Spirituality and addiction.

A Mysterious Overlap

Drug use and spirituality have a curiously intertwined history. Some world religions eschew or prohibit the use of certain drugs, for example, the banning of alcohol within Islam and Mormonism. The ancient aphorism spiritus contra spiritum implies a mutual incompatibility of alcohol and spirituality: each drives out the other. Substance dependence is, by diagnostic definition, (1) a process whereby the drug progressively displaces previous priorities, relationships and values, and becomes the central concern of a person's life--a modern analogue of idolatry.

On the other hand, across diverse cultures, various substances have been used specifically as vehicles in the search for the sacred, among them lysergic acid derivatives, Psilocybe and several other genera of mushrooms, mescaline-containing cacti such as peyote, nightshade species such as Jimsonweed, and many others. (2) Psychoactive drugs also occupy a place of honor in sacraments and rituals of some world religions, for example, wine in Judaism and Christianity and tobacco in Native American religion. It is as though, from a religious perspective, there is something significant about "spirits" and other psychoactive drugs. Avram Goldstein, whose classic work led to the understanding of endogenous opioids, also studied "thrills in music," the common experience of awe and chills occurring at predictable moments in classical music. In a double-blind trial, he found that naloxone reliably suppressed these experiences, suggesting that they are mediated by endorphins. (3)

Furthermore, spirituality has long been regarded as having central importance in the treatment of and recovery from addiction. (4) Alcoholics Anonymous (AA) and related worldwide mutual-help programs conceptualize recovery through the "12 Steps" that are unambiguously spiritual in focus, emphasizing reliance on a Higher Power and the practice of prayer and meditation as means for promoting spiritual awakening and "conscious contact with God." (5)

Spirituality and Religion

In recent decades, the terms "spirituality" and "religion" have been increasingly differentiated. It is common, for example, for Americans to describe themselves as "spiritual but not religious." Psychologists studying this distinction have characterized spirituality as characteristic of individuals, a multidimensional latent construct like personality or health. (6) Religion, on the other hand, has been conceptualized as a social phenomenon, defined by particular boundaries such as belief, practice, and membership. Religiousness, the extent of involvement in institutional religion, is one aspect of an individual's spirituality. This distinction has been particularly emphasized within AA, which is self-described as a program that is spiritual but not religious. (7)

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What Do We Already Know About Spirituality and Addiction?

There is no paucity of scientific and professional publications on spirituality and addiction. Our bibliography on this subject contains nearly 2,000 references (http://casaa.unm.edu/downoad/spiritualitybib.pdf). (8) Less is known about other drugs than about alcohol in relation to spirituality, but the literature is rich and growing rapidly. (9) In collaboration with the Fetzer Institute, the National Institute on Alcohol Abuse and Alcoholism solicited and funded a series of scientific studies of alcoholism and spirituality (See Calhoun, this issue).

A Protective Relationship

One particularly robust research finding is the inverse relationship of personal religiousness to alcohol/drug use and associated problems. Adults and adolescents who are more religious are less likely to be using or dependent on alcohol or other drugs of abuse, both at the present time and in the future. This is one of the most consistently documented risk/protective factors in the literature, similar in magnitude to family history of substance abuse. The reasons for this modest but consistent relationship are unclear. Levels of risk for substance use disorder also vary across religious denominations, with lowest levels typically found in those whose religion clearly prohibits use, suggesting that religious norms about substance use play a role.

Spirituality in Clinical Populations

Conversely, Americans entering treatment for substance use disorders often report very low levels of religiousness and spiritual practices, relative to the general U.S. population, and also tend to report a low level of meaning or purpose in life. (10) Little is currently known about specific changes that occur in personal spirituality over the course of recovery. Data that are available suggest increasing spiritual interest and practice as substance dependence abates. It is unclear whether such spiritual development is an antecedent, cause, result or byproduct of decreased substance use and dependence. Certainly within the 12 steps of AA, spiritual awakening and practice are understood to be essential to recovery. (7) However, one attempt to verify this causal linkage within a multisite clinical trial failed to reveal the predicted mediating relationship. (11)

Spiritual Interventions

If spiritual development does promote sobriety and recovery from addiction, then it is natural to consider spiritual interventions as adjuncts to treatment. Within US treatment programs, patients are often encouraged to attend and become involved in AA or other 12-step programs such as Narcotics Anonymous or Cocaine Anonymous. Of the 12-step programs, most research attention has been focused on AA. (12) As is the case with religious involvement, studies rather consistently report a modest relationship between AA attendance and abstinence, particularly after addiction treatment. (13-15) An apparent exception to this is that mandated attendance at AA (by the courts, employer, etc.) has been found to be ineffective in increasing abstinence. (16) One study found that treatment outcome was predicted not by voluntary AA attendance alone, but by the extent to which the patient became actively involved in AA activities and working its twelve steps. (17)

