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- 1. Spirituality and Substance Abuse Treatment A Review of the Literature Christina Bender Argosy University
- 2. 9 of the 10 Articles Examined Deemed Spirituality Necessary for Recovery
- 3. Unlike diabetes, addiction has no clearly defined cause Review of the literature which examines the relationship between spirituality and maintenance of abstinence from substance abuse Future research is necessary to differentiate the distinction between spirituality and religious practices and to determine specific effective components of spirituality Abstract
- 4. 98.4 percent increase in Emergency Room visits from 2004 to 2009 involving misuse of pharmaceuticals (Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, December 28, 2010) Effective treatment modalities not as clearly defined Addiction is a complex phenomena affecting the body, mind and spirit (DiLorenzo, Johnson & Bussey, 2001) Most treatment approaches include a spiritual component Increasing Relevance
- 5. 9 of the 10 articles reviewed (Avants, Marcotte, Arnold, & Margolin, 2003; Boeving, 2010; Chen, 2010; DiLorenzo et al., 2001; Douglas, Jimenez, Lin, & Frisman, 2008; Heinz, Epstein, & Preston, 2007; Kendler, Liu, Gardner, & McCullough, 2003; Koenig, 2009; Saunders, Lucas, & Kuras, 2007) deemed spirituality necessary to recovery. Effectiveness demonstrated by the current model of treatment, facilitated 12-step recovery including a spiritual component. The Vast Majority View Spirituality as Integral to Recovery
- 6. “The act of surrender sets in motion a conversion experience, which involves a self-change including reorganization of one's identity and meaning in life” (Chen, 2010, p. 363) Saunders et al. (2007) correlated alcohol misuse with spiritual and religious discrepancies The spiritual conversion coupled with spiritual discord associated with addiction may explain the necessity of addressing the spiritual in recovery Weaknesses: Lack of specificity Difficulty obtaining accurate information from addicts Explanations by Chen (2010) and Saunders et al. (2007)
- 7. Small sample sizes 34 (Avants et al., 2003) <100 (Boeving, 2010) Non-random samples Problem and controls non-random (Sanders et al., 2007) Specialized populations Current inner city opiate & cocaine users (Avantset al., 2003) Off-shore treatment facility participants (Boeving, 2010) Homeless mothers (Douglas et al., 2008) Inner city individuals (Heinz, 2007) (Continued Next Slide) Concerns Unique to Examinations of Substance Abusing Populations
- 8. Ethnocentric Populations White men and women born in Virginia (Kendler et al, 2003) African Americans (Heinz et al, 2007) African Americans compared to non-African Americans (Douglas et al, 2007) Potential Secondary Gains $25 for completion of a larger battery of questionnaires (Avants, et al., 2003) Being allowed to keep their children in their homes (DiLorenzo et al., 2001). Concerns Unique to Examinations of Substance Abusing Populations (Continued)
- 9. Kendler et al. (2003) Decreased risk of substance misuse associated with increased religious involvement Koenig (2009) Review of the literature which found religious involvement related to less psychiatric illness and less substance abuse Raised possibility of religious behavioral guidelines serving to decrease substance abuse Added when those who belong to religious traditions who practice abstinence begin using substances, the “use can become severe and recalcitrant” (p. 289). No clear distinction between religion and spirituality was made in either of these two studies. Poor Distinction Between Religion and Spirituality in These Studies
- 10. Avants et al. (2003) HIV risk behavior inversely associated with spirituality Found positive assumptions about the world such as people are basically good associated with increased spirituality Found positive assumptions pertaining to the ability to control outcomes through good personal behavior associated with increased spirituality Professed importance of spirituality evidenced necessity of inclusion of spirituality in recovery plan (Continued on Next Slide) The Importance of Spirituality in Recovery (Avantset al., 2003 & Boeving , 2010)
- 11. Boeving (2010) Suggests shamanistic spiritual systems be considered instead of current models of treatment he defines as “medical” and/or “crypto-Christian” (p. 93) Cites Peele et al. (2000) when he suggests clinical and anecdotal evidence supports no more than a 5% long-term recovery rate using standard 12-step formats Contends inclusion of Shamanistic spiritual practices incorporating spiritual, physical (detoxification) and family relationships are necessary to increase long-term recovery rates The Importance of Spirituality in Recovery (Avants et al., 2003 & Boeving , 2010) (Continued)
- 12. Contends neither religion nor spirituality are requirements for successful recovery Reports rational emotive behavior therapy can be equally effective for religious/spiritual clients and non-religious/non-spiritual clients Contends rational emotive behavior therapy advocates self-acceptance similar to most major religions, but does so without a spiritual component Ellis (2000) the Lone Dissenter
