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Journal of Spirituality in Mental Health
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Spirituality, Meaning in Life, and
Depressive Symptomatology in
Individuals with Alcohol Dependence
George Kleftaras a & Irene Katsogianni a
a Department of Special Education, University of Thessaly, Thessaly,
Greece
Version of record first published: 07 Nov 2012.
To cite this article: George Kleftaras & Irene Katsogianni (2012): Spirituality, Meaning in Life, and
Depressive Symptomatology in Individuals with Alcohol Dependence, Journal of Spirituality in Mental
Health, 14:4, 268-288
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Journal of Spirituality in Mental Health, 14:268–288, 2012
Copyright ©Taylor & Francis Group, LLC
ISSN: 1934-9637 print/1934-9645 online
DOI: 10.1080/19349637.2012.730469
Spirituality, Meaning in Life, and Depressive
Symptomatology in Individuals with Alcohol
Dependence
GEORGE KLEFTARAS and IRENE KATSOGIANNI
Department of Special Education, University of Thessaly, Thessaly, Greece
A growing body of evidence points to the important role of spiri-
tuality and meaning in life in treating people with medical and
psychological conditions. The purpose of the present study was
twofold: first, to examine the relationship among meaning in life,
spirituality, and their dimensions to alcoholism and depressive
symptomatology; and second, to explore the differences in spiri-
tuality and meaning of life among individuals of low, moderate,
and high depressive symptomatology. Results indicated that spiritu-
ality and meaning in life were statistically significantly associated
to alcoholism and depressive symptoms. In particular, depression
was statistically significantly correlated with the onset of alco-
hol use and the dimensions of spirituality and meaning in life.
Implications for counseling and psychotherapy are discussed.
KEYWORDS spirituality, meaning in life, alcoholism, depression
INTRODUCTION
The problem of alcohol abuse and alcoholism pervades our society today,
and constitutes major international public health issue. The problem affects
10 million people in the United States, and is implicated in 200,000 deaths
annually (Rifkind, 2011). The European Union remains the part of the world
with the highest proportion of drinkers and with the highest levels of alcohol
consumption per population (World Health Organization Regional Office for
Europe, 2005). Although parts of Europe are described as having drinking
Address correspondence to George Kleftaras, Department of Special Education,
University of Thessaly, Argonafton & Filellinon, 382 21 Volos, Greece. E-mail: gkleftaras@
uth.gr
268
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Spirituality, Meaning in Life, & Depression in Alcoholics 269
patterns that are less risky to health, alcohol remains one of the most impor-
tant risk factors for ill health and premature death. Alcohol is the third-largest
risk factor for ill health (after smoking and raised blood pressure), more
important than high cholesterol levels and being overweight (World Health
Organization Regional Office for Europe, 2005). Evidence from Greece sug-
gests the approximate age that individuals start drinking is 11 years old.
In addition to this worrying statistic, European surveys indicate that the fre-
quency of consumption of alchoholic beverages has risen to 51% since 1950,
putting Greece in 10th place among other European countries in alcohol
consumption (αραντoπo´
υλoυ[Sarantopoulou], 2008).
In other research, high rates of depression are common among individu-
als with alcohol dependence (Conner, Pinquart, & Gamble, 2009). Data from
the National Comorbidity Survey estimated the lifetime prevalence of major
depression to be nearly one quarter (24.3%) among alcohol-dependent men
and nearly one half (48.5%) among alcohol-dependent women, exceed-
ing the prevalence rates among individuals without alcohol dependence
(Hesselbrock, Meyer, & Keener, 1985). In clinical samples, the lifetime
rates of co-occurrence are greater, ranging from 50% to 70% with alcohol
dependence (Conner et al., 2009).
This article aims to bring to the fore the value and importance of
spirituality and of sense of purpose in life in understanding and explain-
ing alcoholism and its comorbidity to depression. The volume of research
in the areas of religion and spirituality has grown tremendously over the
past decade. Jung (1958) emphasized the importance of spirituality in
the human experience and reported that without an “inner transcendent
experience humans lack the resources to withstand the ‘blandishments of
the world.” He claimed that neither intellectual nor moral insight alone
are sufficient conditions of self-completion and that the real problem
is discovering a healthy spiritual perspective, which is viewed as the
understanding of one’s connection to a purpose beyond oneself (Jung,
1933).
There are different understandings of the distinction between religious-
ness and spirituality. Typically religiousness is viewed as having specific
behavioral, social, doctrinal, and denominational characteristics, because it
involves a system of worship and doctrine that is shared within a group
(Erickson, 1969). Similarly, spirituality is concerned with the transcendent,
addressing ultimate questions about life’s meaning with the assumption
that there is more to life than what we see or fully understand (Fetzer
Institute, as cited in G. L. Underwood & Teresi, 2002). As far as the
link between the two is concerned, according to L. Underwood (1999),
few people are engaged in religious activity with no spiritual sense of it.
