# ind_items

secondary_title_index: psychological assessment
title_index: race/ethnicity and measurement equivalence of the everyday discrimination scale.
full_text_index:
       psychological assessment 2014, vol. 26, no. 3, 892–900   2014 american psychological association 1040-3590/14/ 12.00 doi: 10.1037/a0036431  race/ethnicity and measurement equivalence of the everyday discrimination scale giyeon kim  martin sellbom  the university of alabama  the australian national university  katy-lauren ford this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  the university of alabama the present study examines the effect of race/ethnicity on measurement equivalence of the everyday discrimination scale (eds; williams, yu, jackson, & anderson, 1997). drawn from the collaborative psychiatric epidemiology surveys (cpes; alegria, jackson, kessler, & takeuchi, 2008), adults aged 18 and older from four racial/ethnic groups were selected for analyses: 884 non-hispanic whites, 4,950 blacks, 2,733 hispanics/latinos, and 2,089 asians. multiple-group confirmatory factor analyses were conducted. after adjusting for age and gender, the underlying construct of the eds was invariant across four racial/ethnic groups, with item 7 (“people act as if they’re better than you are”) associated with lower intercepts for the hispanic/latino and asian groups relative to the non-hispanic white and black groups. in terms of latent factor differences, blacks tended to score higher on the latent construct compared to other racial/ethnic groups, whereas asians tended to score lower on the latent construct compared to whites and hispanics/latinos. findings suggest that although the eds in general assesses the underlying construct of perceived discrimination equivalently across diverse racial/ethnic groups, caution is needed when item 7 is used among hispanics/latinos or asians. implications are discussed in cultural and methodological contexts. keywords: perceived discrimination, measurement equivalence, race/ethnicity, everyday discrimination scale (eds), culture  spencer, chen, yip, & takeuchi, 2007; kessler, michelson, & williams, 1999; pascoe & smart richman, 2009; pieterse, todd, neville, & carter, 2012; ryff, keyes, & huges, 2003; williams & mohammed, 2009). one of the most widely used measures for perceived discrimination is the everyday discrimination scale (eds; williams, yu, jackson, & anderson, 1997). the eds has been developed to capture aspects of interpersonal discrimination that are chronic or episodic but generally minor (williams & mohammed, 2009). an original version of the eds consists of nine items on a 6-point likert-type response format, with modified versions of the eds having different numbers of items (e.g., chan, tran, & nguyen, 2012; lewis, yang, jacobs, & fitchett, 2012) or different response formats (e.g., jang, chiriboga, kim, & rhew, 2010; lewis et al., 2012). a total possible range of the original eds is 1 to 54, with higher scores indicating higher levels of perceived discrimination. items included in the eds are daily experiences with unfair treatment such as being treated with less respect, being treated with less courtesy, being called names or insulted, and being threatened or harassed. with the reported advantages of its brevity and good utility (e.g., krieger, smith, naishadham, hartman, & barbeau, 2005; ryff et al., 2003; williams & mohammed, 2009; yoo, gee, & takeuchi, 2009), the eds has been applied to diverse racial/ethnic and cultural groups in the united states, including african americans/ blacks (e.g., barnes et al., 2004; clark, coleman, & novak, 2004; lewis et al., 2012; stucky et al., 2011; taylor, kamarck, &  perceived discrimination— defined as “a behavioral manifestation of a negative attitude, judgment, or unfair treatment toward members of a group” (pascoe & smart richman, 2009, p. 533)—is a widely used concept in psychological research and has been studied in many different types of situations. a general consensus on perceived discrimination in previous research is that it can be a chronic stressor regardless of the sources of discrimination (e.g., race/ethnicity, age, and gender), suggesting potential pathways linking to negative physical and mental health outcomes. there is ample evidence of research indicating that those experiencing greater discrimination in day-to-day life tend to have poorer physical and mental health outcomes than their counterparts (e.g., gee,  this article was published online first april 7, 2014. giyeon kim, center for mental health and aging and department of psychology, the university of alabama; martin sellbom, research school of psychology, the australian national university; and katy-lauren ford, department of psychology, the university of alabama. this research is supported by grant k01ag045342 from the national institute on aging. funding for the collaborative psychiatric epidemiology surveys (cpes) was provided by national institute of mental health grants u01-mh60220, u01-mh57716, u01-mh062209, and u01mh62207. correspondence concerning this article should be addressed to giyeon kim, center for mental health and aging and department of psychology, the university of alabama, box 870315, tuscaloosa, al 35487-0315. e-mail: giyeon.kim@ua.edu 892  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  race/ethnicity and everyday discrimination scale  shiffman, 2004; williams et al., 1997), hispanics/latinos (e.g., lewis et al., 2012; reeve et al., 2011), and asians (e.g., bernstein, park, shin, cho, & park, 2011; chan et al., 2012; gee et al., 2007; lewis et al., 2012; jang et al., 2010). the eds has also been used with international populations such as south africans (williams et al., 2008). with regard to its psychometric properties, previous studies reported good reliability and validity of the eds (bernstein et al., 2011; clark et al., 2004; jang et al., 2010; krieger et al., 2005). for example, in a study of black adolescents, clark and colleagues (2004) reported that the eds items measured a similar construct, with an alpha reliability coefficient of .87 and item–total correlations ranging from .50 to .70. the eds items comprised a single component showing one factor yielded from a principal component analysis with 49.34% of the standardized variance accounted for. studies on korean immigrants (bernstein et al., 2011; jang et al., 2010) reported .90 or higher alpha reliability coefficients of the eds. measurement equivalence (or measurement invariance) of the eds, however, has not been extensively researched. given that items included in the eds are based on qualitative data from interviews with african americans/blacks (essed, 1990 & 1991), it is essential to establish measurement equivalence of the eds further across diverse racial/ethnic groups for more accurate and meaningful cross-cultural comparisons of perceived discrimination. a number of researchers (e.g., kim, 2010; markides, liang, & jackson, 1990; van de vijver, 2001) have suggested that measurement equivalence requires at least three interrelated conditions (i.e., conceptual, metric, and structural equivalence), which constitutes a hierarchy in that conceptual equivalence is required for metric equivalence, and both conceptual and metric equivalence are required for structural equivalence. given that the full version of metric equivalence means all corresponding factor loadings are invariant across groups and that the full metric equivalence is difficult to achieve, some researchers (e.g., byrne, shavelson, & muthen, 1989; gregorich, 2006; knight, roosa, & umana-taylor, 2009) proposed to rely upon partial factorial invariance rather than full factorial invariance, especially for cross-cultural comparisons. an example of partial metric invariance would be that in a onefactor model with five items, four of five factor loadings may be invariant, whereas the fifth differs across groups (gregorich, 2006). two recent studies have specifically examined the effect of race/ethnicity on the measurement equivalence of the eds (lewis et al., 2012; chan et al., 2012). lewis et al. (2012)—in their study of middle-aged women from five racial/ethnic groups including caucasians, african americans, chinese, hispanics, and japanese—found from their differential item functioning (dif) analyses that three items included in the modified 10-item version of the eds were biased by race/ethnicity. the three race/ethnicity-biased items were: “you receive poorer service in restaurants or stores” (item 3), which functioned differently for african american women than for most other racial/ethnic groups; “people act as if they think you are dishonest” (item 6), which functioned similarly for african american women and other racial/ethnic minority (chinese, japanese, and hispanic) women but functioned differently for caucasian women; and “you are treated with less courtesy” (item 1), which functioned differently for hispanic women compared with african american women. in another measurement equivalence study of the eds, chan and colleagues (2012) re-  893  ported that the original nine-item version of the eds did not function similarly between chinese and vietnamese american groups, although information on item-level analysis was not available. the authors noted that after deleting four items (“people act as if they are afraid of you” [item 5], “people act as if they think you are dishonest” [item 6], “you are called names or insulted” [item 8], and “you are threatened or harassed” [item 9], which capture a perceived sense of unfair treatment) based on results from exploratory factor analysis, the modified five-item version of the eds was comparable between chinese and vietnamese americans (chan et al., 2012). chan and colleagues (2012) also reported that the reliability coefficients of the modified five-item version of the eds remained good for both vietnamese ( .90) and chinese ( .87), with some minor changes in the reliability coefficients from the original nine-item version for both groups ( .92 for vietnamese; .88 for chinese). regarding the factor structure, the authors noted that the modified five-item model of the eds was better than the full nine-item model for both the vietnamese and chinese groups, with a much better model fit for the chinese group compared to the vietnamese group (chan et al., 2012). these two studies may indicate potential qualitative differences in the meaning of perceived discrimination across racially/ethnically and cultural diverse groups. given the observed racial/ethnic bias in the eds items in these recent studies (lewis et al., 2012; chan et al., 2012), more comprehensive racial/ethnic comparisons of the measurement equivalence of the eds should be conducted, especially using a nationally representative sample in order to establish measurement equivalence of perceived discrimination. considering strong needs for more research on measurement equivalence issues of discrimination scales, the present study focused on testing measurement bias in the eds across four major racial/ethnic groups in the united states (i.e., non-hispanic whites, blacks, hispanics/latinos, and asians) drawn from nationally representative data. this investigation will further advance science and increase knowledge in psychological and health disparities research.  method sample data were drawn from the collaborative psychiatric epidemiology surveys (cpes, 2001–2003; alegria, jackson, kessler, & takeuchi, 2008). the cpes is a combined data set of three nationally representative data sets including the national comorbidity study–replication (ncs-r; kessler & merikangas, 2004), the national survey of american life (nsal; jackson et al., 2004), and the national latino and asian american study (nlaas; alegria et al., 2004). funded by the national institute of mental health (nimh), the cpes data collections used a multistage area probability sampling method. face-to-face interviews were conducted unless a telephone interview was specifically requested or a face-to-face interview was not feasible. the cpes was selected for the present study because of its inclusion of (a) an original version of the eds measure and (b) diverse racial/ethnic groups, despite the fact that the data were collected about a decade ago. the current analyses utilized 10,656 adults aged 18 or older who responded to items in the eds from four racial and ethnic groups: 884 non-hispanic whites, 4,950 blacks, 2,733 hispanics/  
  kim, sellbom, and ford  894  table 1 descriptive characteristics of the sample across four racial/ethnic groups  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  m sd (range) or % variable  white  black  hispanic/latino  asian  f or ( 2)  age (years) female married educational attainment less than high school high school diploma some college household income perceived discrimination  47.43 16.89 (18–91) 58.1% 48.1%  42.45 16.06 (18–94) 63.4% 36.7%  40.61 15.66 (18–97) 55.8% 61.3%  41.21 14.76 (18–95) 52.4% 70.3%  44.723ⴱⴱⴱ (88.72ⴱⴱⴱ) (88.72ⴱⴱⴱ) (998.513ⴱⴱⴱ)  16.7% 33.0% 50.2% 43k 34.0k 17.12 6.78 (6–53)  23.7% 35.7% 50.6% 34k 31.0k 19.82 8.12 (1–54)  37.6% 25.2% 37.1% 45k 45.5k 15.81 7.45 (4–54)  15.1% 17.6% 67.3% 73k 58.7k 15.84 6.55 (1–54)  411.865ⴱⴱⴱ 230.191ⴱⴱⴱ  note. k 1,000. ⴱⴱⴱ p .001.  latinos, and 2,089 asians. seven individuals who had missing values on all of the eds items were excluded. as described in table 1, background characteristics of the four racial/ethnic groups varied significantly (all ps .001). with the mean age of 42.1 years (sd 15.88, range 18 –97), the hispanic/latino group was the youngest (m 40.6, sd 15.66), and the non-hispanic white group (m 47.4, sd 16.89) was the oldest. more than half were female for all four racial/ethnic groups showing significant racial/ethnic differences: blacks included more females (63.4%), while asians included relatively fewer females (52.4%). asians were more likely than other racial/ethnic groups to have higher levels of education and income (percentage with some college or higher education 67.3%; mean sd of annual household income 73k 58.7k). hispanics/latinos had lower levels of educational attainment (percentage with some college or higher education 37.1%), and blacks had lower levels of annual household income (m 34k, sd 31k) compared with other groups.  measures race/ethnicity. respondents were categorized into four racial and ethnic groups (non-hispanic white, black, hispanic/latino, and asian) in accordance with the u.s. census definition. everyday discrimination scale. the eds (williams et al., 1997) measures chronic and routine unfair treatment in everyday life. adopted from the detroit area study, respondents were asked to report how often they experience unfair treatment in their day-to-day life on a 6-point likert-type response format. response categories ranged from 1 (never) to 6 (almost every day), with higher scores indicating greater perceived discrimination. the nine items included in the eds are “you are treated with less courtesy than other people are” (item 1), “you are treated with less respect than other people are” (item 2), “you receive poorer service than other people at restaurants or stores” (item 3), “people act as if they think you are not smart” (item 4), “people act as if they are afraid of you” (item 5), “people act as if they think you are dishonest” (item 6), “people act as if they’re better than you are” (item 7), “you are called names or insulted” (item 8), and “you are threatened or harassed” (item 9). the internal consistency for the eds was acceptable; cronbach’s was .88 and mcdonald’s was .85. distribution statistics (i.e., skewness and kurtosis) indi-  cated univariate normality (skewness 2; kurtosis 7; see curran, west, & finch, 1996) for items 1–7 but minor violations for items 8 (skewness 2.05) and 9 (skewness 2.49, kurtosis 8.67).  data analysis although the eds has been considered unidimensional, we first conducted an exploratory factor analysis (efa) to determine whether multiple latent constructs explain variance in these indicators. for the primary analyses, confirmatory factor analysis (cfa) was used to estimate a measurement model using mplus 7.0 (muthen & muthen, 2012). because some individual eds items did not meet criteria for univariate normality, we used a robust maximum likelihood estimator to account for violations to multivariate normality.1 model fit was evaluated using the satorrabentler-scaled chi-square statistic (s-b 2), comparative fit index (cfi), tucker–lewis index (tli), root-mean-square error of approximation (rmsea), and standardized root-mean-square residual (srmr). since chi-square statistics are heavily influenced by sample size, cfi, tli, rmsea, and srmr are better estimates of violations to model fit in a large sample (little, 2013). cfi and tli values greater than 0.90 and rmsea values up to 0.08 indicate acceptable fit (kline, 2011; little, 2013). furthermore, for measurement invariance testing across groups, chi-square difference tests have been found too stringent, particularly when using very large sample sizes. we therefore used  cfi .01 (cheung & rensvold, 2002; meade, johnson, & braddy, 2008) and overlapping 90% rmsea confidence intervals to indicate invariance at the measurement (i.e., indicator) level (little, 2013). for latent parameters, however, robust chi-square difference testing was used (little, 2013), as most simulation studies to date have focused on measurement invariance rather than structural invariance. 1 some readers may question why we did not consider eds items ordered categorical data and thus used a robust weighted least squares estimator. we preferred the robust maximum likelihood estimator here due to its flexibility and simulation studies showing that items with five or greater categories can be estimated via maximum likelihood with minimal bias (johnson & creech, 1983).  
  race/ethnicity and everyday discrimination scale  age and gender were used as covariates in all cfa analyses (i.e., representing a multiple indicators multiple indicator causes [mimic] model). the mimic model was used to statistically control for potential demographic confounders such as age and gender, as they are known to be correlated with perceived discrimination (lewis et al., 2012).  results  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  exploratory factor analysis: a test of unidimensionality an efa was conducted first to determine if the eds items were indicated by more than one latent factor. we used maximumlikelihood estimation with robust scaling to extract the optimal number of factors in conjunction with horn’s (1965) parallel analysis. results from the parallel analysis indicated that the first three eigenvalues from the actual data were 4.96, 0.97, and 0.73; the first three corresponding 95th percentile random data eigenvalues were 1.05, 1.03, and 1.02. in addition to the traditional kaiser (1960) criterion of an eigenvalue of 1.00 or greater for a viable factor, these parallel analysis results clearly support a onefactor solution and, thus, unidimensionality.  confirmatory factor analysis: one-factor model next, we estimated a one-factor cfa model with age and gender as covariates separately in all four racial/ethnic groups, as it is appropriate to determine a well-fitting model in all individual groups prior to testing for measurement invariance (byrne, 2011). table 2 shows model fit statistics for each racial/ethnic group for the initial model. the results showed poor model fit in all four racial/ethnic groups for the initial model. we therefore examined whether respecification would improve model fit by consulting modification indices. more specifically, since we were working with a one-factor model, we examined estimating correlated residuals (or more appropriately, item uniquenesses) that could be justified for conceptual reasons. in all four racial/ethnic groups, estimating correlated uniquenesses for items 1 and 2 would be associated with the greatest decrement in the chi-square statistic.  895  we believed that this modification could be applied based on conceptual grounds (both items clearly reflect underlying lack of respect). model fit statistics improved substantially, but the incremental fit indices (cfi and tli) fell within the borderline range (.897–.928 for cfi; .867–.907 for tli) across the four groups. we therefore consulted modification indices again and determined that correlated item uniquenesses for items 8 and 9 were associated with the greatest improvement in model fit in all four groups. this modification would also be applied based on conceptual grounds, in that both items concern overt maltreatment (i.e., insults, threats, harassment) not captured in other items. this modification improved model fit to an acceptable level in all four groups (see table 2). figure 1 shows the overall covariance parameter estimates for the final model.  measurement invariance tests our next step was to examine measurement invariance to determine whether the underlying latent constructs are equivalent across four racial/ethnic groups, following procedures and recommendations by meredith (1993) and little and slegers (2005). results are presented in table 3. a model in which indicator loadings and thresholds were freely estimated served as the baseline (or configural) model. this model met criteria for acceptable model fit. next, we estimated a model in which indicator loadings were constrained to be equal across the four groups (i.e., weak invariance) and used the cfi and rmsea confidence intervals to evaluate potential differences in model fit relative to the configural model. as seen in table 3, there was evidence for weak invariance in multigroup comparisons for both the model with and the model without correlated residuals. finally, we examined a model in which both indicator loadings and thresholds were constrained to be equal across groups (i.e., strong invariance) and compared this model to the weak invariance model. as shown in table 3, there was no evidence for strong measurement invariance. as such, we consulted the modification indices to determine whether freeing up the intercept for a particular group (or groups) would meet criteria for partial strong invariance. indeed, allowing the intercept for item 7 (“people act as if they’re better than you are”) to be freely estimated in the hispanic/latino and asian  table 2 cfa model fit statistics for separate racial/ethnic group one-factor models model   2  df  white black hispanic/latino asian  345.82 2,003.55 908.89 904.22  43 43 43 43  white black hispanic/latino asian  140.35 798.68 308.91 317.77  41 41 41 41  p  cfi  tli  rmsea (90% ci)  srmr  original models  .001 .840  .001 .838  .001 .856  .001 .833  .799 .797 .820 .791  .089 (.081, .098) .096 (.092, .100) .086 (.081, .091) .098 (.092, .104)  .053 .056 .050 .053  final respecified models  .001 .947 .931  .001 .938 .918  .001 .956 .941  .001 .946 .929  .052 (.043, .062) .061 (.057, .065) .049 (.044, .054) .057 (.051, .063)  .037 .036 .030 .035  note. final respecified models include correlated uniquenesses for items 1 and 2 and items 8 and 9. cfa confirmatory factor analysis; cfi comparative fit index; tli tucker–lewis index; rmsea root-meansquare error of approximation; ci confidence interval; srmr standardized root-mean-square residual.  
  kim, sellbom, and ford  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  896  figure 1.  overall covariance parameter estimates. eds everyday discrimination scale.  groups, while constraining all other intercepts to be equivalent, met criteria for partial strong invariance. for item 7, the hispanic/ latino and asian groups had significantly lower intercepts relative to the white and black groups, meaning that lower levels of the underlying latent construct are needed for higher scores on this item for hispanic/latino and asian groups relative to the other racial/ethnic groups.  latent means, variances, and effect sizes across racial/ethnic groups finally, group differences on latent parameters were examined. because this was a one-factor model, we focused on only latent variances and means across groups. using the same multigroup comparisons described earlier, we first examined whether the variances in the latent factor were invariant across groups. we  table 3 measurement invariance tests across four racial/ethnic groups model  s-b 2  df  cfi   cfi  rmsea (90% ci)  1. configural 2a. weak 2b. weak with cu 3a. strong 3b. partial strong  1,511.65 1,698.28  164 188  .945 .938  .007  .056 (.053, .058) .055 (.053, .057)  1,720.27 2,290.75 1,950.46  194 212 210  .938 .915 .929  .007 .023 .009  .054 (.052, .057) .061 (.058, .063) .056 (.054, .058)  note. cu correlated uniquenesses are estimated to be equivalent; s-b satorra-bentler; cfi comparative fit index; rmsea rootmean-square error of approximation; ci confidence interval.  constrained these to be equal and then compared the model fit (using s-b 2 difference test) to that of the weak invariance (with equivalent correlated uniquenesses) model (see table 3). the results indicated that latent variances were not equivalent across groups ( 2 73.30, df 3, p .001). we therefore consulted modification indices, which supported freeing the latent variances in the black and hispanic/latino groups; this modification resulted in a model that was otherwise equivalent to the comparison model ( 2 0.78, df 1, p .382). table 4 shows the latent variances of each group. next, we examined latent means differences across groups. using the partial strong invariance model as baseline (see table 3), we constrained the latent means to be equal across the groups. this constraint was not tenable ( 2 87.16, df 3, p .001). we subsequently allowed the latent means for the black and asian groups to be freely estimated; this resulted in an otherwise equivalent model ( 2 3.27, df 1, p .071). table 4 shows the latent means and variances, as well as estimated effect sizes for group differences (in d units). table 4 latent means, variances, and effect size differences across racial/ethnic groups latent d variable  m  variance  2  3  4  1. white 2. black 3. hispanic/latino 4. asian  0.00a 0.46b  0.26ac  0.46c  1.00 1.81 1.49 1.11  0.35 —  0.22 0.55 —  0.44 0.73 0.17 —  note. means with different subscripts are not equivalent (per invariance analyses).  
  race/ethnicity and everyday discrimination scale  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  discussion in our attempt to identify the effect of race/ethnicity on measurement equivalence of the eds, we found evidence for the overall invariant underlying construct of the eds across four racial/ethnic groups from non-hispanic whites, blacks, hispanics/latinos, and asians, as well as the lack of invariance for one item (item 7, “people act as if they’re better than you are”) showing lower intercepts for hispanics/latinos and asians than for blacks and non-hispanic whites. this suggests that when the eds is used to measure perceived discrimination, the concept of discrimination regardless of the sources of perceived discrimination (e.g., race/ethnicity, age, gender) is in general perceived equivalently across different racial/ethnic groups in the united states. previous studies using modified versions of the eds (e.g., different numbers of items) also supported a one-factor model across different racial/ethnic groups (chan et al., 2012; lewis et al., 2012). however, findings on the nonequivalent item across racial/ethnic groups suggest that the perceived discrimination construct overpredicted responses to the item “people act as if they’re better than you are” for hispanics/latinos and asians compared to blacks and non-hispanic whites, which requires researchers’ careful attention. it was also evidenced that blacks scored higher on the latent construct compared to other racial/ethnic groups, whereas asians scored lower on the latent construct compared to whites and hispanics/latinos. the most intriguing finding was the lack of invariance for the item “people act as if they’re better than you are” across different racial/ethnic groups. it took a lower level of the perceived discrimination latent construct to score higher on this item in the hispanic/latino and asian groups relative to the non-hispanic white and black groups. when interpreting this item bias, researchers should first understand that true mean differences in the perceived discrimination construct across different racial/ethnic groups can occur with or without item bias and that the true mean differences in the perceived discrimination construct do not yield item bias in the eds by race/ethnicity. this item bias occurs when individuals in the same mean perceived discrimination construct, belonging to different racial/ethnic groups, have differential responses. mchorney and fleishman (2006) noted in their epilogue of the special issue on measurement equivalence issues in diverse populations that explaining the occurrence of bias in terms of meaningful psychological constructs is one of the crucial goals of measurement equivalence research. among many potential sources of bias, overendorsement on this item by hispanics/ latinos and asians relative to non-hispanic whites and blacks may be related to hispanics/latinos and asians’ susceptibility to cultural superiority that may be translated to discrimination experiences. it is also possible that the immigration-related factors such as nativity and acculturation might have predisposed hispanic/latino and asian individuals’ greater responses to this item, especially compared to blacks. in addition, given that the cpes data were collected when immigration had taken on very negative connotations in some parts of the united states, more recently immigrated participants could be more sensitive to this particular item, which may reflect real differences in the perceptions of discrimination of these immigrant  897  groups rather than bias in item functioning. although further specific reasons for the item bias are not clear, researchers applying the eds to hispanics/latinos or asians should be careful about the potential risk for overendorsement of this item by these racial/ethnic groups. a previous study examining measurement equivalence of the eds (lewis et al., 2012) did not find any evidence of racial/ethnic bias in this particular item. differences in results may be due to the use of different samples and response formats between lewis et al. (2012) and our study. our analyses used both men and women from nationally representative data, whereas only women were included in lewis et al.’s study. in addition, our study used the original 6-point likert-type response format, whereas lewis et al. used a revised 4-point likert-type response format. researchers should further elucidate potential reasons for the different racial/ethnic responses to this item. additional racial/ethnic-specific findings warrant further discussion. in accordance with previous research (lewis et al., 2012), evidence from the present study suggests that blacks’ experiences with unfair treatment in their day-to-day life are greater than those of all other racial/ethnic groups. previous studies investigating differential item functioning (dif) in depressive symptom items also found that blacks had different responses to items relating to perceived discrimination (e.g., “people were unfriendly” and “i felt people disliked me”; blazer, landerman, hays, simonsick, & saunders, 1998; kim, chiriboga, & jang, 2009), which may be related to their history of lower social status (kim et al., 2009). blacks’ higher score on the latent construct found in the present study may be due to items included in the eds scale being adopted from qualitative work on blacks (essed, 1990, 1991), in that essential components of blacks’ experiences with day-to-day discrimination might have been well represented in the eds scale, whereas some potentially important components of day-to-day discrimination experiences among other diverse racial/ethnic groups might not have been accounted for. in addition, in accordance with a previous study conducted by lewis et al. (2012), asians were less likely than other racial/ethnic groups to report their experiences with unfair treatment in their day-to-day life, which may be related to the “model minority” image of asian americans in the united states. however, given that asian americans are heterogeneous in terms of their immigration history, language, culture, and socioeconomic status, their everyday discrimination experiences may vary dramatically by ethnicity, which requires further investigation. some study limitations should be noted. first, given that our main focus was cross-racial/ethnic comparisons of the eds, the present study did not consider ethnic subgroup differences. given the reported heterogeneous characteristics of ethnic subgroups within blacks, hispanics/latinos, and asians (hajat, lucas, & kington, 2000; kim et al., 2010), future research should examine potential differences in responses to the eds items across different subgroups within each racial/ethnic group (e.g., african americans vs. caribbean blacks). second, other important background characteristics of racial/ethnic groups such as educational attainment and immigration-related factors (e.g., nativity, generational status, and english-speaking ability) were not considered as covariates in the present analyses due to the lack of evidence of the effects of these variables on the  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  898  kim, sellbom, and ford  construct underlying the eds in previous research. given that not many national surveys try to capture linguistic diversity among ethnic minority participants, it is possible that many monolingual spanish- or asian language-speaking individuals may not be included these survey data, suggesting that more limited english-proficient hispanics/latinos and asians might have been represented in these data. thus, further analyses on the influence of educational attainment and immigration-related factors (particularly language use) on measurement equivalence of the perceived discrimination will add to the current literature. third, it is possible that perceived discrimination measured about a decade ago may be different from the concept measured more recently. given the fact that the cpes contains 10-year-old data, results presented in this study should be interpreted with caution and thus should be replicated with more recent data. fourth, although examining differential correlates of the eds by race/ethnicity would add to the existing literature, concurrent measures of the eds were not available in a combined cpes data set of three different national surveys. future research should further examine racial/ethnic differences in correlates of the eds. lastly, qualitative analyses would be helpful to better understand how the individual items and the perceived discrimination construct are perceived. notwithstanding these limitations, the present study holds significant implications and strengths. it should be emphasized that this may be one of the few studies examining the measurement equivalence of the eds across four major racial/ethnic groups in the united states, especially using a very large, nationally representative data set. unlike previous studies demonstrating the measurement equivalence of the eds in samples of two ethnic groups or racially/ethnically diverse women from limited geographic areas (chan et al., 2012; lewis et al., 2012), we made a broad comparison of racially/ethnically diverse adults across the entire united states. findings from the present study indicate that racially/ethnically diverse minority adults in the united states in general perceive, experience, and report their everyday discrimination similarly, which may also imply that researchers can compare the concept of perceived discrimination meaningfully across different racial/ethnic groups with relatively little risk of cultural bias. one biased item identified in the present study, however, should be carefully used in the hispanic/latino and asian groups. given that the term “perceived discrimination” is widely used in psychological and health disparities research, researchers should clearly understand consequences of using nonequivalent perceived discrimination items for comparison and establish measurement equivalence of the existing discrimination scales such as the experiences of discrimination scale (krieger, 1990), the schedule of racist events (landrine & klonoff, 1996), and the racism and life experiences scale (harrell, 1997) before diverse racial/ethnic groups are compared. in addition, given the identified race/ethnicity-specific experiences of and responses to day-to-day discrimination, researchers might want to consider developing culture- or race/ethnicity-specific discrimination scales. in conclusion, the eds can be used to measure perceived discrimination across diverse racial/ethnic groups as originally intended with some caution on racial/ethnic-specific responses to everyday discrimination experiences. however, researchers  should be aware of the potential risk that, compared to other racial/ethnic groups, blacks are more susceptible to the experience of perceived discrimination and asians are less likely to report their experiences of discrimination. in addition, given the identified noninvariant “people act as if they’re better than you are” item among hispanics/latinos and asians, researchers should be careful when interpreting results from the eds across diverse racial/ethnic groups, especially hispanics/latinos or asians. further investigation should focus on structural equivalence of the eds. researchers should pay more attention to measuring perceived discrimination accurately and comprehensively. given that stressful experiences are influenced by many factors and thus should be understood in cultural, historical, and social contexts (williams & mohammed, 2009), cross-national equivalence of the perceived discrimination items should be further investigated.  references alegria, m., jackson, j. s., kessler, r. c., & takeuchi, d. 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(1993). measurement invariance, factor analysis and factorial invariance. psychometrika, 58, 525–543. doi:10.1007/bf02294825 muthen, l. k., & muthen, b. o. (2012). mplus 7: statistical analysis with latent variables: user’s guide. los angeles, ca: muthen & muthen. pascoe, e. a., & smart richman, l. (2009). perceived discrimination and health: a meta-analytic review. psychological bulletin, 135, 531–554. doi:10.1037/a0016059 pieterse, a. l., todd, n. r., neville, h. a., & carter, r. t. (2012). perceived racism and mental health among black american adults: a meta-analytic review. journal of counseling psychology, 59, 1–9. doi: 10.1037/a0026208 reeve, b. b., willis, g., shariff-marco, s. n., breen, n., williams, d. r., gee, g. c., . . . levin, k. y. (2011). comparing cognitive interviewing and psychometric methods to evaluate a racial/ethnic discrimination scale. field methods, 23, 397– 419. doi:10.1177/1525822x11416564 ryff, c. d., keyes, c. l., & huges, d. l. (2003). status inequalities, perceived discrimination, and eudaimonic well-being: do the challenges of minority life hone purpose and growth? journal of health and social behavior, 44, 275–291. doi:10.2307/1519779 stucky, b. d., gottfredson, n. c., panter, a. t., daye, c. e., allen, w. r., & wightman, l. f. (2011). an item factor analysis and item response theory-based revision of the everyday discrimination scale. cultural diversity and ethnic minority psychology, 17, 175–185. doi:10.1037/ a0023356 taylor, t. r., kamarck, t. w., & shiffman, s. (2004). validation of the detroit area study discrimination scale in a community sample of older african american adults: the pittsburgh healthy heart project. international journal of behavioral medicine, 11, 88 –94. doi:10.1207/ s15327558ijbm1102_4 van de vijver, f. (2001). the evolution of cross-cultural research methods. in d. matsumoto (ed.), the handbook of culture and psychology (pp. 77–97). new york, ny: oxford university press.  