- 13. Douglas et al. (2008) Found African Americans reported higher spiritual well being indicating increased relative importance of spirituality in their lives Longitudinal study over 15 months which examined homeless mothers (88 African American & 101 non-African American) Heinz et al. (2007) Found a positive correlation between professed spiritual and religious importance and recovery rates in the African Americans examined Cultural Considerations
- 14. Vast majority of the studies (9 of 10) conclude spirituality is a necessary component Dissent is provided by Ellis (2000) who also provided the only breakdown of the effective components He reports the following similarities between rational emotive behavior therapy and the foundations of many religious philosophies: “unconditional self-acceptance, high frustration tolerance, unconditional acceptance of others, [and] the desire rather than the need for achievement and approval” (p. 29) Conclusions
- 15. Necessary to determine the effective components of spirituality for clients unwilling to embrace spirituality Focus on what makes the spiritual component effective by isolating each variable independently and determining alternatives for those resistant to spiritual practices Future Studies
- 16. Underlying Strengths of These Studies Provides Direction for Further Research
- 17. Avants, S. K., Marcotte, D., Arnold, R., & Margolin, A. (2003). Spiritual beliefs, world assumptions, and HIV risk behavior among heroin and cocaine users. Psychology of Addictive Behaviors, 17(2), 159-162. doi:10.1037/0893-164X.17.2.159 Boeving, N. G. (2010). Sneaking God (back) through the back door of science: A call for a comparative addictionology. Pastoral Psychology, 59(1), 93-107. doi:10.1007/s11089-009-0217-7 Chen, G. (2010). The meaning of suffering in drug addiction and recovery from the perspective of existentialism, buddhism and the 12-step program. Journal of Psychoactive Drugs, 42(3), 363-75. Retrieved from http://search.proquest.com/docview/759967077?accountid=34899 (Continued on Next Slide) References
- 18. DiLorenzo, P., Johnson, R., & Bussey, M. (2001). The role of spirituality in the recovery process. Child Welfare, 80(2), 257-73. Retrieved from http://search.proquest.com/docview/213804524?accountid=34899 Douglas, A. N., Jimenez, S., Lin, H., & Frisman, L. K. (2008). Ethnic differences in the effects of spiritual well-being on long-term psychological and behavioral outcomes within a sample of homeless women. Cultural Diversity and Ethnic Minority Psychology, 14(4), 344-352. doi:10.1037/1099-9809.14.4.344 Ellis, A. (2000). Can rational emotive behavior therapy (REBT) be effectively used with people who have devout beliefs in God and religion? Professional Psychology: Research and Practice, 31(1), 29-33. doi:10.1037/0735-7028.31.1.29 (Continued On Next Slide) References (Continued)
- 19. Heinz, A., Epstein, D., & Preston, K. (2007). Spiritual/Religious experiences and in-treatment outcome in an inner-city program for heroin and cocaine dependence[dagger]. Journal of Psychoactive Drugs, 39(1), 41-9. Retrieved from http://search.proquest.com/docview/207971362?accountid=34899 Kendler, K., Liu, Z., Gardner, C., & McCullough, M. (2003). Dimensions of religiosity ad their relationship to lifetime psychiatric and substance use disorders. The American Journal of Psychiatry, 160(3), 496-503. Retrieved from http://search.proquest.com/docview/220482381?accountid=34899 Koenig, H. G.,MD. (2009). Research on religion, spirituality, and mental health: A review. Canadian Journal of Psychiatry, 54(5), 283-91. Retrieved from http://search.proquest.com/docview/222845928?accountid=34899 (Continued on Next Slide) References (Continued)
- 20. Saunders, S. M., Lucas, V., & Kuras, L. (2007). Measuring the discrepancy between current and ideal spiritual and religious functioning in problem drinkers. Psychology of Addictive Behaviors, 21(3), 404-408. doi:10.1037/0893-164X.21.3.404 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 28, 2010). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD. References (Continued)
Editor's Notes
- Nine of the ten articles deemed spirituality and/or religion essential to recovery while the tenth, an article by Ellis (2000), reported recovery from substance abuse could occur with or without addressing the spiritual component specifically because similar themes, such as building positive self regard, were covered by rational emotive behavior therapy
- Although the course of addiction is similar to other medical conditions such as diabetes in many respects, in many others it differs.Unlike diabetes, addiction has no clearly defined cause and affects the individual’s “body, mind, and spirit” (DiLorenzo, Johnson, and Bussey, 2001, p. 271).This review of the literature examines the relationship between spirituality (a term often not clearly delineated from religion in these studies) and maintenance of abstinence from substance abuse. Future research is necessary to differentiate more clearly the distinction between spirituality and religious practices and to determine the specific effective components of spirituality for further development in the treatment of substance abuse and the maintenance of sobriety.
