A scoping review of spirituality in relation to substance use disorders: Psychological, biological, and cultural issues.

BACKGROUND: Spirituality is a construct encompassing a diversity of strongly held beliefs and pursuits related to life's meaning and purpose. Empirical studies in key domains of spirituality related to substance use disorder (SUD) can be valuable in guiding research, and potentially clinical care. OBJECTIVES: To conduct a scoping review of research on the psychological, biological, and cultural dimensions of spirituality and their role in relation to SUD. To identify limitations in empirical findings within these domains and identify promising areas for related research. DATA SOURCES, STUDY APPRAISAL, AND SYNTHESIS METHODS: Illustrative studies available in the empirical literature are reviewed in order to characterize these three key domains. RESULTS: Certain areas of importance stand out: On Psychology, attribution of SUD to a spiritual outlook; spiritual awakening; the relation of spirituality to drug craving; and spirituality in the context of psychedelic-assisted psychotherapy. On Biology, heritability of traits related to shared spiritual experience; neurophysiologic correlates of spiritually related experiences; and correlates in brain imaging; On Culture, spiritual aspects of SUD in different cultural settings; distinctions between spiritual and religious phenomena; roles that international organizations play; and context of acquiring recovery capital. The need for further research in each area is defined. CONCLUSIONS: There is utility in examining the diversity of findings in the roles of psychology, biology, and culture in the SUD field. Further research, particularly applying randomization and clinical controls, would be useful in improving the effective application of the construct of spirituality in clinical care.

The role of spirituality in addiction medicine: a position statement from the spirituality interest group of the international society of addiction medicine.

Spirituality is a construct that is reflected in a diversity of strongly felt personal commitments in different cultural and national groups. For persons with substance use disorders (SUDs), it can serve as a component of the recovery capital available to them. This position statement reviews empirical research that can shed light on psychological, social, and biological aspects of this construct. On this basis, the Spirituality Interest Group of the International Society of Addiction Medicine (ISAM) makes recommendations for how this construct can be incorporated into research and clinical care.

An empirical study on the construct of "God" in the Twelve Step process.

Background: The term God, included in 5 of the 12 Steps of Narcotics Anonymous (NA) and Alcoholics Anonymous (AA), self-designated spiritual fellowships, has not been studied empirically relative to members' experiences. A greater understanding of this can be clinically useful and can shed light on the 12 Step process of recovery. Objectives: To determine how NA members understand the 12-step concept "God as we understood Him" and the relationship between their understanding of God and the intensity of their craving and depressive symptoms." Methods: 450 (59% male) NA members completed a survey related to their experiences relative to their relationship with "God." The relationship among these variables and comparisons to the general population was analyzed. Craving and depressive symptoms were assessed by self-report. Results: 98% of the NA participants believe in God explicitly or some other higher power (vs 89% of a probability sample of the US population), 67% believe that God determines what happens to them some or all of the time (vs 48%), 78% (vs 28%) report hearing God talking to them "in their mind"; and 37% report that God talks to them "out loud." Acceptance of 12 Step God-related variables inversely predicted a significant portion of the variance of scores on craving (7.5%) and depression (13.5%). Conclusions: Respondents' understanding of God in NA varied considerably and was predictive of their depressive symptoms and craving intensity. These findings can serve as a basis for research into mechanisms underlying NA/AA recovery experiences and can also aid clinicians in how to employ these programs.

Cross-cultural Applicability of the 12-Step Model: A Comparison of Narcotics Anonymous in the USA and Iran.

OBJECTIVE: Narcotics Anonymous (NA), a nonprofessional 12-step fellowship for people seeking recovery from addiction, reports 27,677 meetings in the USA, where it was founded, but there is limited literature on its adaptability cross-culturally. We studied NA within the Islamic Republic of Iran to ascertain its relative adaptation in a different cultural setting. METHOD: We surveyed 262 NA members in Iran, supplemented by member interviews, and compared demographic and substance use-related characteristics of members, and also the nature of their respective involvement in NA, to the survey results of a previous US survey (n = 527). RESULTS: NA in Iran reports 21,974 meetings. The Iranian respondents surveyed differed relatively little (d < 0.50) from US members on demographics and prior ambulatory substance use disorder treatment, but did have fewer female members (means for Iran and US: 42.4 vs 39.0 years; 77% vs 87%; 6% vs 28%, respectively). They were, however, more involved in the fellowship (d > 0.50) in terms of reporting service as sponsors, experience of spiritual awakening, and achievement of diminished craving (scores of 1-10) (85% vs 48%; 95% vs 84%; 1.03 vs 1.89, respectively). Surveyed NA members in Iran publicized the fellowship with public (36%) and religious (20%) figures, and systematically worked the 12 steps in large sponsor-led groups ((Equation is included in full-text article.)= 19 members). CONCLUSION: NA, a 12-step program developed in a Western, predominantly Christian-oriented country, was adapted widely in the Islamic Republic of Iran, a setting different in culture, language, ethnicity, and religious orientation. The growth in its membership derives, in part, from specific innovations that may have broader applicability in other settings.