Most people nest their spirituality in some sort of religious faith, word-
ing, and/or activities (spiritual and religious). And a relatively small group
of people has a spirituality that is not historically or presently connected
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270 G. Kleftaras and I. Katsogianni
to any form of religious belief, activity, or concepts (spiritual but not
religious).
Researchers in the mental health professions have discussed spiritual-
ity in relation to the overall adaptability and well-being of the individual
(Chandler, Holden, & Kolander, 1992; Wright, Frost, & Wisecarver, 1993).
Transcendence, a dimension currently popular in the area of spirituality,
has been broadly theorized as well (Chandler et al., 1992; Frankl, 1967).
Transcendence refers to the awareness or belief in a force or superior power,
whether this is a formal belief in God or some cosmic energy. Spiritual well-
being also implies that the individual is one part of a larger community,
which includes the terms self, others, and God (Beck, 1994). A sense of
selflessness, life purpose, a desire to assist others (Bateson, 1997), and an
increased unconditional love that promotes working toward a greater good
are also present (Fitzpatrick, 2009).
A fundamental dimension of spiritual wellness is meaning in life. This
particular dimension is highlighted in the studies of the major existential
writers as an innate capacity (Frankl, 1959; Maddi, 1967). Although the
self-actualizing individual is depicted as having discovered meaning in life,
nonactualized individuals may struggle with hopelessness and meaning-
lessness of life frequently termed as existential vacuum and depression
(Frankl, 1959). Research has demonstrated that meaning of life is pos-
itively associated with happiness (Robak & Griffin, 2000), psychological
well-being and health (Chan, 2009; Halama & Dedova, 2007; Ho, Cheung, &
Cheung, 2010; Holahan, Holahan, & Suzuki, 2008; Jaarsma, Pool, Ranchor, &
Sanderman, 2007; Lethborg, Aranda, Cox, & Kissane, 2007; Visser, Garssen,
& Vingerhoets, 2010), and life satisfaction (Chan, 2009; Pan, Wong, Joubert,
& Chan, 2008; Steger & Kashdan, 2007).
Spirituality and Meaning of Life: Relation with Alcoholism and
Depressive Symptoms
The consideration of alcoholism and to a lesser degree of depression as
disorders with a meaning, and mainly a spiritual dimension, has histori-
cally posed a problem for the logical positivism and egalitarian orientations
of most Western-trained therapists and academics. In particular, such an
approach to psychological problems has been accused of being nonscien-
tific if not mystical. For this reason, it has been difficult to legitimize both
definitions of alcoholism and to some extent depression that consider spir-
itual and meaning components as part of etiology or treatment (Chapman,
1997). Given the limited research in this area, this article aims to shed light
on the relationship between spirituality with alcoholism and depression.
However, the few studies examining the relationship between church atten-
dance, meaningfulness of religion, and levels of depression in adolescents
and adults found significantly lower depression rates among individuals
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Spirituality, Meaning in Life, & Depression in Alcoholics 271
who found meaning in life through their religion (Olesovsky, 2003; Wright
et al., 1993).
Beck (1994), Seligman and Csikszentmihalyi (1990), and Yalom (1980)
have postulated that a sense of life purpose and satisfaction both relate to
the state of hope, with hopelessness being common among clients with
depression (Beck, 1994; Seligman, 1990) and both depression and hope-
lessness being common among alcoholics. Previous research documents the
high prevalence of lifetime suicide attempts among patients with alcohol
dependence and depressive symptomatology. According to some estimates,
more than 40% of all patients seeking treatment for alcohol dependence
report a suicide attempt at some point in their lifetime (Anderson, Howard,
Walker, & Suchinsky, 1995; Koller, Preuss, Bottlender, Wenzel, & Soyka,
2002; Roy, 2003). Thus, transcendent meaning in one’s life may be cru-
cial not only to life development, but may also be a sustaining factor in
times of crisis (e.g., death of a loved one, divorce, unemployment; Hodges,
2002). The studies that have investigated the relationship between mean-
ing in life and depression are relatively few, and in general they indicate a
significant negative association between these two variables. However, they
have been conducted in the United States with specific populations such
as individuals with multiple sclerosis (Hart, Fonareva, Merluzzi, & Mohr,
2005), HIV (Lyon & Younger, 2001), cancer (Simonelli, Fowler, Maxwell,
& Andersen, 2008), Schizophrenia (Stolovy, Lev-Wiesel, Adiel, & Gelkopf,
2009), older adults (Westerhof, Bohlmeijer, van Beljouw, & Margriet, 2010),
and college students (Mascaro & Rosen, 2005, 2008; Robak & Griffin,
2000).