  900  kim, sellbom, and ford  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly. all rights, including for text and data mining, ai training, and similar technologies, are reserved.  williams, d. r., gonzalez, h., williams, s., mohammed, s., moomal, h., & stein, d. (2008). perceived discrimination, race, and health in south africa. social science & medicine, 67, 441– 452. doi:10.1016/j .socscimed.2008.03.021 williams, d. r., & mohammed, s. a. (2009). discrimination and racial disparities in health: evidence and needed research. journal of behavioral medicine, 32, 20 – 47. doi:10.1007/s10865-008-9185-0 williams, d. r., yu, y., jackson, j., & anderson, n. b. (1997). racial differences in physical and mental health: socio-economic status, stress, and discrimination. journal of health psychology, 2, 335–351. doi: 10.1177/135910539700200305  yoo, h. c., gee, g. c., & takeuchi, d. (2009). discrimination and health among asian american immigrants: disentangling racial from language discrimination. social science & medicine, 68, 726 –732. doi:10.1016/ j.socscimed.2008.11.013  received april 3, 2013 revision received january 22, 2014 accepted february 20, 2014 䡲  
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       development of a spiritual abuse questionnaire  a dissertation submitted in partial fulfillment of the requirements for the degree of doctor of philosophy in the graduate school of the texas woman's university  college of arts and sciences by kathryn hope keller  denton, texas august 2016  
  dedication this dissertation is dedicated to all who have sufferred from spiritual trauma. may the depth of pain be restored a hundred-fold in healing, peace, and joy.  iii  
  acknowledgments i would like to thank my dissertation committee members. dr. stabb, my chairperson, has been a mentor to me throughout my time in my doctoral program. she has mentored me academically as a professor, as a clinical supervisor, and as a research mentor. i feel inspired by her interest in various topics, including the multiple dissertation ideas i had before deciding on this project. she has been a pillar for me throughout my time in the program. dr. mollen, also a significant research mentor for me as the advisor of my thesis equivalency project, has been gracious and patient while introducing me to the world of academic research. she has been encouraging and supportive both personally and professionally throughout the time i have worked with her. dr. harris has been a thoughtful and fun inspiration throughout my program from whom i have learned advanced clinical and theoretical skills. i am grateful for his kindness in checking in with me personally throughout my time at twu. dr. marshall, my stats advisor, successfully intertwined laugher with patience throughout our stats meetings. he was entertaining, encouraging, and inspiring as he walked me through the previously unknown territory that is statistics. i am thankful for each member of my committee and i am honored by the opportunity to work with each of these esteemed mentors. i would also like to acknowledge my clients over the years, several of whom have illuminated the issue of spiritual trauma. your willingness to invite me into your exploration of that which you consider most precious is an honor.  iv  
  my own spiritual legacy includes grandma and grandpa, who inspired my early interest in spirituality and faith. thanks for the years of trekking with the grandkids to glorieta and exposing us to the cultures of the world. thank you for praying for each grandkid, every night, by name. lastly, i could not have asked for a more supportive family while pursuing my doctoral degree and undertaking this project. mom, dad, kristine, and kimberly all contributed in unique ways and have tolerated and embraced my growth as i proceeded through these years of training. thank you for your unwavering support, empathy, and love.  v  
  abstract kathryn hope keller development of the spiritual abuse questionnaire august 2016 the current study initiated the development and validation a measure of spiritual abuse. multicultural and trauma treatment competencies provide the rationale for this investigation as psychologists are charged with providing ethical and sound research and treatment embodying respect and understanding clients’ various cultural and religious experiences, particularly when negative experiences adversely impact their mental health. this study synthesized existing literature on spiritual abuse and drew from that literature in the creation of the spiritual abuse questionnaire (saq). participants were recruited through social media to complete the following questionnaires: (a) the saq, (b) the religious and spiritual struggles scale (rss) (exline, pargament, grubbs, & yali, 2014), (c) the national stressful events survey for ptsd-short scale (nsess-ptsd) (kilpatrick, resnick, & friedman, 2013), (d) the institutional betrayal questionnaire version 2 (ibq.2) (smith & freyd, unpublished manuscript; smith & freyd, 2013; smith & freyd, 2014), and (e) the marlowe-crowne social desirability scale, form c (mcsd) (reynolds, 1982). the original 49-item saq was examined through exploratory factor analysis in study 1 (n 535). analysis from study 1 resulted in shortening the saq to a 20-item scale, which was analyzed with a new sample in study 2 (n 271). it vi  
  was predicted and confirmed that there would be a stable factor structure for spiritual abuse and that the saq would demonstrate appropriate convergent/divergent validity with other measures. seventeen of the questions supported a two-factor structure of spiritual abuse. further implications of spiritual abuse measurement and application are discussed.  vii  
  table of contents page dedication ................................................................................................................. iii acknowledgments ................................................................................................. iv abstract ....................................................................................................................... vi list of tables ............................................................................................................. x list of figures ........................................................................................................... xi chapter i. introduction .......................................................................................................... 1 religion and spirituality ............................................................................................ 2 trauma and abuse ..................................................................................................... 6 spiritual abuse .......................................................................................................... 8 statement of purpose ............................................................................................... 10 definitions of terms ................................................................................................ 10 ii. review of literature...................................................................................... 12 definining spirituality and religion ....................................................................... 12 historical overview of spiritualitly and religion in psychology ..................... 14 history of psychology and religion/spirituality .................................................... 20 impact of spirituality and religion on health ................................................... 23 harmful religion: cults ..................................................................................... 27 trauma and abuse .................................................................................................. 33 examining traumatic stress in the literature ................................................... 33 historical overview of trauma ......................................................................... 34 current posttraumatic stress disorder criteria.................................................. 44 brief overview of clinical treatment of trauma ............................................. 45 differentiated forms of trauma ........................................................................ 49 spiritual abuse........................................................................................................ 56 spiritual abuse in relation to cults .................................................................. 58 spiritual abuse in relation to domestic violence ............................................ 59 spiritual abuse in relation to clergy sexual abuse ......................................... 62 spiritual abuse literature .................................................................................. 66 viii  
  spiritual abuse is abuse .................................................................................... 70 emerging definitions of spiritual abuse .......................................................... 72 instrument development ......................................................................................... 75 psychometrics .................................................................................................... 76 current instruments ........................................................................................... 77 summary ................................................................................................................. 82 rationale for study ................................................................................................. 83 multicultural competency ................................................................................. 83 trauma treatment competency ........................................................................ 85 health and well-being ....................................................................................... 86 relevance to counseling psychology ..................................................................... 87 a word of caution............................................................................................. 88 research questions and hypotheses ...................................................................... 88 iii. methodology ..................................................................................................... 90 study one: scale creation and exploratory factor analysis ................................. 90 participants .............................................................................................................. 90 instrumentation ....................................................................................................... 94 spiritual abuse questionnaire ........................................................................... 94 religious and spiritual struggles (rss) scale .................................................. 96 national stressful events survey ptsd short scale (nsess-ptsd) .............. 97 institutional betrayal questionnaire version 2 (ibq.2) .................................... 97 marlow-crowne social desirability scale, form c .......................................... 98 procedure ................................................................................................................ 99 statistical analyses ............................................................................................... 100 descriptive statistics ........................................................................................ 100 exploratory factor analysis ............................................................................ 100 study two: confirmatory factor analysis ........................................................... 101 participants ............................................................................................................ 101 instrumentation and procedure ............................................................................. 105 statistical analysis ................................................................................................ 106 hypotheses and analysis for study one and study two ..................................... 106 iv. results ................................................................................................................. 109 study one: preliminary analysis.......................................................................... 109 study one: descriptive statistics.......................................................................... 109 study one: analysis of hypothesis ...................................................................... 110 research question #1: factor analysis of the saq ............................................. 110 hypothesis one ................................................................................................ 111 factor one: abuse of power ............................................................................ 114 ix  
  factor two: conditionality .............................................................................. 114 factor three: spiritual injury .......................................................................... 114 factor four: suppression of expression .......................................................... 115 research question #2: saq’s relationship with other instruments ................... 115 hypothesis two ............................................................................................... 118 hypothesis three ............................................................................................. 118 hypothesis four ............................................................................................... 118 hypothesis five ............................................................................................... 119 study two: preliminary analysis ......................................................................... 119 study two: descriptive statistics ......................................................................... 119 study two: analysis of hypothesis ..................................................................... 120 research question #1: factor analysis of the saq ............................................. 120 hypothesis one ................................................................................................ 121 research question #2: saq’s relationship with other instruments .............. 124 hypothesis two ............................................................................................... 127 hypothesis three ............................................................................................. 127 hypothesis four ............................................................................................... 127 hypothesis five ............................................................................................... 128 v. discussion ........................................................................................................... 129 summary of major findings ................................................................................. 129 factor structure of the saq (hypothesis one) ............................................... 129 examination of convergent and divergent validity (hypothese 2, 3, and 4) ...... 130 hypothesis two ............................................................................................... 130 hypothesis three ............................................................................................. 131 hypothesis four ............................................................................................... 131 hypothesis five ............................................................................................... 131 implications for theory and integration with previous literature ....................... 131 implications for clinical training and practice .................................................... 138 strengths, limitations, and future research directions ...................................... 143 strengths .......................................................................................................... 143 limitations ....................................................................................................... 144 directions for research.................................................................................... 145 conclusion ............................................................................................................ 147 references ............................................................................................................... 148  x  
  list of tables table  page  1. herman’s seven criteria for complex ptsd ............................................................. 52 2. characteristics of the sample for study one .............................................................. 91 3. characteristics of the sample for study two ........................................................... 102 4. hypotheses and analyses ......................................................................................... 106 5. descriptive statistics for study one ......................................................................... 109 6. component correlations for study one ................................................................... 111 7. exploratory factor analysis: eigenvalues, percentages of variance, and cumulative percentages of variance ........................................................................ 112 8. scale correlations for study one ............................................................................. 115 9. descriptive statistics for study two ........................................................................ 119 10. scale correlations for study two ............................................................................. 124  xi  
  list of figures table  page  1. scree plot .................................................................................................................. 111 2. overall analysis plan for saq development with cfa and efa results ................. 119  xii  
  chapter i introduction the term spiritual abuse was coined in the early 1990s by a church pastor and a counselor who observed the phenomenon in their respective professions (johnson & van vonderen, 1991). they defined spiritual abuse as, “the mistreatment of a person who is in need of help, support, or greater spiritual empowerment, with the result of weakening, undermining, or decreasing that person’s spiritual empowerment” (p. 20). johnson and van vonderen went on to clarify that the spiritual disempowerment occurs when leaders use their “spiritual position to control or dominate another person” (p. 20) and when “power is used to bolster the position or needs of a leader” (p. 21). the concept of empowerment is complex and integrates several dimensions including personality, belief, and motivation (zani & palmonari, 2003). the dimensions of empowerment converge into a felt sense of one’s control over their environment. since johnson and van vonderen articulated the concept of spiritual abuse, themes of spiritual abuse have been identified in the academic literature through various lines of scholarship including cult literature, domestic violence literature, and clergy sexual abuse literature. several qualitative studies have highlighted consistent themes of spiritual abuse, regardless of the participants’ religious or denominational identifications, including the misuse of power, the victim’s fear, and the victim’s perceived need to perform within their religious community in order to earn favor with the leaders or with their higher power (bhaktavatsala, 2001; dehan & levi, 2009; masis, 2004; oakley, 2013a). 1  
  some people who experience spiritual abuse do so after finding themselves involved in a spiritual or religious community with which they are exploring issues of meaning, purpose, belonging, or morality. sometimes adults find themselves drawn to a group for a particular reason and they join on their own initiative. other times, children are raised by their parents in a particular religious or spiritual tradition, such as is the case for some clergy sexual abuse survivors who were abused as children. yet, seeking a spiritual or religious meaning system is a cross-cultural phenomenon and often provides benefits for those who seek a spiritual or religious connection as well as mental health benefits (koenig, mccullough, & larson, 2001). thus, spiritual abuse needs to be better understood as a phenomenon unto itself. one helpful way to advance the literature on spiritual abuse is to develop a scale measuring spiritual abuse. the theoretical grounds for this project derive from integrating the importance of religion and spirituality with current understanding of trauma and abuse to examine and expand upon the negative impact of abusive religious leaders and/or environments. a brief summary of these literatures is presented below. religion and spirituality religion and spirituality have some overlapping qualities and have historically been loosely defined in the literature (zinnbauer et al., 1997). religion is often seen as a vehicle through which spirituality is expressed. religion tends to be described as a more organized or structured system, such as the definition offered by argyle and beithallahmi (1975), who defined religion as “a system of beliefs in a divine or superhuman power, and practices of worship or other rituals directed towards such a power” (p.1). 2  
  spirituality, on the other hand, is often more elusive than religion (ratnakar & nair, 2012). vaughan’s (1991) definition of spirituality was “a subjective experience of the sacred” (p. 105) and casts a broad net for spiritual experiences that may or may not be associated with an organized religious system. researchers have started to study religion from a scientific perspective, which has yielded several approaches for understanding the phenomena of religion and spirituality (nelson, 2012). for example, the hermeneutic-phenomenological approach explores the self-interpretation of religious experiences, whereas the positivistic naturalism approach is concerned with finding universal natural laws about religion (nelson, 2012). the religious integration approach was created out of the idea of merging scientific ideals with religious insights. religious integration gave birth to several microtheories, which are theories that look at singular components of religious experiences (e.g., forgiveness). all three approaches form the philosophical foundation for the broader areas of the scientific study of religion including the cognitive science of religion, evolutionary psychology of religion, and cultural psychology of religion. the cognitive science of religion concerns itself with the cognitive structures that are involved in religious actions and thoughts (barrett, 2011). individuals who espouse the cognitive science of religion believe humans have natural cognitive biases that are independent from cultural influences and therefore they reject the supremacy of cultural relativism. evolutionary psychologists of religion believe that humans evolved in response to their environments and that religious beliefs may have served a kind of evolutionary function (kirkpatrick, 2013). evolutionary psychologists are concerned with 3  
  why psychological phenomena occur in addition to what cognitive mechanisms are involved and how such cognitive mechanism were designed. evolutionary psychologists have varying views on the evolutionary utility of religious beliefs and they offer a helpful theoretical contribution to the scientific study of religion. cultural psychologists of religion tend to value individuals as a whole and integrate both qualitative and quantitative research methods in an attempt to try to understand individuals’ subjective experiences. cultural psychologists of religion tend to attribute individuals’ religious behaviors to cultural phenomena (belzen, 2010a). there are several historical figures in the history of the psychology of religion and spirituality. wilhelm wundt and william james both included writings about religion in their early exploration of psychology (james, 1902; rambo & haar farris, 2012). freud offered critical views of religion; earlier in his career he viewed religion as a neuroses (fukuyama, puig, baggs, & wolf, 2014) and later in his career he viewed religion as arising out of a need to defend the self from the “terrors of nature” (soenke, landau, & greenberg, 2013, p. 106). in contrast to freud, jung had positive views of religion, particularly that religion promotes individuation, and his views remain influential to this day (rambo & haar farris, 2012). as the field of psychology progressed beyond the founders’ influences, scholarship on the psychology of religion went through several transitions. throughout the early years of the behaviorism movement, there was little to no mention of religion as if it were taboo (belzen, 2009). empirical inquiry was popular and unobservable and unmeasurable phenomena were deprioritized (powers, 2005). with the emergence of 4  
  humanistic psychology, the topic of religion and spirituality became less taboo as maslow included self-actualization, which can have spiritual elements, in his hierarchy of needs. as religion reemerged in scientific discussion and journals, several organizations and journals became dedicated to the study of psychology of religion (piedmont, 2013; powers, 2005). more recently, the influence of multiculturalism on the psychology field has further highlighted the importance of religion and spirituality as components of some individuals’ culture (powers, 2005; sue, arredondo & mcdavis, 1992). spirituality and religion have been found to have a generally positive impact on physical health (saucier & skrzypinska, 2006) and mental health (koenig et al., 2001). spirituality and religion are very important to certain individuals suffering from serious diseases as religion serves as a positive coping skill and promotes greater treatment compliance (stewart, adams, stewart & nelson, 2013). religion also assists with greater meaning both in life (saucier & skrzypinska, 2006) and regarding beliefs about an afterlife (argyle & beit-hallahmi, 1975). there are situations in which religion can be harmful; specifically, this can occur upon cult involvement. for this study, the definition of a cult offered by chambers, langone, dole, and grice (1994) will be used. they defined cults as: ...groups that often exploit members psychologically and/or financially, typically making members comply with leadership’s demands through certain types of psychological manipulation, popularly called mind control, and through the inclusion of deep-seated anxious dependency on the group and its leaders (p. 88).  5  
  despite the fact that religious and spiritual seekers do not intentionally join cults, sometimes these individuals unsuspectingly become involved in cultic groups (almendros, carrobles & rodriguez-carballeira, 2007; martin, pile, burks & martin, 1998; zimbardo, 1997). cult activity often involves elements of authoritarianism, resulting in the individuals losing their sense of self (balch, 1980; durocher, 1999). leaving a cult can be a very difficult transition for former members as they often have minimal to no social support (durocher, 1999). some researchers have described cult involvement as a traumatic experience and suggest treatments that are congruent with other forms of trauma treatments (martin, 1993; rosen, 2014). trauma and abuse trauma and abuse have been depicted in historical literature as early as history has been recorded (birmes, hatton, brunet, & schmitt, 2003). several historical events converged together that eventually led to an increased understanding of human reactions to traumatic events. such events included: the need for a legal definition of psychological injury during the industrial era (horowitz, 1986; peebles, 1989), the growing numbers of hysterical women who shared their stores with a few psychoanalysts (breuer & freud, 1937; herman, 1992b), identification of soldiers’ seemingly bizarre post-battlefield symptoms (birmes et al., 2003; mueser, rosenberg, & rosenberg, 2009), the onset of “concentration camp syndrome” after world war ii (van der kolk, 2007) and the feminist movement’s identification of family violence and its impact (gelles & straus, 1979; hilberman & munson, 1977; straus, 1977; walker, 1979). by better understanding these historical events, scholars have identified several symptoms that are now 6  
  understood to be responses to traumatic experiences. diagnostic criteria were eventually identified to provide a delineation of trauma survivors whose experiences have had severe negative impacts on their lives (american psychiatric association, 1980), the most recent of which manifest in current descriptions of post-traumatic stress disorder (ptsd; american psychiatric association, 2013). several treatments for ptsd have been studied, with most attention being focused on psychotherapy (friedman, cohen, foa, & keane., 2009; watts et al., 2013) and psychopharmacology (friedman, davidson, & stein, 2009; watts et al., 2013). as research on trauma has progressed, several forms of traumatic stress have been identified including sexual, physical, war, and natural disaster trauma. herman (1992a) developed a conceptualization for prolonged trauma that she called complex ptsd. complex ptsd provided researchers and treatment providers a framework for understanding clients who have suffered ongoing abuse, captivity, or other forms of severe traumatic stress. despite continued research on complex ptsd, it is not currently a separate diagnosis from ptsd in the diagnostic and statistical manual of mental disorders (dsm-5) (american psychiatric association, 2013). lastly, psychological and emotional abuse, which are often used interchangeably (babcock, roseman, green, & ross, 2008), have resulted in distinguishable forms of trauma that may not only result secondarily from other forms of abuse (follingstad, rutledge, berg, hause, & polek, 1990). as with many other constructs, defining psychological trauma has been wrought with difficulty (follingstad, 2007; mchugh,  7  
  rakowski, & swiderski, 2013) and researchers are in general agreement that further research is warranted on psychological trauma and abuse. the literature on psychological trauma and judith herman’s (1992b) complex ptsd conceptualization converge to support the idea that psychological abuse, or harmful and controlling messages occurring over time, can be experienced in various environments including religious or spiritual settings. when this occurs, the resulting trauma is not merely psychological; there can also be harmful spiritual implications. spiritual abuse the relatively scarce amount of spiritual abuse literature derives from literature on cults, domestic violence, clergy sexual abuse, and qualitative accounts of individuals who have suffered spiritual abuse. several overlapping themes are identified as these lines of scholarship converge, illumining the topic of spiritual abuse as its own phenomenon, differentiated from other forms of abuse. some scholars have identified that former cult members experience reactions that are similar to other forms of traumatic reactions including depression, detachment, and restricted emotions (martin, 1993). rosen (2014) conceptualized cult involvement through a trauma lens, highlighting that cult trauma is experienced in bodily form much like other kinds of trauma and can include nightmares, flashbacks, and exaggerated startle responses. martin’s recommendations for cult recovery have some similarities with judith herman’s (1992b) trauma recovery model, highlighting some parallels between cult recovery and recovery from other forms of trauma.  8  
  the domestic violence literature has historically focused on physical and sexual violence, although some researchers began to identify a spiritual component to domestic violence (adams & fortune, 1998; west, 1999). the theme of spiritual abuse surfaced during some qualitative inquiries of domestic abuse survivors (bent-goodley & fowler, 2006; dehan & levi, 2009). many women identified a spiritual component to their abuse, such as their partner preventing them from engaging in religious activities or manipulating certain religious beliefs to fit the perpetrator’s agenda. research participants agreed that the spiritual component of the abuse was different from other components such as psychological or physical abuse. clergy sexual abuse survivors have provided further insight into spiritual abuse by articulating the extreme power differential involved in their victimization (fallot & blanch, 2013; mclaughlin, 1994). often, the divine status reserved for a higher power is projected onto the human religious leader, making sexual violation all the more devastating, as if the violation had been perpetrated by the divine itself (farrell, 2004). such abuse can have detrimental consequences as the perpetrator robs the victim of the opportunity for healthy spiritual development throughout the lifespan (isely, isely, freiburger, & mcmackin 2008). resulting effects can include despair, guilt, hopelessness, and loss of a connection with what was previously considered divine (doyle, 2009). a few qualitative studies have been focused specifically on better understanding spiritual abuse among various religious settings. these studies have identified themes including power, fear, and approval-seeking performance occurring in various abusive 9  
  religious traditions (bhaktavatsala, 2001; dehan & levi, 2009; masis, 2004; oakley, 2013a). as qualitative studies have been conducted, researchers have gained a better sense of the personal experiences and impacts of spiritual abuse. statement of purpose the purpose of this investigation was to expand the knowledge of spiritual abuse by synthesizing the existing literature on spiritual abuse, identifying common themes, and utilizing this information to develop an assessment instrument for spiritual abuse. currently, no existing measures of spiritual abuse have been identified. this research provides an important contribution to a topic that is in its infancy in the literature. better understanding spiritual abuse is essential for counseling psychologists in terms of multicultural competence and targeted interventions for this unique aspect of trauma, spiritual trauma. definitions of terms cult – “...groups that often exploit members psychologically and/or financially, typically making members comply with leadership’s demands through certain types of psychological manipulation, popularly called mind control, and through the inclusion of deep-seated anxious dependency on the group and its leaders” (chambers et al., 1994, p. 88). religion – “a system of beliefs in a divine or superhuman power, and practices of worship or other rituals directed towards such a power” (argyle & beit-hallahmi, 1975, p. 1) spirituality – “a subjective experience of the sacred” (vaughan, 1991, p. 105). 10  
  spiritual abuse – “the mistreatment of a person who is in need of help, support, or greater spiritual empowerment, with the result of weakening, undermining, or decreasing that person’s spiritual empowerment” (johnson & van vonderen,1991, p. 20).  11  
  chapter ii review of literature defining spirituality and religion spirituality and religion, which encompass both overlapping and distinct characteristics, have been loosely and inconsistently differentiated in the literature (zinnbauer et al., 1997). spirituality seems to be a more elusive term that is difficult to define and wrought with obscurity, yet is often referenced in terms of a quest for purpose and meaning (ratnakar & nair, 2012). religion, on the other hand, is used to describe a social phenomenon with “particular beliefs and practices, requirements for membership, and modes of social organization” (miller & thoresen, 2003, p. 27). religiousness is defined in relation to religion, whereas spirituality may or may not be in relation to religion (ratnakar & nair, 2012). for the field of psychology, it is important to parcel out the nuances in definition to articulate a more operationalized and measured understanding of religion and spirituality. with a more nuanced understanding, researchers can expand on current research and practitioners can better serve their clients. religiosity includes ascribing to a particular system of beliefs or doctrines, such as what can be found in a particular faith and a belief in a power greater than that of human beings (a higher power) (murray, ciarocchi, & murray-swank, 2007; zinnbauer et al., 1997). zinnbauer et al. (1997) found that religiousness was correlated with higher levels of authoritarianism, religious orthodoxy, intrinsic religiousness, parental religious 12  
  attendance, self-righteousness, and worship service attendance. religiosity is often associated with a particular religious institution, such as a world religion, and is frequently socially influenced (murray et al., 2007; ratnakar & nair, 2012). these findings about religiousness contribute to the idea that religion tends to be more structured and defined than spirituality. for the current study, argyle and beithallahmi’s (1975) definition of religion was used as their definition encapsulates many of the themes in the literature around the illusive definition of religion. argyle and beithallahmi’s defined religion as, “a system of beliefs in a divine or superhuman power, and practices of worship or other rituals directed towards such a power” (p.1). definitions of spirituality often include inherent ideas of connectedness, purpose, and meaning (ratnakar & nair, 2012; zinnbauer et al., 1997). spirituality has been defined as characterized by a relationship with a higher power, often including a transcendent experience (benner, 1989) and has been correlated with mystical experiences, new age beliefs and practices, having a higher income, and the experience of being hurt by clergy (zinnbauer et al., 1997). using a meta-analysis, ratnakar and nair (2012) identified some common themes of spirituality to include relationship with a god or ultimate being, finding meaning and purpose, and living up to one’s deeply held beliefs. ratnakar and nair (2012) noted that spirituality is difficult to operationalize and is better understood as a culmination of various meanings and definitions found in the literature. for the current study, vaughan’s definition (1991) was used. vaughan (1991) defined spirituality as “a subjective experience of the sacred” (p. 105). this definition  13  
  was selected due to the recurrent themes in the literature regarding connectedness and existential themes in relation to another being that is considered sacred. until the rise of secularism in the united states (u.s.), spirituality and religion were considered to be synonymous in popular culture (zinnbauer et al., 1997). the babyboomer generation was the first recent generation that became disillusioned with organized religion, rejecting it in search for a more transcendent, experiential brand of spirituality. although religion and spirituality are now considered to be distinct constructs, they are not fully independent from one another; they were moderately correlated in zinnbauer et al.’s (1997) study. both religion and spirituality were correlated with frequency of prayer, worship service attendance, intrinsic religiosity, and religious orthodoxy, as well as in traditional descriptions of the sacred. understanding the commonality and differences between spirituality and religiosity bolsters a more complete conceptualization of an individual’s religious and/or spiritual experiences. an historical approach is also useful in understanding spiritual and/or religious experiences. the discipline of psychology in particular has sustained a complex relationship with religion/spirituality over the years. historical overview of spirituality and religion in psychology in this section, approaches to studying psychology of religion are covered as well as the history of the sub-discipline. the cognitive science of religion, evolutionary psychology of religion, and cultural psychology of religion are reviewed. the history of the psychology of religion in terms of professional organizations and their research is also examined. 14  
  approaches to studying psychology and religion. the scientific study of religion was housed within scientific study in general and all the strengths, weaknesses, and assumptions that accompany scientific inquiry (nelson, 2012). nelson (2012) characterized scientific study as “a human endeavor that touches on many aspects of our intellectual life” (p. 686). he identified that scientific assumptions present problems within scientific research and suggested such assumptions be addressed through a critical lens. naturally, the science of psychology was not immune from the methodological errors and assumptions offered by scientific inquiry. throughout the study of religion in psychology over the past century, various philosophical approaches have been explored, each containing different strengths and weaknesses and offering various perspectives on the study of religion. the hermeneutic-phenomenological (hp) approach addresses the selfinterpretation of one’s religious experiences (nelson, 2012). the hp approach offers a qualitative framework that captures the lived experiences of the research participants, allowing such discovery to become part of the working theoretical model. hp challenges assumptions inherent in other kinds of empirical inquiry and provides an open context for appreciating unique human experiences. phenomenological methods address the meaning of what are considered facts and they take into consideration cultural factors that inform meaning (hoffman, 2012). despite its benefits, the hp tradition has been underutilized and in many ways marginalized by the scientific community at large (nelson, 2012). the positivistic naturalism (pn) research approach seeks to find universal natural laws and uses methods deriving from natural science (nelson, 2012). pn researchers 15  
  believe they can be detached observers toward their research participants. they reject many assumptions in hp, replacing them with their own assumptions including operationalization, quantitative methods as superior to qualitative methods, and science as superior to philosophy or religion. pn has dominated the scientific study of religion for the past 50 years and although pn has contributed to the field, the assumptions inherent in the method may dilute the strengths of the findings. for example, failure to examine the researcher’s assumptions and beliefs may impact her or his interpretation of the data. additionally, operationalized variables fail to capture the extent of the intended construct, such as using worship service attendance as an indication of religiousness. the religious integration (ri) approach was birthed out of a desire to integrate psychological knowledge with religious insights and was developed as a response to the perceived religious hostility among the scientific community (nelson, 2012). many researchers who engage in the ri approach are committed to christian or buddhist traditions. ri methods generally contain a critical component in which psychology is critiqued through the lens of a particular religious tradition. ri also espouses a constructive component in which a synthesis of psychology and a religious tradition is developed. synthesis of psychological knowledge and religious traditions yielded several microtheories such as research on forgiveness and mindfulness. one line of scholarship on microtheories suggests that although such theories are helpful for delineating particular topics, their utility may become diluted when they are not grounded in a greater theoretical context (mcintosh & newton, 2013).  16  
  cognitive science of religion. in addition to general scientific methods for studying the psychology of religion, other longstanding and emerging fields of academia have scientifically examined the relationship between psychology and religion. the cognitive science of religion (csr) emerged in the 1990s as a push from religious scholars to scientifically examine religious beliefs (barrett, 2011). csr methods examine the cognitive structures that are relevant to religious thoughts and actions. one tenet of csr includes rejecting the supremacy of cultural relativism, claiming that human beings have natural cognitive biases that are independent from cultural influences. another tenet is that some aspects of cognition are pre- or extracultural, including a bias toward processing human faces and a capacity for language. barrett (2011) described these natural processes as “mental tools” (p. 231). mental tools are found across cultures and can be examined to help us understand religious experiences. although religion itself varies cross-culturally, the mental tools used in religion are often consistent. for this reason, cognitive scientists of religion have historically been hesitant to define religion, preferring to examine the underlying cognitive structures or processes that are often utilized in religious expressions and experiences. csr is an interdisciplinary initiative that has explored several topics of a religious nature and holds a promising future for future inquiry. evolutionary psychology of religion. evolutionary psychologists espouse the belief that human beings reproduce through natural selection, which can provide a lens through which to further understand human psychology (kirkpatrick, 2013). kirkpatrick (2013) identified that the primary goal in natural selection is the continuity of the species. 17  
