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We further found that tactile hallucinations and religious delusions were significantly correlated with history of unwanted sexual experiences and, for tactile hallucinations, with past physical and sexual assault. We discuss these findings and their implications in the sections that follow. Our qualitative analyses were designed to further unpack, potentially confirm, and deepen the findings from the quantitative study.

The qualitative findings underscore the complex and synergistic relationships between multiple forms of individual trauma including bullying, harassment, and abuse as they unfold against a backdrop of racial segregation, poverty, drug trafficking, gang violence, and neighborhood disadvantage.

In addition, we report multiple ways in which both individual-level and neighborhood-level themes and dynamics are reflected in the form and content of both voices and unusual beliefs. National comorbidity studies and meta-analysis have reported a potentially causal relationship between cumulative TLEs exposure and psychosis 26 , 53 , Our data are consistent with other studies that show that the overall lifetime TLE exposure is significantly higher in the African-American population 47 , 55 , We suggest that future research needs to more explicitly model both biological and ongoing psychological mechanisms and associated adaptive or maladaptive coping into early adulthood.

Participant narratives also suggest that neighborhood adversity, particularly threat of gang-related violence, may be an important maintaining factor for both paranoid beliefs and voices. Associations between trauma and delusions have been reported in multiple studies 23 , 57 , A study conducted by Scott et al. Exposure to an urban environment has been shown to increase anxiety, negative belief about others, and jumping to conclusions in persons with persecutory delusions when compared to a non-clinical group Interactions amongst discrimination, deprivation, stress, mistrust, social inequality, and lack of social support were proposed as predictors of both affective and non-affective psychosis Likewise, auditory hallucinations across diagnoses have been strongly linked to childhood adversity, particularly sexual abuse 63 , Our finding that several participants reported voices as a source of comfort and support also highlights the need for sensitivity amongst healthcare workers in not treating hallucinations as unilaterally negative experiences, which need to be eradicated.

In the existing literature, religious beliefs have been reported as a source of strength, comfort, and encouragement in managing psychiatric difficulties related to traumatic events 66 , Religion or spirituality may also provide a framework to understand or bring meaning to the individual who experienced a TLE 68 , Religious practices such as prayer or meditation, worship, and participation in religious services can engender hope and increased social support among individuals with serious mental illness 70 — The causative evidence of the association between trauma and psychosis is the strongest for the manifestation of hallucinations Experiencing trauma has been shown to increase the likelihood of verbal hallucination fivefold The phenomenological associations between trauma and hallucinations have shown that hallucinations with content related to trauma are not only found in psychosis they may actually shape the themes of the hallucinatory experience 16 , 73 , In a recent systematic literature review of studies investigating voices, the association between trauma and voices has been explored in multiple realms including phenomenology, causal link, neurobiological hypotheses, and treatment interventions Much of the research emphasis has focused on the associations between trauma and verbal hallucinations with much less emphasis between trauma and other types of hallucinations, including tactile or olfactory Our research examined the association of trauma and all forms of hallucinations.

Our qualitative data further link the association between a specific traumatic event such as sexual assault and the onset of psychosis and draws attention to a potentially traumatogenic subgroup of patients whose voices began in the midst of acute trauma in childhood but were later diagnosed with a psychotic disorder, and a subgroup who, in spite of significant trauma, did not develop psychosis until early adulthood.

This finding further supports the clinical need of evaluating current and past trauma throughout the lifespan as symptoms associated with a TLE may occur during or in close time proximity the event or may not manifest until much later in life There are limitations of this study in that both quantitative and qualitative datasets reported here are cross-sectional and can only establish correlations and perceived causal connections rather than empirical causality. In addition, our sample was predominantly African-Americans living in a particular, notoriously segregated urban environment; our qualitative analyses are meant to deepen our understanding of the interplay of trauma, psychosis, and spirituality within a particular group and associated sociogeographic context, not to generalize.

We also had no mechanism for verifying TLE, although it should be noted that retrospective accounts of adversity amongst psychosis populations have consistently been shown to be reliable and valid and are more likely to underreport than overreport TLEs 79 — Finally, our findings echo the extant literature in foregrounding the importance of childhood adversity, neighborhood characteristics, and cumulative adversity with response to both the epidemiology of psychosis and the process of recovery and healing.

Experiences described by qualitative participants were far from unilaterally negative, and participants consistently linked the content of symptoms to an array of life events and challenges. From a public health perspective, they add further fuel to calls for both research and preventative interventions aimed at addressing the negative impacts of childhood structural adversity and neighborhood disadvantage. The University of Illinois at Chicago Institutional Review Board approved the study, and signed consent was obtained from all participants in accordance with the Declaration of Helsinki before initiation of study procedures.

CR and NJ collected the data. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry 6 — Life events and psychosis: a review and meta-analysis. Schizophr Bull 39 4 —7. Trauma history characteristics associated with mental states at clinical high risk for psychosis.