The need for further investigation of the relationship of meaning in life
with depression and psychological well-being in other populations and in
other sociocultural environments such as that in Europe, and more specif-
ically Greece, is necessary. This need becomes even more important if
we consider that depression is closely connected with suicidal ideation
and mortality, which seem to be mediated by the concept of hopeless-
ness (Edwards & Holden, 2001; Fitzpatrick, 2009; Heisel & Flett, 2004;
Kang, Shim, Jeon, & Koh, 2009; Krause, 2009; Petrie & Brook, 1992; Yang
et al., 2010). The present study addresses the issue of recognizing the spir-
itual and meaning components in the etiology of alcoholism as well as
their relationship to the increased levels of depressive symptoms in alco-
holics. The hypotheses of the present study are the following: (a) there
will be significant negative correlations between spirituality (and its dimen-
sions) and depressive symptomatology in alcoholics; (b) there will be
significant negative correlations between meaning of life (and its dimen-
sions) and depressive symptomatology in alcoholics; and (c) there will be
statistically significant differences between alcoholics with lower, moder-
ate, and higher depressive symptoms on spirituality and meaning in life
dimensions.
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272 G. Kleftaras and I. Katsogianni
METHOD
Subjects and Procedure
Over a 16-month period, patients with symptoms of alcoholism were
approached in the advisory center of the alcohol rehabilitation unit (18 ANO)
in the public psychiatric unit in Athens (Dafni). Initially the subjects were
informed about the material and the duration of the procedure, were
promised confidentiality and anonymity, and were asked to give their
informed consent about their voluntary participation in this study. Those
who agreed to participate answered questions in a self-report assessment
requesting information about sociodemographics; personal and familial his-
tory of alcohol use; as well as spiritual beliefs, practices, and background.
Among the 204 patients approached, four refused to participate due to time
constraints.
A sample of 200 patients were studied, 123 men (61.5%) and 77 women
(38.5%). The participants’ age ranged between 29 to 61 years, with a mean
age of 44.1 years (SD =6.64). With regards to their marital status, 35% of
the participants were married, 23.5% divorced, 1% widowed, and 35% single.
The majority of patients were well educated, with 51% senior high school
graduates, 16.5% university degree holders (including technological univer-
sities), 15% junior high school graduates, 10% technical education graduates
(secondary), and 5% primary education graduates. A summary of the sam-
ple’s sociodemographic characteristics is illustrated in Table 1. All subjects
met interview criteria for past-year hazardous drinking and/or active alcohol
abuse or dependence.
Measures
Except for the questions concerning the subjects’ demographic characteris-
tics, participants completed the following instruments:
ASSESSMENT OF SPIRITUALITY AND RELIGIOUS SENTIMENTS (ASPIRES)
The ASPIRES scale (Piedmont, 2004a) is a nondenominational measure that
is appropriate for working with individuals across a wide range of faith
traditions as well as with nonreligious or agnostic persons. The ASPIRES
measures two major dimensions of numinous functioning: religious senti-
ments (RS) and spiritual transcendence (ST). The RS component is comprised
of two domains. The first, religiosity, reflects how actively involved a person
is in performing various religious rituals and activities (Greenberg, Solomon,
& Pyszczynski, 1997). The second domain, religious crisis, examines whether
a person may be experiencing problems, difficulties, or conflicts with the
God of their understanding and/or faith community. The second dimension
measured by the ASPIRES is spiritual transcendence (ST). ST represents a
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Spirituality, Meaning in Life, & Depression in Alcoholics 273
TABLE 1 Sociodemographic Characteristics of the Sample (N =200)
Characteristics n
Relative
frequencies (%)
Sex
Men 123 61.5
Women 77 38.5
Marital status
Single 71 35.5
Married 70 35.0
Divorced 4–7 23.5
Widowed 2 1.0
Other 10 5.0
Educational level
Primary school 10 5.0
Junior high school (S.E.I.) 30 15.0
Senior high school 102 51.0
Technical education 20 10.0
University 33 16.5
MSc, PhD 3 1.5
Other 2 1.0
Occupation
Public officer 39 19.5
Private officer 33 16.5
Health professional 3 1.5
Freelancer 69 34.5
Businessperson 6 3.0
Housekeeping 15 7.5
Unemployed 34 17.0
Other 1 .5
Residence
Athens 152 76.0
Province 48 24.0
motivational construct that reflects an individual’s efforts to create a broad
sense of personal meaning for his/her life. The individuals scoring high on
transcendence are able to find a larger sense of meaning and purpose to
life that goes beyond their immediate sense of time and place. Those scor-
ing low on transcendence have a more materialistic orientation to life that
stresses more of the “here and now” dimension.