  at times, a species will make adaptations to better survive in its environment and these adaptations may be more beneficial to the species as a whole than to an individual. sometimes such adaptations result in side effects of adaptations that were not necessarily intended to benefit the species, but occur as a consequence of the adaptation. evolutionary psychologists stress the importance of examining why a psychological phenomenon has come to be. the why question must be asked in conjunction with what cognitive mechanisms are being utilized and how those mechanisms are designed. evolutionary psychologists highlight that such adaptations were made by our ancestors many years prior to address challenges in their environment, not challenges in our modern environment. evolutionary psychologists have questioned whether religious experiences are attributed as by-products of evolutionary adaptations designed for different purposes or whether the human species evolved with cognitive adaptations specifically designed to create or enhance religious and spiritual experiences (kirkpatrick, 2013). some evolutionary psychologists argue that the universality of religion across cultures, neurological evidence, and the heritability of religiosity support both the religion as a byproduct and as an adaptation view. many scholars have speculated about how religion might be adaptive and hypothesized that reducing the fear of death, encouraging group cohesion, and reducing conflict are adaptive functions of religion. while evolutionary psychologists are not in agreement on all theories of the evolutionary psychology of religion, they offer an important theoretical contribution when examining the psychology of religion and spirituality. 18  
  cultural psychology of religion. the cultural psychology of religion is another lens through which psychologists attempt to understand the psychology of religion. an entire 2010 issue of the journal mental health, religion & culture was dedicated to the cultural psychology of religion with belzen’s (2010b) publication of a book on the topic, and a summary of that book that appeared in the journal with assenting and dissenting articles from his peers. although scholars debate the tenets of cultural psychology of religion (hill, 2010), the literature has several consistent points to offer. first of all, belzen (2010a) pointed out that cultural psychologists of religion value the hp research approach. they value the research participants as whole people and attempt to understand their subjective experiences. they offer an adjunct to other forms of research that may lose sight of the human being of study by distancing from the participant in exchange for measurable constructs. cultural psychology balances other psychology disciplines as it balances quantitative inquiry with qualitative exploration. cultural psychologists of religion offer insights into the seemingly unconscious religious actions in which people engage. they attribute such acts to cultural phenomenon that impact the individual. critics of cultural psychology of religion suggest that emphasizing culture for explaining religious phenomena is over-exaggerated, that the approach lacks coherence, and that it fails to identify universals (hill, 2010). however, belzen (2010a) offered his thesis that cultural psychology of religion can stand alongside other kinds of investigations of the psychology of religion to enhance a comprehensive understanding of the field rather than overtake it.  19  
  history of psychology and religion/spirituality the founders of modern psychology, including wilhelm wundt (1832-1920) in germany and william james (1842-1910) in the u.s., embraced a diversity of disciplines that influenced their writing on psychology, including the psychology of religion (james, 1902; rambo & haar farris, 2012). this integration of biology, physiology, philosophy, history, religion, and literature formed the foundation for what came to be known as the subfield of the psychology of religion. specifically, james (1902) believed that religion could foster happiness and growth and viewed religion as a buffer from anxiety (soenke et al., 2013). sigmund freud (1856-1939) also influenced the study of religion in psychology with his critical views of religion that are still recognized today as a point of contrast for more empirical studies of religion (rambo & haar farris, 2012). freud generally viewed religion as a neurosis (fukuyama et al., 2014). his views changed over time; earlier in his career he believed that religion served as a protective function by buffering one against anxiety while ultimately viewing religion as a form of psychopathology. later in his career, his understanding of religion was that religion arose out of a need to defend the self from nature (freud, 1961). he described the utility of religion to “exorcise the terrors of nature, reconcile man [sic] to the cruelty of fate and mortality, and compensate the individual for society’s restrictions on his or her freedom” (soenke et al., 2013, p. 106). as freud’s psychoanalytic tradition progressed, emphasizing early representations as informing one’s representations of god, other theorists expanded upon and altered their conceptualizations of religion (rambo & haar farris, 2012). in 20  
  erickson’s life cycle approach (1959, 1963), he took freud’s focus on fatherhood as an early image of a god figure and expanded the representations to include both mothers and fathers as early representations of god (soenke et al., 2013). later researchers, consistent with the psychoanalytic tradition, found that one frequent motivation for engaging in religion stems from one’s need for love (brown & cullen, 2006). unlike freud, carl gustav jung (1875-1961) had a positive view of religious experiences (rambo & haar farris, 2012). jung valued religious rituals, archetypes, symbols, and creative expressions and believed they assisted in reaching the central goal of human life, which he called individuation. jung’s work still influences many people today and some consider his teaching to be a kind of surrogate religion (rambo & haar farris, 2012). as the psychology field progressed beyond the initial founders’ influences, psychologists’ inquiry into religion diminished and became almost taboo (belzen, 2009). possibly, researchers wanted to gain the respect of the scientific community, which was focused on empirical and quantitative examination. empirical research, part of the pn research approach (nelson, 2012), was valued over what may be considered more subjective forms of inquiry. researchers such as john watson and b.f. skinner examined observable phenomena, thereby minimizing the focus on the less visible aspects of spirituality or religion on one’s experiences (powers, 2005). while the widely accepted behaviorist and later cognitive traditions flourished from roughly 1920-1970, another trend emerged as abraham maslow founded humanistic psychology in the 1950s. around this time, the drought of publications regarding religion and spirituality dissipated. 21  
  maslow’s work on the hierarchy of needs included the idea of self-actualization, which can contain spiritual features. maslow’s work eventually led to the founding of the journal of humanistic psychology in 1961 and, with the influence of anthony sutich, the journal of transpersonal psychology in 1969. concurrent with the humanistic movement in the field in the 1950s, both the american counseling association (aca) and the american psychological association (apa) founded divisions dedicated to better understanding religion and spirituality (piedmont, 2013; powers, 2005). true to the ri method of psychological and spiritual inquiry, the catholic guidance councils and a second group called catholic counselors in the american personnel and guidance association were founded in the 1950s in an attempt to integrate counseling and religious interests (association for the spiritual, ethical, and religious values in counseling [aservic], n.d., p.1; powers, 2005). the groups merged and after several transformations, became the association for the spiritual, religious, and ethical values in counseling division of the aca. similarly, the american catholic psychological association was founded in 1949, and after a series rethinking the vision and name of the association, the group evolved into what is known today as the society for the psychology of religion and spirituality, or division 36 of apa (piedmont, 2013). as division 36 refined is focus and evolved into a more mature division, members founded the journal psychology of religion and spirituality, expanding scholarship in the field. as the professional division evolved, they carved out their own discipline and were no longer necessarily tied to a particular theological tradition (piedmont, 2013). 22  
  as research on the psychology of religion and spirituality has progressed, a number of changes have taken place. there have been a number of fields that have contributed to religion and spirituality studies, expanding the breadth of perspectives and knowledge (piedmont, 2013). additionally, constructs relating to spirituality and religion have been increasingly differentiated. this differentiation has contributed to a greater understanding of the complexity of the nuanced experiences under examination. another change in the psychology landscape affecting religion and spirituality research occurred when multiculturalism evolved to include religious and spiritual identities in the early 1990s (powers, 2005; sue et al., 1992). this shift from multiculturalism’s emphasis on gender and ethnicity to a wide spectrum of identities, including religious and spiritual experiences, provided an enhanced perspective for understanding phenomena that had previously been overlooked and undervalued. understanding the psychology of religion and spirituality from a cultural perspective is an important lens through which to consider what health means in various cultures (ting, 2012). as psychologists continue to gain cultural competence, we must consider cultural views of health, mental health, social support, and how each of these interacts with one another. impact of spirituality and religion on health religious and spiritual beliefs can assist with one’s quest to find meaning in life (saucier & skrzypinska, 2006); address issues of creation, injustice, death, and the afterlife (argyle & beit-hallahmi, 1975); and provide a moral compass for life (fowler, 1981). psychologists have started to transition their thinking about when and how to 23  
  broach the topics of religion and spirituality with clients (post & wade, 2009). according to saucier and skrzypinska (2006), religious and spiritual beliefs and practices have an noted that effect on human behavior and functioning. this includes health and longevity (powell, shahabi, & thoresen, 2003), as well as purpose and meaning (saucier & skrzypinska, 2006). according to pargament (2002): religion has both costs and benefits to people. the value of religion depends on the kind of religion, the criteria of well-being, the person, the situation and social context, and the degree to which the various elements of religious life are wellintegrated into the person’s life (p. 169). one scholar, an in attempt to make sense of the religion and health literature, presented a conceptual model of the needs that are satisfied by religion. krause (2011) identified literature on religion and health generally points toward individuals engaging in religion enjoying health benefits (koenig et al., 2001). he proposed a model of human needs that are met when one is involved in religious activity. these include the interrelated needs of self-transcendence, sociality, control, and meaning, which can be met through religious meeting attendance and contribute to improved health. researchers who conducted a meta-analysis of 49 studies examining the relationship between religion and health found that religion is very important to many patients suffering from serious diseases (stewart et al., 2013). many patients frequently practiced their religion and interacted with their higher power about their medical issues. they found that this interaction provided a positive coping skill, leading to greater compliance with treatment and increased quality of life. 24  
  mental health. in their expansive book on religion and health, koenig et al. (2001) determined that spirituality and religiousness were generally positively correlated with mental health. although some previous research had yielded mixed findings regarding the relationship between religion and mental health, luyten, corveleyn, and fontaine (1998) emphasized the importance of researchers being more specific about which aspects of spirituality and religion they are measuring. pargament (2002) argued that traditional measures of religion including worship service attendance, self-reported religiosity, and frequency of religious activities fall short of a solid theoretical association with well-being. pargament (2002) suggested that a more comprehensive understanding of how the religion impacts the individual would yield richer information. luyten et al. (1998) identified that most of the studies regarding psychology and religion used allport and ross’ (1967) distinction between intrinsic and extrinsic religiosity as their metric for religiosity and identified other scholars who have expanded the measurement of religiosity to provide a more comprehensive approach in understanding religiosity. regarding mental health, religion and spirituality have been found to be generally correlated with various aspects of mental health. specifically, religion has been found to be a unique predictor of subjective well-being (aghababaei, 2014). religion and spirituality were also positively correlated with happiness and life satisfaction, specifically in cultures where religious socialization was more prevalent (lun & bond, 2013). higher levels of spirituality, with or without religion, correlated with higher levels of self-actualization, meaning in life, and personal growth initiative (ivtzan, chan, gardner, & prashar, 2013). 25  
  specific religious practices also correlate positively with mental health (day, 2010). when practiced regularly, forgiveness negatively correlates with hostility, stress, depression, and anxiety (coyle & enright, 1997; hood, hill, & spilka, 2009; worthington, berry, & parrot, 2001). the benefits of forgiveness may account for religiosity being positively related to marital satisfaction and stability (hood et al., 2003). meditative prayer has been found to reduce anger, decrease anxiety, and assist with relaxation (carlson, bacaseta, & simanton, 1988). while honoring one’s religious beliefs remains a part of cultural competency (fukuyama et al., 2014), scholars and psychologists have often neglected non-believers in their examinations of religious and spiritual beliefs and psychological health (weber, pargament, kunik, lomax ii, & stanley, 2012). in a meta-analysis of nonbelievers, only 14 articles were found suitable for examination. nonbelievers, many of whom were former believers or considered themselves to be agnostic, endorsed psychological distress regarding anger toward god (exline, park, smyth, & carey, 2011) and difficulty forgiving god (exline, yali, & lobel, 1999). however, nonbelievers are equal or slightly better off than believers when it comes to coping with challenges inherent in aging (wilkinson & coleman, 2010) as well as overall happiness (baker & cruickshank, 2009). weber et al. (2012) identified a positive correlation between strength of conviction of one’s belief (including nonbelief) and worldview and psychological health (baker & cruickshank, 2009; wilkinson & coleman, 2010).  26  
  harmful religion: cults nobody joins a cult (zimbardo, 1997). most people who end up in a cult are genuinely seeking a positive community to help meet their spiritual, moral, or personal goals. cults exist with a variety of ideologies including religious, political, therapeutic, or commercial (durocher, 1999). the term cult is difficult to define due to the number of varying ideologies endorsed by various groups. common characteristics of cults include abuse, mind-control, and the destructive effects on members’ lives. langone (1993) offered the following definition of a cult: a cult is a group or movement that, to a significant degree, (a) exhibits great or excessive devotion or dedication to some person, idea, or thing, (b) uses a thought-reform program to persuade, control, and socialize members (i.e., to integrate them into the group’s unique pattern of relationships, beliefs, values, and practices), (c) systematically induces states of psychological dependency in members, (d) exploits members to advance the leadership’s goals, and (e) causes psychological harm to members, their families, and the community (langone, 1993, p. 5). shortly thereafter, the following definition of a cult was refined by langone and his colleagues. this definition of a cult has been adopted for this study. chambers et al. (1994) defined cults as: ...groups that often exploit members psychologically and/or financially, typically making members comply with leadership’s demands through certain types of  27  
  psychological manipulation, popularly called mind control, and through the inclusion of deep-seated anxious dependency on the group and its leaders (p. 88). many researchers believe that people who join cults initially believe they are joining a healthy group that will assist them with developing their morals and spiritual identity (almendros et al., 2007; martin et al., 1998; zimbardo, 1997). there have been a number of studies attempting to identify characteristics of potential cult members. results have yielded mixed findings; some researchers cite pre-existing psychological difficulties (deutsch & miller, 1983; levine & salter, 1976; sirkin & grellong, 1988; spero, 1984) while others warn against victim-blaming (burks, 2002) and still others point out that the number of cult members who had prior psychological problems is only slightly above the number in the general population who have sought mental health services (martin, 1989). some researchers point to problems in the family of origin as a core dysfunction, resulting in individuals seeking involvement in groups they later come to identify as cults (curtis & curtis, 1993; schwartz & kaslow, 1979). however, others believe that cult involvement is unrelated to familial factors (maron, 1988; wright & piper, 1986). healy (2011) observed that research has been conducted on cults for roughly 40 years, yet researchers still lack a comprehensive understanding of cult phenomena. the cult literature is challenged by a lack of empirical analysis on destructive cults (bohm & alison, 2001). in the 1960s, parents of children who were suspected to have joined a cult banded together for networking and information sharing purposes. they joined others who opposed cults for theological reasons, and the two groups evolved into the anti-cult movement. the movement was united on both its belief that 28  
  cults are psychologically destructive and that cult members were victims of mind control. over the years, theorists have created various lists of what constitutes a destructive cult (baker, 1989; f.c.t., 1956). however, much of this research was descriptive rather than prescriptive (halperin, 1983). bohm and alison (2001) stressed the idea that cults are not destructive at inception; rather they become destructive. to address the lack of empirical literature on cults, bohm and alison (2001) conducted an exploratory study with data from 25 cults with a multivariate analysis that yielded seven behaviors that might form the basis of distinguishing destructive cults from more benign cults. their findings yielded both mass suicide and mass murder to be the most destructive characteristics of cults with seven other characteristics that clustered around these two behaviors, including: physically preventing members from leaving the group, endorsing violence, drills, preparing for doomsday, building defensive structures, collecting weapons, and the leader claiming to be an incarnation of a religious or historically significant figure. the authors’ findings offer a reminder to address one’s assumptions about cults; for instance, some researchers initially believed that groups that are geographically isolated, such as the case of the jonestown cult, indicated a more destructive cult. bohm and alison’s (2001) research yielded a helpful list of characteristics of destructive cults and demonstrated the need for researchers undertake empirical examination of cults. cults often contain elements of authoritarianism and discourage questions or doubts about the group, its beliefs, and practices (balch, 1980; durocher, 1999). obedience is valued and rewarded as new recruits assimilate to the culture and language of their new group. sometimes, the leader breaks promises and members must seek 29  
  explanations to resolve their cognitive dissonance (goldberg, 2012). for example, one cult leader promised a female recruit a new job publishing motivational materials for the group. upon leaving her previous job and joining the group, the new recruit was tasked as a security guard and was required to make photocopies of the leader’s lectures. although disappointed in her assignment, she determined this disappointment was nothing compared to the enlightenment she hoped to receive upon becoming involved in the group. insights from former cult members. some researchers have utilized hp approaches to attempt to understand the lived experiences of former cult members and have identified insights into cult experiences. healy (2011) distinguished between “seekers” and “accidental seekers” (p. 7) in his qualitative study of former members of swami muktananda’s siddha yoga, a religious cult. healy (2011) identified that some individuals overtly seek a spiritual community while others may not necessarily be looking for such a community, but might be introduced to one by somebody in their social network. healy’s participants identified a theme of members feeling they had “come home” (p. 8) upon attending their first meetings. ex-members described a sense of finding what they were seeking. often, the cult meets members’ needs for community and camaraderie as the members spend time together on various tasks in pursuit of their common goals. cult members are often required to spend much of their time together in the community, as was experienced by members of a particular cult in which members were paired together and expected to spend 24 hours per day with their partner (balch, 1980). durocher (1999) identified that many ex-members suffered losses upon leaving 30  
  the cult, including the sharp cutting off of one’s previous support system as friends in the cult abandoned all contact with former members. such cutting off has been known to have similar symptoms as going through a divorce (wright, 1991) and provides a rationale for group support as a helpful intervention for cult recovery (durocher, 1999). additional losses suffered by ex-cult members include their familiar lifestyle and philosophy (durocher, 1999). some members may hold on to parts of the belief system endorsed by the cult while others may become so disenchanted that they turn completely away from their prior beliefs (healy, 2011). at times, former members face the shame of significant personality and behavioral changes as one former cult leader described (goldberg, 2012). she engaged in antisocial behaviors while in her group that resulted in her conviction of a federal crime. cult leaders. almendros et al. (2007) identified that former cult members perceived manipulative behaviors of the group’s leadership to be the most influential factor in their group involvement. consequently, many former cult members must reconcile their beliefs about their leader. cult leaders often hold members to unattainable standards and lead their followers to believe they must uphold these standards for survival, to gain purity, or for a higher standing in the afterlife (balch, 1980; goldberg, 2012). this can be difficult for members who uphold their leaders as a god-like figure and feel the need to suppress or hide any doubts they might have about their leader’s abilities (goldberg, 2012). some theorists conceptualize many cult leaders as having antisocial personality disorder (aspd) (burke, 2006). aspd is characterized by antisocial acts including 31  
  blatant disregard for others’ rights and is often accompanied by hostility, aggression, deceit, and manipulation (dsm-5). some individuals with aspd may be easily identified by their behaviors and history while others may fly under the radar, requiring more extensive assessment. individuals with aspd often exhibit dominant traits in which they attempt to exert influence over others for their own gain as well as aggressive traits by which they may engage in verbally or physically aggressive acts toward others. despite their unempathic and counter-cultural behavior, many individuals with aspd have the intellect to assess others’ emotional vulnerability and exploit it for their own advantage. leaders with aspd encourage followers’ submission to their commands, undermining any autonomy the members previously enjoyed. as new members are manipulated and brought into the group, the leaders with aspd attempt to break the new members’ attachments to her or his outside world, creating a reliance on the leader and the group for sole support. one way to view cult leader dynamics is through a psychodynamic lens in which members are characterized as transferring early attachment figures onto the leader (sankowsky, 1995). the leader then serves as a symbol for the followers, through which the followers unconsciously recreate unfinished business with their early attachment figures, making them vulnerable to the leader’s influences. in turn, the leader’s psychological makeup may prompt abuse toward their followers, disregarding their psychological well-being. as the leader creates a “superior family” (ollson, 2013, p. 41) out of the group, the leader is elevated as a parental figure, prophet, or even a god. some leaders employ tactics that result in decreased ego functioning as the member enters a 32  
  dissociative state for survival purposes (salande & perkins, 2011). members become vulnerable and regress to a primitive state in which their defenses are weakened against the leader’s manipulation. this object relations explanation may account for one woman whose cult membership resulted in her being convicted of a federal crime; she neither seemed to exhibit antisocial traits before nor after her involvement in a cult (goldberg, 2012). trauma and abuse traumatic stress has been occurring for as long as recorded history and long before researchers began to understand and articulate the nuances of trauma, its etiology, variations, and treatment (birmes et al., 2003). trauma has been experienced in response to childhood abuse, war, political upheaval, domestic violence, and many other forms of abuse (herman, 1992b). the experience of trauma has resulted in a diagnostic definition that has evolved since its inception in 1980 (american psychiatric association, 1980). several treatments, including individual and group psychotherapy and medications, have been examined to address the impact of trauma (watts et al., 2013). as researchers have come to better understand the negative impact of overt acts of abuse, there is growing recognition that subtle forms of abuse also result in psychological trauma (shapero et al., 2014). examining traumatic stress in literature evidence of traumatic stress was documented for centuries long before the diagnosis of ptsd (apa, 2013) was identified. ancient writings depict what are now understood to be symptoms of posttraumatic stress including nightmares, despair, 33  
  intrusive memories, detachment, and foreshortened future (birmes et al., 2003; mueser et al., 2009). in the mesopotamian tale dating from the third millennium bce, the epic of gilgamesh, the author depicted the protagonist’s traumatic grief reaction to war and his friend’s violent death. gilgamesh became detached, wandered aimlessly, ruminated about his own mortality, experienced helplessness, and suffered intrusive memories of his friend’s death (mueser et al., 2009). trauma symptoms were also depicted in homer’s the iliad and the odyssey, dating back to 850 bce. the protagonists of both poems experienced emotional and behavioral shifts subsequent to combat and the death of their fellow soldiers. achilles suffered sleep disturbances and intrusive memories. one researcher who re-analyzed both tales based on modern understanding of war identified that the symptoms portrayed in the poems resembled symptoms reported by vietnam veterans (shay, 1995, 2000). more modern fiction is replete with examples of the impact of traumatic suffering on human behaviors, thinking, and feeling (mueser et al., 2009). shakespeare offered several examples including king henry iv’s hotspur, a combat veteran who suffered sleep disturbances, social withdrawal, and startle response subsequent to war. lady macbeth suffered flashbacks upon the king’s murder. several popular war novels about the american civil war, world war i, and world war ii depict trauma reactions as well. historical overview of trauma despite the well-documented trauma symptoms in historical literature, a scientific understanding of the psychology of trauma has lagged behind (mueser et al., 2009). a more medical conceptualization of trauma dates back to the u.s. civil war (1851-1865), 34  
  during which medical journals documented the concept of irritable heart. symptoms of irritable heart were described as, “lethargy, withdrawal, and fits of hysterics with excessive emotionality” (birmes et al., 2003 p. 20; mueser et al., 2009). those symptoms later came to be understood as symptoms of ptsd. the post-war reactions were also referred to as nostalgia and often included conversion reactions (birmes et al., 2003). another contributing factor in the history of trauma conceptualization was the legal need in the mid-1800s for a medical diagnosis of psychological injury for legal purposes (horowitz, 1986; peebles, 1989). as the industrial era flourished, large companies faced lawsuits when large-scale industrial accidents occurred. these accidents often resulted in legal suits and although physical injuries were observable, psychological injuries were not. the legal system needed recommendations for discerning potential psychological injuries that occurred secondarily to the accident or work-related crisis from potential intentional or unintentional malingering on the part of the employee (horowitz, 1986). during the course of the railroad company lawsuits, at least three theories emerged regarding reported symptoms including sleep disturbances, nightmares, avoidance of accident-related stimuli, headaches, and cognitive changes (mueser et al., 2009). first, physicians conceptualized the symptomatic etiology to be related to the nervous system, which was considered an honorable reason for the symptoms. secondly, a theory emerged, particularly when organic issues were unidentifiable, that patients were malingering for financial gain. thirdly, some physicians began to believe that the patients were not necessarily malingering, but that the symptoms represented a subset of 35  
  symptoms associated with the evolving psychiatric category of hysteria (mueser et al., 2009; trimble, 1985). on hysteria. the concept of hysteria is most often attributed to jean-martin charcot, a french neurologist from the late 19th century (herman, 1992b). charcot was one of the first to suggest that hysterical episodes involved dissociation from the unbearable experiences the patient endured (van der kolk, 2007). charcot’s progressive work at a previously neglected insane asylum drew the most talented psychiatrists and neurologists at that time. he was credited with elevating the study of hysteria to a respectful discipline including shifting cultural and scientific thinking about women suffering from hysteria, from being labeled as malingerers to believing that their experiences were real (herman, 1992b). some pupils who studied under charcot’s tutelage were sigmund freud, william james, and pierre janet. charcot’s pupils eventually split into two groups with varying ideas about trauma. one group continued studying adaptation to trauma and the other group studied false memories and suggestibility (van der kolk, 2007). charcot’s successor at his french hospital, babinski, focused his research on hysterical suggestibility, thereby rejecting charcot’s earlier understanding about disassociation and trauma. at this time, suggestibility and simulation were considered the foundational features of hysteria and the work that charcot had done to legitimize the experiences of women suffering from hysteria became dormant (van der kolk, 2007). as the field focused on simulation, the idea of the “will” surfaced as an explanation for hysterical behavior. during world war i and for subsequent decades, veterans in germany were thought to have a failure of willpower. their treatments 36  
  consisted of attempting to bolster the soldiers’ desire for health, resulting in many of them opting for the more dangerous front-line duties on the battlefield. after charcot’s progress in legitimizing hysteria as a field for study, freud, accompanied by his colleagues breuer, in vienna, and janet, in france, attempted to surpass this work by exploring the etiology of hysteria (herman, 1992b). rather than simply observing the hysterics, as they called the women, they began talking with them, often on a daily basis and for several hours at a time. this approach yielded fruit as both researchers independently came up with the same conclusion that hysteria was a result of psychological trauma. freud and janet had different labels for the altered state of consciousness that patients go through as a result of unbearable emotional reactions to traumatic events. freud called it “double consciousness” (freud, 1896) and janet called it “dissociation” (herman, 1992b). freud and janet had some similarities as well as differences in their discoveries (herman, 1992b). both recognized the altered state of consciousness that their hysterical patients underwent. janet believed this dissociation to be the result of suggestibility or psychological weakness. breuer and freud (1937) believed that hysteria could be found even among the intellectuals, those with great character, and those with strong wills. both research parties realized that the hysteria would dissipate upon the traumatic events being put into words and discussed. herman (1992b) pointed out that this method of treatment laid the foundation for the practice of modern psychotherapy. one of breuer’s patients, whose pseudonym was anna o., called this dialogue the “talking cure” (breuer & freud, 1937; herman, 1992b). 37  
  despite freud’s progressive contribution to hysteria as a response to trauma, he reneged on his theory 1 year after his groundbreaking publication, the aetiology of hysteria, was released in 1896 (herman, 1992b). soon after its release, he realized that the social implications of his findings were too grave to be credible. his findings indicated that the hysterical women identified in his case studies were sexually abused as children, precipitating their hysterical symptoms. if this notion were true, such an idea was so socially despicable that freud could not tolerate the social implications. if so many women were sexually abused, society must acknowledge that individuals in respectable social classes were perpetrating the abuse. after retracting his theory of the origins of hysteria, freud continued to study sexuality as a central focus of psychoanalysis, but he did so while denying women’s realities of early childhood abuse (herman, 1992b). for the next several years, studies of hysteria became sparse and almost forgotten and the work that continued on what we understand today as trauma was focused on combat veterans. on war trauma. while freud’s theories were becoming more influential, physicians were beginning to deal with the psychological impacts on combat veterans of world war i (mueser et al., 2009). many military commanders saw their soldiers’ responses to war as a moral weakness. still, others saw the psychological impact of war as having a neurobiological cause. the term shell shock began to be used in military and psychiatry circles to describe soldiers’ experiences of war. their symptoms included “fatigue, slowed reactions, heightened startle responses, irritability, confusion, disconnection from the environment, somatic reactions (e.g., paralysis, seizures), sleep 38  
  disturbance, ruminations, and guilt” (mueser et al., 2009, p. 21). essentially, soldiers were experiencing similar symptoms to hysterical women; however, psychiatrists failed to identify this connection (herman, 1992b). military commanders and physicians attributed the symptoms to the impact of shell blasts on the central nervous system (mueser et al., 2009). meanwhile, there were some psychiatrists who were starting to understand the complexity of the disorder they were witnessing to include prolonged stress and horror (rivers, 1918; smith & pear, 1917). one of the most influential contributions to the trauma field was abram kardiner, who treated traumatized veterans of world war i (van der kolk, weisaeth, & van der hart, 1996; van der kolk, 2007). he finished his personal analysis with freud and then set out to gain an understanding of war neuroses based on freud’s psychoanalytic theory. although initially unsuccessful, he later reassessed the careful observations he had made about his patients and re-conceptualized his war theory in the traumatic neuroses of war in 1941. he provided the field of psychiatry with very poignant observations and detailed notes on the symptoms and previous diagnoses his patients had encountered. kardiner (1941) understood his patients’ sensitivity to their environments to include pain, sudden movements, touch, and temperature. he identified the altered sense of self his patients experienced post-trauma and he understood the re-experiencing phenomenon and dissociative states his patients would enter into upon reminders of their traumas. van der kolk (2007) attributed kardiner’s work as defining ptsd for the remainder of the 20th century.  39  
  although kardiner’s work was published before world war ii broke out, much of his understanding of war trauma was forgotten and needed to be rediscovered (van der kolk et al., 1996; van der kolk, 2007). the same “treatment” used in the first world war, including evacuation from the front, resulted in great cost to the individual soldiers and a loss in the overall strength for the military. however, as military psychiatrists began to see that any soldier could eventually break down proportionate to their combat exposure (herman, 1992b), they soon began researching protective factors including training, group dynamics, leadership, motivation, and morale (belenky, 1987; grinker & spiegel, 1945). researchers discovered the powerful emotional attachments between the men fighting together and that the strongest protective factor against traumatic stress was the degree of relatedness to the soldier, his unit, and his leader (kardiner & spiegel, 1947). some of the pioneers in american psychiatry rediscovered the fact that soldiers could remember the somatosensory experiences of trauma when they were in altered states of consciousness (van der kolk et al., 1996; van der kolk, 2007). they reintroduced methods, including hypnosis, as a means for extracting the traumatic memory, meanwhile affirming janet’s earlier observation that one cannot simply identify the traumatic memory and expect to see reduced symptomatology without transforming that memory. additionally, the u.s. army established stress debriefing for their soldiers (shalev & ursano, 1990).  40  
  on concentration camp survivors. after world war ii, independent examinations of concentration camp survivors began, with researchers coining the term “concentration camp syndrome” (van der kolk, 2007). holocaust and other concentration camp populations provided representative samples of pre-war health (etinger, 1964; etinger & strom, 1973). investigators noted increased mortality, general somatic morbidity, and psychiatric morbidity among survivors (bastiaans, 1970; hocking, 1970; vanzlaff, 1966). researchers noted not only symptoms they had previously identified as war trauma, but also enduring personality change and devastating long-term health consequences. these investigations demonstrated once again that survivors of extreme trauma suffered biological, psychological, social, and existential consequences as well as a decreased capacity for coping with biological and psychological challenges later in life (van der kolk, 2007). henry krystal (1968, 1978, 1988), a psychoanalyst who studied the long-term effects of concentration camp survivors, suggested that the trauma survivor’s experience consists of giving up and accepting death as inevitable. his work was consistent with kardiner’s and janet’s previous research, yet it was couched in psychoanalytic terms. krystal believed that chronic bodily states, including hyperarousal, resulted in an inability to distinguish one’s emotions. this leads to survivors experiencing emotions as somatic states without the skills to interpret their meanings and without the ability to respond in an adaptive manner. not coincidentally, many researchers in the aftermath of world war ii who chose to research the long-term effects of trauma were themselves participants in the war or concentration camp survivors (etinger, 1964; krystal, 1968). 41  
  on traumatic stress since the 1970s. beginning in the 1970s, several branches of studies on traumatized populations began to overlap as trauma received increased attention. vietnam war veterans, women, and children were the identifiably traumatized populations who received much attention in the trauma literature (van der kolk, 2007). between 1895 and 1974, most research studies on trauma had focused on men’s experiences. in 1974, ann burgess and linda holstrom published an article entitled “rape trauma syndrome” in which they identified that the terrifying nightmares and flashbacks women reported resembled the traumatic neuroses of war. around the same time, work was being done on battered children (kempe & kempe, 1978) and the trauma of family violence (gelles & straus, 1979; hilberman & munson, 1977; straus, 1977; walker, 1979). sarah haley (1974), one of the proponents of ptsd as a diagnosis, was both the daughter of a vietnam veteran and an incest survivor and she wrote a comprehensive paper on reports of atrocities in psychotherapy settings. judith herman (1981) began documenting widespread childhood sexual abuse and the impact it has later in life while she challenged culture’s perception that abuse was rare with minimal damage. in 1970, two new york psychiatrists, interested in the impact of the war, partnered with members of the group “vietnam veterans against the war” and began hosting conversations called “rap groups” during which veterans could discuss their war experiences (andreasen, 1980). the rap groups began to spread nationwide and formed a kind of networking group for both vietnam veterans and mental health professionals who were interested in studying the impact of war on men’s health. many of the professionals 42  
  versed themselves in literature about the holocaust, kardiner’s work, and literature on burn and accident victims. they eventually produced a list of common symptoms of traumatic experiences. not surprisingly, their classification system for ptsd resembled kardiner’s 1941 war neuroses description. on an official diagnosis for trauma. by 1980, the american psychiatric association introduced the new diagnosis of ptsd. the new diagnosis served as an umbrella term, subsuming “rape trauma syndrome,” “battered woman syndrome,” the “vietnam veterans syndrome,” and the “abused child syndrome” all under the ptsd diagnosis (van der kolk, 2007). ptsd did not derive from empirical exploration, but rather from previous literature and clinical records of individuals suffering from traumatic experiences. later, when ptsd was reconsidered for the dsm-iv, researchers conducted empirical examinations that yielded a very complex clinical picture for many trauma survivors (american psychiatric association, 1994). since the formal recognition of ptsd as a diagnosis, many researchers and practitioners have dedicated their careers to better understanding the impact of traumatic stress (van der kolk, 2007). one current journal dedicated to psychological trauma is entitled journal of traumatic stress. the journal of trauma and dissociation also explores specialized trauma-related topics and the journals child abuse and neglect and developmental psychopathology focus on the impact of trauma on children. there are several other journals that address trauma and ptsd that include topics of child abuse and neglect, family violence, violence against women, and more. one resource that lists several of these journals can be found on a professor’s website (freyd, 2012). there are 43  
