can be assessed in many other ways and along different dimensions including meaning and purpose in life, relationship with God or a deity figure, personal values, locus of control, and spiritual well-being. Also, though spirituality was found to play an important role in recovery, it was not necessarily the only role as other factors were influential in promoting recovery as well. Despite the surge in research interest on spirituality and alcohol and drug dependence in general, there has been a limited research focus on gender differences within this relationship (Bliss, 2007). Complicating this lack of research focus, the studies that are available regarding gender differences tend to focus more on discreet aspects of spirituality or examined religious practices as a proxy for spirituality. For example, in a review of the literature one study that looked at spirituality in a treatment setting examined the affect of Qigong meditation on substance abuse treatment outcomes for men and women and found that female participants whose meditation was of acceptable quality reported greater reductions in cravings, anxiety, and withdrawal symptoms than did male participants whose meditation was of acceptable quality (Chen, Comerford, Shinnick, & Ziedonis, 2010). Another study evaluated the role of religiosity on the posttreatment abstinence outcomes of African American adults completing 3 months of substance abuse treatment and found that women achieved significantly higher rates of abstinence and were more likely to practice their religion posttreatment than the men in the sample (Stewart, Koeske, & Pringle, 2007). One study that evaluated gender-specific patterns of drug use among active stimulant users in rural Kentucky found that spirituality and/or religiosity may have more influence on drug using behavior for rural male stimulant users than for females (Staton-Tindall et al., 2008). The purpose of this study is to begin to address this gap in the research literature by examining gender differences in alcohol and drug dependence through the lens of spirituality that is diversely conceptualized. Given the breadth of research that identified gender differences in various other aspects of alcohol and drug dependence, this study tests the hypothesis that there will be gender differences in spirituality, although the direction of these differences are not predicted due to the limited research base on gender differences in spirituality to support such specificity.

5 28 D. L. Bliss and S. S. Ekmark METHOD Research Design and Sample A cross-sectional design was used for this study. Four programs located in the Baltimore, Maryland, and Washington, DC, metropolitan areas that offered an array of services such as detoxification, inpatient, outpatient, methadone maintenance, day treatment, and residential treatment agreed to participate in this study. Convenience sampling was used to identify potential participants. Inclusion criteria for participants were men and nonpregnant women, age 18 or older, currently in a substance abuse treatment program, had an alcohol use disorder, and had fewer than 12 months of sobriety from alcohol use disorders. Exclusion criteria were women or men in acute alcohol withdrawal or who were experiencing psychiatric symptoms that impaired their ability to comprehend and/or respond to study questions. Potential participants were prescreened by treatment staff to determine if they were eligible to participate in the study. This study was approved by the University of Maryland Baltimore Institutional Review Board (IRB). All participants signed an IRB-approved informed consent form. This study involved the author going onsite to these treatment centers and administering a survey in groups ranging from 5 to 20 clients (N D 180), which took about 30 minutes to complete. Clients received a $10 honorarium for participating in the study. Measure Expressions of Spirituality Inventory Revised. The Expressions of Spirituality Inventory Revised (ESI-R) (MacDonald, 2000a) is a five-dimension (six items per dimension), 30-item self-administered measure of experiences, attitudes, beliefs, and lifestyle practices concerning spirituality. The ESI-R is scored using a 5-point Likert-type scale (0 D strongly disagree, 1 D disagree, 2 D neutral, 3 D agree, 4 D strongly agree). The five dimensions of the ESI-R are (1) cognitive orientation toward spirituality (pertains to the expressions of spirituality that are cognitiveperceptual in nature such as beliefs and attitudes), (2) experiential/phenomenological dimension of spirituality (concerns experiential expressions of spirituality such as spiritual, religious, mystical, peak, transcendental, and transpersonal experiences), (3) existential well-being(spirituality as expressed through a sense of meaning and purpose in life), (4) paranormal beliefs (e.g., ESP, precognition, psychokinesis), and (5) religiousness (expression of spirituality through religious means such as religious beliefs and practices). Each dimension is individually scored, with higher scores indicating higher degrees of expression of the particular dimension (MacDonald, 2000a).