There are three correlated facet scales to ST: prayer fulfillment; the abil-
ity to create a personal space that enables one to feel a positive connection
to some larger reality universality; and the belief in a superior meaning and
purpose to life and connectedness, feelings of belonging, and responsibil-
ity to a larger human reality that cuts across generations and groups. With
regards to scoring interpretations, respondents scoring higher than average
on the overall dimension of the ASPIRES are seen as concerned with living
a life that is in accord with values and meanings that originate with some
“larger understanding of the purpose of the universe” (Piedmont, 2004a,
p. 5). Respondents scoring above average in the prayer fulfillment dimension
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274 G. Kleftaras and I. Katsogianni
are seen as “finding a personal sense of emotional satisfaction, strength,
and support in their efforts to connect with some larger reality” (Piedmont,
2004a, p. 6). Respondents scoring above average in the universality dimen-
sion “share a common belief that all of life is interconnected ...seeing
humanity as a single interrelated body” (Piedmont, 2004a, p. 6). An above-
average score for the connectedness dimension indicates “a special sense of
responsibility (and gratitude) for the many gifts received from those who
came before,” (Piedmont, 2004a, p. 6). Average scores on the ASPIRES
indicate neither emphasis nor de-emphasis of the particular dimension
measured.
The ASPIRES consists of 23 items. The alpha reliabilities for the scales
were: .95 (prayer fulfillment), .82 (universality), .68 (connectedness), and .89
(total score). The ASPIRES subscales evidenced good convergent and dis-
criminant validity as well as incremental validity in predicting psychosocial
criteria over and above personality. ASPIRES was translated, adapted into
Greek and revised through back-translations by a team of three bilingual
psychologists.
LIFE ATTITUDE PROFILE-REVISED (LAP-R)
The LAP-R, developed by Reker and Peacock (1982), consists of 48 items
rated on a 7-point Likert scale (1 =strongly agree; 7=strongly dis-
agree). This scale measures the degree to which a person experiences a
sense of meaning in his life, as defined by Frankl’s (1963) existential the-
ory. The higher an individual’s score on LAP-R, the higher the sense of
meaning of life experienced by the individual. The LAP-R consists of six
dimensions through factor analysis (Reker & Peacock, 1982): purpose, coher-
ence, choice/responsibleness, death acceptance, existential vacuum, and
goal seeking. The two composite scales are: Personal Meaning Index and
Existential Transcendence.The eight LAP-R dimensions were shown to be
internally consistent, stable over time, and valid measures of their respective
constructs (Reker & Peacock, 1982; Reker, Peacock, & Wong, 1987). Alpha
coefficients were computed to assess internal consistency. The coefficients
are highly satisfactory, ranging from .77 to .91, and remain consistently high
across age groups and gender. The authors of LAP-R have provided evi-
dence for test–retest reliability (stability coefficients) using a subsample of
participants (N=200) retested at a 4- to 6-week interval. Stability estimates
range from .77 to .90. The highly satisfactory test–retest coefficients provide
strong support for the short-term stability of the LAP-R.
Moreover, according to relevant studies (Reker & Peacock, 1982), the
moderate- to high-stability coefficients estimated for each dimension and the
scale overall provide support for the LAP-R as a reliable research instrument
with a good stability. The LAP-R was translated, adapted into Greek and
revised through back-translations by a team of three bilingual psychologists.
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Spirituality, Meaning in Life, & Depression in Alcoholics 275
The validity and reliability of LAP-R was tested against among a sample
of Greek breast cancer patients. Internal consistency reliability of the sub-
scales and convergent validity of LAP-R were satisfactory. LAP-R was able to
detect differences in meaning between different age groups. Confirmatory
factor analysis provided support for a single-factor model including a latent-
meaning variable indicated by the observed subscales. (Anagnostopoulos,
Slater, Fitzsimmons, & Kolokotroni, 2011).
QUESTIONNAIRE OF SELF-EVA L U A T E D DEPRESSIVE SYMPTOMATOLOGY (QD2)
The QD2 is a 52-item self-report measure that taps into a variety of the
affective, cognitive, and somatic symptoms of depression. The response
format is true or false. Higher scores indicate more severe levels of depres-
sion. This questionnaire was constructed and validated by Pichot et al.
(1984) in France. In fact, QD2 derived from the content analysis of the
items of the four best known self-report inventories exploring the symptoms
experienced by depressive patients: the Hopkins Symptoms Check List, the
French version of the Beck Depression Inventory, the Depression Scale of
the Minnesota Multiphasic Personality Inventory, and the Zung Self-Rating
Depression Scale.
