Spirituality and Substance Abuse/Dependence Treatment


  1. Introduction
  2. Slide #2

    1. Overview
      1. Review Definitions
      2. Discuss why spirituality is important to clinicians
          1. Effects on health
          2. Beliefs of patients
          3. Beliefs of medical professionals
      3. Spirituality in Substance Abuse/Dependence Treatment
      4. Research in Alcoholics Anonymous and Spirituality

      Slide #3

    2. Definitions
      1. Religion comes from the root "religio" meaning humanity’s bond with a greater being.
      2. Spiritual comes from the root "spiritus" meaning breath or life.
      3. Abraham Joshua Herschel, a theologian and philosopher, described religious thinking as "an intellectual endeavor out of the depths of reason. It is a source of cognitive insight into the ultimate issues of human existence."
      4. However, the meaning of the word ‘religion’ has evolved to include religious behaviors and rituals which some view as an impediment to a spiritual experience.

      Additional material for Slide #3

    3. Miller, in his review on the subject, likens spiritual variables to other etiologic dimensions such as physiological, genetic, psychological, family, and socio-cultural influences. 1
      1. Miller
          1. The concept of spirit is often defined in contrast to matter, and spirituality in contrast with materialism.
          2. To speak of the spiritual is to refer to that which is transcendent or transpersonal
          3. Descriptively, this might be captured in the general assertion that ‘we have bodies, but we are not our bodies.’
          4. Whether or not a scientist personally embraces this view, it is one that has characterized most of human kind throughout recorded history. As an attribute of humanity, it is a proper subject for scientific investigation. (James, 1902)
          5. Distinction between religion and spirituality
            1. Spirituality at the level of the individual – an idiographic aspect of the person, whereas religion is a social phenomenon. Individuals can be characterized in terms of their religiosity by measuring the extent to which they are engaged in religious belief and practice.
            2. Spirituality is hard to delimit. Because of it’s focus on the transcendent, spirituality defies customary conceptual boundaries, whereas religion is actually defined by it boundaries. In particular, it involves beliefs, practices forms of governance, and rituals; and is, therefore, easier to define and measure in operational terms.
            3. In fact, certain forms of religion interfere with or distort one’s spirituality. For example, spirituality may be obscured when ritual, rule and practice become important in their own right and their purpose is forgotten. Miller asserts that this relationship between the two is a potential subject for empirical investigation.
      2. Miller suggests that the measurement of spirituality should be multi-dimensional involving behavior, belief, and experience. In fact, he references literature that includes measurements of spiritual and religious constructs.

    Slide #4

  3. Why spirituality is important/Health Benefits
    1. The most consistent predictors of quality of life and possible survival among patients with advanced malignancies were a social support system and spirituality/religion. 2
    2. Numerous studies have found an association between religious commitment and lower blood pressure. 3

    Slide #5

  4. Why Spirituality is important/Beliefs of Patients and Health Care Professionals
  5. Slide #6

    1. When polled, more than 90% of Americans reported that they believe in God, 57% reported engaging in daily prayer, and 42% reported attending church within the past week.4
    2. Slide #7

    3. A poll of 1000 US adults conducted in 1996 revealed that 79% believed that religious faith can help in recovery from serious illness and 63% agreed that doctors should talk to patients about spiritual issues. 5
    4. Slide #8

    5. Fewer psychiatrists report believing in God than do individuals in the general population. A survey done in the 70’s revealed that 44% of psychiatrists reported that they believe in God. 6
    6. In a survey conducted at Bellevue Hospital, a city hospital in New York, nursing staff and medical students were found to underestimate the importance that a group of dually diagnosed patients placed on spirituality in their recovery from drugs and alcohol. 7

    Slide #9

  6. Substance Abuse/Dependence Treatment and Spirituality
    1. "Religions have been far from silent on the use of psychoactive drugs, and spirituality has long been emphasized as an important factor in recovery from addiction."
      1. Cite religious practices and the use of substances as well as the prohibition of substances by some religions
        1. religious practices
            1. In Judeo-Christian scriptures, the drinking of wine is assumed to be part of ordinary life and is even commended. Central sacramental observances in both Judaism and Christianity involve the use of wine. (Miller)
            2. Native American, Polynesian, African, and other indigenous religions have often used hallucinogenic and other psychoactive substances such as peyote, khat, alcohol, tobacco, and hashish as vehicles in the quest for spiritual transcendence. Some religions are characterized as based on or inspired by drug use.
  1. prohibition of substances
            1. Judeo-Christian – Biblical denunciation of drunkeness – the use of alcohol in a manner that inflicts impairment and harm. 1
            2. Islam strictly proscribe any ingestion of alcohol and certain other drugs