Psychiatry Res 1—2 — The epidemiology of traumatic event exposure worldwide: results from the world mental health survey consortium. Psychol Med 46 2 — Childhood trauma increases the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull 38 4 — Do specific early-life adversities lead to specific symptoms of psychosis? A study from the the adult psychiatric morbidity survey. From adversity to psychosis: pathways and mechanisms from specific adversities to specific symptoms.

Soc Psychiatry Psychiatr Epidemiol 49 7 — Childhood adversity and psychosis: generalised or specific effects? Epidemiol Psychiatr Sci 25 4 — Visual hallucinations in first-episode psychosis: association with childhood trauma. PLoS One 11 5 :e Psychotic symptoms in PTSD. New Research Program and Abstracts. American Psychiatric Association Annual Meeting.

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The origins of voices: links between life history and voice hearing in a survey of cases. Psychosis 5 3 — Trauma and hallucinatory experience in psychosis.

Spirituality as a Scientific Construct: Testing Its Universality across Cultures and Languages

J Nerv Ment Dis 8 —7. Event attributes and the content of psychotic experiences in first-episode psychosis. Psychol Med 36 2 — Childhood abuse and the content of adult psychotic symptoms. Psychol Trauma — Identifying aspects of neighbourhood deprivation associated with increased incidence of schizophrenia. Schizophr Res 1 — Migration, ethnicity, and psychosis: toward a sociodevelopmental model.

Schizophr Bull 36 4 — Life events and psychosis. Initial results from the Camberwell Collaborative Psychosis Study. Br J Psychiatry —9. Dean K, Murray RM. Environmental risk factors for psychosis. Dialogues Clin Neurosci 7 1 — Psychopathological mechanisms linking childhood traumatic experiences to risk of psychotic symptoms: analysis of a large, representative population-based sample. Schizophr Bull 40 Suppl 2 :S— Bell CC, Chimata R.

Psychiatr Serv 66 5 — Modelling the interplay between childhood and adult adversity in pathways to psychosis: initial evidence from the AESOP study. Psychol Med 44 2 — Cumulative effects of stressful childhood experiences on delusions and hallucinations. J Trauma Dissociation 16 4 — Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: common phenomenology, common cause, common interventions? Front Psychol The relationship between dissociation and voices: a systematic literature review and meta-analysis.

Clin Psychol Rev — Ethnic variation in whether dissociation mediates the relation between traumatic life events and attenuated positive psychotic symptoms. J Trauma Dissociation 16 1 — Childhood trauma mediates the association between ethnic minority status and more severe hallucinations in psychotic disorder. Psychol Med 45 1 — Major discriminatory events and risk for psychotic experiences among black Americans.

Am J Orthopsychiatry 86 3 — Metzl JM. Boston, MA: Beacon Press Myers NA, Ziv T. Med Anthropol Q 30 3 — Strauss A, Corbin J. Basics of Qualitative Research. Psychometric properties of the life events checklist. Assessment 11 4 — Schizophr Bull 13 2 — Five-factor model of schizophrenia. Initial validation. J Nerv Ment Dis 11 —8. Clin Schizophre Relat Psychoses 3 2 — Orfield G, Lee C.

Massachusetts: Harvard University Wilson WJ. American Educator Am J Community Psychol 40 3—4 — Racial and ethnic disparities in mental health care for children and young adults: a national study. Int J Health Serv 46 4 — Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48 3 — Trauma and posttraumatic stress disorder in the community: the Detroit area survey of trauma. Arch Gen Psychiatry 55 7 — Res Aging Stress burden and the lifetime incidence of psychiatric disorder in young adults: racial and ethnic contrasts.

Arch Gen Psychiatry 61 5 —8. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv 59 11 — Investigation of racial and ethnic disparities in service utilization among homeless adults with severe mental illnesses. Psychiatr Serv 60 8 —8. Medicalisation in the 21st century: introduction. Lancet —8. Relationships between trauma and psychosis: a review and integration. Br J Clin Psychol 42 Pt 4 — Childhood trauma is associated with a specific admixture of affective, anxiety, and psychosis symptoms cutting across traditional diagnostic boundaries.

Psychol Med 45 6 — Trauma and psychosis: an analysis of the National Comorbidity Survey. Am J Psychiatry 1 —9. Trauma exposure, schizophrenia symptoms, and the stress vulnerability model. Switzerland: Springer International Publishing J Community Psychol Expanding our understanding of the relationship between negative life events and depressive symptoms in black and white adolescent girls.

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The psychological effect of an urban environment on individuals with persecutory delusions: the Camberwell walk study. Schizophr Res 99 1—3 — The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust. PLoS One 9 8 :e Childhood traumatic events and types of auditory verbal hallucinations in first-episode schizophrenia patients. Compr Psychiatry — Morgan C, Gayer-Anderson C. Childhood adversities and psychosis: evidence, challenges, implications.