The Role of Twelve-Step-Related Spirituality in Addiction Recovery.

This paper reviews empirical studies conducted on the role of spirituality and religiosity (S/R) characteristics in 12-step recovery among program members followed up after substance abuse treatment and those assessed independent of formal treatment. Aspects of spiritual functioning that change in relation to program participation and those S/R characteristics that were found to mediate the association between program involvement and drinking-related outcomes are discussed. In addition, a review is provided of 12-step program studies investigating S/R-related predictors of clinical outcomes relevant to risk of relapse among members in long-term recovery. To further examine the role of S/R characteristics in recovery, a study was conducted on long-term AA members to assess the relationship of S/R characteristics and AA program involvement to craving for alcohol and emotional distress after controlling for relevant demographic variables. Feeling God's presence daily, believing in a higher power as a universal spirit, and serving as an AA sponsor were all predictive of positive outcomes.

Narcotics anonymous: a comparison of military veterans and non-veterans.

Substance use disorder, which is often comorbid with post-traumatic stress disorder (PTSD), is a problem confronted by many veterans. To determine the potential utility of Narcotics Anonymous (NA) for veterans, 508 NA attendees were studied. Veterans (n = 172) were more likely to have been referred by a professional than were non-veterans (77% vs. 27%, respectively); 70% had been hospitalized for alcohol or drug problems, and 51% had been treated for non-substance psychological problems. The 70% of veterans who reported at least 1 of 3 service-related stressful experiences were more likely to report PTSD-related symptoms. NA can serve as a recovery resource for certain veterans with substance use disorders, with or without PTSD.

Physicians in long-term recovery who are members of alcoholics anonymous.

BACKGROUND: There is little empirical literature on the experience in sobriety of long-term, committed members of Alcoholics Anonymous (AA). OBJECTIVE: Studies on the experience of long-term members, however, can yield a better understanding of the role of spirituality in AA membership, and how the program helps stabilize abstinence. METHODS: We studied 144 physicians at a conference of doctors in AA. RESULTS: Respondents had a mean period of sobriety of 140 months. Compared to normative populations, they scored higher on scales for depression and anxiety, and were more adherent to the spiritual character of AA, rather than a formally religious orientation. Those who reported "having a spiritual awakening" were more likely to "experience God's presence" on most days (81% vs. 19%) and were less likely to report craving for alcohol (21% vs. 41%) than those who did not. Respondents who had a history of being enrolled in State Physicians' Health Programs did not differ significantly on any of the aforesaid subjective variables from those who were not enrolled. CONCLUSION: The experience of long-term AA members can be characterized in terms of abstinence, spirituality, and alcohol craving. SCIENTIFIC SIGNIFICANCE: The study of long-term AA members can shed light on mechanisms of achieving abstinence in this fellowship.

Spirituality-based recovery from drug addiction in the twelve-step fellowship of narcotics anonymous.

BACKGROUND: Narcotics Anonymous is a worldwide fellowship that employs the Twelve-Step model for members dependent on drugs of abuse. The spiritual orientation of its program of abstinence has not been subjected to empirical study. METHODS: Responses of 527 American Narcotics Anonymous meeting attendees to a structured questionnaire were evaluated for the roles of cognitive and psychosocial aspects of spirituality in their recovery. RESULTS: Respondents had last used drugs or alcohol on average 6.1 years previously. They were found to be more oriented toward a spiritual than a formally religious orientation than probability samples of the general population. Aspects of membership such as affiliation toward other members and the experience of spiritual awakening were associated with lower rates of drug or alcohol craving, whereas scores on depression were associated with higher craving scores. CONCLUSIONS: Spiritual renewal combined with an abstinence-oriented regimen in Narcotics Anonymous social context can play a role in long-term recovery from drug addiction.

