Mr. W, age 45, is a divorced Army veteran living on the street who has entered alcohol treatment for the sixth time. He has never stayed sober for longer than 1 month after each of his previous treatment episodes.
On a typical day, Mr. W drinks 40 oz of beer, a pint of vodka, and other alcoholic beverages when available. Although he has used drugs, he reports that he did so only to augment the effects of alcohol. Before entering rehab, Mr. W worked for a television network for 16 years and was promoted to associate vice president. He lost that job as a result of drinking.
Mr. W comes from a large Irish Catholic family and has sustained an active religious faith, going to Mass 2 or 3 times a month. Throughout the interview, he appears introspective and describes frequent periods of “going inside” of himself to “rehash” things. He states that he has never been satisfied with his spiritual life and has been unable to “quiet the hunger inside.”
He describes his benders as “mini-retreats” and comments that focusing on the condensation droplets on a glass of beer is nearly a “sacramental experience” for him. He states: “My drinking is a spiritual thing for me. I believe that every time I drink I am on a spiritual search. I believe this with all my heart. I have this emptiness inside of me and alcohol would temporarily fill the enormous hole in my insides. Just for a short period of time, I would feel at peace and connected to others, and maybe even to God.”
Mr. W observes that “Every time I relapse it’s because I’m going through a spiritual withdrawal. Booze filled the void inside of me and now the void is back again. Physically and psychologically I’m fine. I’m just empty inside and when I can’t stand it any longer, I drink again.”
Few patients can so directly articulate the role they feel that spirituality plays in their substance use disorder. It is important for clinicians to be aware of the dynamics of spirituality and religion in the cause, maintenance, and treatment of substance misuse problems.
In this article, we discuss how spirituality can be assessed and suggest ethical and clinical practice concerns that we believe may support treatment of substance use disorder. We do not advocate incorporating spiritual interventions into clinical practice for patients who are uncomfortable with doing so, nor do we feel that consideration of and respect for patients’ spirituality precludes evidence-based pharmaceutical and behavioral treatment strategies. We believe, however, that addressing these issues can enhance treatment adherence in select patients.
Although religion and spirituality are related concepts, they differ.
- Religion has been defined as “an organized system of beliefs, practices, rituals, and symbols through which ones’ relationship to God or others is nurtured and exercised.”1
- Spirituality is more complex and multifaceted. Reflecting his extensive review of articles on spirituality and addiction, Cook2 proposed the following definition:
Spirituality is a distinctive, potentially creative, and universal dimension of
human experience arising within inner subjective awareness of individuals and within communities, social groups, and traditions. It may be experienced as relationship with that which is intimately “inner,” immanent, and personal, within the self and others, and/or as relationship with that which is wholly “other,” transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is therefore concerned with matters of meaning and purpose in life, truth, and values.
In some religions, any use of alcohol or drugs is forbidden; in most religions, abuse of these substances violates norms. Those who misuse a substance also might be alienated from their religious and social support community. People struggling with addiction might feel they are compromising their spiritual values directly through the action itself and indirectly because of the harm their substance misuse causes to close friends and family. Misuse of substances also might be an attempt to “fill the void,” as Mr. W described it, of a spiritual longing or a consequence of doubts about meaning, purpose in life, and God.
Perhaps it isn’t surprising that, among psychiatric disorders, substance abuse problems seem to be most associated with spiritual intervention—especially Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA). Many of the 12 steps contain references to God and spirituality. Although much of the evidence supporting the effectiveness of the spiritual components of AA/NA/CA is correlational,3,4 the resonance that many persons who are recovering from substance abuse find in the 12-step model suggests that spiritual issues are relevant to understanding patients’ viewpoints and for planning treatment.