  several professional organizations dedicated to the topic of traumatic stress including the violence and traumatic stress branch of the national institutes of mental health and the u.s. veterans administration’s national center for ptsd. the u.s. department of health and human services created the national child traumatic stress network. since the official ptsd diagnosis was accepted into the dsm-iii (american psychiatric association, 1980), there have been several important scientific advances enhancing our understanding of ptsd. the impact of trauma has been examined through a developmental lens with the goal of understanding how trauma impacts an individual throughout the lifespan (putnam, 1997; pynoos, steinberg, ornitz, & goenjian, 1997; van der kolk, roth, pelcovitz, sunday, & spinazzola, 2005). researchers have examined the underlying neurobiological processes in traumatic stress (friedman, charney, & deutch, 1995; yehuda, 2006). there have also been several investigations into treatment outcomes for various populations (foa, keane, friedman, & cohen, 2009). overall, the field of trauma research and practice has come to integrate a biopsychosocial approach that strengthens our understanding of traumatic stress (van der kolk, 2007). current posttraumatic stress disorder criteria the dsm-5 (american psychiatric association, 2013) offered some researchbased changes to the ptsd criteria that had remained relatively stable since its introduction as a diagnosis in the dsm-iii in 1980 (american psychiatric association, 1980). ptsd was moved out of the umbrella of anxiety disorders, where it had been housed throughout the dsm-iii and dsm-iv and put into a section called trauma and stressor-related disorders. the dsm-5 maintained criterion a, which required a direct 44  
  stressor in which an individual must be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. the dsm-5 maintained the intrusion criterion, formally labeled re-experiencing in the dsm-iv, while tightening up the symptom descriptions. the dsm-5 split the dsm-iv avoidance and numbing criterion into two separate categories; the first maintained the avoidance label and the next was labeled negative alterations in cognitions and mood. the dsm-5 also retained the arousal and reactivity criterion. symptoms must be experienced in excess of 1 month and must cause marked impairment in social or occupational functioning. symptoms must not be caused by medication, substance use, or other illness. brief overview of clinical treatment of trauma despite the years of research conducted on ptsd treatment and outcomes, more research is needed to clarify what treatments are most effective with particular patients, given their demographics and specific clinical presentations (friedman, cohen et al., 2009). currently, there are a large number of treatments shown to be effective for ptsd (watts et al., 2013). treatment providers are reminded that “science is mainly generic, whereas reality is always specific” (friedman, cohen et al., 2009, p. 618). ptsd treatment is provided to a unique individual and cannot be administered in a generic fashion. that being said, there are some modalities with empirical or evidence-based support that are designed for treating ptsd. mental health providers are responsible for integrating treatment techniques in a manner that is catered to the client.  45  
  individual psychotherapy. the most researched psychotherapy modalities for treating ptsd are cognitive-behavioral therapies (cbts) (watts et al., 2013) including prolonged exposure, cognitive processing therapy, and cognitive therapy. all modalities have demonstrated a large amount of evidence for positive treatment outcomes according to a meta-analysis by watts et al. (2013). eye movement desensitization and reprocessing (emdr) has also been examined as a ptsd treatment and has been shown to be effective, although there is debate in the field over the mechanism of action and whether the change agent for emdr overlaps with underlying mechanisms of cbt (friedman, cohen et al., 2009). psychodynamic therapy, hypnotherapy, skills-based cbt, and desensitization also yielded positive results for treating ptsd (watts et al., 2013). group psychotherapy. group psychotherapy is an efficacious model for treating trauma survivors (friedman, cohen et al., 2009). group therapy has been found to be more effective than no therapy or wait-list controls (sloan, feinstein, gallagher, beck, & keane, 2013). various styles of group therapy have been found helpful including cbt, interpersonal, processing, and insight-oriented groups. (friedman, cohen et al., 2009). there is no benefit to models that address the trauma directly over models that address the trauma indirectly such as supportive therapy; both modalities are efficacious. because group process research is difficult to conduct through randomized controlled trials, further research is warranted to determine more nuanced recommendations for providing group psychotherapy to trauma survivors.  46  
  pharmacotherapy. pharmacotherapy is an important treatment option for clients as it assists with some of the neurobiological symptoms found in ptsd. the most common pharmacological treatments for ptsd include antidepressants, particularly selective serotonin reuptake inhibitors (ssris) and serotonin-norepinephrine reuptake inhibitors (snris) (friedman, davidson, & stein; 2009; watts et al., 2013). atypical antipsychotic medications have also been examined, although to a lesser extent than antidepressants. atypical antipsychotic medications can be helpful as an adjunct to ssri or snri treatment for some patients (friedman, davidson, & stein, 2009). watts et al.’s (2013) recent meta-analysis confirmed the existing line of scholarship on ssri and snri treatment for ptsd and suggested that further research be conducted on the sequencing of treatment when using medications for ptsd. research considerations. research consumers must be reminded of the many pitfalls that lie within academic research including publication bias and undifferentiated/poorly defined constructs (watts et al., 2013). watts et al. (2013) cautioned readers to consider that psychotherapy outcome research may be more likely to be published when outcomes are positive than when they are negative. this may bias the knowledge base as unpublished studies may contain valuable information about ptsd treatments. additionally, psychotherapy studies generally have smaller sample sizes than medication research, which can impact their generalizability. psychotherapy research is also complicated by the idea of specific versus nonspecific psychological interventions (gerger, munder, & barth, 2014). specific interventions are theoretically tied to a unique theory. nonspecific interventions, or 47  
  common factors, include the humanistic components of psychotherapy such as insight, hope, and a trusting relationship (wampold, 2012). nonspecific interventions should offer the same baseline as the specific intervention, only omitting the specific intervention under investigation. gerger et al. pointed out that nonspecific interventions are “rarely evaluated for their efficacy” (p. 601). gerger et al.’s meta-analysis examined specific and nonspecific interventions moderated by clinical complexity and their results suggested that for non-complex clinical presentations, specific interventions are the best treatment option. however, for complex presentations, specific interventions provided little additive benefit over nonspecific interventions including supportive therapies and relaxation controls. gerger et al. contributed to the plea by many other authors that specific interventions are needed for clients with more complicated clinical ptsd presentation (cloitre, koenen, cohen, & han, 2002; foa et al., 2013; gerger et al., 2014; harned, korslund, foa, & linehan, 2012). other studies offer considerations impacting conclusions that may be drawn from ptsd outcome literature. for example, the rupture and repair process within the therapeutic alliance has been found to be an important component of therapy that is not often examined in research for various modalities (mclaughlin, keller, feeny, youngstrom, & zoellner, 2014). xenakis (2014) suggested treatment providers take into consideration medical illness and injuries and focus on quality of life as an outcome measure rather than the more popular symptom reduction focus.  48  
  differentiated forms of trauma in addition to treating ptsd in general, which often addresses childhood sexual abuse, sexual assault, war trauma, and natural disasters, the literature outlines several other forms of psychological trauma. judith herman (1992a) established a diagnosis for complex ptsd and offered ideas on how to conceptualize such complicated clinical pictures. several authors have also examined ideas about emotional abuse and psychological abuse (follingstad, 2007; marshall, 1996; straus, 1979). emotional and psychological abuse can be considered subtler forms of trauma and can accompany more explicit physical or sexual abuse (hoffman, 1984; shepard & campbell, 1992). examining these more subtle and often un-recognized experiences of trauma and abuse can offer several insights into treating clients with trauma histories. complex ptsd. in 1992, judith herman published her renowned work on complex ptsd (herman, 1992a). early on in the conceptualization of ptsd symptomology, men’s experiences more strongly influenced diagnostic criteria. men were more likely to experience trauma through war, accidents, assaults, and natural disasters (van der kolk et al., 2005), whereas women more likely experienced childhood abuse (kessler, sonnega, bromet, hughes, & nelson, 1995). herman reviewed the existing literature in response to the notion that ptsd failed to capture the entire phenomenon experienced by survivors of prolonged and repeated trauma. examples of prolonged trauma include individuals in captivity who are unable to escape and are being controlled by a perpetrator such as the case in concentration camps, prisons, and slave labor camps. prolonged trauma is also experienced in some domestic violence situations 49  
  including child abuse. herman acknowledged that religious cults, brothels, and other institutions engaging in forcible sexual behavior may result in victims demonstrating signs of complex ptsd. she identified three broad categories of disturbance in clients suffering from complex trauma to include a more complex symptom picture, characterological changes including identity disturbances, and increased vulnerability to repeated harm both at the hands of others and self-inflicted. the symptomatic challenges herman (1992a) identified in complex ptsd included somaticizing one’s psychological distress into tension headaches, gastrointestinal disturbances, pains, nausea, tremors, and choking sensations. such symptoms were found in holocaust survivors (de loos, 1990; hoppe, 1968; niederland, 1968), refugees from southeast asia (kinzie et al., 1990; kroll et al., 1989), and many adults with histories of childhood abuse (mai & merskey, 1980; morrison, 1989). affective changes, including depression, found in individuals who suffered prolonged abuse (goldstein, van kammen, shelly, miller, & van kammen, 1987) and rage, which victims often cannot express toward their perpetrator for fear of death or further abuse (hilberman, 1980), further complicate the symptom picture of survivors of repeated trauma. herman (1992a) identified characterological changes in survivors of prolonged abuse secondary to decreasing the victim’s autonomy, increasing isolation, and threating violence. this abuse results in the victim’s dependence on the perpetrator for survival and basic needs. herman pointed out this kind of traumatic bonding can also occur in survivors of totalitarian religious cults (halperin, 1983). some victims become passive or 50  
  helpless as they are so isolated they do not believe they can do anything about their situation. due to the extensive nature of the abuse, many survivors feel they have lost their sense of self. this phenomenon differs from survivors of singular traumas after which they may not feel like themselves; prolonged trauma survivors sometimes lose the sense that they have a self. identity formation suffers disturbances that sometimes result in a fragmented sense of self. repeated victimization perpetrated by the self or others is another unfortunate consequence of prolonged abuse. self-mutilation is commonly seen after prolonged child abuse (van der kolk, perry, & herman, 1991). the risk for abuse, rape, and domestic violence doubles for victims of childhood abuse (russell, 1986). in some cases, the victims later become perpetrators (herman, 1988). these experiences and more contribute to the continued victimization of prolonged abuse survivors. expanding on the broad domains of disturbance, herman (1992a) articulated seven criteria for complex ptsd. see table 1.  51  
  table 1. herman's seven criteria for complex ptsd criterion  symptoms  1 a history of subjection to totalitarian control over a prolonged period including hostages, prisoners of war, religious cult survivors, sexual and domestic abuse over time 2 alterations of affect regulation including dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger, compulsive or inhibited sexuality 3 alterations in consciousness including amnesia or hypermesia for traumatic events, dissociative episodes, depersonalization, reliving the experience in intrusive symptoms or ruminative preoccupation 4 alterations in self-perception including a sense of helplessness or paralysis of initiative, shame, guilt, self-blame, sense of defilement or stigma, sense of complete difference from others (may include specialness, utter aloneness, belief no other person can understand, or nonhuman identity) 5 alterations in perception of perpetrator including preoccupation with relationship with perpetrator, unrealistic attribution of total power to perpetrator, idealization or paradoxical gratitude, a sense of special or supernatural relationship, acceptance of belief system or rationalizations of perpetrator 52 (continued)  
  6 alterations in relations with others including isolation and withdrawal, disruption in intimate relationships, repeated search for a rescuer, persistent distrust, repeated failures of self-protection 7 alterations in systems of meaning including loss of sustaining faith, sense of hopelessness and despair. (source: herman, 1992 p. 121) herman’s (1992a) proposed diagnosis of complex ptsd offers an alternative diagnosis that purports to capture the experiences of trauma survivors extending beyond traditional ptsd diagnoses. since her proposal of complex ptsd as a differentiated disorder, many researchers have contributed to scholarship related to complex ptsd. in 1992, the dsm-iv field trial for ptsd investigated whether survivors of chronic trauma experienced the traditional symptoms identified in the existing ptsd diagnosis or whether they were better described by a different constellation of symptoms that were often found in literature and clinical observation of child abuse and other prolonged trauma survivors (van der kolk et al., 2005). investigators created the category of disorders of extreme stress not otherwise specified (desnos) for their investigation to determine whether herman’s criteria offered a differentiated diagnostic picture from simple ptsd. results confirmed the researcher’s hypothesis that early traumatization and more prolonged traumatization led to a more complex psychopathology and that the symptom cluster of desnos was not necessarily a separate cluster of symptoms from ptsd. individuals traumatized at a younger age were more likely to suffer from desnos symptoms as well as ptsd symptoms. researchers were left wondering 53  
  whether treatment seekers sought treatment due to desnos symptoms or ptsd symptoms and further research was warranted to examine whether desnos could be differentiated from ptsd. in 2012, resick et al. contributed a critical evaluation of the complex ptsd literature in consideration of complex ptsd as a diagnostic category in the dsm-5. they concluded that although the proposal of a complex ptsd diagnosis has resulted in further and needed contributions to the ptsd literature, there is not currently enough evidence to support a separate diagnostic category from ptsd. they suggested that further research is warranted to investigate neurobiological mechanisms involved in individuals with complex ptsd. they offered up the point that there is debate in the field in defining complex ptsd and only one measure of the desnos. they concluded by suggesting that perhaps what is understood as complex ptsd falls on one extreme of a continuum of ptsd. psychological and emotional trauma. psychological and emotional abuse, terms which are often used interchangeably, have historically received less attention in the literature than physical and sexual abuse (babcock et al., 2008). despite this fact, psychological abuse has been found to have a significant and at times greater impact on survivors than physical or sexual abuse (follingstad et al., 1990). much of the research on psychological abuse stems from the research on intimate partner violence that started in the 1970s and 1980s (follingstad, 2007; follingstad & dehart, 2000). as physical abuse was further researched, the idea that psychological abuse coincided with physical and sexual abuse gained popularity (loring, 1994). as scholarship progressed, 54  
  researchers came to believe that psychological abuse can occur on its own, apart from physical violence (hoffman, 1984; shepard & campbell, 1992) and that psychological abuse consisted of dynamics that may not necessarily be found in physical abuse alone (loring, 1994). some psychological abuse victims, unlike physical abuse victims, may not know they are being abused because of the subtle nature of psychological abuse. marshall (1994) offered the idea that subtle psychological abuse may be more effective in controlling one’s victim as the victim may experience both loving and psychologically abusive behaviors from the perpetrator, further confusing the victim. one major issue highlighted in the literature regarding psychological abuse is the variety of definitions and a lack of a unified understanding of psychological abuse (follingstad, 2007; mchugh et al., 2013). straus (1979) defined psychological abuse as “verbal and nonverbal acts which symbolically hurt the other, or the use of threats to hurt the other” (p. 77). marshall’s (1996) cluster analysis yielded six clusters of psychological abuse ranging from subtle to overt and including issues of forced secrecy, isolation, criticism, controlling behaviors, and the psychological abuse that accompanies physical or sexual violence. o’leary’s (1999) conceptualization of psychological abuse included coercive and controlling behaviors including patterns of verbal aggression, domination, isolation, and derogation. these different definitions reinforce the idea that there is not a unified definition of psychological abuse; neither is there a legal definition as there is for other forms of abuse including sexual and physical abuse (follingstad, 2007). because many researchers have offered varying ideas and definitions, many remain in agreement that further research on psychological abuse is warranted (mchugh et al., 2013). one 55  
  application to both herman’s (1992a) complex ptsd diagnosis and the literature on psychological trauma may be an emerging line of work on spiritual and religious abuse. abuse and trauma can be experienced in religious environments in which parishioners hear repeated messages that sometimes result in negative reactions and, in some cases, trauma symptoms. in the same way that scholarship on physical and sexual abuse paved the way for the study of psychological abuse, it may be that the significant body of literature that exists on the overtly harmful effects of religious cults may pave the way for the study of more subtle forms of spiritual abuse. spiritual abuse the topic of spiritual abuse shares a similar history with the history of abuse in general. the topic of abuse struggled to emerge as a credible construct in the literature as survivors have historically been disbelieved, blamed, and silenced (herman, 1992b). spiritual abuse is no different. most of the literature written about spiritual abuse has occurred since the 1990s and much of it is qualitative in nature (oakley, 2013a). parallel to the historical denial of childhood sexual abuse (draucker & martsolf, 2014), and even elder abuse (biggs & goergen, 2010), it is possible that spiritual abuse survivors are discredited in light of the increase of secularization of our culture as well as the perception that members of abusive religious groups can simply leave the group (oakley, 2013a). similar to victims of domestic violence, leaving the abusive relationship is not as simple as it may seem. leaving an abusive environment, although a healthy choice, can be wrought with fear, confusion, and other uncomfortable feelings.  56  
  the term spiritual abuse has been used since the early 1990s when johnson and van vonderen (1991) published a book on the topic and coined the phrase “spiritual abuse.” johnson was a christian church pastor and van vonderen was a counselor and author. since that time, academic articles on spiritual abuse remain sparse while popular culture has taken an interest in the topic as evidenced by the numerous blogs upon which countless individuals express their pain at the hands of religious institutions. some blogs address spiritual abuse in general (e.g., http://futuristguy.wordpress.com; www.spiritualsoundingboard.com; and http://www.churchexiters.com) while others address abuse perpetrated by a specific religious institution or group (e.g., http://www.recoveringgrace.org; http://marshillrefuge.blogspot.com). it may be helpful for psychologists to join together with laypersons who encounter spiritual abuse for the purpose of studying spiritual abuse in a more scientific manner (newman, bakina, & tang, 2012). notably, the spiritual abuse literature developed after the cult literature. early examination of what is now understood to include spiritual abuse began in the 1970s when parents of young adults banded together out of concern for their children (langone, 1993). many parents of adult children who had joined new religious movements became increasingly troubled when they observed personality and behavioral changes in their loved ones. although neither clergy nor helping professionals seemed interested in the parents’ concerns, many journalists took notice of the parents’ plight and began publicizing stories of america’s youth being exploited by cults. this awareness brought families together and grassroots movements began to collaborate in a more unified 57  
  manner. eventually, people in these movements banded together, forming an organization that has evolved into the cult awareness network, which seeks to provide educational resources about cults for loved ones of cult members (http://www.cultawarenessnetwork.org/). just as the psychological abuse literature emerged from the sexual/physical abuse literature, the spiritual abuse literature appears to have developed out of the literature addressing more explicit forms of abuse. specifically, the literature exploring cults, domestic violence, and clergy sexual abuse preceded the newer literature on spiritual abuse. thus, various lines of scholarship have converged, illuminating the topic of spiritual abuse and differentiating it as its own construct. spiritual abuse in relation to cults cult involvement can be conceptualized through a trauma lens, as suggested by rosen (2014). rosen described cult involvement as creating traumatic memories in the body including flashbacks, nightmares, and former members becoming triggered by events that remind them of their cult experiences. she also discussed the idea of interpersonal trauma. it can be a severe feeling of betrayal to realize the person or group to which one has devoted much energy, time, and emotional resources does not contain the positive or healthy qualities as previously believed. the constant stress cults place on members to perform is another kind of trauma as the pressure tends to be severe and constant, at times requiring the member to deny who they are by submitting to the cult’s standard of who they should be.  58  
  martin (1993) described ex-cult members as having been traumatized. having worked with many ex-cultists, he described symptoms to include painful memories of the cult involvement, loss of interest in the world outside the cult, feelings of detachment from society, and restricted emotionality. interestingly, martin’s three-stage recovery process, although not explicitly compared with herman’s (1992) trauma treatment recommendations, does contain some parallels. herman’s (1992) of stages include safety, remembrance and mourning, and reconnection. martin’s first stage includes safety through the ex-cultist developing a conceptual framework to include increased understanding and gaining information about cults and recovery and thought reform. his second stage involves grieving, reconciliation, and reaching out. his third and last stage includes reintegrating into society. spiritual abuse in relation to domestic violence part of the emerging understanding of spiritual abuse derives from the domestic violence literature, which focuses primarily on physical and sexual violence. researchers and practitioners began to see that domestic violence survivors often experienced a spiritual dimension of abuse that went unnoticed or unexamined. additionally, many abuse survivors seek help from their faith communities (adams & fortune, 1998; west, 1999). help-seeking behavior from religious communities is particularly common among women of color as many seek assistance from their faith communities instead of seeking help from mental health agencies (allard, 2005; nason-clark, 2004). sometimes faith communities can perpetuate attitudes that contribute to a culture of domestic violence, both overtly and covertly (adams & fortune, 1998; bent-goodley 59  
  & fowler, 2006; west, 1999). covertly, some parishioners may be denied participation in religious activities, isolating them from their support systems and limiting their chances for spiritual renewal. religious texts may serve as sources of confusion and anger as the victim struggles to make sense of the domestic violence. sometimes, through use of religious texts, victims are encouraged to forgive their partners, often resulting in feelings of powerlessness and hopelessness as they question their faith and their own agency (fortune, 1998). in a qualitative examination of african american congregants and ministers regarding their understanding of domestic violence from a spiritual or religious perspective, several themes emerged (bent-goodley & fowler, 2006). participants identified concerns over defining spiritual abuse. many participants viewed spiritual abuse as a broad topic and resisted a universal definition in favor of individually defined examples of spiritual abuse. participants agreed that spirituality could be “used against you” (p. 288) and that abusers could damage their victims by telling them that god has forgotten about them, denying church attendance, and emphasizing forgiveness for the abuse. when asked about how the church perpetuates abuse, participants highlighted the gender disparity in many churches and how this often parallels women’s domestic experiences. one participant pointed out that religious values including “keeping families together at all costs, victims being forgiving, and wives being submissive” (p. 288) were all oppressive belief systems perpetuated systemically and in need of change. lastly, the theme of understanding african american women’s spirituality was highlighted as essential because connectedness with god and faith communities is often a primary 60  
  coping mechanism subsequent to domestic abuse. participants identified that distinguishing spiritual and religious abuse as components of other kinds of abuse could validate the need for the unique role of faith communities as healing communities for the abused. another perspective of a spiritual dimension of abuse concurrent to other forms of domestic abuse was illuminated upon an examination of haredi (ultraorthodox jewish) women (dehan & levi, 2009). the researchers obtained qualitative data through group interviews to investigate the women’s experiences of abuse. the researchers quickly realized that the traditional power and control wheel, deriving from the duluth model of domestic violence awareness (pence & paymar, 2003), was inadequate at fully capturing the women’s experiences. throughout the year and a half of contact with the participants, the researchers identified spiritual themes and articulated a spiritual dimension of the women’s experiences. when the idea was presented to the participants, they concurred that identifying a spiritual component of their abuse was valid and they expressed satisfaction that the researchers were able to capture a part of their experience, the spiritual dimension, which had not previously been understood. in the context of their research, the authors described spiritual abuse among the haredi wives to include, “any attempt to impair the woman’s spiritual life, spiritual self-or spiritual well-being” (p. 1300). they further identified three levels of abuse to include, “(a) belittling the women’s spiritual worth, beliefs, or deeds; (b) preventing the woman from performing spiritual acts; and (c) causing the woman to transgress spiritual obligations or prohibitions” (p. 1300). 61  
  in dehan and levi’s (2009) study of abused haredi women, the researchers identified an important distinction between spiritual abuse from other forms of abuse including psychological and emotional abuse. they emphasized that when an abuser perpetrates using the woman’s spirituality against her, the resulting damage occurs at the transcendental level. dehan and levi’s (2009) research resulted in the following definition of spiritual abuse: damaging the woman’s spiritual life, spiritual self, or spiritual well-being, by means of purposely and repetitively criticizing, limiting, or forcing her to compromise or go against her spiritual conscience, resulting in a lowered spiritual self-image, guilt feelings, and/or disruption of transcendental connectedness. (p. 1303) spiritual abuse in relation to clergy sexual abuse much like the domestic violence literature, the research on clergy sexual abuse illuminates a need for better understanding the spiritual components of abuse perpetrated by a trusted religious leader. similar to the shocking notion that some children are abused by family members, the knowledge of abuse perpetrated by clergy dismantles all that is understood about the supposed trustworthy role of religious leaders (farrell, 2004). this shock and subsequent avoidance has impacted the field of spiritual abuse, including clergy sexual abuse, as evidenced by its sparse mention in the literature until more recently. the egregious abuse of power not only harms the victim sexually, physically, and psychologically, but is spiritually wounding as well. many clergy sexual abuse survivors exhibit symptoms of depression, anxiety, and ptsd subsequent to clergy 62  
  sexual abuse (isely et al., 2008). many survivors also report an intangible, spiritual consequence of the abuse including a lack of interest in or connection with spirituality and some report a crisis of faith (gartner, 2004). evidence of sexual abuse by clergy has been documented as early as the second century (farrell, 2004). the history of religious institutions’ responses to abuse largely involves denying the abuse has happened, justifying the reasons for the abuse, and geographically relocating the perpetrator to another jurisdiction. many recent accounts of clergy sexual abuse have been focused in the catholic tradition, per media attention, although clergy sexual abuse is not limited to the catholic faith and has been identified in various religious traditions. perhaps the most harmful factor in the sexual abuse of clergy and religious leaders is the abuse of power perpetrated onto trusting victims (fallot & blanch, 2013). many religious leaders, particularly those who hold high offices in their religious system or places of worship, are elevated to a god-like status among their congregants (mclaughlin, 1994). this elevation results in a system of abuse that is not only, though horrifically, perpetrated from one human being onto another, but there is the phenomenon of many victims feeling they have been victimized by the divine itself, exceeding the simpler person-to-person abuse. this experience of betrayal and abuse of power becomes exacerbated when the victim associates the leader with the religion itself, resulting in  63  
  many survivors leaving the religion in which they were raised. in a 2004 historical account of clergy sexual abuse, farrell pointed out that: clerics and religious (people) are privileged persons of power, and in many respects this power is considered divine. when clergy or religious abuse this for their own sexual gain and advantage, they distort their position of spiritual guide, and instead become an instrument of destruction, pain and trauma. (p. 45) farrell (2004) went on to explain that the divine becomes entangled with the perpetrator, resulting in a mistrust of both the religious leader and the divine. this particularly egregious abuse of power was argued to be a distinguishing factor that differentiates sexual abuse perpetrated by clergy from other forms of sexual abuse (ormerod & ormerod, 1995). several insights and themes have been identified through qualitative inquiry of clergy sexual abuse survivors and therapists who work with them (doyle, 2009; isely et al., 2008). doyle (2009) identified that in his experience of working with victims of clergy sexual abuse, spiritual trauma has often been described by survivors as worse than the emotional pain they suffered. doyle pointed out that the spiritual trauma is not limited to the survivor, but may extend to the family members, attorneys, counselors, media, law enforcement professionals, and other helping professionals who come into contact with the abused persons. upon working with many catholic clergy abuse survivors, doyle (2009) found that many survivors have become further traumatized upon entrusting their stories to their own churches in seek of refuge and support. not only have they been betrayed by a 64  
  trusted religious leader, their own church or religious leaders may not believe them and may fail to provide needed support. at times, religious institutions deny that the abuse happened and may even transfer the perpetrating clergy to another geographical location, where the cycles of abuse usually continue. this perpetual abuse further traumatizes the victims in a uniquely painful manner. in interviews with male survivors of clergy sexual abuse, isely et al. (2008) extrapolated unique themes seen in clergy sexual abuse, differentiating it from typical symptoms of depression, anxiety, and ptsd often found in sexual abuse survivors regardless of the relationship with the perpetrator. one such theme specific to clergy sexual abuse was that the participants’ accounts indicated a kind of “developmental insult with a high likelihood of compromising social, relational, and intrapsychic functioning later in life” (p. 209). pargament, murray-swank, and mahoney (2008) identified that a sense of the sacred is often discovered in childhood. for children who are victimized by clergy, the typical course of spiritual development becomes stymied as the children learn they cannot trust their religious leaders. doyle (2009) identified symptoms of spiritual trauma that he observed in his work with catholic clergy abuse survivors. one theme includes the various feelings toward priests including conflict and confusion between the deep anger they feel and the previous awe and respect they had for their priests. further complicating their confusion is the belief that they are not allowed to feel anger toward god. many also feel guilt over the sexual abuse resulting from the belief that sex outside of a marriage relationship is unacceptable. often, survivors project their feelings from the perpetrating priest to others 65  
  in the priesthood, resulting in difficulty attending religious services. many survivors avoid religion altogether. this avoidance can result in feelings of emptiness as they previously found meaning in their religious environments. other symptoms of spiritual trauma secondary to clergy sexual abuse include despair from loss of connection with god, as god is often comingled with the abuser (doyle, 2009). this spiritual loss can lead to anxiety, depression, and hopelessness. guilt is another complicated feeling many survivors endorse, including guilt over the belief that they must have done something to deserve the abuse as well as guilt over “outing” their perpetrator, resulting in consequences in their faith communities and families. spiritual trauma can also include a loss of spiritual security whereby the survivor’s primary source of meaning becomes contaminated with distrust and betrayal. spiritual abuse literature given increased and recent attention to spiritual abuse as its own construct, an overview of the literature that directly addresses spiritual abuse is provided below. most of the current work on spiritual abuse is qualitative in nature as researchers have sought to understand the lived experiences of those who have suffered spiritual abuse. spiritual abuse in various religious communities. although the literature specifically identifying spiritual abuse is sparse, there are some peer-reviewed articles on religious abuse occurring in certain religious communities. themes of power, fear, and approval-seeking performance have emerged, and are found in various abusive religious traditions (bhaktavatsala, 2001; dehan & levi, 2009; masis, 2004; oakley, 2013a). although different religions and sects within religions have varying beliefs, exploring 66  
  overarching themes of spiritual abuse can contribute to the knowledge base of spiritual abuse as a specific construct before more nuanced characteristics are identified within certain religious groups. hindu tradition of vaisnava. bhaktavatsala (2001) identified five dynamics that are conducive to a spiritually abusive environment from the perspective of a hindu tradition called vaisnava. the author described an environment in which external appearance and position are promoted as equivalent to spiritual success. they also described a spiritually abusive environment as one that endorses unrealistic expectations such as the idea of an infallible leader and the idea that followers can be totally surrendered to their deity or religious leader. misusing sacred teachings or theology to manipulate followers into institutional or leadership agendas is another dynamic that can occur in a spiritually abusive environment. like others, bhaktavatsala recognized shame and fear as vehicles of spiritual abuse. followers experienced name-calling, criticism, and humiliation perpetrated by the leader. premature transcendence is the final marker the authors identified as indicative of spiritual abuse. the perception of spiritual elitism is used as justification for judgment and prejudice of others. followers believe themselves to be so elite that they are beyond meeting their own physical, psychological, emotional, or social needs. such dynamics reinforce a spiritually abusive system. the authors epitomized these dynamics in their definition of spiritual abuse, in which, “in the name of spirituality or spiritual authority, the individual’s dignity and right to advance through serving krsna is violated” (para. 6).  67  
  american zen centers. spiritual abuse has also been identified in american zen centers (masis, 2004). although some might view abuse in zen centers as counterintuitive, given the discouragement of zen students to proselytize, abuse in zen centers share similar qualities to those found in other traditions. the particular zen center masis’ (2004) study analyzed had one zen teacher who was vested with absolute authority for the center’s spiritual and administrative affairs. the ego was seen as the ultimate enemy for students who were encouraged to overcome the power of their ego. the researcher likened the intense suppression of “the ego” to the christian dichotomy of good versus evil. the goal at the zen center was to suppress the ego, but at the expense of what many psychologists consider a healthy ego. any attempts to question the teacher’s views were reportedly angrily squelched. ironically, zen students were forbidden to express anger, which was considered a shameful emotion. the overall goal for students at the center was to refrain from acting “out of ego” (p. 33). this doctrine, among others, was taught in such a way that doubts, questions, and critical thinking about the teaching were seen as manifestations of the ego, leaving no room for students to explore their own thoughts and feelings. much like bhaktavatsala’s (2001) study on vaisnava, the idea of the infallible leader, or ultimate authority, was infused into the teachings at the zen center, suppressing what might otherwise be a healthy skepticism on behalf of the students. additionally, students at the zen center were isolated from others, including other zen communities. many zen students seeking psychotherapy described feelings of guilt and shame over their lack of ability to gain wholeness solely through their meditation practices. similar to johnson and van vonderen’s (1991) research on spiritual 68  
  abuse among christian environments, masis (2004) emphasized the subtlety of spiritual abuse in american zen centers. bible-based groups. ward (2011) conducted a qualitative analysis of former members of judeo-christian bible-based religious groups and identified six core themes describing the essence of spiritual abuse. ward (2011) argued that “not all spiritual abuse is found in a cult” (p. 900). leadership representing god was a core theme that participants revealed. specifically, participants expressed that disobeying their former religious leaders meant disobeying god. spiritual bullying was the second theme identified in ward’s (2011) research and included the leadership’s manipulation of group members under the assumption of the first theme that the leader represented god. the third theme ward (2011) found was acceptance via performance, which was identified as a fear-based system in which members had to meet certain religious standards to earn their leader’s approval. spiritual neglect was the fourth theme ward (2011) identified, which included members’ physical, psychological, and spiritual needs being unmet. dissonance between one’s inner and outer feelings and experiences described the fifth theme of expanding external/internal tension. participants described the need to put up a facade on the outside to look a certain way and gain the approval of the leadership while often feeling differently on the inside. lastly, the manifestation of internal states, including physiological difficulties, emerged as a theme. specifically, members reported having physical symptoms as a manifestation of the stress and anxiety they were attempting to manage as they tried to follow the group’s rules and earn the leadership’s approval. 69  
  in addition to the six core themes, several other characteristics of spiritual abuse emerged from ward’s (2011) research. he described the diverse experiences of spiritual abuse including physical, emotional, and existential challenges with participants describing significant confusion in making sense of their experiences. the participants’ experiences were all-consuming; few areas of their lives were not impacted by their involvement in their respective religious groups. ward (2011) concluded that spiritual abuse is both a process and an event within a reinforcing cycle strengthening the group’s negative impacts. ward (2011) concluded, suggesting that: spiritual abuse is a misuse of power in a spiritual context whereby spiritual authority is distorted to the detriment of those under its leadership. it is a multifaceted and multilayered experience that includes acts of commission and omission, aimed at producing conformity. it is both process and event, influencing one’s inner and outer worlds and has the potential to affect the biological, psychological, social and spiritual domains of the individual. (p. 913) spiritual abuse is abuse there are several ways in which spiritual abuse parallels other forms of abuse (oakley, 2013b). often, parishioners initially experience positive feelings about their new religious group, similar to what might be experienced in the early stages of a romantic relationship. the group may meet some social needs and a need for belonging and even feel like a family for some members. later, members experience changing perceptions of reality as the group leader or other members seem to be inconsistent in their words or values and the member becomes confused about what is real. at times, members 70  
  experience feelings of anger, self-blame, and fear at their perceived betrayal and do not know what to do with these feelings within the abusive environment. similar to childhood sexual abuse survivors, members may blame themselves or be blamed by their perpetrator for the abusive episodes (oakley, 2013b; zinzow, seth, jackson, niehaus & fitzgerald, 2010). much like survivors of other forms of abuse (herman, 1992b), spiritual abuse survivors often experience a deep sense of distrust (oakley, 2013b). this distrust in themselves and others can have a direct impact on their personal faith and their involvement in religious services. survivors may also experience social isolation. particularly considering that spiritual abuse is not yet a widely understood or accepted form of abuse, survivors themselves may lack understanding of the abuse they have experienced in their religious group. secrecy and silence frequently accompany spiritual abuse as survivors are told not to speak of the injustices they have experienced. all of these implications of spiritual abuse can leave a lasting impact on the survivor, as is the case in many other forms of abuse. this lasting impact remains particularly difficult to overcome, given the sense of powerlessness many survivors experience. this powerlessness and inaction may leave a group susceptible to continued perpetration of new members as little or no attention has been brought to the system of abuse. oakley (2013b) suggested there are factors that differentiate spiritual abuse from other forms of abuse. their research was conducted on spiritual abuse survivors coming from christian groups in the united kingdom. the distinguishing factors of spiritual abuse that oakley identified include: 71  