Abstinence from drugs of abuse in community-based members of Narcotics Anonymous.

OBJECTIVE: Narcotics Anonymous (NA) is an abstinence-based fellowship with more than 58,000 groups worldwide. There has, however, been little research reported on its members. This study was designed to clarify the nature of the participants in NA who are primarily abstinent, long-term members. METHOD: A protocol was implemented to survey members at 10 NA group meetings in three different states, through the cooperation of the NA World Service Office. A 51-item self-administered questionnaire, addressing key aspects of substance use and recovery, was anonymously completed by 396 respondents. RESULTS: Respondents were 71.5% male; the mean age was 38.1 years; 68.2% were White; and the principal drug problems comprised cocaine (28.5%), heroin (27.5%), other opiates (13.4%), methamphetamine (12.9%), alcohol (8.6%), marijuana (6.6%), and other stimulants (2.5%). Eighty-seven percent had prior treatment for a substance use disorder. On average respondents had first encountered NA at age 26.9, they had been abstinent an average of 5.7 years at the time they filled out the questionnaire, and 47.5% had served as sponsors. Ninety-four percent designated themselves as spiritual, and only 29.6% designated themselves as religious. CONCLUSIONS: NA offers support for long-term abstinence from diverse misuse of drugs among users of different backgrounds.

Young People in Alcoholics Anonymous: the role of spiritual orientation and AA member affiliation.

Empirical findings characterizing long-term, committed Alcoholics Anonymous (AA) members are limited, particularly among younger members. The authors studied a sample of 266 highly committed attendees (mean age, 27 years) at an annual conference of Young People in Alcoholics Anonymous (YPAA), whose first encounter with AA was 6 years previously. Most (72%) had abused drugs and alcohol, and 36% had never received substance abuse treatment. They now reported a mean duration of abstinence of 44 months and had attended an average of 233 AA meetings in the previous year; 66% had served as AA sponsors, and 92% reported experiencing an AA "spiritual awakening," itself associated with a decreased likelihood of alcohol craving. Scores on AA beliefs, affiliation to other members, and the experience of spiritual awakening were associated with lower depression scores. These findings are discussed to clarify the nature of long-term AA membership.

Introducing spirituality into psychiatric care.

Spirituality is important to many psychiatric patients, and these patients may be moved toward recovery more effectively if their spiritual needs are addressed in treatment. This, however, is rarely given expression in the psychiatric services of teaching hospitals. In order to develop this potential area of improved care, we (1) evaluated the differential attitudes of patients and psychiatric trainees toward the value of spirituality in the recovery process, (2) established a program of group meetings conducted by psychiatric residents and staff where patients can discuss how to draw on their spirituality in coping with their problems, and (3) established related training experiences for psychiatric residents. The results and implications of these three initiatives are presented.

An exploratory study of spiritual orientation and adaptation to therapeutic community treatment.

The purpose of this study was to determine the extent to which spiritual orientation was associated with adaptation to therapeutic community treatment. Spiritual orientation was assessed by the Spirituality Self-Rating Scale, a measure consistent with the conceptualization of spirituality typically reflected in Alcoholics Anonymous members' views. Spiritual orientation was positively correlated with acceptance of therapeutic community principles and clinical progress. Further assessment of spirituality related characteristics and their relation to treatment outcomes is important in informing the design of interventions aimed at improving progress in the therapeutic community, particularly those aspects involving the relative value of integrating the 12-Step group approach in therapeutic community programs.

Spirituality in psychiatry: a biopsychosocial perspective.

This paper reviews a body of findings in order to define the nature of spirituality from a biopsychosocial perspective and to illustrate its relevance to the field of psychiatry. The emergence of spirituality within the common culture is described, after which a number of sociobiologically related studies are presented to illustrate how its component dimensions can be defined. These are evolutionary adaptation, affectional ties, subjective experiences, and positive psychology. The relevance of spiritually related issues in psychiatric diagnosis are illustrated, along with examples of their role in symptom relief. The paper concludes with a description of a program implemented to integrate the issue of spirituality into resident training and into group support for hospital-based patients.

Medical versus spiritual orientations: Differential patient views toward recovery.