6 Gender Differences in Spirituality 29 Although the ESI-R represents diverse expressions of spirituality rather than assessing a single construct of spirituality, given it is revised from the original 98-item Expressions of Spirituality Inventory, which was derived from a factor analysis of 11 existing measures of spirituality to determine if there was a stable factor structure that could be used to develop a model and measure of spirituality (MacDonald, 2000b), the ESI-R does have a stable factor structure of spirituality. MacDonald (2000a) stated the ESI-R had similar psychometric properties and correlated with those of the 98-item version, which was reported to have interitem reliability, factorial validity, construct validity, and predictive validity. RESULTS Sample Demographic Characteristics A sample of 180 women and men in various types of alcohol/other drug treatment settings completed the surveys. The sample comprised slightly more males than females. The mean age was 39.6 years (SD D 10.4). Slightly less than two thirds identified themselves as African American, whereas slightly less than one third stated they were White. Slightly more than one half stated their income for the previous year was less than $10,000. Mean years of education was 12.0 (SD D 2.12). Slightly more than one half reported being single/never married, with slightly less than one third stating they were separated/divorced. Outpatient treatment was the most common type of alcohol/other drug program setting, followed by detox, and inpatient. The mean length of current sobriety was days (SD D 77.98). There were no statistically significant gender differences in demographic variables, except for gender itself as there were significantly more males than females in the study (99 vs. 81). See Table 1 for additional information on sample demographic characteristics. Statistical Analysis Given there were no statistically significant gender differences in the demographic variables and that only two categories of gender were used (men and women), it was not necessary to use ANOVA or analysis of covariance (ANCOVA) to test the research hypothesis as these statistical analyses are more suited when comparisons are made between more than two categories (ANOVA) and when covariates needed to be statistically controlled for (ANCOVA) (Grimm & Yarnold, 2000). Therefore, t tests were used as there were only two categories, and there were no statistically significant differences between these categories in terms of salient demographic variables.

7 30 D. L. Bliss and S. S. Ekmark TABLE 1 Sample Demographic Characteristics by Gender (N D 180) Type Male frequency (%) Female frequency (%) Significance Gender 99 (55.0) 81 (45.0) ** Race/ethnicity NS African American 52 (28.8) 53 (29.4) White 32 (17.7) 24 (13.3) Hispanic 1 (.05) 1 (.05) Asian/Pacific Islander 1 (.05) 0 (.00) Other 8 (4.4) 3 (1.6) Income previous year NS Less than $10, (26.1) 50 (27.7) 10,000 19, (8.3) 12 (6.6) 20,000 29, (12.7) 8 (4.4) 30,000 39,999 6 (3.3) 5 (2.7) 40,000 49,999 4 (2.2) 3 (1.6) 50,000 or more 4 (2.2) 3 (1.6) Marital status NS Single/never married 48 (26.6) 43 (23.8) Separated/divorced 31 (17.2) 28 (15.5) Married 14 (7.7) 5 (2.7) Living with someone 3 (1.6) 4 (2.2) Widowed 3 (1.6) 1 (0.5) Type of program NS Outpatient 34 (18.8) 20 (11.1) Detox 27 (15.0) 12 (6.6) Inpatient 24 (13.3) 11 (6.1) Women-specific 0 (0.0) 21 (11.6) Day support 4 (2.2) 10 (5.5) Halfway house 4 (2.2) 4 (2.2) Methadone maintenance 5 (2.7) 3 (1.6) Other 1 (0.5) 0 (0.0) Type Mean (SD) Mean (SD) Significance Years of education (2.26) (1.93) NS Age (10.75) (9.86) NS Length current sobriety in days (74.52) (81.65) NS *p <.05, **p <.01. There were statistically significant differences in gender in terms of cognitive orientation toward spirituality (t D 2.56, df D 178, p D.011). Women had a mean score of (SD D 4.92) and men had a mean score of 17.1 (SD D 4.8). There were no statistically significant gender differences in religiousness (t D 1.52, df D 178, p D.129), paranormal beliefs (t D 1.38, df D 178, p D.169), experiential/phenomenological dimension of spirituality (t D 1.09, df D 178, p D.277), and in existential well-being (t D.369, df D 178, p D.713). See Table 2 for additional information on gender differences in the five ESI-R dimensions of spirituality.