World Psychiatry 15 2 — God in the brain: experiencing psychosis in the postsecular United States. Transcult Psychiatry 53 4 — Chen YY, Koenig H. Traumatic stress and religion: is there a relationship? A review of empirical findings. J Relig Health 45 3 — Park CL. Handbook of the Psychology of Religion and Spirituality. Guilford Press Understanding and addressing religion among people with mental illness. World Psychiatry 12 1 — Pargament K. New York: Guilford Press The prevalence of religious coping among persons with persistent mental illness. Psychiatr Serv 52 5 —5.

Fallot RD. Spirituality and religion in recovery: some current issues. Psychiatr Rehabil J 30 4 — Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder. Psychol Psychother 76 Pt 1 :1— Freeman D, Fowler D. Routes to psychotic symptoms: trauma, anxiety and psychosis-like experiences. Psychiatry Res 2 — Considering its benefits and especially how it helps to address the problems associated with the use of metaphysical concepts, we elected to use this approach for a definition of general spirituality.

The experiences themselves are characterized as involving states and modes of consciousness which alter the functions and expressions of self and personality and impact the way in which we perceive and understand ourselves, others, and reality as a whole. With this working definition of spirituality, it should be apparent that spirituality is complex, involving experiences with specific phenomenological features as well as cognitive and behavioral components.

The question now becomes—what are the unique qualities and dimensions that make up this complex domain of functioning? As noted earlier, there appears to be fairly broad agreement that spirituality is a multi-faceted concept. However, the number and content of those facets vary across the available models and measures with some proposing a few as two [ 72 ] and others as many as nine [ 47 ]. Such a state of affairs presents considerable difficulties for researchers as there is little by way of guidance as to which one would be most suitable to use as a comprehensive model for cross-cultural research.

For the sake of the present study, we elected to use the model of MacDonald [ 12 , 73 ]. Motivated to address the problems with definition and measurement seen in the research, MacDonald [ 12 ] completed a series of conjoint exploratory factor analyses using a wide variety of instruments designed to assess spirituality and related concepts available in the literature with data obtained from two large samples of Canadian university students. His findings provided strong evidence supporting the existence of five robust dimensions which he argued could serve as a framework for organizing existing empirical findings on the relation of spirituality to other aspects of functioning e.

The dimensions are Cognitive Orientation toward Spirituality i. Concurrent to developing the model, MacDonald also constructed a item measure to operationalize the five dimensions. Named the Expressions of Spirituality Inventory ESI , MacDonald [ 12 , 73 ] found the instrument to demonstrate satisfactory reliability and convergent, discriminant, criterion, and factorial validity. Immediately subsequent to the publication of his initial findings, MacDonald [ 73 ] devised a shorter item version of the test ESI-Revised or ESI-R using items from the parent scale selected on the basis of the uniqueness of content and item-to-scale reliability.

First, the model appears to capture the common latent constructs that are tapped by available spirituality instruments in a way which makes it one of the most comprehensive approaches to spirituality presently available. As a concrete illustration of this, MacDonald [ 12 ] found in his analyses that all dimensions were comprised of strong loadings from two or more measures but none of the instruments employed in his analyses, including those that are themselves attempts at comprehensive models [ 47 , 74 ], loaded substantively on all five dimensions.

With this mind, it is important to acknowledge that some investigators have been critical about the inclusion of paranormal beliefs in his analyses and model [ 75 ], and that MacDonald himself has raised issues with existential well-being representing a discrete aspect of spirituality [ 15 , 76 ].

In response to such criticisms, particularly the latter one, it is important to remember that the dimensional model is based upon the latent constructs found within existing tests. In regard to the former criticism, MacDonald [ 12 ] has justified the incorporation of paranormal beliefs by pointing out that many faith systems accommodate beliefs in phenomena typically considered paranormal e.

More recently, independent research has suggested that spirituality may be best differentiated from other concepts through belief in supernatural spirits [ 77 ]. MacDonald found that such beliefs contribute to his paranormal beliefs dimension. Thus, it may be argued that paranormal beliefs have a place within a comprehensive model of spirituality.

In particular, he was cognizant of the issues associated with the relation of spirituality to religion and to the predominance of Western conceptualizations of spirituality in the psychological literature. In response, when planning his analyses, he made sure to include tests that measure constructs derived from Eastern cultural and faith systems [ 78 , 79 ] as well as instruments tapping religious variables most commonly associated with devout belief and practice thought to represent spirituality i.

The result was the identification of a dimension i. Though his factor analytic findings suggest that the religiousness factor is more reflective of Western religious traditions e. As a product of this work, the model has also helped to clarify how spirituality manifests multifarious relations to functioning with some dimensions showing more positive associations e.