BACKGROUND: Relapse among patients in substance abuse treatment has generated interest in identifying attitudinal factors that sustain recovery. OBJECTIVE: To assess the relationship of attitudes toward approaches to motivation for treatment and Twelve Step beliefs. METHODS: Dually diagnosed patients (N = 100) completed a survey assessing treatment attitudes, motivation, and Twelve Step beliefs. RESULTS: Endorsement of medical services was positively correlated with motivation but unrelated to Twelve Step beliefs. Endorsement of religious services was unrelated to motivation but was associated with Twelve Step beliefs. CONCLUSIONS: Patients may have differing perceptions regarding routes to recovery based on preferences for professional services or spiritual resources.

The importance of hopelessness among university students seeking psychiatric counseling.

Hopelessness is a clinically important state relative to morbidity and suicide risk among university students. We examined its role in relation to presenting concerns, diagnosis, psychopharmacologic treatment and spiritual orientation among students seeking treatment at a university counseling center. The most commonly identified concern was anxiety, followed by stress and depression. Eighty-two percent were given a DSM IV diagnosis. Hopelessness was higher among students dually diagnosed with anxiety and depressive disorders and those who were started on psychiatric medication. Spirituality was inversely correlated with hopelessness and constitutes a personal characteristic warranting further investigation. The concerns bringing students to counseling, the rates of DSM IV diagnosis and the use of psychiatric medication suggest a preponderance of psychopathology over developmental or situational concerns that may be more prominent than has been noted in the counseling literature. In this regard, hopelessness appears to be an important feature even beyond its relationship to suicidality and merits attention and evaluation in student counseling.

Music therapy: a novel motivational approach for dually diagnosed patients.

Co-occurring mental illness and addiction is very common and results in worse treatment outcomes compared to singly diagnosed addicted individuals. Integrated treatment for co-occurring disorders is associated with better treatment outcomes; however there is a wide range of what is included in integrated treatment. Due to patient and staff interests, integrated treatment often includes complementary and alternative therapies, including music and art therapy. There is a need to study how these approaches effect treatment engagement, retention, and outcome. This study was a prospective naturalistic non-randomized pilot study without a control group that sought to evaluate how participation in a music therapy program affected treatment outcomes for individuals with co-occurring mental illness and addiction. In summary, music therapy appears to be a novel motivational tool in a severely impaired inpatient sample of patients with co-occurring disorders. Future studies of music therapy in integrated co-occurring disorder setting should include a control group.

The concept of spirituality in relation to addiction recovery and general psychiatry.

This chapter is directed at defining the nature of spirituality and its relationship to empirical research and clinical practice. A preliminary understanding of the spiritual experience can be achieved on the basis of diverse theoretical and empirically grounded sources, which will be delineated: namely, physiology, psychology, and cross-cultural sources. Furthermore, the impact of spirituality on mental health and addiction in different cultural and clinical settings is explicated regarding both beneficial and compromising outcomes. Illustrations of its application in addiction and general psychiatry are given: in meditative practices, Alcoholics Anonymous, and treatment programs for addiction singly and comorbid with major mental illness. Given its prominence in Alcoholics Anonymous and related Twelve-Step groups, spirituality plays an important role in the rehabilitation of many substance-dependent people. The issue of spirituality, however, is prominent within contemporary culture as well in the form of theistic orientation, as evidenced in a probability sampling of American adults, among whom 95% of respondents reply positively when asked if they believe in "God or a universal spirit." Responses to a follow-up on this question suggest that this belief affects the daily lives of the majority (51%) of those sampled, as they indicated that they had talked to someone about God or some aspect of their faith or spirituality within the previous 24 h (Gallup, 2002).

Spirituality and recovery in 12-step programs: an empirical model.

Alcoholics Anonymous (AA) and other 12-step programs are widely employed in the addiction rehabilitation community. It is therefore important for researchers and clinicians to have a better understanding of how recovery from addiction takes place, in terms of psychological mechanisms associated with spiritual renewal. A program like AA is described here as a spiritual recovery movement, that is, one that effects compliance with its behavioral norms by engaging recruits in a social system that promotes new and transcendent meaning in their lives. The mechanisms underlying the attribution of new meaning in AA are considered by recourse to the models of positive psychology and social network support; both models have been found to be associated with constructive health outcomes in a variety of contexts. By drawing on available empirical research, it is possible to define the diagnosis of addiction and the criteria for recovery in spiritually oriented terms.