  •  the notion of divine position;  •  the use of scripture and the pulpit to enforce agendas and challenge behavior;  •  the spiritual context within which spiritual abuse occurs;  •  the threat of spiritual consequences for individuals who do not conform;  •  the impact upon core faith beliefs following spiritual abuse. (p. 73).  emerging definitions of spiritual abuse the existing literature offers a few definitions and descriptions of the phenomenon of spiritual abuse. a common theme in the spiritual abuse literature is the idea of exploitation and an emphasis on a spiritual leader as manipulative or selfish (oakley, 2013a). one set of authors described spiritual abuse as “denying other’s spiritual freedom through claiming that only one’s way to god is valid” (linn, linn & linn, 1994, p. 12). other authors have captured the essence of blame and shame perpetrated toward the victim in their descriptions of spiritual abuse. one such definition states “spiritually abused individuals have received the message that their spirituality is defective as if there is something wrong with them” (bhaktavatsala, 2001, para. 10). along a similar line of thinking, johnson and van vonderen (1991) highlighted the idea that shame is frequently used as a means of manipulation or to avoid questions from followers. often, the individuals seeking spiritual help receive the message that they are spiritually defective and cannot live up to a particular spiritual standard. for the current examination of spiritual abuse, the author chose to adopt the definition offered by johnson and van vonderen (1991), who defined spiritual abuse as “the mistreatment of a person who is in need of help, support, or greater spiritual 72  
  empowerment, with the result of weakening, undermining, or decreasing that person’s spiritual empowerment” (p. 20). this definition is simple enough that it encompasses various places on the spectrum of spiritual abuse from subtle to traumatic. their definition is relatable to extreme forms of spiritual abuse, such as that found in cults where members lose their sense of individual identity (langone, 1993) to forms of gender-based disempowerment found in religious systems (adams & fortune, 1998; bent-goodley & fowler, 2006; west, 1999) to spiritual abuse concurrent with other forms of abuse including emotional, physical, or sexual abuse (bent-goodley & fowler, 2006; doyle, 2009; farrell, 2004; isely et al., 2008). johnson and van vonderen’s (1991) definition also lends itself to the phenomenon of spiritual abuse that can be found in various religious or spiritual contexts and is not limited to a particular religious belief system. differentiating spiritual and religious abuse. research on spiritual and religious abuse is sparse (simonic, mandelj & novsak, 2013). examination of this particular type of abuse appears to be early enough in its development that the literature does not provide clearly defined terms. for instance, some authors use the term religious abuse (simonic et al., 2013), and others use the term spiritual abuse (oakley, 2013a; ward, 2011). many authors point out that religious or spiritual abuse often co-occurs with other types of abuse including domestic violence (bent-goodley & fowler, 2006; dehan & levi, 2009), clergy sexual abuse (fallot & blanch, 2013; pargament et al., 2008), and cult abuse (langone, 1993). the co-occurrence happens when the perpetrator uses spiritual or religious ideas to control or manipulate their victim. 73  
  simonic et al. (2013) identified religious abuse as a type of emotional abuse, explaining that clinicians without much exposure to religious abuse may better understand it in terms of a kind of emotional abuse with which they might be more familiar. the authors delineated between two types of religious-related emotional abuse. one type of religious abuse occurs when abusers use religion to justify their actions. the second type of religious abuse involves emotional abuse as the abuser instills fear, guilt, and shame in the victim through using religious doctrine in an emotionally manipulative manner. common features in all forms of religious abuse include isolation, distorted selfimage, and the victim’s disconnection from their higher power. bent-goodley and fowler (2006), in their grounded theory exploration of african american women survivors of domestic violence, identified several spiritual and religion-related themes among the women they interviewed. consistent with the historical difficulty of defining spiritual abuse (oakley, 2013a), the women were reluctant to define it. rather, they emphasized the personal differences in how one can experience spirituality and were not interested in defining a construct that could potentially be used against them. one woman identified the reason people seek help from their ministers rather mental health professionals is her perception that the ministers will deal with “the most important part of who they are” (bent-goodley & fowler, 2006, p. 289). another participant differentiated the spiritual impact as “bigger” than the physical abuse alone. although the participants did not explicitly differentiate between religious and spiritual abuse, it is possible that the harm to their personal experience with the divine might have suggested a spiritual injury rather than religious injury. 74  
  in dehan and levi’s (2009) qualitative study on abused haredi women, the authors shared their process in choosing the term spiritual abuse over religious abuse. they identified that spiritual abuse better described the women’s experiences due to the transcendental meanings attributed to the abuse. for their study, the haredi tradition emphasizes spirituality over religion in everything one does and the experience of one’s spirituality better captures the holistic view of the person rather than religion. lastly, the term spiritual abuse could be attributed to other religions or non-religious experiences and lends itself to future studies on the phenomenon of spiritual abuse across various cultures and faith systems. instrument development social scientists attempt to measure psychological phenomena based on theory (devellis, 2012). sometimes there are multiple and evolving theories that complicate the measurement of a construct, creating a challenge for social scientists to measure the identified construct. the better understood the construct, such as spiritual abuse, the more accurately it can be measured. thus, both qualitative and quantitative data contribute to the theoretical understanding about a given topic (merriam, 2009). it is often helpful to obtain interviews by participants who have experienced the phenomenon of interest and to identify themes that can eventually be measured quantitatively. continued development and refinement of a measure of a construct will increase understanding of the topic (devellis, 2012). scales are developed to help measure theoretical variables that are believed to exist, but may be difficult to assess.  75  
  some variables are more complicated to assess than others (devellis, 2012). the question of age, for example, may yield an easy and straightforward answer from a participant when asked. more abstract phenomena, such as spiritual abuse, may require more cognitive resources for responding to items inquiring about this phenomenon. when responding to theoretical variables, a participant may need to “reconstruct, interpret, judge, compare, or evaluate less accessible information” (p. 12). the underlying phenomenon or construct a scale attempts to measure is a latent variable (devellis, 2012). a latent variable is not directly observable, it may vary over time, and the strength or magnitude of the variable is subject to change. latent variables are unique to the person who is the source of the data. when a participant completes a questionnaire, the scale is used to estimate the magnitude of the latent variable for the respondent at that time. this measurement is otherwise known as the true score. psychometrics reliability. reliability is an important factor in scale development as it reflects that a scale performs consistently and predictably (devellis, 2012). reliability identifies the amount of variance in the measure attributable to the true score or latent variable. since the latent variable rarely accounts for the entire variance, researchers estimate the amount of error based on various models for determining reliability. some methods include the analysis of variance (anova), chronbach’s (1951) coefficient alpha (α), or the kuder-richardson formula 20 (kr-20). validity. whereas reliability reflects a scale’s consistency, validity refers to whether latent variable is the underlying cause of the covariance in the item pool 76  
  (devellis, 2012). there are three primary types of validity. content validity is concerned with the accuracy of the scale items reflecting the content domain. criterion-related validity, otherwise known as predictive validity, means that the item or scale must be empirically associated with some criterion. construct validity (cronbach & meehl, 1955) is the extent to which the variable reflects what is predicted based on other measures of a similar construct. one example of construct validity involves convergent/discriminant validity, which is a measure of how similarly or differently a scale measures in comparison to other scales purporting to measure the same (or different) latent variable. factor analysis. factor analysis is a statistical method that helps researchers determine how many latent variables underlie a given scale by determining which items cluster together under a common factor (devellis, 2012). factor analysis also helps to explain variance between variables. for example, a scale with a larger number of items could be condensed upon a factor analysis revealing that the latent construct can be measured adequately with fewer items. factor analysis can also help identify separate constructs, or factors, that account for some of the overall variance for a given scale. current instruments there are no known measures of spiritual abuse assessing victims who suffered spiritual abuse. there are, however, measures that may demonstrate some overlap with topics of spiritual abuse including instruments measuring spiritual and religious experiences and trauma/abuse instruments. one known instrument designed to assess spiritual abuse from a therapist’s perspective is also briefly discussed.  77  
  spirituality and religious experience instruments. measuring spirituality and religious experiences includes a broad spectrum of examining spiritual and religious phenomenon from various angles (hill & edwards, 2013). in apa’s 2013 handbook of psychology, religion, and spirituality (pargament, exline, & jones 2013), several categories of religious measures covered in hill and edward’s (2013) analysis included: general religiousness or spirituality, beliefs, commitment, relational/attachment measures, spiritual and religious development, social participation, private practices, religious motivation, meaning and values, religious support, spiritual experiences, religious coping, and religious struggle. religion and spirituality assessments in the u.s. have expanded beyond scales espousing judeo-christian norms to include a diversity of religious and non-religious meaning systems including atheism and agnosticism. many of the spiritual and religious measures are beyond the scope of this research as many assess for religious experiences are not directly relevant to spiritual abuse. however, there are two scales that remain relevant to the current project. the first of these two instruments falls in the category of religious support. fiala, bjork, and gorsuch (2002) developed a 21-item religious support scale (rss). this scale yielded three subscales including support from god, congregation members, and group leaders and can be used outside of christian populations. because this scale measures for religious support, it could yield helpful information for participants who experience minimal or no support from their religious communities. the second instrument measures religious struggle and strain. the religious coping and strain (rcs) scale was developed by exline, yali, and sanderson (2000). the rcs is a 20-item 78  
  face-valid scale that yields comfort as a subscale as well as three categories of religious strain including alienation from god, fear and guilt, and religious rifts. exline et al. (2014) later developed a 26-item religious and spiritual struggles (rss) scale that focused only on struggles and yielded six domains including divine, demonic, interpersonal, moral, doubt, and ultimate meaning struggles. the rss demonstrates good validity and reliability and was used in this study for convergent validity measures. further details about the rss are provided in the method section. trauma/abuse instruments. several abuse instruments came out of the line of scholarship addressing domestic violence and were primarily geared toward women (mchugh et al., 2013). the domestic violence literature succeeded in defining physical abuse, but there is no agreed upon definition of psychological abuse. some of the scales designed to capture psychological abuse contained difficult psychometric issues regarding gender differences and the scope of abuse. for instance, follingstad et al. (2005)’s psychological aggression scale yielded some data about behaviors termed abusive that could be considered normative in other kinds of relationships (e.g., “did not live up to a commitment that they made to the partner” (p. 29). the measure of wife abuse (rodenburg & fantuzzo, 1993) contained 29 items of psychological and verbal abuse, but the measure was primarily based on clinical experience rather than empirical support. the same is true for the abuse behavior inventory, which measured both psychological and physical abuse (shepard & campbell, 1992). the psychological maltreatment of women inventory (tolman & tolman, 1999) yielded two factors including verbal/emotional abuse and dominance/isolation. follingstad et al. (1995) 79  
  developed the follingstad psychological aggression scale and then later used this scale as a model for the creation of measure of psychologically abusive behaviors, which expanded the original scale by assessing for severe psychological aggression (follingstad, 2011). the emotional abuse questionnaire (eaq) has been widely used in previous research (jacobson & gottman, 1998). the eaq contains four categories including destruction of pets and property, sexual coercion, isolation attempts, and degradation. the subtle and overt scale of psychological abuse (sosps) (jones, davidson, bogat, levendosky, & von eye, 2005; marshall, 1999) is another psychological abuse scale that was intended to tap into a broader range of psychological abuse. the sosps is primarily used for psychological abuse perpetrated by an intimate partner. the national stressful events survey ptsd-short scale (nsess-ptsd; kilpatrick, et. al., 2013) measures the severity of posttraumatic stress symptoms. the scale demonstrates strong reliability and validity and was used in this study for convergent validity purposes. further details are discussed in the method section. the institutional betrayal questionnaire version 2 (ibq.2; smith & freyd, unpublished manuscript, 2014) is a checklist that assesses the amount of institutional betrayal that one may have experienced. institutional betrayal is defined as “a description of individual experiences of violations of trust and dependency perpetrated against any member of an institution in a way that does not necessarily arise from an individual’s less-privileged identity” (smith & freyd, 2014, p. 577). the ibq.2 is relevant for this study, given the institutional nature of many spiritual and religious groups and was used 80  
  for convergent validity. further details about the ibq.2 are provided in the method section. the scale of economic abuse (sea) was developed to capture the distinct phenomena of abuse inflicted upon women in abusive relationships (adams, sullivan, bybee, & greeson, 2008). the scale demonstrated strong psychometric properties and helps to differentiate economic abuse from other forms of abuse that occurs in intimate partner violence situations. the sea provides a supporting example for the current study of how one kind of abuse can be differentiated from other types of concurrent abuse. the group psychological abuse scale (gpa) (chambers et al., 1994) is another scale that differentiates one kind of abuse, psychological abuse, and specifically assesses psychological phenomena that occur in cults and extreme religious groups. the gpa has four subscales including compliance, anxious dependency, mind control, and exploitation. religious abuse instrument. one scale called the religious/spiritual abuse and neglect of children and youth scale was developed for a single study to glean information from clinical social workers about their experiences with spiritually abused youth (kvarfordt, 2010). the scale was not tested concurrent to other scales for convergent or discriminant validity and the author stated the scale yielded an “acceptable estimate of reliability” (p. 157) and indicated it will need further psychometric testing. this scale was not considered for convergent validity in this study because of its focus on obtaining data from treating professionals rather than victims of spiritual abuse.  81  
  however, the scale was referenced for the purposes of item development for the spiritual abuse scale developed in this study. summary the literature is overwhelmingly supportive of the impact, both positive and negative, of religion and spirituality in people’s lives (pargament, 2002). religion has been studied from various angles and by researchers in several academic disciplines, including the field of psychology. when religious adherents experience acts of abuse or neglect as a result of their religious or spiritual involvement, the consequences can be spiritually wounding as well as harmful in other ways. the history of trauma is such that trauma and abuse are often avoided or denied, leaving its victims to suffer in silence (herman, 1992b). this neglect and silences appears to be the case with spiritual trauma as well as other kinds of trauma. complicating this idea is the range of personal experiences and interpretations of such experiences that may or may not be identified as spiritual abuse. there are streams of scholarship including the literature on cults, domestic violence, and sexual abuse, from which themes of spiritual abuse have been identified through qualitative inquiry. although there are qualitative accounts of the impact of spiritual and religious abuse, there are currently no scales designed to measure an individual’s experience of spiritual abuse. this study was designed to develop an exploratory measure that can be used to quantify the construct of spiritual abuse. the measure was developed based on previous literature in religion, trauma, and spiritual abuse. many of the qualitative accounts of spiritual and domestic abuse survivors were used to design items for the scale. 82  
  rationale for study the intention of this study was to strengthen the literature on the topic of spiritual abuse for both clinical and research purposes. piedmont (2013) acknowledged that constructs examined by the field of the scientific study of psychology and religion/spirituality are becoming differentiated and this study purports to contribute to that end. spiritual abuse is becoming differentiated from other types of abuse and harmful religious experiences. because there are no known measures of spiritual abuse, this investigation was an important attempt to synthesize the qualitative and theoretical literature on the topic and to enhance understanding of it by developing a quantitative measure of spiritual abuse. multicultural and trauma treatment competencies provide the foundation of the rationale for this investigation as psychologists are charged with providing ethical and sound research and treatment embodying respect and understanding clients’ various cultural and religious experiences. additionally, the importance of spirituality as it pertains to health and well-being provide further support for the rationale of this study as psychologists often serve as healthcare providers for their clients. multicultural competency multicultural competency, which is an essential component of ethical practice (gallardo, johnson, parham, & carter, 2009), includes religious competency. this investigation was positioned to advance understanding of a unique subset of multiculturalism by investigating harmful components of religious and spiritual 83  
  experiences. this study aligns with the recommended spiritual and religious competencies proposed for all licensed psychologists (vieten et al., 2013). although psychologists have identified spiritual and religious identities as part of human diversity (crook-lyon et al., 2012; mcminn, hathaway, woods, & snow, 2009), most psychologists lack formal training in how to effectively attend to clients’ spiritual and religious issues in treatment (schafer, handal, brawer, & ubinger, 2011; schulte, skinner, & claibom, 2002; vogel, mcminn, peterson, & gathercoal, 2013). upon investigating the need for psychologists to competently tend to religious and spiritual issues, vieten et al. (2013) proposed 16 spiritual and religious competencies for psychologists based on a thorough review of the literature, gathering both qualitative and quantitative data from psychologists and mental health professionals who were considered experts at addressing religious and spiritual issues. two competencies that were directly relevant to the current research project included, “psychologists can identify spiritual and religious experiences, practices and beliefs that may have the potential to negatively impact psychological health” (p. 137) and “psychologists can identify and address spiritual and/or religious problems in clinical practice and make referrals when necessary” (p. 138). this study was theoretically congruent with vieten et al.’s (2013) recommendations to identify when religious or spiritual experiences are harmful to clients. this study contributes to competent assessment of spiritual abuse and its impact. additionally, using a spiritual abuse assessment tool could illuminate a psychologist’s competency or lack thereof concerning a client’s spiritual abuse if the psychologist administers the measure and determines she or he is not adequately trained 84  
  to address the spiritual trauma component of the client’s clinical presentation. in this case, psychologists could refer to or consult with another mental health professional or clergy to attain proper support for the client. training programs can assist with enhancing knowledge and competency among their psychology students regarding spiritual and religious diversity, even when students themselves endorse lower levels of personal involvement with spirituality and religion (rosmarin, green, pirutinsky, & mckay, 2013). this is important, given that seven out of ten americans identify as very or moderately religious (gallup, 2012). some psychology students, despite formal training in addressing spiritual and religious issues, are even formulating their own ways of assessing spirituality among clients (saunders, petrik, & miller, 2014). this is an interesting antidote, particularly in light of research identifying that psychologists are significantly less religious than the populations they serve (delaney, miller, & bisono, 2013). this discrepancy between the religiosity of psychologists and the clients they serve indicates a need for psychologists to educate themselves on this important diversity topic and further supported this investigation. trauma treatment competency upon interviewing clergy sexual abuse survivors, doyle (2009) pointed out that sexual abuse treatment for this population failed to address the victims’ spiritual trauma. the current study filled an important gap in the general understanding of spiritual trauma through the development of a measure of spiritual abuse. because spiritual abuse can coexist with other forms of trauma, a comprehensive understanding of their client’s clinical picture, including possible spiritual trauma, is important information for 85  
  researchers and psychologists to obtain. although the academic literature on spiritual abuse remains in its infancy, future conceptualizations of spiritual trauma will likely correspond with many existing principles of treating other forms of psychological trauma, including ptsd, while addressing the unique symptoms and needs of the spiritually traumatized. addressing spiritual trauma as its own construct has enhanced overall knowledge of trauma much like addressing psychological trauma has proven to be a helpful addition to the sexual and physical abuse literature. health and well-being research has shown that spirituality and religion are generally positively correlated with mental health (koenig et al., 2001). both religious institutions and mental health providers assume the task of promoting a sense of well-being for their constituents (arnow, 1998). this overlap of interest provides support for the fields of religion and psychology to collaborate. because some spiritual assessment instruments lack sophistication for yielding how religious experiences actually impact the individual (pargament, 2002), a new measure was needed to address this void. this need has been particularly salient for more negative spiritual experiences. as psychologists become more adept at assessing and treating spiritual trauma, their clients will have a greater opportunity to continue with a healthy spiritual journey. from an existential perspective, clients who are free to explore their spirituality can create a coherent meaning system, thus enhancing their life experiences (hoffman, 2012), as well as enhancing treatment for other potential forms of trauma and abuse. this healthy spirituality, in addition to mental  86  
  health benefits, can have a positive effect on clients’ behavior and functioning (saucier & skrzypinska, 2006). relevance to counseling psychology developing a greater understanding of the construct of spiritual abuse is imminently relevant for counseling psychologists. in addition to the aforementioned attention to and importance of multicultural values maintained by counseling psychologists, counseling psychologists also value assessments, both formal and informal (fretz, 1982). comprehensive and competent assessment practices are congruent with ethical principles of beneficence and nonmaleficence (apa, 2002). developing a measure of spiritual abuse points to both the multicultural and assessment values of counseling psychologists. competent integration of evidence-based research into practice is another value espoused by counseling psychologists (huppert, fabbro, & barlow, 2006). as a measure of spiritual abuse becomes tested and refined, practitioners and researchers alike could utilize the tool for further advancement of research and more specialized conceptualization and intervention with clients. lastly, ethical practice is of utmost importance for counseling psychologists (pope & vasquez, 2011). because qualitative accounts of spiritual abuse victims’ stories have come to light in clinical work and in the research literature, counseling psychologists have an ethical obligation to listen to and respect the concerns of individuals who have contributed to the current understanding of spiritual abuse. one way to honor their stories is to continue developing the research base by quantifying 87  
  some of what they have shared in hopes of developing stronger treatment interventions than perhaps they were able to receive. the ethical principles of integrity, justice, and respect for people’s rights and dignity provide a foundation for the relevance of this project to counseling psychologists (apa, 2002). a word of caution although current literature can be synthesized in such a way as to propose need for further research into the topic of spiritual abuse, psychologists must approach this task with sensitivity. bent-goodley and fowler (2006) pointed out in their qualitative investigation of african american women who highlighted spiritual aspects of their domestic abuse that their participants remained leery of scientists who might operationalize spirituality into a science that might fail to capture the lived experience of one’s spirituality. as research progresses in this field, it will be important to acknowledge the difficulty in quantifying spiritual experiences that remain unique to the individual. research questions and hypotheses in this study, two research questions and five hypotheses were formulated. the first research question was, “what are the dimensions or factors underlying the construct of spiritual abuse?” and the second research question was, “does this measure of spiritual abuse demonstrate predicted relationships (i.e., convergent and divergent validity) with other instruments? the hypotheses were as follows: hypothesis 1. there would be a clear and systematic factor structure for the construct of spiritual abuse.  88  
  hypothesis 2. the saq would demonstrate convergent validity by having a significant positive relationship with the religious and spiritual struggles scale (rss). specifically, the saq would have convergent validity with the rss as well as each of the six rss subscales (divine struggles, demonic struggles, interpersonal struggles, moral struggles, doubt struggles, and ultimate meaning struggles). hypothesis 3. the saq would demonstrate convergent validity by having a significant positive relationship with the national stressful events survey ptsd short scale (nsess-ptsd). hypothesis 4. the saq would demonstrate convergent validity by having a significant positive relationship with the institutional betrayal questionnaire version 2 (ibq.2). hypothesis 5. the saq would demonstrate discriminant validity by having a nonsignificant negative relationship with a scale of social desirability.  89  
  chapter iii method the following chapter will outline the methodology for the current research study, which was divided into two phases (study one and study two). for each study, the participants will be discussed, the instruments will be described, and the overall procedure and statistical analysis will be provided. study one: scale creation and exploratory factor analysis participants participants were adults18 years old or older who had been involved in a christian or bible-based church or group at any point in their lives for at least 1 year. involvement included regular attendance at religious meetings or services (averaging two per month) and/or forming personal relationships with members of the church or group. participants were assumed to be able to read english for the purposes of this study. pursuant to nunnally’s (1978) recommendations on the number of participants recommended for a factor analysis, data collection ended once there was a minimum ratio of ten participants per item on the spiritual abuse scale. nunnally’s (1978) recommendation is a conservative guideline that followed earlier research focusing more on sample size than item to participant ratios. the proposed spiritual abuse scale contained 49 items; therefore, sample size goal was 490.  90  
  a total of 535 participants completed the entire survey for study one and their data were analyzed in the exploratory factor analysis. as shown in table 2, most, though not all, of the participants were heterosexual, white women. table 2 characteristics of the sample for study one  variable  frequency  %  age  mean range 41.97  standard deviation  21-84  gender male  105  19.6  female  423  79.1  2  .4  male)  2  .4  other  3  .6  heterosexual  474  88.6  gay or lesbian  22  4.1  bisexual  21  3.9  queer  2  .4  questioning  4  .7  other  3  .6  prefer not to answer  9  1.7  transgender (male to female) transgender (female to  sexual orientation  (continued) 91  12.68  
  ethnicity white  494  92.3  african american/black  3  .6  hispanic/latino/latina  12  2.2  asian/pacific islander  3  .6  biracial/multiracial  3  .6  american/indigenous  1  .2  other  19  3.5  northeast  45  8.40  midwest  98  18.30  west  101  18.90  south  249  46.50  canada  14  2.60  other  28  5.20   30,000 (usd)  83  15.50   30k-60k  150  28.00   60k-100k  145  27.10   100k-150k  81  15.10   150k  45  8.40  prefer not to answer  31  5.80  native  location  annual household income  (continued) (  spiritual/religious orientation christian - protestant  324  60.60  christian - evangelical  97  18.10  christian - catholic  25  4.70 (continued)  92  
  christian - other (examples: lds, seventh day adventists, etc.)  20  3.70  liberal/progressive  54  10.10  jewish  7  1.30  muslim  0  0.00  hindu  1  0.20  buddhist  4  0.70  agnostic  43  8.00  atheist  37  6.90  religious  45  8.40  other (fill in the blank)  40  7.70  christian -  spiritual, but not  note: the total exceeds 100% because religious demographics asked participants to “check all that apply.” the mean age for participants for study one was 42 years, and ranged from 21 to 84. nearly half of the participants were from the southern united states, with smaller proportions from the west, midwest, northeast, canada, or other countries. regarding annual income in u.s. dollars, the largest number of participants were in the two middle income brackets, encompassing household income ranges between 30,000-100,000. the religious demographics for study one show that primarily protestant christians (60.6%) participated, followed by liberal/progressive christians and evangelical christians. small percentages of catholic christians and other christians 93  
  were represented, as well as persons of jewish, hindu, and buddhist faiths. approximately 8% of participants identified in each of the categories agnostic, atheist, spiritual but not religious, or “other.” of note, participants were asked to mark “all that apply” regarding their religious identities; therefore, some may have made more than one selection pursuant to multiple identities. instrumentation in addition to their informed consent (see procedure and appendix a), six instruments were used in this study. they included a demographic form (appendix b), the spiritual abuse questionnaire (saq; appendix c), the religious and spiritual struggles (rss) scale(exline et al., 2014; appendix d), the national stressful events survey ptsd short scale (nsess-ptsd; kilpatrick et al., 2013, see appendix e), the institutional betrayal questionnaire version 2 (ibq.2; smith & freyd, unpublished manuscript, 2013, 2014, see appendix f), and the marlow-crowne social desirability form (mc-sd; reynolds, 1982, see appendix g). spiritual abuse questionnaire the creation of a spiritual abuse scale (saq) is the primary focus of this study. the original item pool was created based on the spiritual abuse literature as well as clinical and personal observations of the author of this dissertation. the theoretical context is embedded in the literature supporting the importance and impact of religion and spirituality for many people (zinnbauer et al., 1997), as well the impact of both subtle and overt forms of trauma (herman, 1992b). devellis’ (2012) suggestions on scale development served as the guideline for creating saq. the researcher made a 94  
  spreadsheet with organized columns of themes and quotations extracted from qualitative research on spiritual abuse. from those themes and ideas supported by previous literature, the researcher constructed 65 items. the list of items was sent to item evaluators including professionals and non-professionals with experience in the field of religion, psychology, or others including some that identified as being familiar with or having experienced spiritual abuse. a total of nine evaluators contributed feedback. evaluators were asked to rank whether items were “not relevant,” “moderately relevant,” or “highly relevant” to spiritual abuse. the item evaluators were also asked to create their own items if they did not believe the original item pool covered the breadth of spiritual abuse. the original 65 items was reduced to 49 items based on evaluator feedback. the instructions to participants for taking the scale stated, “please consider your current or previous involvement in a christian or bible-based church or group (eg., a church, student organization, missions organization, etc.). respond by checking the box that most closely matches your experiences in that group. if you have been involved in more than one church or group, please answer according to the church/group that stands out to you the most.” the directions also requested that participants identify on a 4-point likert scale that which most closely resembles their experience in a spiritual/religious church/group, ranging from “strongly disagree” to “strongly agree.” nine items in the scale were reverse-scored. higher scores indicate higher levels of spiritual abuse. the scale includes items such as, “i now feel cynical about church/religious groups,” and “at times i was scolded by my leader and made to feel ashamed and helpless.” reliability for study 1 was high (α .98). 95  
  religious and spiritual struggles (rss) scale the second instrument measured religious struggle and strain. the religious and spiritual struggles (rss) scale was developed by exline et al. (2014). the rss is a 26item scale demonstrating convergent validity with other measures of religious difficulties, yielding six domains of religious struggle as well as an overall scale score. the first domain, divine, involves negative emotions surrounding one’s beliefs or perceived relationship with god and has five items. the second domain, demonic, involves concern about evil spirits causing negative events or causing problems for the individual and contains four items. the third domain, interpersonal, involves negative experiences with religious individuals or institutions and contains five items. the fourth domain, moral, involves struggles to follow moral principles and worry over not measuring up to one’s morals and contains four items. the fifth domain, doubt, involves feeling uncomfortable about one’s uncertainties about their belief system and contains four items. the last domain, ultimate meaning, involves concern over not perceiving deep meaning in one’s life and contains four items. reliability for the rss is high (α .91) and the subscale reliabilities include divine (α .93), demonic (α .93), interpersonal (α .85), moral (α  .88), doubt (α .90), and ultimate meaning (α .89). items are on a 5-point likert scale assessing to the extent to which participants endorse the scale items ranging from “not at all/does not apply” to “a great deal.” sample items include, “had conflicts with other people about religious/spiritual matters,” and “felt as though god was punishing me.” higher scores indicate greater religious struggle. the reliability was high for study 1 (α .95). 96  
  national stressful events survey ptsd short scale (nsess-ptsd) the nsess-ptsd is a 9-item scale that measures the severity of posttraumatic stress symptoms (kilpatrick et al., 2013). reliability for the nsess-ptsd is strong at (α  .91) (lebeau et al., 2014). the reliability for study 1 was also strong (α .95). participants for this study were instructed to think about the variety of religious/spiritual experiences they have had in their lifetime and to keep the experience that stood out most in their mind as they completed the survey. they were then asked to respond to the how much they were bothered by the items in relation to their religious/spiritual experiences. the measure utilizes a 5-point likert scale ranging from “not at all” to “extremely.” sample items include, “feeling jumpy or easily startled when you hear an unexpected noise” and “feeling very emotionally upset when something reminded you of a stressful event.” institutional betrayal questionnaire version 2 (ibq.2) the ibq.2 is a 15-item scale that measures the severity of institutional betrayal (smith &freyd, unpublished manuscript, 2013, 2014). although unpublished, the author claimed the ibq.2 demonstrates strong unidimensionality with alphas typically around .80 (c. smith, personal communication, october 8, 2014). the reliability for study 1 was higher (α .85). the instructions ask participants to think about institutions to which they belong or have belonged. next, they provided a prompt to guide the participants’ thinking. one prompt the scale developer used included assessing sexual assaults being perpetrated within the context of an institution. for this study, the prompt read, “this section will ask you to think about a christian or bible-based church or group (college 97  
  group, fellowship group, small group) to which you belong or have belonged. please answer according to the church/group that stands out to you the most.” this prompt was intentionally left open-ended as not to be too directive about the participants’ experiences. participants who responded by indicating, “i am unable to think of a negative church or group experience” were routed out of the ibq.2 and onto the next measure. participants who responded by indicating, “i am able to think of a negative church or group experience,” proceeded with the ibq.2. the participants who continued with the ibq.2 were asked to think about a negative experience in which they were hurt in any way by a christian or bible-based church or group and to keep those experiences in mind while responding to the items. the first 12 questions instructed the participants to select whether items applied to them or not. next, they were asked to rate on a scale of 1 through 4 how much they identified or felt a part of the institution. after that, they were asked whether they are still a part of the institution. lastly, they were asked to briefly identify the institution (school, church, etc.), which was optional in this study. the questionnaire was intended to be a checklist for gathering information about participants’ experiences rather than a scale measuring an underlying trait. marlow-crowne social desirability scale, form c the marlow-crowne social desirability scale was developed in 1960 by crowne and marlow with several modified short forms developed later including form c (m-c form c) (reynolds, 1982). form c is a 13-item true/false version of the scale found to have adequate reliability (α .76) and to be significantly positively correlated (r .93) with the original marlow-crowne social desirability scale. the scale was designed to 98  
  assess one’s self-reported social desirability and demonstrates convergent validity with other measures of social desirability (reynolds, 1982). the m-c form c includes items such as, “i’m always courteous, even to people who are disagreeable,” and “i sometimes feel resentful when i don’t get my way.” items 5, 7, 9, 10, and 13 are given a score of 1 for true responses and 0 for false responses. the remaining items are given a 0 for true responses and a 1 for false responses. higher scores on the measure demonstrate the individual’s tendency to report socially desirable answers on self-report measures. the reliability for study 1 was adequate (α .73), and comparable to the original authors’ findings. procedure the research protocol for this study was submitted to the texas woman’s university institutional review board (irb) for approval. the irb ensured that the study would be conducted in an ethical manner, particularly given the use of human subject participants. after the study was approved, the measures were uploaded onto a psychdata platform. psychdata meets or exceeds industry and irb standards for on-line security (see https://www.psychdata.com/content/security.asp). participants were recruited through a variety of methods. these included snowball sampling on facebook and through blogs that focus on religious issues including abuse. participants were asked to re-post the link to the survey on their social media sites or blogs. participants were asked to click on a link to psychdata.com that led them to the study that first contained an informed consent document (appendix a), informing them of the eligibility requirements, potential risks, the confidentiality of their data, and a list 99  
  of counseling resources, should they experience discomfort while taking the survey. after agreeing to the informed consent, participants were provided with the statement, “i have been involved in a christian or bible-based church or group for at least one year.” those who selected “yes” were directed to take the measures; those who selected “no” were routed to the end of the study and thanked for their willingness to participate. upon completion of the measures, participants were directed to a screen providing counseling resources (see appendix i). participants were thanked for their participation. once the data were collected, they were downloaded, analyzed, and stored securely in password protected files. statistical analyses descriptive statistics descriptive statistics including scale means, standard error of mean, standard deviations, internal consistency, cronbach’s alpha, and scale ranges were computed for all continuous demographic variables and for all the measures in the study. frequencies and percentages were calculated for categorical demographic variables. correlation tables were run to examine the simple relationships between all continuous variables. exploratory factor analysis an exploratory factor analysis (efa) was used to examine the data for the development of the saq (kaiser & rice, 1974). first, frequencies were calculated on each item. analysis revealed that no homogenous scores (all high scores or all low scores) were identified, so no participant data needed to be dropped for that reason. items with a sufficient diversity of response and a smaller standard deviation than other items 100  