Thus, each dimension appears to uniquely and incrementally contribute to our understanding of how spirituality impacts functioning. A fourth advantage, which may appear on the surface to be a liability, concerns the pattern of intercorrelations between the dimensions. MacDonald [ 12 ] found significant correlations between various pairs of the five ESI dimensions with the association between Religiousness and Cognitive Orientation emerging as conspicuously high e.

Though his factor analytic work revealed that these dimensions emerged separately, it may be argued that such results were the product of the samples used and that a four dimensional model wherein Religiousness and Cognitive Orientation are combined would be more parsimonious.

This provides a good basis on which to compare and test four and five factor models to determine the best fitting model. Fifth and finally, the ESI is one of the few measures of spirituality to include items to assess response validity i. With the inclusion of a face validity item, researchers are permitted the opportunity to directly evaluate the extent to which different test-takers see the test as measuring something that is similar to their own understanding of spirituality. In order to provide a rigorous evaluation of the cross-cultural generalizability of spirituality as a psychometric construct, we adopted a complex approach to study design that attempted to address to the various shortcomings of the available research.

In particular, we aimed to examine the reliability, factorial validity, and configural and measurement invariance of the ESI-R across samples drawn from several countries in disparate geographic areas that included both individualistic and collectivistic cultures. To assess the impact of culture alone versus culture and language together, samples from cultures in which English is a dominant language received all measures in English while the ESI-R and other tools used were translated to the dominant language spoken for the remaining samples.

To ensure that our findings were not merely the product of the ESI-R, we incorporated a second novel questionnaire of spirituality developed through a content analysis of narrative descriptions of a spiritual person see method section to determine if it produced a factor structure akin to that of the ESI-R and to serve as a convergent validation measure. In terms of research expectations, several hypotheses were tested.

In particular, for all cultural samples, it was expected that a the ESI-R would be perceived as measuring spirituality as per responses to the face validity item, b the ESI-R would demonstrate satisfactory reliability and similar patterns of intercorrelations between dimensions as well as associations with demographic variables i. The Canadian data were originally used in MacDonald [ 12 ] but were included here to permit reanalysis and comparison to the other samples.

The remaining data were gathered between and Data for the Polish sample were obtained as part of a study on religious orientation but were not used in that study [ 92 ]. Finally, the data of participants of the American sample have been used in a study to examine the relation of spirituality to well-being measures [ 15 ]. A survey form was used which obtained basic demographic information e. The ESI-R is a item self-report questionnaire developed from a longer item parent instrument [ 12 , 76 ] designed to operationalize a five dimensional model of spirituality created through the conjoint factor analysis of 19 different tests selected due to their perceived representativeness of the content domain of spirituality.

While the items for the item ESI were included in the test on the basis of factor and reliability analyses, the selection of 30 of the items for the ESI-R was based upon item content uniqueness and reliability e. Each dimension is tapped by six items. The test employs a five point scale ranging from 0 Strongly Disagree to 4 Strongly agree which is used by respondents to rate the extent to which they agree with the content of the item. For the interested reader, the 30 items for the test appear in a table in the results section.

The SAL is a 40 item self-report instrument that utilizes a five point response scale ranging from 0 Strongly Disagree to 4 Strongly Agree. The items were developed from a thematic content analysis of written narrative descriptions of a spiritual person obtained from 50 Canadian university students. Thereafter, the authors devised items to embody adjectives that were found to be most commonly used across respondents. The questionnaires were administered to students at universities in their respective countries.

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Students who expressed interest in participating completed paper-and-pencil copies of the measures either during class time, during scheduled testing sessions, or were given hardcopies to complete and return to the researcher or research assistant. For all the remaining samples save Poland, the test was translated using the standard translation-back translation procedure.

Empirical evidence about recovery and mental health

For the Polish sample, the test was translated using a committee approach wherein a number of people fluent in both English and Polish collaboratively worked to create the translation [ 92 ]. All data gathering was completed in a manner consistent with standard ethical practices for questionnaire based psychometric research in place at the time of data collection. For both samples, the first author D. For the Indian data, permission was obtained from chairpersons and administrative heads of the University of Mysore Faculties of Arts and Humanities, Commence and Management, Education, Law, and Science and Technology.

Data collection was completed by the fifth author K. Data gathering was done by research assistants supervised by the second author H. Data collection was done by the eighth author H.

Data collection was done by the third author J. Data collection was completed by a research assistant under the supervision of the fourth D.

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Data collection was completed by the sixth author K. For the American, Canadian, Indian, Japanese, Korean, and Ugandan samples, written informed consent was obtained prior to the completion of the questionnaires. For the Polish and Slovakian samples, informed consent was communicated verbally. In these instances, only individuals who gave verbal consent were provided with hardcopies of the questionnaires to complete. For all samples, participation was voluntary and no personal identifying information was obtained.