- An alarming 98.4 percent increase in Emergency Room visits “involving misuse or abuse of pharmaceuticals […] from 627,291 visits in 2004 to 1,244,679 visits in 2009” was reported by the Drug Abuse Warning Network (DAWN) Report released by the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality (December 28, 2010, p. 1). Effective treatment modalities for this distressing rise in substance abuse are not as clearly defined as the above statistics. As DiLorenzo, Johnson, and Bussey (2001) reported, “Addictive processes are complex phenomena, without clear cause or origin that envelop the whole person-body, mind, and spirit” (p. 271). Most common approaches to substance abuse treatment include a spiritual - some would argue a religious - component. This paper will examine the relationship between spirituality and maintaining abstinence from substance abuse.
- It has been hypothesized (Avants, Marcotte, Arnold, & Margolin, 2003; Boeving, 2010; Chen, 2010; DiLorenzo et al., 2001; Douglas, Jimenez, Lin, & Frisman, 2008; Heinz, Epstein, & Preston, 2007; Kendler, Liu, Gardner, & McCullough, 2003; Koenig, 2009; Saunders, Lucas, & Kuras, 2007) that spirituality is a necessary component of maintaining abstinence. The effectiveness of this format has been demonstrated by the current model of treatment, facilitated 12-step recovery, which includes a spiritual component. Chen (2010) provided a potential explanation for the effectiveness of the current model of facilitated 12-step treatment.
- Chen (2010) suggested, “The act of surrender sets in motion a conversion experience, which involves a self-change including reorganization of one's identity and meaning in life” (p. 363). Saunders et al. (2007) reported similar findings correlating alcohol misuse with spiritual and religious discrepancies. The participants (80 adults seeking alcohol abuse treatment compared to 106 adults randomly chosen from the phone book) in the Saunders et al. (2007) study with the greatest reported difference between their current and ideal levels of spiritual and religious functioning were also those with the greatest problems of alcohol misuse. The combination of Chen’s (2010) spiritual conversion experience during recovery coupled with Saunder’s et al. (2007) contention that substance abuse is associated with spiritual discord may explain the radical changes accompanying recovery from substance abuse. Unfortunately, the weakness in these studies can also be attributed to the lack of specificity and the difficulty of obtaining accurate information from this study population.
- In comparison to standard research studies, the present or former substance abusing research population adds unique concerns which were evidenced in these studies. Difficulties such as small sample sizes in the research of Avants et al. (2003) (sample size 34) and Boeving (2010) (sample population <100) or nonrandom samples evidenced in the sample population of Saunders et al. (2007), in which problem and controls were nonrandom, were widespread. Specialized populations were frequently encountered in the literature as in the research of Avants, et al. (2003) which examined current opiate and cocaine users in an inner-city methadone maintenance program, Boeving (2010) which examined the population of two off-shore treatment facilities that incorporate shamanistic practices, Douglas et al. (2008) which examined homeless mothers, and Heinz et al. (2007) which examined inner-city individuals.
- In addition, ethnocentric populations were common in this research such as white men and women born in Virginia (Kendler et al, 2003), African Americans (Heinz et al, 2007) and African Americans compared to non-African Americans (Douglas et al, 2007). Potential secondary gains should be examined such as $25 for completion of a larger battery of questionnaires (Avants, et al., 2003) and/or the psychosocial gains of participants being allowed to keep their children in their homes (DiLorenzo et al., 2001).