According to the authors, the QD2 has: (a) a good homogeneity (stud-
ied by computing the phi [] coefficient for each item: all coefficients were
significant at the α=.01 level of significance except from two which
were significant at the α=.05 level of significance); (b) a good reliabil-
ity (split-half method; Spearman-Brown formula) studied in four groups of
depressed (.93, N=157), normal (.92, N=89), organic (.95, N=90),
and psychiatric patients (.94, N=145); (c) a good concurrent validity
according to three criteria: contrasts between groups of depressed and non-
depressed subjects (normal, organic, and psychiatric patients), correlation
with Zung Questionnaire, and correlation with the intensity of depression
as rated clinically; and (d) a satisfactory factorial structure. The responses
of a group of clinically depressed patients (N=157) to QD2 were sub-
jected to factor analysis which revealed three basic dimensions (factors),
which correspond respectively to the feelings of loss of general drive, to the
depressive-pessimistic mood, and to anxiety.
The QD2 was translated and adapted in Greek by a team of three
bilingual psychologists (Kλεϕτ´
αρας &Tζoνιχ´
ακη [Kleftaras & Tzonichaki],
2012). The factorial structure of the Greek version of QD2, as studied in both
our sample and a population of young and elderly individuals (Kleftaras
& Tzonichaki, 2010; Tzonichaki & Kleftaras, 1998), proved satisfactory and
confirms the results of the relevant studies in France (Kleftaras, 1991, 2000;
Pichot et al., 1984). The reliability coefficients of the Greek version of QD2,
as found in the present study are .92 (Cronbach’s α) and .91 (split-half
reliability).
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276 G. Kleftaras and I. Katsogianni
ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)
The AUDIT was developed by the World Health Organization as a simple
method of screening for excessive drinking. The AUDIT elicits a concise
alcohol history using ten questions about the quantity and frequency of the
patient’s usual drinking, as well as the frequency of heavy drinking.
RESULTS
Previous studies in Greece have provided satisfactory evidence of the
instruments’ psychometric characteristics of QD2 (depression) and LAP-R
(meaning in life) questionnaires (Anagnostopoulos et al., 2011; Kleftaras
& Tzonichaki, 1998, 2010). Consequently, in the series of statistical anal-
yses performed in order to investigate the hypotheses of this study, the
participants’ total scores on depression, meaning in life, and alcoholism
questionnaires were used. Since the validity of the ASPIRES had not been
studied in a Greek population, we decided to study its factorial structure
based on our sample. The reliability analysis revealed that the subscale
prayer fulfillment had a high reliability: α=.929 (N=10, M=25.30, SD =
9.34) as well as the subscale universality: α=.830 (N=7, M=19.02, SD =
5.74). However, the subscale connectedness failed to acquire an acceptable
reliability: α=.431 (N=6, M=19.79, SD =3.61). Furthermore, the results
of the factor analysis on ASPIRES were inconclusive even when the subscale
connectedness was removed. Therefore, the first two subscales of ASPIRES
questionnaire were included as two concurrent scales and not under a unite
scale for hypotheses testing.
Exploration revealed that the data lacked univariate normality. In par-
ticular, the univariate normality of data was tested through the use of both
Kolomogorov-Smirnov (Massey, 1951) and Shapiro Wilk (Shapiro & Wilk,
1965) tests. In both tests all individual subscales, incorporated in this analy-
sis, were found to be statistically significantly deviant (p<.05) from normal
distribution. Given these results, data were tested using nonparametric meth-
ods. The nonparametric correlations (Kendall tau-b), revealed that the total
score of QD2 is negatively and significantly correlated with the onset of
alcohol use (τB=−.18, p<.05) as well as with all 6 dimensions of the
LAP-R plus the 2 composite dimensions on the questionnaire (see Table 2).
Moreover, the stage of therapy (1 =initial stage, 2 =main stage, 3 =reha-
bilitation stage, 4 =rehabilitated) was correlated significantly and positively
with some of the meaning of life dimensions, namely, with life purpose,
coherence, choice, death acceptance, personal meaning index, and existen-
tial transcendence as well as with universality dimension of the ASPIRES
questionnaire. However, the stage of therapy was correlated significantly
and negatively with the existential vacuum (Table 2).
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TABLE 2 Nonparametric Correlations (Kendall’s tau -b) Between Depression (QD2), Meaning in Life (LAP-R) and Spirituality
Meaning in life Spirituality
Onset of
alcohol use
Life
purpose Coherence Choice
Death
acceptance
Existential
vacuum
Goal
seeking
Personal
meaning
Existential
transcendence Universality
Depression −.18∗−.39∗∗ −.32∗∗ −.27∗∗ −.19∗∗ .17∗−.37∗∗ −.34∗∗ −.24∗∗ −.02
Stage of therapy −.08 .23∗∗ .21∗∗ .19∗∗ .21∗∗ −.11∗.07 .23∗∗ .23∗∗ .18∗∗
∗p<.05. ∗∗p<.01.