The approach to analyzing data for this study was multi-tiered and involved looking at questionnaire scores at both the item and scale level and with the samples combined and separated. First, to ascertain the extent to which the ESI-R demonstrated face validity, responses to item 31 which asked participants to rate the extent to which they viewed the test as measuring spirituality were analyzed via ANOVA and examination of response frequencies. Next, descriptive statistics and reliabilities for the ESI-R items and dimension scores were calculated for all samples combined and then for each country sample separately.

These analyses were done in response to the recommendations of Byrne and Watkins [ 43 ] who suggested that examination of score differences across cultures should be included in any evaluation of measurement invariance. Since there is evidence that the ESI-R dimensions may differ as a function of age and sex of respondent [ 12 , 18 ], product-moment correlations were next calculated with the ESI-R dimensions and these two participant variables across all country samples.

Thereafter, inter-correlations between the ESI-R dimensions were computed. Next, both exploratory EFA and confirmatory factor analyses CFA were completed in order to assess the structural consistency and factor and measurement invariance of the ESI-R dimensions. Both approaches were employed in this study in response to issues raised regarding the use of confirmatory factor in the evaluation of personality inventories [ 94 , 95 ].

In consideration of the fact that the original ESI was developed using an EFA approach very similar to that employed for creating measures of the Five Factor Model of personality [ 12 , 76 ], these issues seemed to us to be applicable to this study. The utilization of CFA based techniques to assess structural and measurement invariance was done in a manner consistent with experts in the area of Structural Equation Modeling and CFA [ 42 , 44 , 45 , 96 ].

Finally, the SAL was examined across American, Ugandan, and Indian samples using EFA to identify latent factors and to construct subscales based upon similar patterns of varimax rotated factor loadings. Reliabilities of the emergent subscales, subscale intercorrelations, and correlations with the ESI dimensions were then calculated. Prior to beginning any analyses, data were examined for completeness, accuracy, and evidence of response bias e. Any cases demonstrating one or more of these problems were excluded from all analyses.

This resulted in a total participants being removed from the study. Table 1 presents information on the basic demographic characteristics for the total combined samples and for each country sample separately including age, gender, and religious affiliation. As an initial set of statistics, we focused on the response to item 31 that asks participants to rate the extent to which they perceive the ESI-R as measuring spirituality since it struck us as a good initial indicator of the extent to which spirituality in general and the instrument itself hold up across cultures.

With all but three of the participants providing a response to this item, the mean response for all samples combined is 2. Examination of frequencies for the pooled samples indicates that For a more detailed analysis, we examined differences across each country sample via a one-way ANOVA. Notwithstanding these statistical findings, examination of response frequencies indicates that the majority of respondents from the Canadian, American, Indian, and Ugandan samples responded with agree or strongly agree to the item. For the remaining samples, the majority of responses fall between neutral to strongly agree.

Correlations were also examined for each country sample separately. Scale reliabilities were calculated for each ESI-R dimension for the total combined sample and each country sample separately. Table 5 presents the scale level descriptive statistics and reliability coefficients for each country sample separately along with the mean corrected item-to-scale total correlations for all items within each ESI-R dimension.

As can be seen in the tables, alphas and item-to-scale correlations are reasonably good for the total combined sample and each country sample with only a two notable exceptions. Only general trends in these findings will be described here. For EPD, Uganda was found to produce significantly higher scores than all other countries. Last, the American sample has a significantly higher score compared to the Korean sample. For EWB, the American sample generated a significantly higher score than all other countries.

At the other extreme, the Polish, Japanese, and Slovakian samples did not produce any pairwise differences with any countries. Finally, for PAR, the Indian and Korean samples produced significantly lower scores compared to each other and all other countries. The Canadian sample generated a significantly higher score than all other countries save Japan and Slovakia.

Product-moment correlations were computed between the ESI-R dimensions for age in years and sex male coded 0 and female coded 1 for the total combined sample and each country sample separately see Table 7. When considering the findings for the combined sample, while there are a number of statistically significant correlations, the coefficients are generally low in magnitude for both age and sex. Closer inspection of the findings across the country samples reveals some notable differences in the strength of associations.


With age, the Korean sample followed by the Slovakian sample produced at least one correlation of moderate magnitude. With sex, the most substantive correlations were found with the American, Canadian, and Ugandan samples. Looking at the findings across the ESI-R dimensions, Religiousness and Cognitive Orientation toward Spirituality appear to be most strongly and significantly related to age and sex.

Given the significant findings obtained with age and sex and the observed significant differences for all ESI-R dimensions as a function of culture, it was surmised that interaction effects between the three variables should be examined. In response, five 2 sex x 2 age; two groups based on pooled median split—18—21 years versus 22 and older x 8 country samples ANOVAs were computed wherein each ESI-R dimension served as the dependent variable.