- Another concern arises in an attempted examination of the distinction between religion and spirituality in these studies. One study (Kendler et al, 2003) found “high levels of religious involvement predict a reduced risk for substance misuse” (p. 499). Koenig (2009) in his review of the literature reported that in different settings, varying ethnic origins, all age groups, and in varying geographic locations “religious involvement is related to better coping with stress and less depression, suicide, anxiety, and substance abuse” (p. 289). He also raised the issue of the behavioral guidelines provided by most major religions as a potential motivating factor in substance abuse abstinence/maintenance. Although Koenig (2009) also reported that spiritual and religious factors appear to be “generally positive” for many substance abusers, he added, “When people from religious traditions that promote complete abstinence start using alcohol or drugs, substance use can become severe and recalcitrant” (p. 289). The distinctions between religion and spirituality are not clearly made in either of these two studies (Kendler et al. 2003; Koenig, 2009).
- The importance of spirituality, however, was stressed in one study (Avants et al., 2003).In this study, it was found “HIV risk behavior was inversely associated not only with strength of spiritual and religious faith but also with characteristics of drug users' assumptions about the world—the perception that the world and the people in it are basically good and the perception of a ‘meaningful world’ (i.e., the belief that outcomes are just, not randomly distributed, and can be controlled by personal behavior)” (Avantes, et al., 2003, p. 161). The researchers in this study examined 34 adults who were currently in a methadone maintenance program and using cocaine. The professed importance of spirituality in the lives of these currently using substance abusers evidenced the necessity of addressing spirituality in their future recovery plans.
- Boeving (2010) also views the spiritual component as primary to substance abuse treatment, but suggests shamanistic spiritual systems should also be considered as an addition to the current models of addiction that he defines as “medical” and/or “crypto-Christian” (p. 93). Boeving (2010) cited Peele et al. (2000) when he reported “Statistics reported both clinically and anecdotally suggest that, of those who complete most courses of recommended therapy (including 12-step group attendance), no more than 5% sustain any long-term abstinence from chemical dependency” (p. 396, as cited by Boeving, p. 94). Boeving (2010) provides a description of the Shamanistic spiritual practices which holistically incorporate spiritual, physical (detoxification) and family relationships into the spirituality component of treatment.
- Ellis (2000) contended neither religion nor spirituality is a requirement of successful recovery from substance abuse. He reported that rational emotive behavior therapy can be effectively used to treat clients who are from religious/spiritual backgrounds or non-religious/spiritual backgrounds. Ellis (2000) contended that rational emotive behavior therapy advocates similar self-acceptance but does not do so with the requirement of a spiritual component.
- Finally, Douglas et al. (2008) pointed out ethnic considerations when they reported, “African Americans reported significantly higher SWB [spiritual well being] than non-African Americans, indicating the relative importance of spirituality in their lives” (p. 344). The study (longitudinal study over 15 months with interviews every 3 months) looked at 88 African American and 101 non-African American homeless mothers examining ethnicity as a moderator variable in spiritual well being and psychological/behavioral results (Douglas et al., 2008). Another study (Heinz et al., 2007) examined African-American, inner-city residents and found a positive correlation between professed spiritual and religious importance and recovery rates supporting Douglas et al. (2008).
- The vast majority of the studies in this review (Avants et al., 2003; Boeving, 2010; Chen, 2010; DiLorenzo et al., 2001; Douglas et al., 2008; Heinz, et al., 2007; Kendler et al., 2003; Koenig, 2009; Saunders et al. 2007) support a relationship between spirituality and attaining/maintaining abstinence from substance abuse. The lone, sometimes conflicting, viewpoint belonged to Ellis (2000) who also provided the only breakdown of the potential effective components of spirituality. When spirituality as found in traditional recovery is compared to rational emotive behavior therapy, Ellis (2000) reported the following similarities: Rational emotive behavior therapy advocates “unconditional self-acceptance, high frustration tolerance, unconditional acceptance of others, [and] the desire rather than the need for achievement and approval” similar to the foundations of many religious philosophies (p. 29). All of the articles, excepting Ellis (2000), included the spiritual component of addiction. Only one of the articles, Ellis (2000), provided an examination of the components of spirituality which positively effect recovery.
- This review of the literature provided multiple studies supporting the use of the spiritual components of substance abuse treatment, but more research is necessary to determine the effective components to be applied for those who are unwilling to embrace spirituality yet wish to attain sobriety. What components of spirituality/religion assist the substance abuser in attaining and maintaining abstinence? Further research might focus on what makes the spiritual component of substance abuse treatment effective by isolating each variable independently and determining what alternatives can be developed for those who are adverse to a spiritual focus in their lives. The underlying strengths of the studies provide the direction for further research in effective substance abuse treatment.
- The underlying strengths of the studies provide the direction for further research in effective substance abuse treatment.