  were retained as this indicates relative agreement within the sample. next, the kaisermeyer-olkin (kmo) statistic was run to determine degree of shared variance among items. the kmo statistic met the .5 minimum to proceed. lastly, an inter-item correlation matrix with all remaining items was run. pairs of items that correlated .8 or higher were examined and taken into consideration during the refinement of the saq. the remaining items were used in the principle components analysis (pca) with oblique rotation, which is the primary analysis to determine the factor structure of the instrument (kaiser & rice, 1974). the pca was run and the factor items with an eigen value of 1 or higher were retained. next, the scree plots of eigen values x factor numbers were run to examine the possibility of additional factors. the identified factors were labeled and the form was shortened. the loading criterion of 0.40 was the basis for keeping items and naming factors to begin with, while a short form of the tool retained items that have high loadings (for example 0.80) and made sense regarding the content and themes identified by pca. study two: confirmatory factor analysis for study two, a secondary analysis was conducted on a new sample using the version of the saq that was refined through the exploratory factor analysis conducted in study 1 (kaiser & rice, 1974). participants identical requirements for study one pertained to study two. participants were to be a minimum of 18 years old and had to be or have been a part of a christian or biblebased church or group at any point in their lives for at least 1 year. for this study, a 101  
  minimum of 200 participants was needed to meet nunnally’s (1978) recommendations for a conservative item to participant ratio. data from 271 participants were analyzed after the data from one 17 year old was deleted. similar to study one, study two contained participants that were primarily white, heterosexual women. table 3 characteristics of the sample for study two variable age  frequency  %  mean range 39.91  18-74  standard deviation 12.7  gender male  53  19.60  female  211  77.90  2  0.70  male)  3  1.10  other  1  0.40  prefer not to specify  1  0.40  heterosexual  216  79.70  gay or lesbian  22  8.10  bisexual  15  5.50  queer  2  0.70  questioning  7  2.60  other  3  1.10  prefer not to answer  6  2.20  transgender (male to female) transgender (female to  sexual orientation  (continued) 102  
  ethnicity white  243  89.70  african american/black  7  2.60  hispanic/latino/latina  2  0.70  asian/pacific islander  3  1.10  biracial/multiracial  5  1.80  native american/indigenous  3  1.10  other  8  3.00  northeast  26  9.60  midwest  40  14.80  west  49  18.10  south  113  41.70  canada  27  10.00  other  16  5.90   30,000 (usd)  34  12.50   30k-60k  69  25.50   60k-100k  76  28.00   100k-150k  42  15.50   150k  28  10.30  prefer not to answer  22  8.10  location  annual household income  (continued)  103  
  spiritual/religious orientation christian - protestant  155  57.20  christian - evangelical  54  19.90  christian - catholic  11  4.10  5  1.80  liberal/progressive  59  21.80  jewish  3  1.10  muslim  0  0.00  hindu  1  0.40  buddhist  3  1.10  agnostic  33  12.20  atheist  20  7.40  spiritual, but not religious  35  12.90  other (fill in the blank)  20  7.40  christian - other (examples: lds, seventh day adventists, etc.) christian -  note: the religious demographics asked participants to "check all that apply." the mean age for study two was 40 and ranged from 18-74. participants came from a variety of locations, primarily in the u.s. nearly half of the participants were from the southern u.s, with smaller portions from other regions of the u.s., as well as some international participants. regarding annual household incomes for study two,the largest portion of participants indicated between 30,000-100,000 per year. the religious demographics for study two consisted of primarily protestant christians, followed by 104  
  liberal/progressive christians and evangelical christians. smaller percentages from other traditions were represented as well. as in study two, participants were asked to mark “all that apply” regarding their religious identities; therefore, some may have made more than one selection pursuant to multiple identities. instrumentation and procedure the same instrumentation and procedures used in study one were used in study two with the exception of taking a shorter version of the saq, pursuant to the modifications resulting from the exploratory factor analysis in study one. the shorter saq contained 20 items (appendix k). the reliability for participants taking the saq in study 2 was α .95. all other instruments remained the same and participants took the measures with the same instructions outlined in study one. for study two, the reliabilities are as follows. the reliability for the rss (exline et al., 2014) was α .96. reliability for the nses-ptsd (kilpatrick et al., 2013), was α .94. reliability for the ibq.2 (smith & freyd, unpublished manuscript, 2013, 2014) was α .85. reliability for the mc-sd (reynolds, 1982) was α .70. participants were recruited through social media, as in study one. however, to avoid overlap with the sample, the study was posted on different facebook groups and different blogs than study one. several people “shared” the post through their personal social media outlets, resulting in the complete second sample.  105  
  statistical analysis data from study two were analyzed just as they were in study one. descriptive analyses were run and principal components analyses with oblique rotation were utilized to further understand the factor structure of the saq. based on the analyses, several other principal components analyses were run to identify the factor structure based on deleting certain items and based on different approaches to the factor analysis. specifics will be outlined in the results section. hypotheses and analyses for study one and study two for this study, two research questions and five hypotheses were formulated. the research questions and hypotheses were consistent for both study one and study two. the first research question was, “what are the dimensions or factors underlying the construct of spiritual abuse?” and the second research question was, “does this measure of spiritual abuse demonstrate predicted relationships (i.e., convergent and divergent validity) with other instruments? the hypotheses and analyses were as follows.  106  
  table 4 hypotheses and analyses study 1  study 2  analysis  analysis  exploratory  confirmatory  hypothesis 1. there will be a clear  factor analysis  factor  and systematic factor structure for  (principal  analysis  the construct of spiritual abuse.  components  hypothesis  analysis)  hypothesis 2. the saq will  pearson  pearson  correlation  correlation  hypothesis 3. the saq will  pearson  pearson  demonstrate convergent validity by  correlation  correlation  demonstrate convergent validity by having a significant positive relationship with the religious and spiritual struggles scale and each of the six subscales (divine struggles, demonic struggles, interpersonal struggles, moral struggles, doubt struggles, and ultimate meaning struggles)  having a significant positive relationship with the nsess-ptsd.  107  
  hypothesis 4. the saq will  pearson  pearson  demonstrate convergent validity by  correlation  correlation  hypothesis 5. the saq will  pearson  pearson  demonstrate discriminant validity  correlation  correlation  having a significant positive relationship with the ibq.2.  by having a non-significant relationship with a scale of social desirability.  108  
  chapter iv results this chapter will present an overview of the data for studies one and two. study one: preliminary analysis a preliminary analysis of the data was conducted to determine which of the data to retain for analysis. a total of 780 participants clicked on the link to take the survey. of those participants, one was deleted for not meeting the age requirement as the individual endorsed her or his age as 17 years old. the settings on the survey for each measure required that participants answer all questions as they completed the survey. therefore, no random answers were left incomplete on any of the measures. however, 244 participants stopped taking the survey before completing all the measures. to ensure that data retained for analysis included participants who completed all the measures included in the survey, 244 participants were deleted, leaving 535 participants who completed the survey in its entirety for this analysis. the final participant count of 535 exceeds the recommended ratio of 10 participants per item for the scale under construction (nunnally, 1978). as there were 49 items for the saq, a minimum of 490 participants was expected for a comprehensive exploratory factor analysis, making 535 a strong participant pool. study one: descriptive statistics descriptive statistics, including the frequencies, scale means, standard error of mean, standard deviations, internal consistency, cronbach’s alpha, and scale ranges were 109  
  all computed and appear in table 5. higher scores for each of the scales represent higher levels of the variable measured. internal consistency reliabilities ranged from .73 (mcsd) to .98 (saq). correlation tables were also run to examine the simple relationships between all the scales used in the study. correlations appear in table 5. table 5 descriptive statistics for study one measure  n  mean  sem  sd 38.56  actual  possible  range  range  0.983  52-192  49-196  alpha  saq  535  125.342 1.667  rss  535  71.136  1.118 25.868 0.958  26-130  26-130  nses-ptsd  535  23.374  0.489 11.311 0.949  9-45  9-45  ibq.2  430  6.326  0.164  3.39  0.847  1-12  0-12  mc-sd  535  18.714  0.129  2.988  0.725  13-26  13-26  note: saq spiritual abuse questionnaire; rss religious and spiritual struggles scale; nses-ptsd national stressful events survey for ptsd-short scale; ibq.2 institutional betrayal questionnaire; mc-sd marlow-crown social desirability scale, form c study one: analysis of hypotheses research question #1: factor analysis of the saq the first research question is, “what are the dimensions or factors underlying the construct of spiritual abuse?” to address this question, exploratory factor analysis was used to examine the factor structure of the saq (kaiser & rice, 1974). prior to 110  
  conducting the principal components analysis, reliability and descriptive statistics were conducted to provide an overall assessment of the scale. for the original 49-item scale, cronbach’s alpha was .98. frequencies were calculated on each item and it was determined that no item needed to be dropped due to having all high or all low scores. the kmo statistic was .98, indicating a satisfactory level of shared variance among the items. lastly, an inter-item correlation matrix with all remaining items was run. three pairs of items (20 and 22; 34 and 49; and 40 and 41) were further examined for having greater than .80 correlation. specifically, items 40 and 41 were analyzed and only one was retained in the final scale and the other items with high correlations failed to load as highly as other items in their respective components and were eliminated from the scale based on selection criteria. hypothesis one. to address hypothesis one, which proposed there would be a clear and systematic factor structure for the construct of spiritual abuse, an exploratory principal components analysis was conducted on the saq. a factor analysis using oblique rotation with kaiser normalization was conducted on the original 49 items on the saq. results of the analysis revealed a four-factor solution, accounting for 64.77% of the variance. eigenvalues and the scree plot (see figure 1) were examined to determine which factors should remain in the scale. eigenvalues below 1.0 were removed, confirming a four-factor solution. table 6 provides the correlations between the original components.  111  
  table 6 component correlations for study 1 1  2  3  1  1.00  2  .585  1.00  3  .518  .304  1.00  4  -0.557  -.335  -.409  upon further analysis, items 25 and 42 were removed from the saq because their factor loadings failed to meet the .4 minimum recommended by thompson (2004). five items (3, 17, 19, 23, and 37) loaded on more than one factor. items 3, 17, 19, and 23 were automatically removed. item 37 was included on factor 3 after a content analysis was conducted, determining that the item was a candidate to be retained in the scale in factor 3. after the removal of the dual-loading items, items, factor 1 contained 25 items, factor 2 contained 7 items, factor 3 contained 5 items, and factor 4 contained 6 items. the decision for the item number for the final saq was made based on the smallest number of items yielded in one factor (factor 3; 5 items). the researcher believed that for research and clinical purposes, having a scale with the same number of items in each subscale would be most beneficial for ease of scoring. additional analysis of the factors, outlined below, resulted in reducing the overall item number of the scale to 20 items, including four factors containing five items each. 112  
  table 7 exploratory factor analysis: eigenvalues, percentage of variance, and cumulative percentage of variance factor  eigenvalue  % of variance  cumulative %  1  27.09  55.28  55.28  2  2.11  4.31  59.59  3  1.36  2.78  62.37  4  1.18  2.40  64.77  figure 1 scree plot  113  
  factor one: abuse of power. the first factor contained 25 items, accounting for 55.28% of the variance (see table 7). overall cronbach’s alpha for factor 1 including all 25 items was .97. two of the higher loading items (40 and 41) correlated at .82. based on both the high correlation and the content of each item, only item 40 was retained in the scale and included in factor one. two higher-loading items were not included in the factor due to their content. conceptually, the five items included in factor one related to the active abuse of power perpetrated by religious leaders. examples included, “i was harshly criticized by religious leaders or church/group members” and “my religious leaders used fear to control people.” the cronbach’s alpha for the five items retained in factor 1 was .89. factor two: conditionality. the second factor originally contained nine items and accounted for 4.31% of the variance (see table 7). the reliability for the factor two for the seven items remaining after the double-loading items were removed was .89. the five highest-loading items that fell under factor 2 contained elements of conditional acceptance and dependence on the leaders or church/group. examples included, “i believed i could be totally surrendered to god if i did everything perfectly according to the church/group’s instructions” and “i felt dependent on the church/group.” the five items retained in the factor 2 had a cronbach’s alpha of .89. factor three: spiritual injury. the third factor contained five items and accounted for 2.78% of the variance (see table 7). one of the items (37) loaded on both component 2 and component 3. through a content analysis, it was determined that the item fit more appropriately with factor three than with factor 2. additionally, the item 114  
  loading was higher for factor 3 (.53) than factor two (.44). including item 37 with factor three allowed the factor to contain five items. the five items that fell under factor three related to negative emotional outcomes as a result of spiritual abuse. examples included, “i no longer trust myself to find a good spiritual community” and “i now feel cynical about church/religious groups.” the cronbach’s alpha for the five items included in factor 3 was .87. factor four: suppression of expression. the fourth factor contained ten items and accounted for 2.40% of the variance (see table 7). the cronbach’s reliability for the six items on factor four after the double-loading items were removed was .90. the top five items that loaded under factor four contained a theme of suppressing one’s feelings and self-expression. examples included, “i discerned an inner conflict between the narrow teachings of the group and my own understanding of god” and “others were judged as inferior or ungodly for not conforming with my church’s/group’s norms.” the cronbach’s alpha for the five items retained in factor 4 was .88. research question #2: saq’s relationship with other instruments correlations between study scales and where relevant, subscales, were run to answer the second research question. table 8 shows all of these correlations for study one.  115  
  table 8 scale correlations for study 1 saq  rss  rss  rss  rss  rss  (moral)  (divine)  (ultimate meaning  rss  nses-  (interpers (doubt)  (demo  ptsd  onal)  nic)  saq  1  rss  .749**  1  rss (moral)  .541**  .824**  1  rss (divine)  .628**  .861**  .626**  1  rss (ult  .498**  .812**  .608**  .702**  1  .828**  .812**  .567**  .616**  .539**  1  .652**  .873**  .741**  .684**  .716**  .689**  rss  ibq.2  meaning) rss (interpersonal) rss (doubt)  116  1  (continued)  
  rss  .312**  .538**  .423**  .367**  .285**  .329**  .288**  1  nses-ptsd  .734**  .738**  .547**  .648**  .514**  .703**  .579**  .461**  1  ibq.2  .615**  .419**  .270**  .376**  .216**  .525**  .285**  .250**  .548**  1  mc-sd  .481  -.114**  -.180**  -.103**  -.158**  .034  -.126**  -.046  -.023  .084  (demonic)  note: saq spiritual abuse questionnaire; rss religious and spiritual struggles scale; nses-ptsd national stressful events survey for ptsd-short scale; ibq.2 institutional betrayal questionnaire; mc-sd marlow-crown social desirability scale, form c **p .01 *p .0  117  
  hypothesis two. this hypothesis stated that the saq would demonstrate convergent validity by having a significant positive relationship with the rss as well as with all six rss subscales. this hypothesis was supported as significant positive relationships were found. for the rss, r .75, p .01. for the subscales, results are as follows: divine struggles, r .63, p .01; demonic struggles, r .31, p .01; interpersonal struggles, r .83, p .01; moral struggles, r .54, p .01; doubt struggle, r .65, p .01; and ultimate meaning struggles, r .50, p .01. these findings suggest that participants with higher levels of spiritual abuse also experience higher levels of religious and spiritual struggles. hypothesis three. this hypothesis stated that the saq would demonstrate convergent validity by having a significant positive relationship with the nsess-ptsd. this hypothesis was supported as a significant positive relationship was found, r .73, p .01 (see table 8). this finding indicates that individuals who experience more spiritual abuse also have more ptsd symptoms when taking a ptsd scale that prompts for thinking about religious experiences. hypothesis four. this hypothesis stated that the saq would demonstrate convergent validity by having a significant positive relationship with the ibq.2.this hypothesis was supported as a significant positive relationship was found, r .62, p .01 (see table 8). this finding suggests that individuals who endorse higher levels of spiritual abuse also endorse higher levels of institutional betrayal.  118  
  hypothesis five. this hypothesis stated that the saq would demonstrate discriminant validity by having a non-significant relationship with marlow-crowne social desirability scale, form c. this hypothesis was supported as a no significant relationship was found, r .481 (see table 8). study two: preliminary analysis study two involved gathering a second data sample on all the measures used in study 1, with the exception of using the newer version of the saq, which was shortened from 49 to 20 items as a result of study 1. a preliminary analysis of the data was conducted to determine which of the data to retain for analysis. a total of 420 participants clicked on the link to take the survey. however, 133 participants stopped taking the survey before completing all the measures. during the data cleaning process, 16 participants’ data were deleted for failing to answer each item on the saq and one participant was deleted because he or she did not meet the age requirement. the final participant count of 271 exceeded the recommended ratio of 10 participants per item for the scale under construction (nunnally, 1978). as there were 20 items for the saq, a minimum of 200 participants was expected for a comprehensive confirmatory factor analysis, making 271 a strong participant pool. study two: descriptive statistics descriptive statistics, including the frequencies, scale means, standard error of mean, standard deviations, internal consistency, cronbach’s alpha, and scale ranges were all computed and appear in table 8. higher scores for each of the scales represent higher levels of the variable measured. internal consistency reliabilities ranged from .70 (mc119  
  sd) to .96 (rss). correlation tables were also run to examine the simple relationships between all the scales used in the study. correlations between the measures appear in table 9. table 9 descriptive statistics for study two measure  n  mean  sem  sd  actual  possible  range  range  alpha  saq  271  50.62  0.903  14.863  0.951  21-80  20-80  rss  271  72.92  1.534  25.247  0.958  27-129  26-130  nses-ptsd  271  23.27  0.638  10.496  0.940  9-45  9-45  ibq.2  228  5.9  0.235  3.553  0.849  0-12  0-12  mc-sd  271  18.36  0.172  2.837  0.700  13-25  13-26  note: saq spiritual abuse questionnaire; rss religious and spiritual struggles scale; nses-ptsd national stressful events survey for ptsd-short scale; ibq.2 institutional betrayal questionnaire; mc-sd marlow-crown social desirability scale, form c study two: analysis of hypotheses research question #1: factor analysis of the saq the first research question is, “what are the dimensions or factors underlying the construct of spiritual abuse?” to address this question, several principal components analyses were run to examine the factor structure of the saq (kaiser & rice, 1974). these analyses were based on both statistical analyses and theoretical approaches. after 120  
  considering several analyses, the researchers recommended utilizing results from the following two analyses, as outlined below, in their recommendation for the saq as a promising measure of spiritual abuse. hypothesis one. to address hypothesis one, which proposed there would be a clear and systematic factor structure of spiritual abuse, a series of confirmatory factor analyses with oblique rotation and kaiser normalization were run to explore the best fit of the data between sample one and sample two. the strategy was to compare the factors generated by forcing items into the 4-factor structure that emerged from the original 49item efa versus allowing items to emerge in possible new factors using eigenvalues to determine these factors in an unforced fashion. analyses yielded a fairly clear and stable factor structure for the saq for both research and clinical use. results from each analysis are outlined below and summarized in figure 2).  121  
  exploratory factor analysis 49 original items sample 1 yielded 4 factors 20 items retained  confirmatory factor analyses  sample 1 20 item scale  sample 2  forced 4 factor solution  unforced solution  factor 4 weak  2 factor solution  (1 item only)  (conditionality all others)  3 defector items  3 factor structure  (did not load anywhere) sample 1 17 item scale  factor 4 weak  clear 2 factor structure  (1 item only) sample 2  1 defector item  clear 2 factor structure  (did not load anywhere) figure 2. overall analysis plan for saq development with cfa and efa results  122  
  the first principal components analysis included all 20 items in the shortened saq based on the exploratory analysis from study one. the analysis was based on a forced four-factor structure, pursuant to the four-factor structure identified in study one. for the 20-item scale, cronbach’s alpha was .98. the kmo statistic was .95, indicating a satisfactory level of shared variance among the items. this analysis resulted in three items (2, 11, 20) defecting from their original components into new ones. next, the same 20-item scale was examined using a forced four-factor structure for sample one. this analysis resulted in factor four only retaining one of its original items. secondly, the same 20 items were analyzed using an unforced solution for both samples. the analysis yielded a two-factor structure for sample two. the conditionality subscale retained all its original items from the exploratory factor analysis and gained an additional item. the remaining 14 items all loaded on the first component, subsuming all items originally identified in the abuse of power, spiritual injury, and suppression of expression, subscales. examining 20-items from sample one with an unforced solution yielded a three-factor solution. thirdly, based on the three items that defected in the first analysis those three items (2, 11, 20) were removed and the principal components analysis was run again for sample two, leaving 17 items being analyzed. this analysis was run with a forced fourfactor structure. the analysis from sample two yielded one defector item that did not load anywhere. a similar analysis was run for sample one in that the 17 items were analyzed with a forced solution. this analysis yielded a weak factor 4, containing only one item.  123  
  lastly, the same 17 remaining items based on the three defector items were run, yet rather than forcing a four-factor structure, the analysis was based on an unforced solution for sample two. the analysis yielded a two-factor structure. the conditionality subscale retained all its original items and the remaining items all loaded on loaded together as one component. a similar analysis was conducted for sample one, using an unforced solution. the results were comparable as the conditionality scale remained in tact with all other items loading on one scale together. summary. based on data from the above analyses, it was determined that the strongest solution for the saq would be to eliminate the three items (2, 11, 20) that defected from their original components in study one, reducing the 20-item saq to a 17-item saq and to allow the statistical software to run the analysis based on an eigenvalue of one, producing a strong two-factor structure that is exemplified in analysis two. research question #2: saq’s relationship with other instruments correlations between study scales and where relevant, subscales, were run to answer the second research question. table 10 shows all of these correlations for study two.  124  
  table 10 scale correlations for study 2 saq  rss  rss  rss  rss  rss  (moral)  (divine)  (ultimate meaning  rss  nses-  (interpers (doubt)  (demo  ptsd  onal)  nic)  saq  1  rss  .759**  1  rss (moral)  .516**  .802**  1  rss (divine)  .675**  .882**  .634**  1  rss (ult  .539**  .835**  .596**  .741**  1  .807**  .767**  .434**  .606**  .535**  1  .655**  .867**  .681**  .683**  .710**  .692**  rss  ibq.2  meaning) rss (interpersonal) rss (doubt)  125  1  (continued)  
  rss  .313**  .574**  .540**  .452**  .360**  .230**  .313**  1  nses-ptsd  .695**  .757**  .580**  .687**  .607**  .662**  .587**  .424**  1  ibq.2  .567**  .332**  .141*  .327**  .181**  .537**  .183**  .140*  .523**  1  mc-sd  -.09  -.222**  -.270**  -.155*  -.220**  .049  -.203**  -.209  -.194**  .010  (demonic)  126  
  hypothesis two. this hypothesis stated that the saq would demonstrate convergent validity by having a significant positive relationship with the rss and all rss subscales. just as in study one, this hypothesis was supported for study two as significant positive relationships were found. for the rss, r .76, p .01. for the subscales, results are as follows: divine struggles, r .68, p .01; demonic struggles, r .31, p .01; interpersonal struggles, r .81, p .01; moral struggles, r .52, p .01; doubt struggle, r .66, p .01; and ultimate meaning struggles, r .54, p .01. these findings suggest that participants with higher levels of spiritual abuse also experience higher levels of religious and spiritual struggles. hypothesis three. this hypothesis stated that the saq would demonstrate convergent validity by having a significant positive relationship with the nsess-ptsd. just as in study one, this hypothesis was supported as a significant positive relationship was found, r .70, p .01 (see table 10). this finding indicates that individuals who experience more spiritual abuse also have more ptsd symptoms when taking a ptsd scale that prompts for thinking about religious experiences. hypothesis four. the saq will demonstrate convergent validity by having a significant positive relationship with the ibq.2. just as in study one, this hypothesis was supported as a significant positive relationship was found, r .57, p .01 (see table 10). this finding suggests that individuals who endorse higher levels of spiritual abuse also endorse higher levels of institutional betrayal.  127  
  hypothesis five. the hypothesis stated that the saq would demonstrate discriminant validity by having a non-significant relationship with marlow-crowne social desirability scale, form c. this hypothesis was supported as no significant relationship was found, r -.090 (see table 10).  128  
  chapter v discussion this chapter provides a discussion of the results presented in this study. the goal of this study was to develop a measure of spiritual abuse. all hypotheses are discussed, including the factor structure of the saq and measures for convergent and divergent validity. limitations are also discussed as well as implications for clinical training and practice, research, and theory. finally, a conclusion of the study is presented. summary of major findings factor structure of the saq (hypothesis one) exploratory and confirmatory factor analyses ultimately resulted in a two-factor solution for the saq, providing a psychometrically and conceptually sound assessment of spiritual abuse. data analysis from study one resulted in reducing the original 49-item pool of the saq to a 20-item measure for study two. results from study two identified three items that defected out of their original factors. when these three items were removed from the item pool, the data yielded a strong 2-factor solution. thus, the final recommended saq consists of 17 items falling into two factors. this two-factor solution also had high internal consistency. thus, hypothesis 1 was supported as the saq contains a clear and systematic factor structure of spiritual abuse. the first factor, called power-based affective wounding (pbaf), essentially absorbed items that had been identified in study one as three different factors, which were labeled abuse of power, spiritual injury, and suppression of expression. the name 129  
  of this factor, pbaf, recognizes both the underlying power dynamic and the emotional injury that occurs as a result of spiritual abuse. sample items include “at times, i was scolded by my leader and made to feel ashamed and helpless” and “i now feel cynical about church/religious groups.” the second factor, conditionality, reflects a relationship between the participant and their church/group or god that is based on performance and dependence. sample items include “i believed i could be totally surrendered to god if i did everything perfectly according to the church/group’s instructions,” and “i believed god would punish me if i didn’t do what my church/group encouraged me to do.” examination of convergent and divergent validity the saq was compared, through correlational statistics, with conceptually similar instruments to assess convergent validity. the saq was also compared with a measure of social desirability, which was expected to have divergent validity as indicated by a lack of significant relationship. hypothesis two. correlation statistics were computed to assess convergent validity between the saq and the rss (exline et al., 2014). analyses from both study one and study two supported the hypothesis, identifying significant, positive correlations between the saq and the rss total score and all subscale scores. these relationships held true as the 20-item saq, the newly recommended 17-item saq, and both the pbaf and conditionality subscales were correlated with the rss. these findings make conceptual sense as the more spiritual abuse one endorses, the more likely  130  
  the participant is to experience religious struggles and spiritual struggles, thus supporting hypothesis two. hypothesis three. as expected, the saq had a significant, positive relationship with the nses-ptsd (kilpatrick et al., 2013) in both study one and study two. this finding suggests that the higher amount of spiritual abuse individuals experience, the higher they will score on this measure of ptsd. although not a causal relationship, this positive association suggests that people who experience spiritual abuse may also experience ptsd symptoms. hypothesis four. the saq and the ibq.2 (smith & freyd, unpublished manuscript, 2013, 2014) had a significant, positive relationship in both study one and study two. this suggests that those endorsing higher spiritual abuse also experience higher institutional betrayal. this finding was expected, due to the often-institutional nature of spiritual abuse, which comes from churches and religious groups. as institutions, particularly religious institutions, abuse their power and diminish the autonomy of their members, both institutional betrayal and spiritual abuse may co-occur. hypothesis five. as expected, the saq and the mc-sd (reynolds, 1982) were not significantly correlated in either study. this finding supports the hypothesis that the amount of spiritual abuse one experiences and the amount of social desirability one endorses are not significantly related. implications for theory and integration with previous literature this examination contributes to an emerging empirical understanding of spiritual abuse, specifically identified in the two factors yielded in the saq. although themes of 131  
  exploitation of power (masis, 2004; oakley, 2013a; ward, 2011), emotional injury (bent-goodley & fowler, 2006; dehan & levi, 2009; ward, 2011), and dependence (oakley, 2013a; ward, 2011) had emerged in the qualitative research on spiritual abuse, this study has contributed an empirical backing for these themes. additionally, considering the pbaf was a combined item-pool of three scales that had previously been labeled as abuse of power, spiritual injury, and suppression of expression, these three themes also contribute to a theoretical understanding of spiritual abuse. contributions from this study highlight the convergence of religious and spiritual impacts when spiritual abuse occurs. the power abuses perpetrated in religious environments are a product of the religious doctrine or beliefs being used in harmful ways to control people (argyle and beit-hallahmi, 1975). the resulting affective injury can damage people’s ability to connect with that which they consider sacred (vaughan, 1991). although spirituality and religion had historically been considered to be synonymous and more in more recent times differentiated (zinnbauer et al., 1997), the present research shows how both phenomena can converge in such a way as to create a unique kind of abuse and subsequent trauma. this convergence is demonstrated in the particular items on the saq, which incorporate both religious power abuses as well as injury to one’s connection with what they consider sacred. this study shares some similarities and differences with many theoretical lenses through which religion and spirituality are examined. phenomenological perspectives on religion seek to surface the essence of individuals’ experience and meaning (nelson, 2012). the saq items were at least in part built upon such meanings. while the saq is 132  
  intended to capture a range of experience with spiritual abuse, the instrument quantifies and to some extent standardizes that experience, rather than continuing in the phenomenological tradition of using people’s own words and idiosyncratic meanings. the positivistic naturalism (pn) approach seeks to find universal natural laws and uses methods deriving from science, seeking to operationalize variables of study (nelson, 2012). the quantification of the experiences of spiritual abuse survivors through the saq is in some ways consistent with the pn approach. however, this study strays from a pure pn approach in that the items were not developed based solely on empirical observation. rather, item development stems from data gleaned from qualitative research that is more aligned with the phenomenological approach and from additional information from empirical studies in related areas (e.g., the general trauma literature). the religious integration (ri) approach has historically been utilized by individuals of faith who integrate their religious beliefs and perspectives with psychological insight (nelson, 2012). the saq items were in part created with this motivation. the primary investigator’s faith background as well as the faith background of some of the item reviewers likely influenced their input in this study by virtue of their religious beliefs and values being internalized. however, this study cannot be considered fully aligned with the ri perspective, as item development was not based upon the tenets of any particular faith tradition. additionally, item reviewers varied in their religious or non-religious perspectives. development of the saq strayed from one important component of the ri approach in that aspects of psychology were not necessarily  133  
  critiqued; rather, it could be argued that aspects of religion, when used abusively, were critiqued through this study. this study does not align with cognitive psychology of religion (csr) approach (barrett, 2011). csr focuses on cognitive structures inherent in religious actions and thoughts, which were not examined in the development of the saq items. as the field of spiritual abuse expands, the csr approach might serve as a helpful future approach through which to understand the cognitive mechanisms present upon or after spiritual abuse. a similar conclusion can be made about the evolutionary psychology of religion approach, which claims that natural selection serves as a lens through which to understand psychological experience (kirkpatrick, 2013). this study focuses strictly on experiences of spiritual abuse for an individual, rather than examining historical or generational experiences of spiritual abuse. the evolutionary approach could be utilized in future studies, should researchers wish to understand generational similarities and differences in spiritual abuse and how the idea of natural selection relates to those experiences. the idea that religion can contribute positively to health (krause, 2011; pargament, 2002; saucier & skrzypinska; 2006), including mental health (koenig et al., 2001), is broadly accepted in the scientific community. equally accepted is the idea that extreme religious groups, such as cults, can be destructive to one’s health and well-being (bohm & alison, 2001) and that cult leaders are often abusive (almendros et al., 2007; balch, 1980; durocher, 1999; goldberg, 2012). this study allows for the idea of spiritual 134  
  abuse to be identified on a spectrum; spiritual abuse in cults may be considered obvious while spiritual abuse perpetrated in environments in which others may also experience positive or healthy spirituality is not as obvious. it is possible, consistent with previous literature on the history of trauma (herman, 1992b), that the non-obvious experiences of spiritual abuse have occurred without recognition of such perpetrations being considered abusive. survivors of various kinds of trauma often make sense of their trauma by blaming themselves; cultural views on abuse also contribute messages of victim-blaming, possibly reducing victims’ likelihood of speaking out against their abusers. this selfblaming phenomenon may be no different for survivors of spiritual abuse. for example, johnson and van vonderen’s (1991) definition of spiritual abuse, which includes the idea of disempowerment, is captured by the saq dimensions. this study filled in a gap in the literature that intentionally and specifically integrates what is understood about religion and what is understood about trauma and how the two can converge into a harmful spiritual situation, thereby compromising health, including mental health, for survivors. based on the idea of converging abuses of religion with resulting trauma, the qualitative studies on domestic violence become particularly salient and provide a specific example of interpersonal betrayal laced with a spiritual or religious message (bent-goodley & fowler, 2006). this study’s samples for the saq relied on participants endorsing current or past involvement in a christian or bible-based church or group and the researcher did not ask about spiritual abuse in the context of a domestic partnership. therefore, further research is needed on samples for which domestic violence involves spiritual abuse in an individual, or non-group context. it is possible many of the same 135  
  themes of pbaf and conditionality would apply. the idea of a domestic partner being spiritually abusive in a one-on-one context supports the notion that spiritual abuse may occur both inside and outside of the context of institutional religion. as research grows in this area, it will be helpful to distinguish among the psychological, spiritual, physical, and sexual elements that can be involved in domestic violence situations. this study contributes to that end by directly examining the spiritual component of what could otherwise be a more multi-dimensional abuse situation. the interpersonal betrayal that occurs with clergy sexual abuse may or may not occur concurrently with abusive messages disseminated from one’s institution (i.e., sermons, talks, or messages delivered to all group members). of course, the context in which the abuse occurs will impact the victim’s response to the trauma. in the scenario of clergy sexual abuse, spiritual abuse can occur apart from a group setting although it may also impact the victim’s experience of being a part of that particular religious group. this study on spiritual abuse contributes to that end; it supports the idea that spiritual abuse can occur on its own, regardless of whether other abuses have occurred and regardless of whether the spiritual abuse was perpetrated individually or through a group setting. for some survivors of spiritual abuse, herman’s (1992a) work on ptsd and trauma recovery becomes particularly relevant. some individuals are raised in religious systems that perpetrate disempowering and controlling messages over time. sometimes, those messages can become internalized when one is involved in the religious group for an extended period of time. this may happen regarding particular theological views or rigid scriptural interpretations, and when those messages are oppressive or outright 136  
  abusive, they can cause detrimental effects. additionally, when people experience their own sense of self being demeaned or oppressed, the results could be particularly harmful. for instance, people who identify as a members of sexual minority groups might have internalized the idea of their sexual identity as sinful or wrong (jackle & wenzelburger, 2015). blatant or subtle sexism, sometimes disguised as benevolent sexism, is perpetuated by some religious organizations (maltby, hall, anderson, & edwards, 2010). in both instances, individuals may internalize messages that are in conflict with their identities or sense of self. this could result in negative health, including mental health, symptoms (van der kolk, 2014). this study, by virtue of producing a promising measure of spiritual abuse, aligns with herman’s (1992a) proposed complex ptsd diagnosis. many of the symptoms of complex ptsd have to do with power abuses and resulting emotional symptoms; the pbaf subscale of the saq directly captures the power abuse aspect of spiritual abuse as well as its affectively based consequences. the conditionality subscale of the saq speaks to members feeling the need to perform in certain ways for the approval of their deity or religious leaders. although these phenomena may occur in such extreme religious environments as cults, having the saq as a promising measure of spiritual abuse will enable researchers to study spiritual abuse in a variety of settings, including religious settings that are not considered as blatantly abusive as cults. using herman’s (1992b) complex ptsd diagnosis as a frame of reference when assessing for clients’ potential experiences of spiritual abuse can provide a theoretical backdrop through which to understand clients’ experiences. 137  
  as speculated, spiritual abuse in religious environments that are less extreme than what one would find in a cult may have gone unnoticed by researchers of spiritual abuse. this is parallel to the idea that psychological abuse research came subsequent to research on more obvious kinds of abuse such as physical or sexual abuse (babcock et al., 2008), despite the claim by some that psychological abuse can have equally, and sometimes more detrimental consequences than physical or sexual abuse (follingstad et al., 1990). the saq offers a meaningful and promising measure of a phenomenon which had not yet become operationalized. the development of the saq is theoretically embedded in the idea that some less obvious forms of abuse may have similar detrimental effects as more obvious abuses. to assess the impact of spiritual abuse, a measure of spiritual abuse is essential. concurrent with literature now citing the negative impacts of psychological abuse (hoffman, 1984; shepard & campbell, 1992), the saq follows suit in its contribution to understanding spiritual abuse that may occur within various religious contexts and has shown clear associations with the endorsement of ptsd symptoms. implications for clinical training and practice findings from this study point toward specific implications for working with clients who have suffered from spiritual abuse. when psychologists work with clients who endorse high scores on pbaf, established frameworks, such as herman’s (1992a) model, may be useful from a conceptualization and treatment perspective. power abuses are at the root of many other kinds of victimizations including sexual and physical abuse. it is likely that the abuse of power perpetrated onto the client may impact her or his ability to trust anyone in authority, which could transfer into the therapeutic relationship. 138  