In all five ANOVAs, non-significant three-way interactions and non-significant two-way interactions between sex and age were produced. For Existential Well-Being, no two-way interactions were significant. Effect sizes for all significant interactions were small eta-squared ranged from.

When running the 2x2x8 ANOVAs, examination of cell frequencies revealed that the Slovakian and Japanese samples had far too few participants in some subgroups. Since unequal cell sizes can have a distorting effect on ANOVA results, we re-ran all five analyses excluding the Slovakian and Japanese samples to make sure that evidence of interaction effects was robust.

While these results are not identical to those found using all country samples, thus suggesting that asymmetry of cell sizes did have some impact on our main analyses, they still point to the existence of interaction effects. Product-moment correlations were next calculated between the ESI dimensions for pooled samples and for each country sample see Table 8. Examination of these coefficients reveals a few conspicuous trends. Another observable trend concerns the three samples with the lowest numbers of Christian participants i.

Lastly, though some statistically significant coefficients were obtained with EWB, the size of the coefficients for the total pooled sample and each country sample is consistently small. Since the original ESI was developed using EFA [ 12 , 76 ], we decided to first complete two principal axis factor analyses extracting and varimax rotating five factors in an effort to see if the factors were replicable with the ESI-R.

This latter analysis was done in response to the fact that the Canadian sample was employed by MacDonald [ 12 , 76 ] to develop the ESI. We reasoned that the analysis would be a better indicator of the replicability of the factors. Rotated factor loadings for the two analyses can be seen in Table 9. For both analyses, elevated factor loadings i. In particular, items comprising each of the ESI-R dimensions loaded strongly on separate factors with the exception of COS and REL which produced notable loadings on the first factor followed by COS generating strong loadings on a second separate factor.

While not reported in this article for the sake of brevity, we also ran the analyses with oblique oblimin rotation. Pattern matrices, which provide information on the unique association of a variable to a factor, showed elevated loadings for all items on completely separate factors i.

The analyses were set to extract five factors and obliquely oblimin rotated factor loadings examined. For both sexes, the items comprising the five ESI-R dimensions loaded strongly on separate factors. We did a similar pair of principal axis factors with age. Using a median split, we created a young i.

The pattern matrix from both solutions showed loadings consistent with the ESI-R dimensional structure. For the sake of thoroughness, the factorial stability of the ESI-R dimensions as a function of perceived face validity was also examined. More specifically, responses to ESI item 31 were used to create two groups. Principal axis factor analyses involving the extraction and oblique oblimin rotation of five factors produced solutions supportive of the five ESI-R dimensions; pattern matrices showed that all items loaded on clearly identifiable factors.

In order to evaluate the goodness-of-fit of the dimensional model underlying the ESI-R, a series of maximum-likelihood confirmatory factor analyses using Analysis of Moment Structures AMOS software were completed. Due to the fact that COS and REL are highly inter-correlated, it was considered worthwhile to also examine the goodness-of-fit of a four factor model wherein these two dimensions were combined into one to see which model four versus five factors resulted in better fit.

In total, 18 CFAs were done 9 four factor and 9 five factor , using data for the combined samples first, followed by separate analyses for each country sample. The standardized regression weights along with a variety of fit statistics for the combined sample analysis can be found in Table The overall model fit statistics for the analyses for each country separately can be found in Tables 11 through In all analyses for both four and five factor models, inspection of parameter estimates indicated that all regression weights i.

Alternatively, examination of covariances i. For instance, all covariances emerged significant with the total combined sample in both four and five factor models. However for the Canadian sample, the four-factor model produced nonsignificant estimates for all covariances involving EWB and in the five-factor model, five covariances were nonsignificant i. For the American sample, two covariances were nonsignificant in the four-factor model i. For the four-factor model for the Polish sample, one covariance estimate was nonsignificant i. In the Slovakian sample, four emerged nonsignificant in the four-factor model i.

In the Ugandan sample, two covariance estimates were not significant i. In the Korean sample, two covariances were found to be nonsignificant i. Lastly, for the Japanese sample, two covariance estimates were not significant in the four-factor model i. When comparing the overall model fit statistics between four and five factor models for the total combined sample and for each country sample, the correlated five factor model emerged superior as reflected in significant reduction in chi-square values i.

Based on this, the five factor model became the focus of our remaining analyses. Notwithstanding the findings supporting the five-factor model, closer examination of the fit indices suggests that overall model fit was not wholly satisfactory across all analyses. On the positive side, fit statistics for the combined total sample, Canadians, Americans, and Indians provide reasonably good support for model fit e.

The fit statistics for the Ugandan sample, while not as compelling, also appear to be at least somewhat adequate. On the other hand, for the remaining samples, all of which used translated versions of the ESI, fit statistics are less consistently supportive of good fit of the five factor model. To identify possible causes for the poorer model fit i. While a number of modification indices were generated, none of them indicated that any part of the model for these four samples could be respecified in a manner that made rational sense. For instance, there was nothing pointing to correlated error variances suggesting possible systematic measurement error due to unintended overlap in item content [ 45 ].