Slide #10

    1. Alcoholics Anonymous
      1. ‘If sin is that which separates humanity from God, these are biblical expressions of the same idea underlying the ancient epithet spiritus contra spiritum cited by Carl Jung in a letter to Bill Wilson, the co-founder of Alcoholics Anonymous. The fundamental idea is that the misuse of alcohol, which interestingly came to be called "spirits", is in some manner incompatible with spirituality. One drives out the other. This understanding is fundamental within the core writings of Alcoholics Anonymous. The essence of AA’s program is not the disease model with which it has so often been confused, but the understanding that an alcoholic’s best, if not only, hope for sobriety is through recognizing, appealing to, accepting help from and directing his or her life toward a transcendent higher power, referred to as "God".’ 1
      2. Alcoholics Anonymous derived from a Christian fellowship in 1935 has helped millions of dependent persons in their recovery from drugs and alcohol.8
      3. 12 Steps
      4. Slide #11

          1. Steps 1 – 3
            1. Step 1 - Admit powerlessness over alcohol
            2. Step 2 – Belief in a "power greater than ourselves"
            3. Step 3 – Turn will over to the care of God "as we understood Him"

            Slide #12

          2. Steps 4 through 7
            1. Step 4 – Take a moral inventory
            2. Step 5 – Admit to God, to ourselves, and to another human being the exact nature of our wrongs
            3. Step 6 – Ready to have God remove all these defects of character
            4. Step 7 – Ask Him to remove our shortcomings

            Slide #13

          3. Steps 8, 9, 10
            1. Step 8 –Made a list of all persons harmed and became willing to make amends to them all
            2. Step 9 – Made direct amends wherever possible
            3. Step 10 – Ongoing personal inventory and promptly admitted when we were wrong

            Slide #14

          4. Final two
            1. Step 11 – Through prayer and meditation, improve our conscious contact with God, ‘as we understood Him’
            2. Step 12 – "having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs"

Slide #15

  1. Spirituality Research in Substance Abuse/Dependence Treatment
    1. One of the most consistent research findings in this field is that religious and/or spiritual involvement appears to be associated with less use. 1
      1. Religiously involved individuals are consistently less likely to use alcohol and other drugs although there appear to substantive differences among religious denominations in the risk of alcohol problems.
          1. Those of the Jewish faith are typically found to have relatively low rates of alcohol problems and dependence despite low rates of total abstinence.
          2. When looking at those who currently drink, the risk of problems and dependence appears to be highest among conservative Protestant denomination where abstinence is the norm; however, even in this highest-risk group, the risk for drinkers is only 40% of that for drinkers with no religious affiliation.
          3. Irish Catholics are another group with high rates of alcohol abuse and dependence.
      1. The possible protective mechanisms of religious involvement are poorly understood.
          1. Principled avoidance of drugs?
          2. Presence of social support for abstinence or moderation?
          3. Engagement in time-occupying activities that either compete with or are incompatible with drug use?
          4. A life free of drug involvement be part of a larger complex of prosocial values that are promoted by religious affiliation?
    1. This relationship is complicated because some religious variables are associated with increased risk of alcohol abuse and dependence.
        1. Gorsuch (1995) has suggested that one’s concept of God may be linked to the likelihood of substance related problems. A more wrathful, punitive conception of God may put one at higher risk for developing problems with alcohol and drugs. 9
        2. Affiliation with religious groups that show a higher incidence of substance abuse or dependence would put one at higher risk, but adults also tend to affiliate with groups that more resemble their own behavior patterns.
          1. People who are actively using drugs and alcohol tend to have low levels of religious involvement.
          2. Spiritual re-engagement appears to be correlated with recovery. 1
        1. More than a dozen studies have found that alcohol/drug abuse or dependence is associated with a lack of sense of meaning in life, relative to normal samples using the Purpose in Life scale. 1, 10
  1. AA Research findings
    1. In Emrick’s review, meta-analytic techniques were used to integrate findings across 107 studies of AA that only included alcohol use disorders. 11
    2. Slide #16

      1. AA Participation and drinking behavior
          1. modest and positive correlations:
            1. having a sponsor
            2. engaging in twelfth-step work
            3. leading a meeting
            4. increasing one’s degree of participation in the organization compared to a previous time (for example, being more involved after an alcohol rehab program)
      2. Less sizable, but remarkable, positive relationships between drinking behavior and AA participation are seen:
          1. for sponsoring another AA member
          2. working the last seven of the twelve steps
      3. Conclusions:
          1. Unlike earlier findings, the magnitude of the relationships between drinking outcome and participation variables has been found to be modest at best with the possible exception of "has an AA sponsor" and "increased AA participation." Does commitment to AA have limited importance? Only better studies will tell.
          2. A caution about the data presented – except for "has an AA sponsor," large samples of patients treated at the Hazelden Foundation may not be representative of the AA population at large.
          3. Future research may focus on the individuals steps and "the active ingredients" of AA to further improve its success.