8 Gender Differences in Spirituality 31 TABLE 2 Gender Differences in Five Expressions of Spirituality Inventory Revised (ESI-R) Dimensions of Spirituality (N D 180) Male Female Dimension Mean SD Mean SD Significance Cognitive orientation Religiousness Paranormal beliefs Experiential/phenomenological Existential well-being Note. Scores for each ESI-R dimension can range from 0 to 24, with higher scores indicating greater expression of a particular dimension. Internal Consistency Reliability and Intercorrelations among ESI-R Dimensions Cronbach s alpha for the five dimensions of the ESI-R in this study was.67, which is slightly less than the ideal minimum of.70 (de Vaus, 2002). A subsequent analysis of intercorrelations among the five dimensions of the ESI-R indicated that cognitive orientation toward spirituality dimension and experiential/phenomenological dimension of spirituality were significantly correlated with three other ESI-R dimensions. Existential well-being and religiousness were significantly correlated with two other ESI-R dimensions, whereas paranormal beliefs was significantly correlated with one other ESI-R dimension. See Table 3 for additional information on intercorrelations among ESI-R dimensions. TABLE 3 Correlations among the Five Dimensions of the Expressions of Spirituality Inventory Revised Cognitive orientation Experiential/ phenomenological Existential well-being Paranormal beliefs Religiousness Cognitive orientation Pearson Correlation Significance (Sig.) Experiential/ Pearson phenomenological Correlation Sig Existential well-being Pearson Correlation Sig Paranormal beliefs Pearson Correlation Sig Religiousness Pearson Correlation Sig

9 32 D. L. Bliss and S. S. Ekmark DISCUSSION The hypothesis of this study was supported as gender differences in cognitive orientation toward spirituality were found with women having higher levels of expression compared to men. Although this finding is not unexpected in light of the research literature on gender differences in various aspects of alcohol and drug dependence, the paucity of research on gender differences in spirituality in this population necessitates the need for a broader review of gender differences in cognitive functioning and emotional expressiveness to assist in the interpretation of the study finding that women had higher levels of expression of cognitive orientation toward spirituality compared to men. Research on gender differences in aspects of cognitive functioning lends support for the validity of the finding that women had higher levels of expressions of spirituality that are cognitive-perceptual in nature such as spiritual beliefs and attitudes compared to men. For example, gender differences in cognitive processing have been closely analyzed in psychological and neuropsychological literature (e.g., Ardila, Rosselli, Matute, & Inozemtseva, 2011; Hedges & Nowell, 1995; Kimura, 1999; Weiss, Kemmlera, Deisenhammerb, Fleischhackera, & Delazer, 2003). Cognitive processing, including core cognitive abilities such as verbal, visuospatial, and quantitative abilities, has been shown to differ between males and females (Halpern et al., 2007). As cited in Ardila et al., three major differences in cognitive abilities between men and women have generally been reported (a) higher verbal abilities, favoring women; (b) higher spatial abilities, favoring men; and (c) higher arithmetical abilities, also favoring men, although differences in calculation abilities have, in some cases, been interpreted as a result of men s stronger spatial abilities (Benbow, 1988; Geary, 1996); thus, the three differences described could be reduced to only two (Ardila et al., 2011, p. 984). Similarly, the expression of these cognitive beliefs and attitudes is consistent with research that shows that women consistently report being more emotionally expressive than men (Bronstein, Briones, Brooks, & Cowan, 1996). For example, studies have found that women talk about emotions more than men and use more emotion words than men (Goldschmidt & Weller, 2000). Furthermore, in many studies women have self-reported more intense experience of emotions than men, more intense expression, and greater comfort with and tendency to seek out emotional experiences (Grossman & Wood, 2003, p. 1010). Women have been shown to experience greater emotional intensity of positive and negative emotions, such as happiness and anger, respectively, as well as experiencing such intensity of emotion across the life span from early childhood to adulthood (Aldrich & Tenenbaum, 2006; Grossman & Wood, 1993). Furthermore, the hypothesis that emotional expression, recognition, and experiences may differ dramatically for males and females is implicit in almost every theory of emotional development (Brody, 1985).