Despite the consistent positive relationship between voluntary AA involvement and abstinence, many patients do not attend 12-step groups. It is also the case that patients who do not go to AA during treatment are unlikely to start doing so later. (18) For this reason, various interventions have been developed to encourage AA attendance. (19) Active physician encouragement can enhance AA involvement. (20) A counseling method of Twelve-Step Facilitation was developed specifically to encourage AA involvement and to help patients work the first few steps of the 12-step program. (21) In a multisite clinical trial, Twelve-Step Facilitation therapy did increase AA involvement and yielded reductions in frequency and quantity of drinking at least comparable to those for two state-of-the-art behavioral therapies. The rate of total abstinence from alcohol, however, was significantly better--about 10 percentage points higher--for the Twelve-Step Facilitation group over the course of 3 years of follow-up. (22,23) Similarly, positive findings emerged for this approach in a multisite cocaine treatment trial. (24)

Less is known about the effects of specific spiritual practices on substance use. The practice of mindfulness meditation tends to be inversely related to the use of alcohol, tobacco, and other drugs of abuse, and training in meditation has been found in several trials to increase post-treatment abstinence. (See Marlatt, this issue.) In one randomized trial, patients' post-treatment drinking was unaffected by intercessory prayer of others on their behalf. (25) Unknown are the effects of personal prayer, as advocated in AA, on the individual's own substance use and treatment outcomes.

What Should We Know More About?

Explaining the Consistent Correlational Findings

How does religiousness protect against substance use problems? There is robust evidence that religiousness is associated with lower rates of substance use, and that spirituality and religiousness is lower in those with substance use disorders. However, it is not at all clear why this is the case. Although there is some evidence that religiousness protects against later substance use, it is likewise possible that substance use or dependence leads to decreased religiousness and spirituality. The consistent differences between denominations (lower rates of substance use in groups that proscribe use of substances) suggest that religion's norms and attitudes toward substance use may have a direct effect. The effects of other spiritual dimensions are less clear.

Spirituality Over the Course of Recovery

Is spiritual change a cause or consequence of recovery from problematic use of alcohol and drugs, or is it causally unrelated? (See Tonigan, this issue.) According to 12-step ideology and the testimonials of many individuals who have achieved sobriety both within and outside of 12-step programs, spiritual growth is the engine that maintains sobriety, defined as abstinence and increased well-being. To date, scientific study of the recovery process has been unable to verify this claim. Process research on psychosocial treatments (eg, cognitive behavioral therapy (26)) has shown that effective treatments do not necessarily work in the manner predicted by theory. Longitudinal studies with multidimensional assessment of spirituality are necessary to determine whether changes in particular dimensions of spirituality (beliefs, values, relationship with God, relationship with spiritual community, subjective spiritual experiences, self-transcendence, etc.) play a causal role in recovery within and independent of 12-step programs.

Spiritual Interventions

What is the therapeutic potential of spiritual interventions in the prevention and treatment of substance use disorders? In spite of the clinical potential of interventions aiming to effect spiritual change, scientific study of spiritually oriented interventions, with the notable exception of the 12-step literature, has been extremely limited, and the number of high-quality, well-controlled trials remains small. Since spirituality is a multidimensional construct, there are potentially multiple nonoverlapping spiritual approaches that could be developed and tested. Strategies based on mindfulness are one promising example. Approaches linked to particular religions raise concerns of generalizability and political issues if funded publicly. However, the 12-step example shows that even an intervention that is explicitly theistic can be separated from organized religion and can be helpful even to atheists and agnostics who choose to participate. (27) An array of spiritually-oriented therapies would allow for the possibility of matching of an individual to an approach that is relatively consistent with the person's belief system.

Unpacking the Construct of Spirituality

What dimensions of spirituality are relevant as protective factors (See Knight, this issue.), risk factors, mediators of change, and secondary outcomes in the natural history and clinical treatment of addiction? The very word "spirituality" should be used cautiously in this context since the word means so many different things to different people. Although valid instruments exist for assessing various dimensions of spirituality, most of the correlational studies have used simple (even single-item) measures of religiosity, and much less is known about the role of other dimensions of spirituality, which may have little in common with religious belief or church attendance. Future studies of spiritual factors in addiction and recovery should be mindful of the multiple dimensions of spirituality and be explicit in hypothesizing effects of specific dimensions or factors. In addition, further methodological work is needed to improve our understanding of the dimensional structure of spirituality, and our ability to measure the various dimensions.

Conclusion

Research on spirituality and addiction remains at an early stage, with recent developments in methodology. Correlational evidence supports an inverse relationship of substance use both with religiousness and with certain spiritual practices. Post-treatment abstinence has been associated with Alcoholics Anonymous attendance, Twelve-Step Facilitation counseling, and training in mindfulness meditation. Emerging and future research on spirituality and addiction may yield important new knowledge useful in prevention and treatment.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th ed. Washington, DC, American Psychiatric Association, 1994.

2. Schultes RE, Hofmann A. Plants of the Gods. New York, McGraw-Hill, 1979.

3. Goldstein A. Thrills in response to music and other stimuli. Physiol Psychol 1980;8:126-129.

4. Miller WR. Spirituality, treatment and recovery. In: Galanter M, ed. Recent Developments in Alcoholism, vol 16: Research on Alcoholism Treatment. New York, Plenum Press; 2003, pp 391-404.