277
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278 G. Kleftaras and I. Katsogianni
TABLE 3 Nonparametric Correlations (Kendall’s tau-b) Between Onset of Alcohol Use,
Duration of Pathological Use, Meaning in Life and Spirituality
Meaning in life Spirituality
Existential vacuum Goal seeking Connectedness
Onset −.19∗∗ −.15∗∗ −.00
Duration of pathological use .02 −.04 −.17∗∗
∗∗p<.01.
Additionally, it was found that the onset age of alcoholism (1 =
0–15 years old, 2 =16–18 years old, 3 =19–23 years old, 4 =24–28 years
old, 5 =more than 29 years old) was significantly and negatively correlated
with the Existential Vacuum scale (τB=−.19, p<.001) as well as with
the Goal Seeking scale (τB=−.15, p<.001) of the LAP-R questionnaire
(see Table 2). This could mean that participants that suffered later in life
from alcohol problems may have scored lower on the Existential Vacuum
subscale as well as on the Goal Seeking subscale. Similarly, the duration
of pathological use (1 =0–3 years, 2 =4–6 years, 3 =7–10 years, 4 =
11–15 years, 5 =more than 15 years) was found to correlate significantly
and negatively with the connectedness dimension (τB=−.17, p<.001) of
the ASPIRES questionnaire (Table 3).
The total score of the QD2 (depression scale) was divided into three
groups: participants that scored 0 to 19 (lower depressive symptoms, M=
7.09, SD =6.18), those who scored 20 to 36 (moderate depressive symptoms,
M=29.88, SD =4.64), and those who scored 37 to 52 (higher depressive
symptoms, M=42.59, SD =3.82). The Kruskal Wallis test revealed that
these three groups differ significantly in life purpose, coherence, choice,
death acceptance, existential vacuum, Personal Meaning Index, existential
transcendence, ASPIRE’s prayer, and ASPIRE’s universality. The results show
that the first group acquired a higher mean score and mean rank across all
the aforementioned dimensions than the second group, and the third group
acquired the lowest mean score and mean rank (Table 4).
There were two exceptions to these results, relating to the death accep-
tance and the existential vacuum dimensions. In particular the second and
third groups (i.e., the groups with moderate and high depression symp-
toms, respectively) had a high mean score and mean rank on existential
vacuum, and the first group (i.e., the group with low depression symptoms)
had the lowest mean score and mean rank. Note, however, that a high
score on existential vacuum shows a negative attitude towards life. In addi-
tion, the first group with low depressive symptomatology had the highest
mean score and mean rank on death acceptance, while the second group
(with moderate depression symptomatology) had the lowest mean score
(M=23.04) and mean rank on the same dimension, and, accordingly, the
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TABLE 4 Comparison (Kruskal Wallis Test) of Means and Mean Ranks Regarding Meaning in Life and Spirituality Among Individuals of Low,
Moderate, and High Depressive Symptoms
Meaning in life Spirituality
QD2 nM/MR
Life
purpose Coherence Choice
Death
acceptance
Existential
vacuum
Personal
Meaning
Index
Existential
transcendence Prayer Universality
0–19 (low) 67 M33.37 33.22 39.38 31.49 32.43 66.60 65.02 21.51 20.51
MR 137.51 130.66 126.86 125.20 74.67 135.60 136.61 127.17 122.25
20–36 (moderate) 69 M23.65 25.10 32.97 23.04 38.55 48.75 25.23 17.84 19.75
MR 87.67 92.35 92.38 82.50 124.82 89.49 81.81 88.05 90.12
37–52 (high) 64 M21.30 22.09 30.80 25.17 35.92 43.39 24.30 17.67 19.08
MR 75.59 77.72 80.52 94.05 101.32 75.63 81.85 86.00 88.92
Chi-square 42.72∗∗∗ 29.52∗∗∗ 22.92∗∗∗ 19.69∗∗∗ 25.60∗∗∗ 38.97∗∗∗ 39.92∗∗∗ 21.49∗∗∗ 14.29∗∗∗
Note. MR =mean rank.
∗∗∗p<.001.
279
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280 G. Kleftaras and I. Katsogianni
third group (with high-depression symptomatology) had the second lower
mean score (M=25.17). Therefore, it seems that the participants that had
higher scores on QD2 had lower scores on positive attitudes to life (e.g., life
purpose, coherence, etc.; Table 4).
As the results illustrated in Table 5 indicate, in all of the dimensions
of life purpose, coherence, choice, death acceptance, existential vacuum,
Personal Meaning Index, existential transcendence, universality dimension
of the ASPIRES questionnaire, and on the total score of the QD2, there are
statistically significant differences among participants in different stages of
alcoholism therapy. Examining the means and mean ranks in each stage
of therapy of alcoholism across the aforementioned dimensions, with the
exception of the existential vacuum dimension, participants in the initial
stage of alcoholism therapy had lower mean ranks and mean scores than
participants who were in the rehabilitated stage of alcoholism therapy;
unsurprisingly results were reversed for the existential vacuum dimension.