Similarly, there were no modification indices which strongly supported the re-assignment of an ESI-R item from one dimension to another in a way that would be defendable from a conceptual point of view or would generalize beyond a single country sample. Finally, to determine the extent to which parameter estimates for the five-factor model are stable and generalizable beyond the current samples, maximum likelihood bootstrap analyses were completed for the total combined sample and each country sample.

Confidence intervals for nonsignificant covariances as reported above, conversely, were found to include zero. As the most rigorous test of the ESI-R, we completed a series of CFA analyses wherein a freely estimated five factor model was compared to a model with parameter estimates constrained to equality and the change in goodness of fit evaluated simultaneously across each country sample. Based upon the previous CFAs done for each country separately, it was decided that we would test a model with only the factor loadings constrained as factor inter-correlations varied across samples and appeared likely to contribute to poor model fit.

Table 15 presents the freely estimated standardized regression weights for the country samples along with essential fit statistics. Table 16 provides an overview of the model invariance testing analyses that were done. For the first analysis, the baseline model i. For the constrained model, chi-square remained significant and the CFI value falls below. Comparison of the change in chi-square across the two models indicates that the constrained model reflects a significantly poorer fit suggesting non-invariance.

While Byrne [ 42 ] recommends systematically modifying and testing the constraints in a model to identify elements that are invariant versus non-invariant across samples, we reasoned that such an approach was not practical in the case of our study as there are simply too many comparisons to be made with a 30 item test across eight samples. Instead, we adopted the approach of examining the same constrained model with different sets of country samples as we saw this as being more consistent with our hypotheses. In this vein, we evaluated our baseline model to a constrained model using the four samples which completed the ESI-R in English i.

We next used just the American, Canadian, and Indian samples with the same result i. We did the same analyses comparing just Americans and Canadians, Americans and Indians, and Canadians and Indians, respectively. In all cases, the same pattern of findings were obtained; the baseline model and constrained model showed adequate CFI and RMSEA values but the change of chi-square came out significant with the constrained model always demonstrating poorer fit. We then completed analyses comparing the Polish and Slovakian samples, and the Korean and Japanese samples, respectively.

Regardless, in both instances, the constrained model was found to produce a significantly poorer fit. To further evaluate whether or not the findings reported thus far were the product of the type of test used and by association the type of item and test development strategy , exploratory principal component analyses were used to examine the internal structure of the SAL with the American, Indian, and Ugandan samples. In all cases, the analyses were set to extract and orthogonally varimax rotate five components.

To ascertain their association to the ESI dimensions, regression based component scores were calculated and used in a correlational analysis. The rotated component loading coefficients can be found in Table Examination of Table 17 reveals that for all three country samples, all five components house elevated loadings i. Also, while there appear to be a large number of differences in the pattern of item loadings across the three countries, there are also some points of similarity which find corroboration in the correlations with the ESI-R as per Table All of these items concern positive self-evaluation e.

The content of these items revolve around putative religious beliefs and behavior e. All four of these items have content which has obvious ties to paranormal beliefs e. Components 3 and 4 from all three solutions show much less similarity to each other in terms of the pattern of high item loadings and their correlations with the ESI-R dimensions. In terms of the correlations, for the Indian and Ugandan samples, though some statistically significant coefficients were obtained, the correlations are generally of small magnitude.

For the American sample, no significant correlations were obtained between component four and any ESI-R dimension but, unlike the other samples, the correlations with component three were statistically significant and of medium magnitude between four of the five ESI-R dimensions i. Taken as a whole, these findings suggest that three of the ESI-R dimensions i. In consideration of these results, we elected to create three subscales with the SAL items common to all three country samples so as to see if they function adequately in terms of reliability and if they produce a similar array of associations as found with the ESI-R.

Analyses show a pattern of findings that are generally consistent with what was found for the ESI-R though some deviations are noted. Post-hoc analyses Scheffe test showed that all country samples were significantly different from one another for all three SAL subscales. Second, reliability analyses indicate that the three SAL subscales produce mostly satisfactory inter-item consistency coefficients and good corrected item-to-scale total correlations. Third, in terms of associations with demographic variables, akin to the ESI-R, the SAL subscales produce a pattern of small correlations with age.

With sex, SAL Religiousness produced significant and moderately sized correlations in all three country samples while the remaining two SAL subscales generated small coefficients. Fourth, for all three country samples, the SAL subscales produced correlations with the ESI-R dimensions supportive of convergent validity e. This investigation offers a wealth of information that has substantive ramifications for the cross-cultural study of spirituality.