  thus, creating an emotionally safe therapeutic environment will be an essential part of the treatment plan. commensurate with other kinds of trauma recovery treatment, clients will likely benefit from the psychologist tending to their autonomy by giving them choices and empowering them with educational materials around power and abuse (herman, 1992b). given that the wounds that clients experience are spiritual in nature, it will be helpful for psychologists to engage with clients in their spiritual journey, including assisting them in making their own meaning out of their spiritual connection of their past, present, and what they hope for their future. psychologists working with clients who score high on the conditionality subscale can be especially attentive to themes of performance-based acceptance and dependency on others. it is possible that clients may unconsciously pull for a re-creation of their dependency within the therapeutic relationship. it is also possible that clients may try to seek approval from the therapist by attempting to be a “good client” through faithfully completing assignments, thanking or flattering the therapist, or other acts that would pull for approval-oriented feedback from the therapist. should this be the case, clients may benefit from their psychologist engaging in some exploration around what they attempt to gain through these behaviors and what feelings might arise should they disengage from them. as clients explore their interpersonal patterns, they may become empowered and begin to feel safe in the psychologist’s unconditional acceptance of them (herman, 1992). this safety will hopefully allow them to continue in the stages of trauma recovery including remembrance/mourning and reconnection.  139  
  additionally, psychologists can utilize the saq items as a basis for conversation with their clients. in addition to providing clients’ overall score and subscale scores, psychologists can discuss individual items with clients and inquire more about what informed their responses. using the saq in this way could open up a dialogue that may not necessarily have been explored without it. this would assist in assessing the severity of the clients’ spiritual abuse as well as providing a backdrop for psychoeducation around spiritually abusive environments and typical trauma reactions to such abuse. psychoeducation is considered an important part of trauma treatment as knowledge can be empowering for clients in their recovery process (herman, 1992a). in addition to applying ideas from the saq and the two recommend subscales to clinical practice, psychologists can utilize the information gleaned from examining convergent validity with other scales as they are working with clients. for example, knowing that clients high on spiritual abuse likely also experience a high degree of religious and spiritual struggles, psychologists may benefit from assessing their clients’ experiences of the rss (exline et al., 2014) subscale categories, regardless of whether they administer the rss to clients. exploring these subscale categories may further illuminate specifics of the spiritual abuse that could be explored in therapy. it is possible that clients may struggle in one domain more than another, depending on the nature of their spiritual abuse and the emphases of the church or religious group from which they came. this study also confirms the hypothesis that higher ptsd symptoms are correlated with higher scores on the saq. because the assumption cannot be made that 140  
  spiritual abuse is the sole reason for increased ptsd symptomology, psychologists should further assess their clients to identify any other forms of abuse that might also be impacting a client’s ptsd symptoms. they should then try to assess what aspects of their clients’ symptoms are attributed to spiritual trauma versus other kinds of trauma. there may be times in which clients experience ptsd symptoms and the only kind of abuse yielded during the assessment process is spiritual abuse. this notion is consistent with rosen’s (2014) analysis on cults as incubators for trauma and ptsd symptoms. psychologists should be aware that abusive religious environments or experiences, even in the absence of other forms of abuse, may result in ptsd symptoms in clients. this study also supports the idea that when working with clients high on spiritual abuse, psychologists should listen for possible institutional betrayal as they develop their treatment plan. if institutional betrayal is involved as a result of spiritual abuse occurring in a church or group context, this added dynamic to spiritual abuse could be approached with some suggestions by smith and freyd (2014), who recommend helping the client explore their evolving perceptions of their relationship with the spiritual abuse perpetrator. smith and freyd also advise that psychologists examine their own institutional context in which they are working with the client. for example, the psychologist should be aware of the institution’s resources and the potential for retraumatization of the client as a result of perceived institutional betrayal. additionally, if spiritual abuse occurred as a result of involvement in a church (mosque, synagogue, etc.), and the psychologist works as a therapist at that house of worship, the psychologist should be attuned to the power dynamic involved in that particular religious institution 141  
  and discuss with clients the potential for perceiving (whether as a transference issue or a true boundary violation) possible power abuses in that particular institution. beyond the specific findings of this research as it applies to religious struggles, ptsd symptoms, and institutional betrayal, the results of this study have important broad implications for clinical training and practice. psychologists in training are introduced to multicultural values and are trained to provide culturally-informed services to their clients (gallardo et al., 2009). this includes providing psychotherapeutic services that are sensitive to religious and spiritual diversity (vieten et al., 2013). additionally, trauma-informed treatments are also an important part of training as many psychologists will encounter clients with trauma and ptsd (saunders et al., 2014). this study provides a new tool for assessing spiritual trauma in clients. validation of the saq further supports the notion that spiritual trauma exists as an independent construct that can occur in conjunction with or separate from other kinds of trauma. graduate courses could include spiritual trauma. this would introduce the idea to graduate students that spiritual and religious experiences can produce symptoms of trauma similar to other forms of trauma. should this training not be provided, students may neglect to obtain a thorough conceptualization of clients’ presenting issues, including spiritual abuse. additionally, the information gleaned from this study could be presented in classes focused on multicultural counseling. it would be beneficial for psychologists in training to understand the importance of religion and spirituality (vieten et al., 2013) as a point of comparison for when spiritual experiences are harmful so that psychologists can learn how to assists their clients in a psychologically and spiritually healthier direction. 142  
  for professionals in the field, the results of this study may encourage treatment providers to consider various treatment modalities, including assisting their clients in exploring their own spiritual beliefs. this may include consulting with other professionals with more expertise in religious and spiritual diversity or even consulting with religious professionals, as appropriate, for ideas in how to assist their clients (schafer et al., 2011; schulte et al., 2002;vogel et al., 2013). similar to smith and freyd’s (2014) recommendations for helping clients deal with institutional betrayal, psychologists can help spiritual abuse survivors to explore their relationships with the spiritual abuse perpetrators and how their perception of the relationship may have changed over time. additionally, psychologists may assist clients in identifying what healthier relationships in spiritual and religious contexts may look like; for example, those void of power abuses and conditional acceptance. psychologists can help clients explore their own identities, including spiritual identities, and help them learn to trust themselves to find a healthy spiritual community, should that be a goal of theirs. strengths, limitations and future research directions strengths there were several strengths to this study. first of all, the study was grounded in multicultural values, including tending to one’s religious and/or spiritual cultures, as being an essential component of ethical competent practice (gallardo et al., 2009). this study also aligns with vieten et al.’s (2013) recommended competencies for attending to spiritual and religious issues in that it assists in psychologists’ ability to assess harmful 143  
  religious experiences that adversely impact psychological health. strengthening the theoretical grounding, a comprehensive conceptualization of trauma, offered by herman (1992a), provided a context through which to understand trauma, including spiritual and religious trauma. the strength of herman’s previous work may bolster future researchers’ abilities to use the findings from this study to enhance understanding and treatment for spiritual trauma and abuse. an additional strength is that this study exceeded the conservative recommended sample ratio of participants per item (nunnally, 1978) for both samples obtained, thus increasing confidence in the current findings. limitations while this study was based in sound psychometric theory and recommendations, several limitations should be noted. first, the researcher had only limited control over the recruitment process by using social media as a recruitment tool. this method assisted with higher sample sizes for both studies, but also limited the researcher’s control over where the studies were posted as several social contacts re-posted the study in places of which the researcher had no control. secondly, a limitation lies in the demographics of the study. for both study 1 and study 2, the samples were primarily heterosexual, white women. it is possible that the demographics of the researcher and subsequent social networks may have contributed to a largely homogenous sample. future research into spiritual abuse should attempt to expand the demographic representation in the sample. cultural competence in trauma work has been identified as an area of important need (mattar, 2011). a third limitation lies in the use of self-report data. although the mc-sd scale 144  
  was used for divergent validity purposes, theoretically illuminating the use of socially desirable responses to the saq items, participants are not immune from their own biases, which may have impacted their responses. self-report data has been known to be empirically problematic (adams, soumerai, lomas, & ross-degnan, 1999). one way to reduce this problem in the future would be to utilize qualitative interviewing techniques and take into consideration the interviewer’s perception of the participant to assess the impact of participant bias in their responses. a fourth limitation is the use of a sample that required a christian or bible-based church or group background. although the item development derived from spiritual abuse literature across various faith traditions, the item language (eg., use of the words god, church, etc.) were biased toward language often used by those of the christian tradition. future research could include attempts to validate the scale with language found in other traditions (eg., mosque, temple, etc.). this would enhance the usability of the assessment tool while maintaining cultural relevancy. directions for research research implications for the findings in this study are numerous. the nascent field of spiritual abuse now has a psychometrically sound measure by which to measure spiritual abuse. future studies could be conducted on populations from different religious and spiritual traditions, as this study was limited to those from christian and bible-based groups. the saq was created based on spiritual abuse themes found in various religious and spiritual traditions, so it would not be expected to be valid just on individuals with 145  
  christian or bible-based backgrounds. as more research is conducted on various populations, the saq could also be translated and validated in other languages. given the potential strengths of mixed method studies, the saq could be used as a screening tool to identify people that have been through spiritual abuse who could then be interviewed, thereby increasing understanding of how their spiritual abuse manifests in their lives. understanding the greater context of their abuse, by specifically attending to pbaf and conditionality themes for the interviews, may yield richer information about the nature of spiritual abuse, further enhancing scholarship on the topic. as researchers continue to better understand spiritual abuse as differentiated from other forms of trauma, research specific to spiritual abuse recovery is warranted. perhaps future researchers could examine spiritual abuse through herman’s (1992a) framework of complex ptsd. as spiritual abuse continues to be empirically supported as its own construct, perhaps theoretical work merging herman’s conceptualization of complex ptsd and spiritual abuse recovery could yield some helpful ideas for treatment and possibly prevention of spiritual abuse. lastly, to further distinguish effects of various forms of abuse, including, but not limited to sexual, spiritual, and institutional abuse, it may be helpful to conduct research on people with various forms of abuse to assess the exacerbative effects of each. this exploration may further identify the additive impact of a particular kind of betrayal to help researchers examine effects, recovery strategies, and possible prevention of these negative additive impacts.  146  
  conclusion this study documents the development of the first measure known for assessing spiritual abuse, the spiritual abuse questionnaire (saq). results from this study indicate that the 17-item saq is a psychometrically sound instrument for assessing spiritual abuse with a clear 2-factor structure, power-based affective wounding and conditionality. the saq demonstrated convergent validation with other measures of related constructs and was unrelated to social desirability. this study represents a unique contribution to the field of counseling psychology, the trauma literature, and the religious experience assessment literature by highlighting themes that appear to be strongly related to spiritual abuse. the saq shows great promise as a useful tool in research and practice.  147  
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  appendix a informed consent  180  
  texas woman’s university consent to participate in research title: positive and negative experiences with christian religious institutions investigator: kathryn keller lamar, m.ed.,ed.s ........................klamar@twu.edu dissertation chair: sally d. stabb, ph.d........................... sstabb@mail.twu.edu explanation and purpose of the research you are being asked to participate in a research study for ms. keller lamar’s dissertation at texas woman’s university. participation is voluntary. the purpose of this research is to develop a new measure exploring various spiritual and religious experiences for adults over 18 years-old. to participate in this study, you must identify as having been involved at some point in a christian or bible-based church or group for at least one year. involvement can include regular attendance at religious meetings or services (averaging two per month) and/or forming personal relationships with members of the church or group. research procedures for this study, you will be asked to fill out a series of questionnaires related to your religious and spiritual experiences as well as your emotional reactions to those experiences. your maximum total time commitment in the study is estimated to be approximately 30 minutes. you will be able to fill out the questionnaires at your own convenience. potential risks potential risks related to your participation in this study include the possibility of a release of confidential information. confidentiality will be protected to the extent that is allowed by law. there is a potential risk of loss of confidentiality in all email, downloading, and internet transactions. only the investigator, her dissertation committee, and her statistics advisor will have access to the data collected. all files will be password protected and stored on a blank flash drive that will be stored in a locked file cabinet in the investigator’s residence. all data will be deleted within 5 years of the conclusion of this study. it is anticipated that the results of this study will be published in the investigator’s dissertation as well as in other research publications and local and national presentations. however, no names or other identifying information will be included in any publication.  181  
  another risk of participating in this study is possible emotional discomfort due to the material in the surveys. if you do experience any emotional discomfort regarding any aspect of any of the questionnaires, you may stop answering the questions at any time. if you have experienced emotional discomfort at any time during this survey, the following resources are available to help you locate assistance: american psychological association psychologist locator http://locator.apa.org/ national register of health service psychologists http://www.findapsychologist.org/ psychology today find a therapist http://therapists.psychologytoday.com/rms/ american association for marriage and family therapy http://www.therapistlocator.net/imis15/therapistlocator/ national board for certified counselors http://www.nbcc.org/counselorfind these counseling resources will also be provided to you at the completion of the survey. you may choose to print this resource for future reference. the researchers will try to prevent any problem that could happen because of this research. you should let the researcher know at once if there is a problem and she will help you. however, twu does not provide medical services or financial assistance for injuries that might happen because you are taking part in this research. a third possible risk is your loss of time. the instruments were chosen to be as quick and easy to understand as possible. the entire survey should take about 30 minutes. however, you are free to withdraw from the study at any time without penalty. a final risk relates to any coercion or pressure you may feel for participating in this study. please know that your participation in this study is completely voluntary and should you feel that you would like to withdraw from the study, you are free to do so at any time without penalty. participation and benefits your involvement in this research study is completely voluntary, and you may discontinue your participation at any time without penalty. if you are in psy 1603 or 182  
  1013 at twu, you may be given course credit by entering your numeric 4-digit sona id number at the end of the study. questions regarding the study if you have any questions concerning this research you may ask the researchers; their email addresses are at the top of this form. if you have any questions about your rights as a participant in this research or the way the study has been conducted, you may contact texas woman’s university office of research and sponsored programs at 940-898-3378 or via e-mail at irb@twu.edu. you may print a copy of this consent form to keep for your records.  please acknowledge that you have read and understand this information and are giving your informed consent to participate in this study. (check one): i agree to participate in this study i do not agree to participate in this study  i have been involved in a christian or bible-based church or group for at least one year. (check one): yes no  183  
  appendix b demographic questionnaire  184  
  question  1  please indicate your gender:  2  please indicate your age:  3  please indicate your ethnicity:  4  please indicate your sexual orientation:  5  please indicate your (current) spiritual/religious orientation (check all that apply):  response choices male female transgender (male to female) transgender (female to male) other prefer not to specify (open response) caucasian/white african american/black hispanic/latino/latina asian/pacific islander bi-racial/multi-racial native american/indigenous other (do not prefer to specify) other (open response) heterosexual gay or lesbian bisexual queer questioning other prefer not to answer christian – protestant (examples: baptist, nondenominational, pentecostal, episcopalian, etc.) christian – catholic christian – other (examples: lds, seventh day adventists, etc.) christian - liberal/progressive jewish muslim hindu buddhist agnostic atheist 185  
  6  7  please indicate where you live  please indicate your household income (in u.s. dollars)  spiritual, but not religious other (open response) northeast midwest west south canada other (please specify country)   30,000 between 30,000 and 60,000 between 60,000 and 100,000 between 100,000 and 150,000  150,000 prefer not to answer  186  
  appendix c 49-item spiritual abuse questionnaire (saq) for study 1  187  
  spiritual abuse questionnaire instructions: please consider your current or previous involvement in a christian or bible-based church or group (ex: a church, student organization, missions organization, etc.). respond by checking the box that most closely matches your experiences in that group. if you have been involved in more than one church or group, please answer according to the church/group that stands out to you the most. if the church/group that stands out to you the most is one in which you are currently involved, please answer the items as if they are written in the present (felt-- feel, etc). strongly disagree   disagree  agree      strongly agree   1  i felt i could be myself in the church/group  2 3  i felt bullied in my church/group people in my church/group twisted/misinterpreted the bible to try to control others  4  i believed i could be totally surrendered to god if i did everything perfectly according to the church/group's instructions  5  i believed god would punish me if i didn't do what my church/group encouraged me to do  6  i was told i needed to work through my personal issues with others in my church/group so they could hold me accountable  7  i know some religious leaders shared information about other people (through prayer requests or otherwise) that should have been kept private  8  leaders in my group acknowledged harm they caused to others  188  
  9  i felt freedom to ask questions or express concerns in my church/group  10  i know that i or others were asked to serve as the "eyes and ears" for our leader to get information about our members  11  when i had questions or concerns, i was made to feel i had a rebellious attitude or a lack of faith  12  input for church/group decisions was welcomed from leaders and nonleaders alike  13  it was acceptable to express my true emotions in my church/group  14  i believed that god's love and acceptance of me was dependent upon my performance in the church/group  15  my time commitment to the church/group did not prevent involvement in outside activities  16  submitting to my leader's authority was very important  17  i was led to believe bad things would happen if i didn't live up to certain spiritual/religious standards  18  i felt free to decline religious activities (fasting, prayer groups, studies) that i was not interested in  19  i was led to believe doubts were unholy and i should trust god  20  my religious group encouraged harsh child discipline that i believed bordered on child abuse  21  others were judged as inferior or ungodly for not conforming with my church's/group's norms  22  failure to conform to the group's norms resulted in loss of status or friendship within the group  189  
  23  in my church/group, i heard frequent criticism of other churches/groups that were deemed inferior  24  pursuing a non-church/group related educational or career pursuit could result in disapproval or the loss of friendship  25  it was uncommon to judge those who left the church/group  26  members received counsel/advice from leaders which seemed beyond the leader's expertise  27  i discerned an inner conflict between the narrow teachings of my church/group and my own understanding of god  28 29  i felt dependent on the church/group i felt like a spiritual failure and i depended on my leader/church group to "get it right" sometimes church/group members/leaders disguised controlling motives by offering to "help you stay on the right path"  30  31  sometimes when people left the group they were publically discredited to other church/group members  32  sometimes i feel guilty for having stayed too long in my church/group  33 34  i was afraid to leave my church/group my religious leaders used fear to control people  35  i currently have no trouble trusting religious leaders/churches/groups  36  i no longer trust myself to find a good spiritual community  37  at times i asked myself, "how can i live 'god's way' when 'god's way' was itself a source of so much pain?"  38  i now feel cynical about church/religious groups  39  i now feel lonely and misunderstood because of my church/group experiences 190  
  40  i was harshly criticized by religious leaders or church/group members  41 42  i was shunned by my church/group i felt (in my church/group) i could only share positive stories and had to keep my struggles private  43  at times i felt nobody else could see the negative things going on in the church/group except me  44  i felt powerless to stop bad things from occurring in my church/group  45  at times, i was scolded by my leader and made to feel ashamed and helpless i had to pretend to be someone i wasn't for so long in the church/group that it affected my physical health (ex: headaches, stomach issues, etc.)  46  47  i felt inferior because i was not as "gifted" as others in the group  48  i was encouraged to back away from relationships with family and long trusted friends if they did not agree with my church/group's teachings  49  when i think about it, i believe i experienced spiritual abuse  191  
  appendix d religious and spiritual struggles scale (rss)  192  
  religious and spiritual struggles scale at times in life, many people experience struggles, concerns, or doubts regarding spiritual or religious issues. on the list of items below there are no right or wrong answers; the best answer is the one that most accurately reflects your experience. please select “not at all/does not apply” for any items that simply don't make sense within your belief system. given the church/group experience that stands out to you the most, to what extent have you struggled with each of the following? currently or in the past, few months, to what extent have you struggled with each of the following? not at all / a little somewhat quite a a does not bit bit great apply (n/a) deal a. felt guilty for not living up to my moral standards b. felt angry at god c. had concerns about whether there is any ultimate purpose to life or existence d. felt hurt, mistreated, or offended by religious/ spiritual people e. struggled to figure out what i really believe about religion/spirituality f. felt attacked by the devil or by evil spirits g. questioned whether life really matters h. felt torn between what i wanted and 193  
  what i knew was morally right i. questioned god’s love for me j. had conflicts with other people about religious/spiritual matters k. felt as though the devil (or an evil spirit) was trying to turn me away from what was good l. felt as though my life had no deeper meaning m. felt angry at organized religion n. worried that my actions were morally or spiritually wrong o. felt confused about my religious/spiritual beliefs p. felt as though god was punishing me q. felt rejected or misunderstood by religious/spiritual people r. worried that the problems i was facing were the work of the devil or evil spirits s. felt as though god had abandoned me t. worried about whether my beliefs about religion/spirituality 194  
  were correct u. wrestled with attempts to follow my moral principles v. questioned whether my life will really make any difference in the world w. felt as though god had let me down x. felt troubled by doubts or questions about religion or spirituality y. felt tormented by the devil or evil spirits z. felt as though others were looking down on me because of my religious/spiritual beliefs  195  
  appendix e national stressful events survey for ptsd-short scale (nsess)  196  
  national stressful events survey for ptsd-short scale instructions: think about the variety of religious/spiritual experiences you have had in your lifetime. keep the experiences that stand out most in your mind as you complete this survey. how much have you been bothered by each of the following problems that occurred or became worse in relation to your religious/spiritual experiences? please respond to each item by marking one box per row.  not at all 0  a little bit 1  moderately 2  quite a bit 3  extremely 4  1. having “flashbacks,” that is, you suddenly acted or felt as if a stressful experience from the past was happening all over again (for example, you reexperienced parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)? 2. feeling very emotionally upset when something reminded you of a stressful experience? 3. trying to avoid thoughts, feelings, or physical sensations that reminded you of a stressful experience? 4. thinking that a stressful event happened because you or someone else (who didn’t directly harm you) did something wrong or didn’t do everything possible to prevent it, or because of something about you? 5. having a very negative emotional state (for example, you were experiencing lots of fear, anger, guilt, shame, or horror) after a stressful experience? 6. losing interest in activities you used to enjoy before having a stressful experience? 7. being “super alert,” on guard, or constantly on the lookout for danger? 8. feeling jumpy or easily startled when you hear an unexpected noise? 9. being extremely irritable or angry to the point where you yelled at other people, got into fights, or destroyed things? 197  
  appendix f institutional betrayal questionnaire version 2 (ibq.2)  198  
  institutional betrayal questionnaire version 2 this section will ask you to think about a christian or bible-based church or group (college group, fellowship group, small group) to which you belong or have belonged. please answer according to the church/group that stands out to you the most. question a: i am unable to think of a negative church or group experience. i am able to think of a negative church or group experience. (if unable, the participant will be routed to the next survey and will not have to answer the questions below for the ibq. if able, they will respond to the following prompts.) think about a negative experience in which you were hurt in any way by the christian or bible-based church or group you have in mind. in thinking about the negative experience, did the church or group play a role by (check all that apply). 1. not taking proactive steps to prevent this type of experience? 2. creating an environment in which this type of experience seemed common or normal? 3. creating an environment in which this experience seemed more likely to occur? 4. making it difficult to report the experience? 5. responding inadequately to the experience, if reported? 6. mishandling your case, if disciplinary action was requested? 7. covering up the experience? 8. denying your experience in some way? 9. punishing you in some way for reporting the experience (e.g., loss of privileges or status)? 10. suggesting your experience might affect the reputation of the institution? 11. creating an environment where you no longer felt like a valued member of the institution? 12. creating an environment where continued membership was difficult for you? 13. prior to this experience, was this an institution or organization you identified with or felt a part of?  199  
  1- not at all 2-very little 3-a good deal 4-very much 14. are you still a part of this institution? yes/no (optional): please briefly identify the institution involved (you can state the name of the church (e.g. “first baptist church of smalltown, tn”) or the name of the organization, (e.g. “campus crusade for christ”) or the kind of group (e.g. small group affiliated with the village church in dallas, tx; “advanced training institute”). if there is more than group with which you have had negative experiences, please list the one that stands out to you the most.  200  
  appendix g marlow-crowne social desirability scale, form c (m-c form c)  201  
  marlow-crowne scale form c listed below are a number of statements concerning personal attitudes and traits. read each item and decide whether the statement is true or false as it pertains to you personally. 1. it is sometimes hard for me to go on with my work if i am not encouraged. 2. i sometimes feel resentful when i don’t get my way. 3. on a few occasions, i have given up doing something because i thought too little of my ability. 4. there have been times when i felt like rebelling against people in authority even though i knew they were right. 5. no matter who i’m talking to, i’m always a good listener. 6. there have been occasions when i took advantage of someone. 7. i’m always willing to admit it when i make a mistake. 8. i sometimes try to get even rather than forgive and forget. 9. i am always courteous, even to people who are disagreeable. 10. i have never been irked when people expressed ideas very different from my own. 11. there have been times when i was quite jealous of the good fortunes of others. 12. i am sometimes irritated by people who ask favors of me. 13. i have never deliberately said something that hurt someone’s feelings.  202  
  appendix h counseling resources  203  
  counseling resources if you have experienced emotional discomfort at any time during this survey, and you are a student, you should contact your university or college counseling center if one is available. their services are likely to be free or low-cost to you. if you are not a university of college student, the following resources are available to help you locate assistance: american psychological association psychologist locator http://locator.apa.org/ national register of health service psychologists http://www.findapsychologist.org/ psychology today find a therapist http://therapists.psychologytoday.com/rms/ american association for marriage and family therapy http://www.therapistlocator.net/imis15/therapistlocator/ national board for certified counselors http://www.nbcc.org/counselorfind  204  
  appendix i permission to use religious and spiritual struggles scale (rss)  205  
  permission to use religious and spiritual struggles scale (rss)  religious comfort and strain measure 4 messages kathryn keller lamar khlamar@gmail.com to: julie.exline@case.edu  sat, sep 27, 2014 at 12:41 pm  hi dr. exline, i am a fourth year graduate student in counseling psychology at texas woman's university. i am currently working on my dissertation in which i am developing a measure of spiritual abuse. i was wondering if you would be willing to grant permission for me to use your religious coping and strain measure for my study. if so, any recent copies of the scale and/or psychometric information would be greatly appreciated. thank you so much, kathryn lamar -kathryn keller lamar, m.ed., ed.s., lpc doctoral candidate, counseling psychology texas woman's university klamar@twu.edu  julie exline jaj20@case.edu reply-to: julie.exline@case.edu to: kathryn keller lamar khlamar@gmail.com  sat, sep 27, 2014 at 4:40 pm  kathryn-thanks for your interest in our work. unfortunately, the only copy that i have of the religious comfort and strain scale is in the initial article (which i assume you have seen: exline, yali, & sanderson, 2000). you're more than welcome to use it, though. more recently we've developed the religious/spiritual struggles scale (see attached article and scale), which has gone through more validation than the earlier measure. this one focuses just on struggle, though, not on both comfort and struggle in the same scale. for a quick measure of positive/negative attitudes toward god, the atgs-9 measure (wood et al., 2010--attached) may also be of interest. i wish you all the best with your project! -julie [quoted text hidden]  -julie j. exline, ph.d.  206  
  armington professor; director of clinical training department of psychological sciences case western reserve university 10900 euclid avenue cleveland, ohio 44106-7123 office phone: (216) 368-8573 faculty page: http://psychology.case.edu/faculty/exline_julie.html psychology today blog, light & shadow: http://www.psychologytoday.com/blog/light-and-shadow  3 attachments exline et al., 2014 (the religious and spiritual struggles scale).pdf 225k rss scale scrambled with key sept 2014.docx 17k wood_worthington_exline_yali_aten_mcminn.pdf 139k  kathryn keller lamar khlamar@gmail.com to: julie.exline@case.edu  sat, sep 27, 2014 at 5:43 pm  hi dr. exline, thank you so much! that was immensely helpful. i am more concerned about the struggles than the comfort for my study, so this scale is perfect. i may even use both of the ones you sent, depending on what my chair advises. thanks again, kathryn [quoted text hidden]  julie exline jaj20@case.edu reply-to: julie.exline@case.edu to: kathryn keller lamar khlamar@gmail.com  sat, sep 27, 2014 at 6:24 pm  kathryn--sounds good. note that the anger/disappointment subscale of the atgs-9 has considerable overlap with the divine struggle scale of the rss--we used the one to help develop the other. so it might make sense for you to use the positive attitudes toward god items from the atgs-9 but not the anger/disappointment items (if you're using the rss). -julie  207  
  appendix j permission to use institutional betrayal questionnaire version 2 (ibq.2)  208  
  permission to use institutional betrayal questionnaire version 2 (ibq.2)  request permission for institutional betrayal questionnaire 3 messages stabb, sally sstabb@mail.twu.edu to: "jjf@uoregon.edu" jjf@uoregon.edu cc: "lamar, kathryn" klamar@mail.twu.edu  mon, sep 29, 2014 at 1:46 pm  hello dr. freyd:  while our recent correspondence has been around pwq, i think i mentioned that one of my dissertation students (kathryn lamar,m.ed., ed.s., lpc) was investigating spiritual/religious abuse. she is proposing a scale-development study and it occurred to me after reading your article that using the ibq would be an interesting and very valuable addition to our convergent/divergent validity measures. would you be open to us using your measure in this fashion? we would gladly share our data on the ibq from the sample we obtain.  if you're comfortable with this request, an electronic copy of the instrument and its scoring protocol, as well as psychometric data regarding it would be most welcome. i also completely understand if you are not up for sharing at this point, but figured there was no harm in asking.  thanks for considering this request, we appreciate that regardless of your decision.  sincerely, sally  sally d. stabb, ph.d. professor & director, doctoral program in counseling psychology texas woman's university stabb, sally sstabb@mail.twu.edu to: kathryn lamar khlamar@gmail.com  209  mon, sep 29, 2014 at 10:51 pm  
  she said yes! - dr. stabb ________________________________________ from: jennifer j. freyd [jjf@uoregon.edu] sent: monday, september 29, 2014 10:32 pm to: stabb, sally cc: carly smith subject: re: request permission for institutional betrayal questionnaire hi sally, you are very welcome to use the ibq. it is available on our website at: http://dynamic.uoregon.edu/jjf/institutionalbetrayal/ibq.html tomorrow we'll be presenting new data from the ibq at the uo we collected from our campus climate survey. should be interesting! jennifer  210  
  appendix k 20-item spiritual abuse questionnaire for study 2  211  
  20-item spiritual abuse questionnaire for study 2 instructions: please consider your current or previous involvement in a christian or bible-based church or group (ex: a church, student organization, missions organization, etc.). respond by checking the box that most closely matches your experiences in that group. if you have been involved in more than one church or group, please answer according to the church/group that stands out to you the most. if the church/group that stands out to you the most is one in which you are currently involved, please answer the items as if they are written in the present (felt-- feel, etc). strongly disagree   disagree  agree      strongly agree   1 it was acceptable to express my true emotions in my church/group 2 at times i asked myself, "how can i live 'god's way' when 'god's way' was itself a source of so much pain?" 3 leaders in my group acknowledged harm they caused to others  4 i know some religious leaders shared information about other people (through prayer requests or otherwise) that should have been kept private 5 i believed that god's love and acceptance of me was dependent upon my performance in the church/group 6 i currently have no trouble trusting religious leaders/churches/groups 7 i no longer trust myself to find a good spiritual community 8 i was harshly criticized by religious leaders or church/group members  212  
  9 i felt like a spiritual failure and i depended on my leader/church group to "get it right" 10 i believed god would punish me if i didn't do what my church/group encouraged me to do 11 i discerned an inner conflict between the narrow teachings of group and my own understanding of god 12 i now feel cynical about church/religious groups 13 i felt freedom to ask questions or express concerns in my church/group 14 i felt dependent on the church/group 15 my religious leaders used fear to control people 16 i know that i or others were asked to serve as the "eyes and ears" for our leader to get information about our members 17 at times, i was scolded by my leader and made to feel ashamed and helpless 18 i believed i could be totally surrendered to god if i did everything perfectly according to the church/group's instructions 19 i now feel lonely and misunderstood because of my church/group experiences 20 others were judged as inferior or ungodly for not conforming with my church's/group's norms  213  
  appendix l recommended 17-item spiritual abuse questionnaire  214  
  recommended 17-item spiritual abuse questionnaire instructions: please consider your current or previous involvement in a christian or bible-based church or group (ex: a church, student organization, missions organization, etc.). respond by checking the box that most closely matches your experiences in that group. if you have been involved in more than one church or group, please answer according to the church/group that stands out to you the most. if the church/group that stands out to you the most is one in which you are currently involved, please answer the items as if they are written in the present (felt-- feel, etc). strongly disagree   disagree  agree      strongly agree   1 it was acceptable to express my true emotions in my church/group 3 leaders in my group acknowledged harm they caused to others  4 i know some religious leaders shared information about other people (through prayer requests or otherwise) that should have been kept private 5 i believed that god's love and acceptance of me was dependent upon my performance in the church/group 6 i currently have no trouble trusting religious leaders/churches/groups 7 i no longer trust myself to find a good spiritual community 8 i was harshly criticized by religious leaders or church/group members  215  
  9 i felt like a spiritual failure and i depended on my leader/church group to "get it right" 10 i believed god would punish me if i didn't do what my church/group encouraged me to do 12 i now feel cynical about church/religious groups 13 i felt freedom to ask questions or express concerns in my church/group 14 i felt dependent on the church/group 15 my religious leaders used fear to control people 16 i know that i or others were asked to serve as the "eyes and ears" for our leader to get information about our members 17 at times, i was scolded by my leader and made to feel ashamed and helpless 18 i believed i could be totally surrendered to god if i did everything perfectly according to the church/group's instructions 19 i now feel lonely and misunderstood because of my church/group experiences **note: the items remained numbered as they had been numbered in study 2. there are only 17 items although the numbering goes up to #19. this is because items 2, 11, and 20 were deleted.  216  
       


secondary_title_index: spirituality in clinical practice
title_index: an examination and validation of a short form of the spiritual abuse questionnaire.