We consider these results alongside two additional issues emerging from
this analysis: first, participants at the initial stage of alcoholism therapy
had higher mean ranks and mean scores on existential vacuum and on
QD2 than rehabilitated participants; and second, the mean ranks and the
mean scores of participants of the main stage and of the rehabilitation
stage are very close to each other compared to the mean ranks and mean
scores of the initial and the final stage, hence they have low discriminat-
ing value. Seen collectively, the results suggest that participants rehabilitated
from alcoholism may have a more positive view on several aspects of the
life than participants that had been in the initial stage of the alcoholism
therapy.
Finally, nonparametric testing revealed that there were significant differ-
ences on the scores of QD2 between the different onset ages of alcoholism
(χ2K–W =11.83, df =4, p<.001). Specifically, it was found that participants
with early onset of alcoholism had higher mean ranks and mean scores on
QD2 (MR =102.54, M=28.24) than the participants with later onset (MR
=48.93, M=7.57). Analyses with sociodemographic variables are not pre-
sented as part of this article in order to maintain the focus and address the
hypotheses discussed in the first section of this article.
DISCUSSION
Our first and second hypotheses about the links between depressive
symptomatology and (a) spirituality and (b) meaning of life (and its
dimensions) in individuals with alcohol problems were both confirmed.
In particular, results indicate that the higher an individual has scored in
spirituality (i.e. the spirituality scale), the less the depressive symptoms they
have.
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TABLE 5 Comparison (Kruskal Wallis Test) of Means and Mean Ranks Regarding Meaning in Life, Spirituality and Depression Among Individuals
in Different Stages of Therapy
Meaning in Life Spirituality Depression
Stages of therapy nM/MR
Life
purpose Coherence Choice
Death
acceptance
Existential
vacuum
Personal
Meaning
Index
Existential
transcendence Universality Total
Initial stage 110 M23.68 24.35 32.41 23.55 36.49 48.03 28.30 17.89 28.00
MR 87.07 88.33 89.21 86.43 105.49 86.94 86.42 97.63 108.31
Main stage 50 M27.82 28.88 35.46 29.86 36.04 56.70 45.04 19.92 25.18
MR 110.07 110.19 105.50 116.54 103.43 110.87 110.72 102.37 95.38
Rehabi-litation
stage
20 M26.55 27.45 36.15 28.75 35.70 54.00 37.80 19.65 27.70
MR 105.58 105.65 109.28 109.32 109.32 106.55 100.15 106.58 102.75
Cured 20 M35.20 35.05 40.80 32.60 30.10 70.25 74.70 22.30 18.50
MR 145.38 138.08 135.78 128.95 56.90 143.12 147.08 105.55 68.10
Chi-square 19.49∗∗∗ 14.88∗∗∗ 12.53∗∗∗ 15.65∗∗∗ 12.79∗∗∗ 18.72∗∗∗ 21.16∗∗∗ 11.89∗∗∗ 9.87∗∗
Note. MR =mean rank.
∗∗p<.01. ∗∗∗p<.001.
281
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282 G. Kleftaras and I. Katsogianni
Furthermore, individuals who have low depressive symptoms also
scored higher in, and experience a higher, meaning of life (i.e., the meaning
of life scale) as manifested by their routine behaviors and attitudes. These
include setting goals and having direction throughout life, embracing life
and not being disrupted by anxiety thoughts and phobias about death, hav-
ing a sense of personal identity and social conscientiousness, perceiving self
and other in a consistent and integrated way, exercising agency by holding
themselves responsible for their actions and choices, having the will to live
and welcoming new challenges, and having a positive attitude towards life
and being motivated to look for meaning and purpose in life.
Results are consistent with the literature, as authors like Gerwood (1998)
have emphasized that individuals in treatment for substance-related disor-
ders are excellent candidates for understanding Frankl’s (1968) concept of
the existential vacuum, a dimension of meaning of life construct that encap-
sulates the failure of a person to experience meaning of life. As the author
argued, such people actually tend to fill their emptiness (existential vac-
uum) with alcohol and other drugs. This seems to be confirmed in our
study, in the sense that severity in depressive symptomatology is linked to
high levels of feelings of emptiness. These results are consistent with evi-
dence from previous studies, whereby individuals presenting a more intense
sense of meaning in their life are more socially functional and have better
psychological health (Kleftaras & Psarra, in press).