10 Gender Differences in Spirituality 33 Finally, another plausible explanation for the finding that women experience greater expression in cognitive orientation toward spirituality than men is that women differ from men in terms of religious expression (Miller & Stark, 2002). Research has shown that men and women throughout different religions appear to construct their religious experiences and/or engagement in contrasting ways, men being more active, that is, oriented to action, and women more affective in their expression or understanding of their own religiousness (Sullins, 2006, p. 847). The affective dimension of religiosity, which includes measures such as frequency of prayer, the subjective experience of comfort and strength in religion, or self-assessed intensity of religious identity, consistently shows a greater difference between men and women than those measures that express the more active dimension of religion, such as church attendance, membership, or volunteerism (Sullins, 2006, p. 847). Implications for Alcohol and Drug Dependence Treatment and Research The findings from this study that women were more expressive of spiritual beliefs and attitudes compared to men has important implications for alcohol and drug dependence treatment for women and men. For women, treatment should be structured to provide opportunities for women to learn how to use the expression of their spiritual attitudes and beliefs in a manner that supports their recovery needs. Of particular importance is the need for treatment providers to help women translate these attitudes and beliefs into specific behaviors and practices that promote recovery. Just as the specific treatment needs of women has led to the creation of gender-specific treatment programs, mixed-gender treatment settings need to offer the flexibility in the provision of treatment services to more effectively target how women can better utilize spirituality in their recovery efforts. Fortunately, the increased research interest in spirituality has identified a wide array of specific behaviors and practices that treatment providers can offer to promote spiritual growth in women. For example, Canda and Furman (1999) provided a detailed discussion of spiritually sensitive practice skills and techniques that practitioners can use ranging from creating a spiritual development time line and narrative to focused relaxing and guided visualization (p. 291). Hodge (2003) discussed how spiritual assessment tools including spiritual histories, life maps, ecomaps, genograms, and ecograms can be used to provide more effective client-centered services. Finally, in Spiritually Oriented Social Work Practice, Derezotes (2006) provided a practical, theoretical framework for spiritually oriented social work practice that can be used to help facilitate spiritual development in traditional social work populations such as women. At the same time, the fact that men were found to have lower expressions of spiritual beliefs and attitudes does not necessarily mean this is not an