full_text_index:
       spirituality in clinical practice an examination and validation of a short form of the spiritual abuse questionnaire kaelyn r. griffin, david a. l. johnson, nicholas c. borgogna, and shane w. kraus online first publication, february 24, 2025. https://dx.doi.org/10.1037/scp0000391  citation griffin, k. r., johnson, d. a. l., borgogna, n. c., & kraus, s. w. (2025). an examination and validation of a short form of the spiritual abuse questionnaire. spirituality in clinical practice. advance online publication. https://dx.doi.org/10.1037/scp0000391  
  spirituality in clinical practice  2025 american psychological association issn: 2326-4500  https://doi.org/10.1037/scp0000391  an examination and validation of a short form of the spiritual abuse questionnaire kaelyn r. griffin1, david a. l. johnson2, nicholas c. borgogna2, and shane w. kraus1 this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  1  2  department of psychology, university of nevada, las vegas department of psychology, university of alabama, birmingham  the present study aimed to evaluate the psychometric properties of the spiritual abuse questionnaire (saq). additionally, the present study sought to conduct analyses to assess the measurement invariance of the saq and potential differences of experience of spiritual abuse based on sexual orientation, gender, and racial/ethnic identity. utilizing online self-report survey results from religious university students located in the united states, exploratory and confirmatory factor analyses, measurement invariance analyses, t tests, analysis of variance, and intraclass correlations were performed to examine the factor structure, loadings, validity, and reliability (test–retest, internal consistency) of the saq. pearson’s correlations were also performed to assess relationships between saq factors, religiosity, anxiety, and depression. exploratory and confirmatory factor analyses indicated that a four-item, one-factor version of the saq demonstrated good fit (n 1,744), had acceptable test–retest reliability (n 36, r 0.78–0.90), and met strict measurement invariance for gender. correlations revealed weak but significant positive relationships between all three saq factors, religiosity, anxiety, and depression. significant differences were found in reported experience of spiritual abuse between lesbian, gay, bisexual, queer, and questioning and heterosexual participants. results support the use of a one-factor, four-item version of the saq. this measure may be useful for future research, clinical practice, and screening for spiritual abuse. study findings were also consistent with prior literature indicating that lesbian, gay, bisexual, queer, and questioning identity is associated with higher levels of self-reported experiences of religious harm compared to heterosexual identity. keywords: spiritual abuse; psychometric; lesbian, gay, bisexual, transgender, queer, and questioning; religious harm; measurement supplemental materials: https://doi.org/10.1037/scp0000391.supp  oakley and kinmond (2014) defined spiritual abuse as coercion and control of one individual by another, within a spiritual context. they posit that this abuse may include manipulation, exploitation, censorship of decisions or speech, pressure for conformity, misuse of scripture, or isolation. spiritual abuse may occur when a spiritual leader (e.g., pastor, priest, or other group leader) misuses their authority and may be physical, sexual, or emotional in nature. spiritual abuse may also be perpetrated by a religious group more broadly, directed toward either a specific individual or a group of people. for example, abuse perpetrated by a religious group could consist of using religious teachings to oppress marginalized or minoritized  anthony isacco served as action editor. https://orcid.org/0000-0002-1910kaelyn r. griffin 8850 david a. l. johnson https://orcid.org/0000-0001-84514575 https://orcid.org/0000-0002nicholas c. borgogna 5085-3656 https://orcid.org/0000-0002-0404shane w. kraus 9480 the authors report there are no competing interests to declare. shane w. kraus receives funding support from kindbridge research institute. jacob vaughn, texas tech university, lubbock, texas, aided in conducting statistical analyses. correspondence concerning this article should be addressed to shane w. kraus, department of psychology, university of nevada, las vegas, 4505 maryland parkway, las vegas, nv 89154, united states. email: shane.kraus@unlv.edu 1  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  2  griffin, johnson, borgogna, and kraus  groups, which in turn has been associated with the experience of spiritual trauma (oakley, 2009; swindle, 2017). one group that may be particularly at risk for experiencing spiritual abuse due to nonaffirming messages and culture (e.g., homophobia, heterosexism) present within many christian churches is lesbian, gay, bisexual, transgender, queer, and questioning (lgbtq ) individuals (ginicola et al., 2017). for example, lgbtq individuals from more fundamentalist/conservative religious backgrounds may feel shame and guilt when attempting to reconcile their sexual identity with their religious beliefs. this incongruity between sexual identity and religious belief may have a detrimental impact on their identity formation, mental well-being, and self-concept (wood & conley, 2014). a meta-analysis by lefevor et al. (2021) shows the potential for harm within spiritual or religious environments for sexual minorities, along with the possibility of neutral or positive outcomes for individuals choosing to engage in religious or spiritual practice. as one example of spiritual abuse, scheitle and adamczyk (2010) identified a pattern within high-cost religious groups wherein the social and psychological stakes are raised if a member decides to leave the group, resulting in strained relationships, isolation, stress, and loss of personal identity. individuals who leave a high-cost religious group report worse health outcomes compared to those who stay within high-cost groups (scheitle & adamczyk, 2010). stevens et al. (2019) found that the levels of depression and anxiety in american university students who were previously abused by religious authorities were comparable to those who were previously abused by parents, both groups more symptomatic than without spiritual abuse. although spiritual abuse is not included in the assessment of adverse childhood experiences, the long-term negative impacts of adverse childhood experiences are well documented (e.g., chang et al., 2019; felitti et al., 1998), and the nature of spiritual harm may result in similar outcomes. individuals affiliated with the minority religious group in each area may be at increased risk for suicidal ideation or attempt due to lack of belongingness or feelings of ostracization stemming from their sexual orientation (lawrence et al., 2016). participation in nonaffirming religious settings is associated with increased internalized homophobia, which in turn predicted depressive  symptoms and decreased psychological wellbeing for lesbian, gay, and bisexual individuals (barnes & meyer, 2012). paulez et al. (2023) found high rates of religious/spiritual struggles reported by lgbtq individuals, particularly those with experiences within nonaffirming religious environments. exposure to religious antigay sentiment predicted increased anxiety, stress, shame, problematic alcohol use, and exposure to physical and verbal abuse for lesbian, gay, and bisexual individuals (sowe et al., 2017). currently, measures proposed for spiritual abuse or difficulty within religion are limited (e.g., religious/ritual abuse questionnaire, nobakht & dale, 2018; religious and spiritual struggles scale, exline et al., 2013). keller (2016) developed the 17-item spiritual abuse questionnaire (saq) to assess experiences of spiritual abuse within christian or bible-based groups. participants for the creation of the saq were current/previous adult christian or bible-based church members ( 1 year activity). four factors were initially identified on the saq across 20 items via exploratory factor analysis (efa); this model was later discarded due to poor item loadings in a four-factor confirmatory factor analysis (cfa). keller (2016) also examined a possible three-factor model: the first factor, labeled mistrust, comprised eight items that assessed feelings of emotional harm, betrayal, and invasion of privacy; the second factor, labeled power-based affective wounding, comprised four items that assessed emotional harm and feelings of dependence or restriction; and the third factor, labeled conditional acceptance, comprised four items that assessed feelings of conditional care or inclusion based on obedience and cooperation. however, the items in any of these factors were not reported by keller (2016). keller (2016) also identified a two-factor structure, when an additional three items were removed resulting in the extant 17-item scale via efa and cfa. convergent validity was assessed through correlations between a saq sum score (despite being validated as a multidimensional instrument) and measures of posttraumatic stress disorder, r .73, p .01 (i.e., national stressful events survey posttraumatic stress disorder short scale; kilpatrick et al., 2013); institutional betrayal, r .62, p .01 (institutional betrayal questionnaire.2; smith & freyd, 2014); and religious and spiritual struggles, r .75, p .01 (religious and spiritual struggles scale; exline et al., 2013). however, keller  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  short form of the spiritual abuse questionnaire  (2016) did not report the specific item loadings, measurement invariance, or test–retest reliability. additionally, the original saq (keller, 2016) was never published in a peer-review outlet and is limited in dissemination by its dissertation format. altogether, the saq demonstrates potential as a flagship measure of spiritual abuse but needs substantial revision, consistent with modern psychometric standards. given the limited scope of the original saq validation dissertation (keller, 2016), including the atypical factor analysis approach, no reported item loadings onto factors, lack of discriminant validity, and lack of measurement invariance, a reanalysis of the saq factor structure and preliminary validity and reliability estimates in a larger, more diverse sample is needed to better understand its psychometrics. by validating and publishing this measure, research and clinical work regarding spiritual abuse will improve. the present study the present study evaluated the saq in a diverse sample of university students to extend generalizability of the saq. due to the lack of a clear theoretical structure for measuring items, we performed exploratory and confirmatory factor analysis without an anticipated factor structure; based on analyses, several items from the saq can be utilized to create a brief, unidimensional short form of the saq. due to the original study samples being composed primarily of women, the present study included measurement invariance testing for gender as well. we additionally assessed convergent and discriminant validity and 1-week test–retest reliability of the saq. finally, given the limited diversity in the original saq studies, the present study will also examine differences in saq scores based on gender, sexual orientation, and racial/ethnic identity to better understand variations in prevalence and support scale validity. this study also evaluated the relationships between spiritual abuse, religiosity, and symptoms of depression and anxiety among a diverse sample of young adult college students. next, because sexual minorities have reported prior incidences of spiritual trauma due to their sexual identity (e.g., dahl & galliher, 2012; ginicola et al., 2017; lefevor et al., 2023), we hypothesized that lesbian, gay, bisexual, queer, and questioning (lgbq ) students, relative to heterosexual individuals, would have higher  3  saq scores. in support of discriminant validity of the saq, we hypothesized that higher scores would be associated with increased anxiety and/ or depression symptomatology (r .20). we expected a robust correlation between the duke university religion index (durel) and saq as evidence of convergent validity (r .20). given the lack of available literature, no hypothesis was formulated when examining possible racial/ ethnicity group and gender differences. method participants male and female undergraduate students (n 1,744) from two universities in the south and southwest regions of the united states were recruited from introductory psychology courses and received course credit upon completion of the survey (see supplemental file for demographic information). participants who declined to answer sex at birth or gender (n 2) or race (n 2) were removed from the sample. due to sample sizes too small to be included in analyses, participants who reported their race as middle eastern (n 16), native american (n 4), or preferred not to share their ethnic or racial group (n 9) were also removed from the sample. participants who reported childhood religion as atheist, agnostic, spiritual but not committed to one religion, or nonreligious (n 270) were removed from the sample due to limited exposure to religious or spiritual settings to experience spiritual abuse. additional sample demographic information is available at https://osf.io/xt2jk. measures a general demographic questionnaire was used to collect information regarding biological sex, gender, sexual orientation, age, race and ethnicity, and religion. the original 17-item saq (keller, 2016) was used to assess participants’ experience of spiritual abuse on a one to four scale (1 strongly disagree, 4 strongly agree; keller, 2016). the durel (koenig & bussing, 2010) is a five-item self-report that assesses participants’ level of religiosity rated on a one to six scale (1 rarely or never, 6 more than once/week or more than once a day) or a one to five scale  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  4  griffin, johnson, borgogna, and kraus  (1 definitely not true, 5 definitely true of me) for a total score range between 5 and 27. for the present study, the alpha coefficient indicated that internal consistency was good, α .85. the patient health questionnaire–9 (kroenke et al., 2001) was used to assess past 2-week depression on a one to four scale (0 not at all, 3 nearly every day). sum scores were created from participant responses, with higher scores indicating more depression. for the present study, the alpha coefficient indicated good internal consistency, α .89. the generalized anxiety disorder–7 (spitzer et al., 2006) was used to assess past 2-week anxiety on a zero to three scale (0 not at all, 3 nearly every day). sum scores were created, with higher scores indicating more anxiety. for the present study, the alpha coefficient indicated excellent internal consistency, α .90. procedure participants signed up for the study through the psychology department subject pool system (i.e., sona systems research participation platform). participants anonymously completed the survey online, and it took approximately 1 hr to complete. prior to beginning, participants were asked to read the consent form. study procedures were approved by the institutional review board of the university of nevada, las vegas and university of south alabama, and data were collected 2020–2021. statistical analyses means and standard deviations of the factors were conducted on r (r core team, 2021). before conducting an efa, the skewness and kurtosis were examined for each of the 17 saq items. when examining individual items, data are considered normal if the skewness is between  2 and 2 and kurtosis is between 7 and 7 (ryu, 2011). next, the interitem correlations of the 17 items for the saq were evaluated for any highly (r .80) or weakly (r .30) correlated items for possible deletion (field et al., 2013). the sample was randomly divided into two equal groups; these two independent samples were used for conducting the efa and cfa. we used r (r core team, 2021) to conduct an efa (n 873) to determine the number of factors within the saq and to conduct a parallel analysis  using the r package “fa.parallel” (horn, 1965). common factors were extracted using a principal axis factoring method and direct oblimin rotation (nonorthogonal). items were retained if the factor loading was .70 and only loaded onto one factor. a “backward” procedure was implemented, similar to the borgogna and colleagues experiential avoidance rating scale validation article (borgogna et al., 2023), in which the efas were conducted iteratively, during which the weakest loading items were removed until all items had loadings .70. using the second half of the sample (n 874), we used r (r core team, 2021) to perform tests of cfa using the “lavaan” (rosseel, 2012) and “semtools” (jorgensen et al., 2022) packages. to conduct a cfa, a minimum of three cases per parameter is needed (kline, 2016). the maximum likelihood robust estimator (mlr) was used to investigate the fit of the factor model identified from the efa above. the chi-square statistic (χ2; cutoff for good fit p .05), comparative fit index (cfi), root-mean-square error of approximation (rmsea), standardized root-mean-square residual (srmr), and tucker–lewis index (tli) were used to establish model fit. good model fit is suggested by a cfi and tli .95, rmsea .05, and srmr under .05 (hu & bentler, 1998, 1999). acceptable model fit is indicated by a cfi and tli .90, rmsea .08, and srmr .08 (hu & bentler, 1998, 1999). the retained factor structure from the cfa was used as the configural model for gender measurement invariance tests. using the full sample (n 1,716), multigroup cfa was utilized to perform measurement invariance by gender (i.e., men and women) in mplus (muthen & muthen, 2020) using the maximum likelihood estimation with robust standard errors (mlr; satorra & bentler, 2001). measurement invariance is typically tested in four steps: in configural invariance, participant responses demonstrated the same factor structure across the groups. metric invariance was used to determine whether the items in the measure have the same relationship to the underlying latent construct across both groups (i.e., equivalent factor loadings; xu & tracey, 2017). scalar invariance was used to determine the equivalence of intercepts between the groups. attainment of scalar invariance indicates equivalence of mean points on the scale (mean scores are comparable). residual invariance was used to evaluate the equivalence of errors.  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  short form of the spiritual abuse questionnaire  achieving residual invariance suggests that the scale measures the same underlying construct between groups with an equivalent degree of accuracy (borgogna, 2021). several alternative global fit indices (i.e., cfi, tli, rmsea, and srmr) were used to evaluate the relative/incremental goodness of fit of my models based on the robust maximum likelihood estimator (mlr) because of the limitation of the chi-square test overestimating the discrepancy in goodness of fit in large samples (davidov et al., 2014). to assess for differences between the four measurement invariance models, the cfi (i.e., δcfi) and rmsea (i.e., δrmsea) statistics were examined for changes. a decline in cfi greater than 0.01 and increases in rmsea greater than 0.015 indicated a significant worsening of fit (chen, 2007). pearson’s correlations were conducted to evaluate saq scores with the durel to further assess convergent validity of the saq. correlations between spiritual abuse, anxiety, and depression were conducted to assess discriminant validity. using the full sample (n 1,280), a series of oneway between-subjects analyses of variance were conducted on spss 27.0 (spss, inc., chicago, illinois) to examine group differences on spiritual abuse across race/ethnicity (i.e., non-hispanic/ latino white, hispanic/latino, multiracial). effect sizes are reported by η2. independent-samples  5  t tests were utilized to examine group differences on spiritual abuse across gender (i.e., men and women) and sexual orientation (i.e., heterosexual or lgbq ; binary groupings utilized due to small lgbq sample size). bonferroni’s post hoc was used to examine group differences for race/ ethnicity. cohen’s d effect size calculations followed all between-group comparisons. the test–retest reliability of the saq was assessed using a subsample (n 17) recruited from psychology courses specifically to collect test–retest data. participants completed a brief two-part online survey with 1 week between part 1 and part 2. the survey included demographic information (i.e., age, sex, gender, race, sexual attraction, relationship status, current religion, and childhood religion), the durel, and the 17-item saq.  results the 17 items in the saq were assessed for means (range 0.61–1.76), skewness ( 0.09 to 1.28), and kurtosis ( 1.12 to 0.84). no significant outliers were detected across the 17 items. next, the interitem correlations for all 17 items in the saq were evaluated. interitem correlations ranged from 0.01 to 0.65 (total interitem correlation r 0.15), indicating that items, overall, did not fit  figure 1 confirmatory factor analysis of a one-factor, four-item model of the spiritual abuse questionnaire with standardized factor loadings and residuals  
  6  griffin, johnson, borgogna, and kraus  together well empirically. additional analyses are posted at https://osf.io/q62b8/.  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  efa, cfa, and measurement invariance testing the data set was randomly split in half (n 873) via computer-generated random seed on r. the kaiser–meyer–olkin was 0.92, and the bartlett’s test was significant, χ2(136) 6451.57, p .001, indicating that the data was suitable for factor analysis. the kaiser–guttman rule suggested three factors. scree suggested two strong and a third weak factor. parallel analysis suggested that two factors should be utilized. given the lack of prior research on the saq factor structure and identification of two clear factors and a potential third factor, both the two-factor and three-factor solutions were tested. to assess a potential sum score for all items, a one-factor solution was also tested. all 17 items in the saq were entered into the efa and tested in one-factor, two-factor, and three-factor models. the two-factor analyses showed fit indices below acceptable thresholds in the 17-item and 15-item (items removed for cross-loading) efas. the two-factor 17-item efa showed cumulative variance 0.43, tli 0.88, rmsea 0.08. the two-factor 15-item efa showed cumulative variance 0.43, tli 0.88, rmsea 0.08. three iterations were conducted with the twofactor model to remove items that did not meet the 0.7 loading threshold criteria (items 2, 3, 4, 5, 6, 7, 10, 12, 13, 16, and 17). given the poor fit of these two-factor models, three iterations were  performed to test a three-factor model to remove items that did not meet the above criteria (items 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 17). the three-factor, 17-item efa showed cumulative variance 0.43, tli 0.92, rmsea 0.06. next, four iterations were then conducted with the one-factor model to remove items that did not meet criteria (items 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, and 16). the one-factor, four-item efa showed proportion variance 0.58, tli 0.94, rmsea 0.14. consistent with these conditions, four items were retained for the final onefactor efa, accounting for 58% of the variance (table 1). while tli improved to acceptable in the one-factor model, rmsea was above the acceptable cutoff. however, this could be due to the small degrees of freedom rather than true model misfit (shi et al., 2022). as such, because of the additional improvements above the two-factor and three-factor models, we proceeded forward using the one-factor model (see figure 1). next, using the second half of the sample, a cfa was conducted utilizing the other half of the randomly split data set (n 874). in the overall sample, the one-factor, four-item model displayed excellent fit, χ2(2) 3.71, p .156, cfi 1.00 and tli 1.00, rmsea 0.03, srmr 0.01. additionally, the one-factor, fouritem model displayed an acceptable fit by gender (see table 2). overall, given the adequate fit in the whole cfa sample, the one-factor, four-item model was retained as the configural model to test measurement invariance for gender (table 3). using the full sample, the configural model fit the data well across all indices besides rmsea and allowed factor loadings and intercepts to vary  table 1 means and standard deviations and factor loadings for one-factor exploratory factor analysis with the four-item spiritual abuse questionnaire item  m  sd  pa1  range  7. i was harshly criticized by religious leaders or church/group members. 13. my religious leaders used fear to control people. 14. i know that i or others were asked to serve as the “eyes and ears” for our leader to get information about our members. 15. at times, i was scolded by my leader and made to feel ashamed and helpless. sum of squared loadings proportion variance α coefficient  .80 .83 .73  .94 .99 .88  0.75 0.78 0.70  3 3 3  .60  .83  0.86 2.36 0.60 .84  3  note. cutoff 0.7. tucker–lewis index 0.95, root-mean-square error of approximation 0.12. pa principle axis factor.  
  short form of the spiritual abuse questionnaire  7  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  table 2 overall fit statistics and measurement invariance of the one-factor, four-item saq-sf by gender model  n  χ2(df )  cfi  tli  rmsea [90% ci]  srmr  four-item saq-sf gender men women  874  3.71(2)  fit statistics 1.00  1.00  0.03 [0.00, 0.09]  0.01  246 628  2.48(2)* 1.98(2)  1.00 1.00  1.00 1.00  0.04 [0.00, 0.15] 0.00 [0.00, 0.08]  0.01 0.01  note. saq-sf spiritual abuse questionnaire short form; χ2 chi-square; cfi comparative fit index; tli tucker–lewis index; rmsea root-mean-square error of approximation; ci confidence interval; srmr standardized root-mean-square residual. * p .05.  by gender (see table 2). when the loadings were constrained to be equal between genders in the metric model, the fit did not appear to worsen compared to the configural model, as shown in the small changes in cfi, while rmsea improved. scalar invariance for gender showed acceptable model fits across all indices, and while rmsea still did not meet acceptable cutoffs, it again improved. finally, the residual variances of each item are shown to be similar across all groups in strict invariance. in the residual measurement invariance model for gender, all fit indices (including rmsea) were acceptable and differences in cfi were small. measurement invariance for gender of the one-factor, four-item model was supported at the residual level. because rmsea improved in each step of the invariance testing as degrees of freedom were added, this supports the idea that rmsea was initially above acceptable limits due to the small number of items in the scale. correlations using the full sample, the modified four-item saq was examined for correlations with the durel sum score, anxiety, and depression scores.  correlation results showed that the saq was weakly associated with anxiety (r .25, p .001) and depression (r .27, p .001), suggesting evidence of discriminant validity given small to moderate relationships. support for discriminant, but not convergent, validity was noted by the significant, although weak, correlation between the saq and durel (r .27, p .001). the 17-item saq and modified four-item saq were moderately correlated (r .68, p .001). mean comparisons using the full sample, we conducted independentsamples t tests to assess differences in saq scores based on gender and sexual orientation. a significant difference and moderate effect size were identified based on lgbq status, with higher mean scores for lgbq participants (n 155, 11.05%) compared to heterosexual participants (n 1,248, 88.95%), mheterosexual 2.55 (sd 2.78), mlgbq 3.91 (sd 3.08), t(1,401) 5.68, p .001, d .48. there was no significant difference found between men and women, t(1,424) 1.34, p .18, d .08, with mwomen 2.79 (sd 2.92) and mmen 2.55 (sd 2.70). these results support  table 3 measurement invariance of the one-factor, four-item spiritual abuse questionnaire by gender gender  n  χ2(df )  cfi  tli  rmsea [90% ci]  srmr  δcfi  δrmsea  difftest χ2(df )  configural metric scalar residual  1,716 1,716 1,716 1,716  72.881(4) 82.756(7) 85.143(11) 92.174(15)  0.983 0.981 0.982 0.981  0.949 0.968 0.980 0.985  0.142 [0.114, 0.171] 0.112 [0.091, 0.135] 0.089 [0.072, 0.107] 0.077 [0.063, 0.093]  0.022 0.036 0.040 0.034   0.002 0.001  0.001   0.03  0.012  0.012  7.99(3)* 2.42(4) 2.46(4)  note. χ2 chi-square; cfi comparative fit index; tli tucker–lewis index; rmsea root-mean-square error of approximation; ci confidence interval; srmr standardized root-mean-square residual. * p .05.  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  8  griffin, johnson, borgogna, and kraus  the hypothesis that lgbq participants would have higher saq scores compared to heterosexual participants. to assess differences in saq scores based on race/ethnicity, we conducted a one-way betweensubjects analyses of variance. analyses of variance and bonferroni’s post hoc tests were performed for white, black, hispanic or latino, asian or pacific islander, and multiracial participants. there was a significant difference by race (mwhite 2.68, sd 2.99; mblack 3.48, sd 2.96; mhispanic or latino 2.50, sd 2.69; masian/pacific islander 2.50, sd 2.43; mmultiracial 3.12, sd 2.95), f(4, 1,418) 3.60, p .006, η2 .01. the bonferroni post hoc test revealed significant differences with moderate effect sizes between black and latino or hispanic participants (mdifference .98, se .32, p .023, d .35). results indicate the experience of spiritual abuse may vary somewhat based on racial/ethnic identity, specifically showing that black individuals endorsed more experiences of spiritual abuse on average relative to latino or hispanic participants. test–retest reliability of the saq to assess the 1-week test–retest reliability of the saq, an intraclass correlation on participants’ (n 36) saq scores from survey 1 with their scores on survey 2 was performed. the intraclass correlation coefficients indicated that the brief saq factors yielded moderate test–retest reliability, r(16) .52, p .001. internal consistency for the four-item saq was good (α .85). discussion the present study examined the psychometric properties of the saq to evaluate its factor structure, measurement invariance, test–retest reliability, and convergent/discriminant validity. first, through a series of exploratory and confirmatory analyses, results suggested that a modified onefactor (four-item) model fit the data best. this is a modification from the suggested two-factor model in the original study (keller, 2016), with the additional alteration of removing several items due to low factor loadings. overall, the findings from both the efa and cfa support the use of a modified four-item model for the saq. the modified four-item, one-factor structure achieved strict (residual) invariance for gender.  this is the most difficult form of invariance to attain and had not previously been demonstrated with the saq. these results indicate that the residual that is associated with latent variables, factor loadings, and intercepts is approximately equal across men and women. given this, any differences in item responses across gender are likely due to group differences, rather than item bias. as the present study is the first to examine measurement invariance of the saq and the first to examine measurement invariance across the reduced-item, one-factor saq, this is a significant contribution to the limited body of literature on spiritual abuse. correlation analyses demonstrated weak relationships between spiritual abuse and anxiety and depression, supporting the hypothesis that negative spiritual experiences will have a negative psychological impact and demonstrating the distinction between the experience of spiritual abuse and symptoms of depression or anxiety. similarly, the weak correlation between the saq and religiosity shows that reports of spiritual abuse are not related to personal religiosity. we also evaluated whether there were differences in experiences of spiritual abuse across gender, ethnicity/race, and sexual orientation in university students. consistent with the hypotheses, lgbq individuals reported higher scores on the saq compared to their heterosexual counterparts. these results indicate that lgbq status may increase the risk for experiencing spiritual abuse, important identities to consider for prevention, treatment, and research of spiritual abuse. overall, these results are consistent with existing literature suggesting that lgbq individuals may experience additional harms in a religious environment due to nonaffirming messaging and exclusion due to their sexual orientation (ginicola et al., 2017; wood & conley, 2014). next, limited differences based on race/ethnicity were identified. given the primarily white sample in the original study (keller, 2016), assessing race and ethnicity provides improved understanding of the suitability of the saq across potential racial/ethnic differences without assuming all items would be perceived and applicable equally across groups. results revealed that black, relative to white and latino or hispanic, students reported higher levels of spiritual abuse (see supplemental file). the existing literature supports the ubiquity of spiritual abuse, as the experience has been identified in numerous races and countries (e.g.,  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  short form of the spiritual abuse questionnaire  dehan & levi, 2009; nobakht & yngvar dale, 2018; stevens et al., 2019), but in the present study, it suggests it may be a more common experience or more highly endorsed among black students. the shortened saq may be useful as a screening tool in clinical work and research, particularly on college campuses and in environments targeting university students and young adults. specifically, it may be particularly useful for religious organizations to implement the saq to screen for spiritual abuse to aid in establishing prevention and intervention of spiritual abuse among their members. religious groups with strict guidelines or limited alternatives for engagement with the religious community may benefit from utilizing the saq to monitor potentially harmful experiences and implement interventions to reduce spiritual abuse. similarly, other programs or offices (e.g., medical providers, community centers, sport clubs) working with young adults may find the saq useful for assessing harmful religious experiences, need for services, or overall well-being. the saq short form may also be used to further explore adverse childhood experiences, expanding understanding and measurement within this area of research. limitations and future directions the present study has limitations. first, additional analyses specifically targeting the use of the saq across religious groups and lgbtq individuals would significantly add to the spiritual abuse literature. the present sample provides some insight into this area; however, it did not contain a sufficient sample size to investigate specific hypotheses regarding religious affiliation and lgbtq identity. second, the results are cross-sectional and come from a sample of young college students who largely fall in the western, educated, industrialized, rich, and democratic demographic, and data were collected during 2020–2021, which may have impacted responses for some participants due to the societal changes during covid-19. due to this, present findings may not generalize across other populations, including noncollege students, children, adolescents, or older adults, or those living in other countries. to explore the potential impact of age on these effects, future research should examine reported spiritual abuse in other samples across the lifespan; further research examining the saq and experience of spiritual abuse among other  9  religious groups with strict guidelines or limited alternative communities would be beneficial in better understanding the use of the measure and scope of spiritual abuse. third, not all individuals who report a history of spiritual abuse or other negative experiences within religion are willing and comfortable to openly disclose their experiences. due to the sensitive nature of this topic, as well as the possibility of social desirability bias in responding to the survey items or perceived risk of ostracism based on disclosing spiritual abuse, participants may adjust their responses on a direct questionnaire such as the saq. future research and measures could identify less overt methods for measuring negative religious experiences to reduce potential impression management and socially desirable responding effects. assessing the experience and impact of spiritual abuse in a more subtle way could greatly improve the understanding of prevalence rates as well as the influence that willingness to identify an experience as spiritual abuse may have on well-being. fourth, the acceptance of saq items as reflective of spiritually abusive practices as perceived by religious leaders, believers, or those who have experienced spiritual abuse or trauma has not yet been assessed. future research examining the acceptance of these items and willingness to utilize the measure within religious organizations, community groups, and other spaces would contribute greatly to the understanding of the feasibility of scale implementation. finally, future research should further explore convergent validity for this measure, as these results showed spiritual abuse as unrelated to religiosity, anxiety, and depression; further examination of related issues is warranted. conclusion present study findings provide a new contribution to the limited field of spiritual abuse, as this scale has not previously been explored in men or racially diverse college students. this is one of the first studies to examine a link between spiritual abuse and anxiety and depression. results from the present study suggest that a shortened version of the saq is more psychometrically sound, improving future use and reducing questionnaire burden on the participant. considering these findings, the newly established brief four-item saq can be useful for clinical and research purposes moving forward,  
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