The results addressing the hypothesis about the link between the differ-
ent stages of alcohol therapy and meaning of life constructs were interesting,
too. In particular, results indicated a pattern identical to the one described
for depression: it can be argued that individuals identified as alcoholics and
in an initial stage of alcohol therapy have a negative attitude towards differ-
ent aspects of life and feel emptiness in their lives. Consistent with previous
research and theory (Crumbaugh, 1968; Crumbaugh & Carr, 1979; Frankl,
1972), the present investigation indicates that alcoholics have a lower sense
of meaning in life than nonalcoholics, and that their sense of life purpose
increases during treatment programs for alcohol addiction.
A number of other significant findings were also identified. One of the
most significant results from this analysis was that the onset of alcoholism
and depressive symptomatology are closely linked. Results indicate that if
an individual faces alcoholism early in their lives then they may encounter
more severe depression symptoms than an individual with a later onset,
including feelings of meaningless and emptiness, along with a lack of goals,
direction, and motivation for life. Note that the majority of the participants
in the present study were identified for past-year hazardous drinking and/or
active alcohol abuse or dependence.
This research comes with few caveats and therefore some limitations for
its results. The first relates to the psychometric properties of the ASPIRES.
Note that the ASPIRES measure is not currently standardized with the Greek
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Spirituality, Meaning in Life, & Depression in Alcoholics 283
population. A second caveat relates to the matter of the limited sample size,
which does not allow the generalization of the results. Lastly, claims on
the basis of these analyses should be made with caution, given they are
correlational in nature. The undoubted relationships between the variables,
though ascertained, do not allow “cause and effect” conclusions, regarding
the relationship between onset of alcoholism, depression, meaning in life,
and spirituality. Although the dominant view, to which we subscribe, is that
spirituality and dimensions of meaning of life affects psychological well-
being in general and especially depression, it is also possible that a person’s
depressive symptomatology may affect their perception of what is meaning-
ful and spiritual, and how much. The data of this study are not sufficient for
answering this question, which still remains open for future investigation.
These limitations, however, do not jeopardize the findings of this analysis,
which are in accordance with results from previous international literature
(Compton, 2000; Halama & Bakosova, 2009).
Despite the number of studies conducted internationally in the field
(e.g., Hart et al., 2005; Kλεϕτ´
αρας [Kleftaras] et al., 2007, 2009; Lyon &
Younger, 2001; Mascaro & Rosen, 2005, 2008; Olesovsky, 2003; Robak &
Griffin, 2000; Simonelli et al., 2008; Stolovy et al., 2009; Westerhof et al.,
2010), there are very few articles that have explored the aspects of alco-
holism in relation with spirituality and meaning of life in Greece. We suggest
that further research with different Greek population should become the
focus of researchers in this area in Greece. Whether lack of meaning in life
precedes, follows, or is reciprocally related to substance abuse problems is
a question to be pursued through research in the future.
Further research, including more treatment centers and a longer follow-
up period, would be required too in order to determine whether attaining
a certain posttreatment level of sense of life meaning would be a use-
ful indicator of successful treatment completion (Waisbert & Porter, 1994).
Furthermore, we emphasize the importance of rehabilitation practices that
will impact spirituality issues, empowerment, and potential sources of life
meaning (Waisbert & Porter, 1994). Given that the efficiency of such inter-
ventions is assessed through various quality of life indices, all of which
stress the importance of humans ability to experience broader, more inter-
connective relations with others and nature (e.g., Beck, 1994; Pain, Dunn,
Anderson, Darrah, & Kratochvil, 1998), we propose that the focus of further
research should be especially placed on such factors.
This research has implications for health practitioners. A number of
years ago, Victor Frankl (1959) spoke about the value of both meaning
and a spiritual belief system: According to the author, the fundamental the-
sis posited by logotherapy is that the striving to find meaning in one’s life
is the primary motivation force in man. Frankl (1959) argued furthermore
that humans are primarily spiritual beings, whose humanness is rooted in
the spiritual dimension. Our hypotheses regarding the relationship between
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284 G. Kleftaras and I. Katsogianni
spirituality, meaning of life, and depressive symptomatology in alcoholics
were confirmed. It would be interesting for future studies in the field of
psychological health to consider the way that existential theory interprets
and explains human behavior, as it seems a very promising theoretical
approach, mainly in regard to the understanding and coping with depressive
symptomatology and alcoholism.
In conclusion, the findings of the present study have added to our
understanding of alcohol dependence and depression by incorporating vari-
ables that also address the existential and spiritual needs of the individuals.
The ability to find meaning and purpose in life and to accept death as a nat-
ural part of life offers promising ways of transcending personal and social
losses, culminating in heightened feelings of well-being, life satisfaction, and
overall adjustment. It is hoped that the present results will encourage future
research with greater emphasis on an alcoholic person’s existential belief
system and its impact on successful recovery. Finally, it is hoped that the
results of such research would lead to the implementation of intervention
strategies which will account for the dimensions of both meaning of life
and spirituality, that this research have identified as potentially contributing
towards a more successful rehabilitation process.
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