Recovery on higher ground: Spirituality in the treatment of substance abuse

Religion and spirituality in risk and recovery

Although alcohol and drugs can have positive religious significance (eg, wine in the Christian Eucharist or in the Hindu practice of Ayurvedic medicine; peyote in some indigenous American religious rituals), substance use and abuse are less prevalent among persons who identify themselves as highly religious or spiritual.⁵ Studies indicate that alcohol use and abuse are less prevalent among persons who identify as Jewish, Muslim, or conservative Protestant, compared with those who are Catholic or liberal Protestant.⁶

Research suggests that consideration and accommodation of religious and spiritual practices in the recovery process is effective^7-9—and preferred—by many patients.¹⁰ Psychiatrists do not need to and, in many cases, should not deliver overtly spiritual treatments to patients recovering from substance abuse. Spirituality and religion are complex issues largely outside the expertise of psychiatry; it would be naïve to consider spirituality and religion as universally beneficial elements for all patients recovering from substance abuse. Instead, psychiatrists should be equipped to:

• assess for religion and spirituality in patients
• be aware of, and supportive of, resources for integrating spirituality into treatment (eg, clergy and hospital chaplains, local AA/NA/CA groups, community religious organizations, spirituality groups).

Assessment

Post and colleagues¹¹ note: “When patients feel that their spiritual needs are neglected in standard clinical environments, many of them may be driven away from effective medical treatment.” This is of particular concern when working with persons who have a substance use disorder—among whom, regrettably, only a minority avail themselves of professional care. You should carefully gauge the importance of these dimensions in how patients understand their disorder and the components of treatment they think their recovery process should involve.

Asking about the religious and spiritual aspects of patients’ lives shows respect for their views and facilitates a therapeutic alliance by recognizing their autonomy in treatment. Pargament and Lomax¹² state: “Religion speaks to highly sensitive issues that lie at the core of the individual’s identity, commitments, values and world view. Patients are unlikely to engage in a conversation about the deepest side of themselves unless their psychiatrist demonstrates an openness to, interest in, and appreciation of the patient’s religiousness.” This exploration process can suggest natural environmental support systems available to complement recovery efforts and can indicate whether consultation with a clergy­person knowledgeable about and sensitive to their particular religious tradition is appropriate.

Assessment of spirituality and religious practice usually should occur during the initial clinical interview. Examples of revealing interview questions are listed in Box 1.

The Table^13-20 lists well-researched psychometric measures that can provide clues to aspects of your patient’s spirituality. These scales yield quantitative results, yet it may be more useful to review with the patient his (her) responses to the items and to pursue issues further based on the responses.

In discussing responses to questions about their spirituality and religious practices, some patients might ask about your views and whether you agree with their views. You could respond with a direct, concise answer, but refocusing the discussion on why the topic of spirituality is important to understanding one’s life and choices might be more therapeutic. This also might be a good time to remind patients that the treatment plan should reflect their view of the role of religion and spirituality in their life.

Of course, some patients are disinclined to discuss spirituality or religion, or prefer that it not be considered in treatment. This is clearly a matter of patient choice, but be aware that the patient may change his (her) mind as the recovery process continues and that the topic can be revisited if desired.

Recommendations for practice

Give careful consideration to ethical and clinical practice issues related to spiritual components in the recovery process. Plante²¹ and Meador and Koenig¹ addressed several relevant ethical principles in considering spirituality in, respectively, psychological and psychiatric practice. Delaney and co-workers²² also presented similar principles, specifically within the context of substance use treatment. These can be summarized as a series of recommendations:

• Although psychiatrists as a group typically have a lower rate of conventional spirituality and religious practice than many of their patients,^23-25 it is important not to ignore the patient’s perspective and show respect for the patient’s spiritual needs. However, if the psychiatrist has strong personal religious beliefs, he (she) must carefully guard against proselytizing or exerting undue, unintentional influence.

• Given the variety of religious traditions in the United States, understanding their particular features, as with other issues of cultural diversity, requires competence and sensitivity. Your work requires study and consultation with knowledgeable peers and experts in various faith traditions. Clergy and clinically trained chaplains, in particular, can conduct more comprehensive spiritual assessments that can yield additional treatment-relevant information.