5. Kurtz E. Not God: A History of Alcoholics Anonymous. Center City, Hazelden, 1987.

6. Miller WR, Thoresen CE. Spirituality, religion, and health: An emerging research field. Am Psychol 2003;58:24-35.

7. Alcoholics Anonymous. Alcoholics Anonymous The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism, 3rd ed. New York, A.A. World Services, 1976.

8. Bogenschutz MP, Geppert CMA, Miller WR. Development of a comprehensive bibliography on spirituality and addictions. Alcohol Clin Exp Res 2006;30(6 Suppl):359.

9. Miller WR. Researching the spiritual dimensions of alcohol and other drug problems. Addiction 1998;93:979-990.

10. Tonigan JS, Miller WR, Connors GJ. The search for meaning in life as a predictor of alcoholism treatment outcome. In: Longabaugh R, Wirtz PW, eds. Project MATCH Hypotheses: Results and Causal Chain Analyses. Project MATCH Monograph Series, Vol. 8. Bethesda, National Institute on Alcohol Abuse and Alcoholism, 2001, pp 154-165.

11. Connors GJ, Tonigan JS, Miller WR. Religiosity and responsiveness to alcoholism treatments. In: Longabaugh R, Wirtz PW, eds. Project MATCH Hypotheses: Results and Causal Chain Analyses. Project MATCH Monograph Series, Vol. 8. Bethesda, National Institute on Alcohol Abuse and Alcoholism, 2001, pp 166-175.

12. McCrady BS, Miller WR. eds. Research on Alcoholics Anonymous: Opportunities and Alternatives. New Brunswick, Rutgers Center of Alcohol Studies, 1993.

13. Tonigan JS, Toscova R, Miller WR. Meta-analysis of the literature on Alcoholics Anonymous: sample and study characteristics moderate findings. J Stud Alcohol 1996;57:65-72.

14. Ouimette P, Moos R, Finney JW. Influence of outpatient treatment and 12-step group involvement on one-year substance abuse treatment outcomes. J Stud Alcohol 1998;59:513-522.

15. Tonigan JS, Miller WR, Connors GJ. Prior Alcoholics Anonymous involvement and treatment outcome. In: Longabaugh R, Wirtz PW, eds. Project MATCH Hypotheses: Results and Causal Chain Analyses. Project MATCH Monograph Series, Vol. 8. Bethesda, National Institute on Alcohol Abuse and Alcoholism, 2001, pp 276-284.

16. Miller WR, Wilbourne PL, Hettema J. What works? A summary of alcohol treatment outcome research. In: Hester, RK Miller WR, eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd ed. Boston, Allyn & Bacon, 2003, pp 13-63.

17. Montgomery HA, Miller WR, Tonigan JS. Does Alcoholics Anonymous involvement predict treatment outcome? J Subst Abuse Treat 1995;12:241-246.

18. Tonigan JS, Connors GJ, Miller WR. Participation and involvement in Alcoholics Anonymous. In: Babor T, Del Boca F, eds. Treatment Matching in Alcoholism New York, Cambridge University Press, 2003, pp 184-204.

19. Sisson RW, Mallams JH. The use of systematic encouragement and community access procedures to increase attendance at Alcoholic Anonymous and Al-Anon meetings. Am J Drug Alcohol Abuse 1981;8:371-376.

20. Pettinati HM, Weiss RD, Miller WR, et al. Medical Management (MM) Treatment Manual: A Clinical Research Guide for Medically Trained Clinicians Providing Pharmacotherapy as Part of the Treatment for Alcohol Dependence. COMBINE Monograph Series vol 2. Bethesda, National Institute on Alcohol Abuse and Alcoholism, 2004.

21. Nowinski J, Baker S, Carroll KM. Twelve Step Facilitation Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. Rockville, National Institute on Alcohol Abuse and Alcoholism, 1992.

22. Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol 1997;58:7-29.

23. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcohol Clin Exp Res 1998;22:1300-1301.

24. Crits-Christoph P, Siqueland L, Blaine J, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry 1999;56:493-502.

25. Walker SR, Tonigan JS, Miller WR, et al. Intercessory prayer in the treatment of alcohol abuse and dependence: a pilot investigation. Altern Ther Health Med 1997;3:79-86.

26. Longabaugh R, Morgenstem J. Cognitive-behavioral coping-skills therapy for alcohol dependence. Current status and future directions. Alcohol Res Health 1999;23:78-85.

27. Tonigan JS, Miller WR, Schermer C. Atheists, agnostics and Alcoholics Anonymous. J Stud Alcohol 2002;63:534-541.

The noblest of all studies is the study of what man is and of what life
he should live.
--Plato

William R. Miller, PhD, Michael P. Bogenschutz, MD

From the Center on Alcoholism, Substance Abuse and Addictions (CASAA) and the Departments of Psychology and Psychiatry, University of New Mexico, Albuquerque NM.

Reprint requests and correspondence to: William R. Miller, PhD, Department of Psychology MSC 03-2220, 1 University of New Mexico, Albuquerque, New Mexico 87131-0001. E-mail: [e-mail]