11 34 D. L. Bliss and S. S. Ekmark important area to focus on in men s recovery. Instead, societal expectations of the gender role of men may inhibit this expression in a manner that can hinder their recovery efforts (Green et al., 2004; Grella, 2008). Rather than presume that spirituality is somehow of less importance to men in the recovery efforts, treatment providers would be well advised to more robustly help men identify their spiritual beliefs and attitudes, and as with women, learn how to translate them into specific behaviors that promote recovery. As with any research that explores new terrain, this study does have limitations that suggest caution in the interpretation of the study findings. First, spirituality is a multidimensional construct that can be assessed in many ways. It is possible that other measures of aspects of spirituality may lead to different results. As such, the ESI-R should not be considered the definitive measure of spirituality, despite the comprehensive manner in which the measure was developed from 11 other measures of spirituality. Second, despite the number of significant correlations among the various dimensions of the ESI-R, when analyzed as a function of gender, only one of the five dimensions of spirituality had statistically significant differences between males and females. This does raise the possibility that the results of this study were not necessarily clinically significant as it would be reasonable to presume that if one dimension of spirituality was significantly different in terms of gender, the same might be true for other dimensions as well given the number of significant intercorrelations. Third, the Cronbach s alpha of.67 was less than the ideal minimum of.70 for exploratory research, which raises questions about the reliability of the ESI-R. However, some researchers have questioned the utility of the coefficient alpha as an ideal indicator of reliability and have suggested that other indicators of reliability may be considered (DeVellis, 2012). Although this can be controversial to some researchers given the wide use and acceptance of the Cronbach s alpha as an indicator of reliability, such an alternative perspective does allow for the tentative acceptance of the reliability of the ESI-R in this study despite it not reaching the.70 threshold, while still calling for a cautious interpretation of the findings and the need for additional psychometric research on the ESI-R. Despite these limitations, this study highlighted an important, yet underexplored area that has implications for alcohol and drug dependence treatment. As treatment providers continue to include spirituality as part of a more holistic framework for assessing and treating clients, providers will also need to encourage clients to continue with their spiritual development after discharge. However, while many treatment providers support, and perhaps require participation in 12-Step groups such as Alcoholics Anonymous, which has an explicitly spiritual focus, it is important to note that given how broadly spirituality can be conceptualized, the existence of other support groups that can also facilitate spiritual growth including secular recovery support groups such as SMART Recovery, Secular Organization for Sobriety, LifeRing, and

12 Gender Differences in Spirituality 35 Secular Recovery, explicitly religious alternatives such as Celebrate Recovery, and gender-specific and secular recovery groups such as Women for Sobriety. Clearly, gender differences in diverse aspects of alcohol and drug dependence will continue to be an important area of research in the identification of ways to differentially provide treatment services based on gender in the hope of improving treatment outcomes. As the role of spirituality in the recovery process continues to be an area of focus, further research is needed on examining gender differences using other measures of spirituality as the ESI-R examined only five dimensions of spirituality. For example, in a review of the literature on the relationship between spirituality and alcohol and drug dependence, Bliss (2007) found that spirituality is a multidimensional construct that can be assessed in many ways and along different dimensions including meaning and purpose in life, relationship with God or a deity figure, personal values, locus of control, and spiritual well-being, to name but a few. Pursuing this line of research could pave the way for the development of more spirituality-based treatment interventions that could be differentially targeted toward women and men with the intention of improving treatment outcomes for those afflicted with alcohol and drug dependence problems. REFERENCES Aldrich, N. J., & Tenenbaum, H. R. (2006). Sadness, anger, and frustration: Gendered patterns in early adolescents and their parents emotion talk. Sex Roles, 55, Ardila, A., Rosselli, M., Matute, E., & Inozemtseva, O. (2011). Gender differences in cognitive development. Developmental Psychology, 47(4), Ashley, O. S., Marsden, M. E., & Brady, T. M. (2003). Effectiveness of substance abuse treatment programming for women: A review. American Journal of Drug and Alcohol Abuse, 29, Benbow, C. P. (1988). Sex differences in mathematical reasoning ability in intellectually talented preadolescents: Their nature, effects, and possible causes. Behavioral and Brain Sciences, 11, Bliss, D. L. (2007). Empirical research on spirituality and alcoholism: A review of the literature. Journal of Social Work Practice in the Addictions, 1, Bliss, D. L. (2009). Ethnic differences in spirituality in a sample of men and women in diverse substance abuse treatment settings: Implications for practitioners. Journal of Ethnicity in Substance Abuse, 8, Brody, L. R. (1985). Gender differences in emotional development: A review of theories and research. Journal of Personality, 53(2), Bronstein, P., Briones, M., Brooks, T., & Cowan, B. (1996). Gender and family factors as predictors of late adolescent emotional expressiveness and adjustment: A longitudinal study. Sex Roles, 34(11/12), Canda, E. R., & Furman, L. D. (1999). Spiritual diversity in social work practice: The heart of helping. New York, NY: Free Press.

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