      Slide #17

    3. Research Involving AA /Drinking Outcome When AA and Professional Treatment are Combined
      1. Participation in AA prior to professional treatment does not correlate with drinking outcome
      2. Positive correlations were found between drinking outcome and going to AA during or after treatment.
      3. These studies suggest that AA may not be enough particularly when AA is introduced before the professional treatment.
      4. Prospective studies are needed to identify characteristics of those most likely to affiliate successfully with AA.
      5. Project Match is the largest randomized trial of a spiritually based treatment. The study compared Twelve-Step facilitation therapy (TFT) with cognitive-behavioral skill training (CBT) and with motivational enhancement therapy(MET). Twelve-Step treatment was designed to engage clients actively in AA and help them work through the first few steps of AA’s spiritual program. Clients randomized to TFT fared at least as well on most items and showed significantly better outcomes on measures of complete abstinence. 13
      6. Project Match – Religious Background and Behavior Scale with 16 measures of severity of drug use and alcohol consumption, problems and dependence was normally distributed in this sample. Only modest correlation between higher religious/spiritual involvement and better outcomes (none exceeded r = .15). 13

      Additional information

    4. Alcohol/drug use and spirituality – Relationship is correlational between alcohol and drug use factors and spirituality. Excessive use of drugs may exert detrimental effects on spirituality as it does on physical and psychological health. However, it must also be acknowledged that certain drugs have sacred uses and are used within some religions to facilitate deeper spirituality. Study designs exist that will hopefully untangle whether prediction is stronger from spiritual factors to alcohol/drug variables or from alcohol/drug factors to subsequent spiritual variables. Both paths may be important. 1
    5. Spiritual correlates and mechanisms of recovery – Do spiritually focused interventions promote recovery from alcohol/drug problems? Limited evidence for a predictive relationship of spirituality to recovery. 12 Step fellowships provide a place in which to study spirituality in the recovery process. AA attendance is often found to be modestly predictive of better treatment outcomes. 11 One study, suggested that drinking outcomes were unrelated to the attendance at AA after treatment but related to the extent of involvement. Involvement includes working program steps and AA-recommended activities. 12

Slide #18

  1. Future Research
    1. Mechanisms underlying the benefits of spirituality and religion are unclear. The following have been postulated:
      1. Stress reduction - Cultural groups use religious faith and ritual as coping mechanisms.
      2. Cognitive behavioral effects (giving problems "up to God")
      3. Affiliation with a religious group (lessens feelings of alienation as well as depression and anxiety)
      4. Yalom group therapy principles including instillation of hope, group cohesiveness, altruism, universality, catharsis, and existential factors.
    1. Continued research is necessary to help further understand the benefits of spirituality and religion as well as to guide the application of these mechanisms to treatment.

Slide #19

  1. Summary
    1. Spirituality and religion have an important role in medicine especially in the addiction field.
    2. The data presented have demonstrated that spirituality and religion play an important role in the lives and health of patients.
    3. Also, the lecture has highlighted potential bias that clinicians may have regarding spiritual issues.
    4. Finally, an overview of research in spirituality and AA has been provided with suggestions for future research.


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      6. American Psychiatric Association: Psychiatrists’ Viewpoints on Religion and Their Services to Religious Institution and the Ministry: A Report of a Survey Conducted by the Task Force on Religions and Psychiatry. Washington, DC, American Psychiatric Association, 1975.
      7. Goldfarb L, Galanter M, McDowell D, Lifshutz H and Dermatis H: Medical student and patient attitudes toward religions and spirituality in the recovery process. Am J Drug Alcohol Abuse 22:549-561, 1996.
      8. Alcoholics Anonymous. Comments on AA’s Triennial Surveys. New York: AA World Services, Inc. 1998.
      9. Gorsuch RL: Religious aspects of substance abuse and recovery J of Soc Issues 51: 65-83, 1995.
      10. Black, WA: An existential approach to self-control in the addictive behaviours, in: Heather N, Miller, WR, and Greeley, J (Eds.) Self-control and the Addictive Behaviours (pp. 262-279) Sydney, Australia, Maxwell-MacMillan Publishing Australia, 1991.
      11. Emrick C. "Alcoholics Anonymous: What Is Currently Known?", chapter 4 of McCrady, BS and Miller, WR (eds.) Research on Alcoholics Anonymous: Opportunities and Alternatives, 1993.
      12. Montgomery HA, Miller WR, and Tonigan, JS: Does Alcoholics Anonymous involvement predict treatment outcome? J of Substance Abuse Treatment 12:241-246, 1995.
      13. Project Match Research Group: Matching alcoholism treatments to client heterogennneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol 58:7-29, 1997. 1997).