Insight in Psychosis: An Integrated Perspective

Related to our research expectations, results provide generally satisfactory support for the first three hypotheses, no support for our fourth expectation and mixed support for our fifth. As per the second hypothesis, the ESI-R was found to produce satisfactory reliability coefficients and corrected item-to-scale correlations for the pooled sample and mostly adequate alphas and correlations for the country samples separately.

A noteworthy and unexpected trend, however, was observed with the samples that had the lowest representations of Christians i. Lastly, correlations of the ESI-R dimensions with demographic variables show similar trends across most country samples; with the exception of the Koreans, coefficients were of generally low magnitude and in the direction where age and females showed associations with higher scores especially with COS and REL.

In the case of the Korean sample, correlations tended to be of more moderate size with both age and sex. Third, evidence of factor replicability, configural invariance, and superiority of a five factor over a four factor model was provided by the EFAs and CFAs with the pooled sample and with the CFAs done for each country separately. With the former analyses, ESI-R items loaded in a manner very similar to MacDonald [ 12 ] both with and without the Canadian sample included in the analysis.

In the CFAs, while loadings were significant for all items in both the four and five factor models, the five factor model displayed a significantly better fit to the data as reflected in both the change in chi-square and virtually all other fit indices. For CFAs involving the country samples, item loadings were ubiquitously significant for all models tested, but the five factor model consistently demonstrated better goodness-of-fit. With that stated, inspection of numerous fit indices for the five factor model for each country separately suggests that the model demonstrates elements of misfit for the Korean, Japanese, Polish, Slovakian, and Ugandan samples.

Nevertheless, modification indices were examined and there were no indications of how the model could be meaningfully respecified in a congruent manner across all samples, so the five factor model appears to be the most defendable. The fourth hypothesis which predicted that the ESI-R would demonstrate measurement invariance was not corroborated by our findings. Tests comparing an equality constrained model to a freely estimated correlated five factor model consistently revealed that the constrained model had significantly poorer fit.

Also, significant differences were found at the item and dimension level as a function of country as per ANOVA findings. ESI-R Cognitive Orientation toward Spirituality was also observed to generate notable associations with the same factor as Religiousness, a result which seems copasetic with what we found with each and every country sample in this study. In addition, when three subscales were created for the SAL, they demonstrated a pattern of findings in terms of reliability, and correlations with demographic variables mostly similar to what was seen for the ESI-R. With the SAL, Religiousness was found to produce significant and moderately sized coefficients with both Paranormal Beliefs and Existential Well-Being for all three country samples.

Such associations were not found with the ESI-R. All the same, many of the findings with the SAL seem to be fall in line with our expectations. So what do all of these findings tell us? In general, it appears that when defined and assessed quantitatively, spirituality may be viewed as a viable concept which empirically behaves in a similar manner across cultures. It also seems that spirituality is best treated as a multidimensional construct made up of related but unique components.

While the number of these components was found to vary as a function of the inclusiveness item content seen in measures employed in the present study, based upon the results using the Expressions of Spirituality Inventory-Revised, it may be argued that spirituality is comprised of at least five dimensions. Rather, it seems the opposite holds true; the specific meaning ascribed to spirituality appears to be intrinsically bound by culture and cannot be fully understood without consideration given to cultural factors.

That is, while there are similarities, spirituality is not the same across cultures. The significance of our results seem quite apparent—nomothetic approaches to the study of spirituality are at best incomplete and at worst run the risk of misrepresenting the construct and any associations claimed to exist between it and other aspects of functioning.

Accordingly, a concrete recommendation for future research is for investigators to be mindful of the role and influence of culture and to augment quantitative methods based solely on self-report questionnaires with other hard quantitative procedures e. We offer this suggestion not just for research using samples drawn from different nation states but also for studies using samples of different ethnicities obtained within more pluralistic societies e.

As well, we strongly suggest that any and all empirical findings generated with samples obtained from one culture be tested and replicated with samples taken from several other cultures prior to making any claims regarding generalizable scientific knowledge. In this vein, we encourage investigators throughout the world to challenge and expand upon our findings using samples from the same and different cultures.

20. Is it Bipolar Disorder or a Spiritual Awakening?

The manner in which we report our results in this paper e. Our findings hold other important implications. First, while not demonstrating measurement invariance, the five dimensional model of MacDonald [ 12 ] did receive support for its configural invariance and its pattern of associations with the SAL were similar across cultures. Given that the dimensions have been found to be differentially related to psychological functioning [ 91 ], it seems reasonable to conjecture that such results may also be manifested in studies with different cultures.

Though this is an empirical question which would be best answered by future cross-cultural research, when considering the current state of the science, it seems necessary if not prudent at the present time to discourage investigators and practitioners from characterizing the association of spirituality to functioning in solely positive terms [ 98 ] as it appears likely that any link found may be a product of how spirituality is defined and measured [ 99 ].