The Role of Spirituality in Addiction Medicine: A Position Statement from the Spirituality Interest Group of the International Society of Addiction Medicine *

Abstract

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.

Introduction

Over many years, acts of deeply felt commitment have served as a basis for people trying to gain control over their substance use disorders (SUDs). Given the many settings in which this can occur, and the diverse, culturally defined beliefs upon which individuals may draw, the generic term of spirituality can be applied to such phenomena. Spirituality has been defined with regard to clinical settings as a commitment to transcendent or existential personal meaning in one's life, typically involving a connection with something larger than oneself ¹ and is distinguished from the pursuit of material needs or organized religion per se. Additionally, empirical studies have been undertaken to assess the degree of individuals’ spiritual orientation. ^{2 , 3} The International Society of Addiction Medicine (ISAM) includes a spiritual dimension, in addition to psychological and biological dimensions of SUDs, as in its definition of addiction and certification note.4

The need for attention to empirical evidence for the relationship between spirituality and SUDs has been long recognized. ⁵ The current document represents a position statement adopted by the Spirituality Interest Group of ISAM to clarify the role of spirituality within the addiction field, and includes how neuroscience, social science, and psychology can advance our understanding of spirituality and its role in recovery from addictions and provides recommended actions. It complements the inclusion by the World Health Organization of religion and spirituality as a dimension of quality of life, ⁶ and the World Psychiatric Association's guidelines for introducing religion and spirituality into the practice of psychiatry.7

Background

Despite considerable advances in both pharmacological and behavioral treatment modalities, there is a worldwide deficit in the availability of professional treatment for SUDs. There is also a need for developing improved approaches for clinicians ^{8 , 9} to promote addiction recovery tailored to the diversity of respective national cultures. ¹⁰ The way this can be done is by generating, evaluating, and employing spiritually oriented approaches that may help to address this deficit.

One aspect of securing sustained recovery is included under the concept of “recovery capital,” describing resources upon which people with addictive disorders may draw. This term has been defined by the World Health Organization in the International Standards for the Treatment of Drug Use Disorders ⁶ as the internal and external resources available to an individual to promote a sustained recovery, including peer-based and culturally related support for discovering “meaning and purpose in life.” In this respect, achieving an enhanced spiritual orientation can provide increased recovery capital, the enhanced ability to sustain recovery from substance use disorders (SUDs). This can be valuable in adding to the resources, such as pharmaceutical or institutional, on which such a person can draw. Consequences of a deficit in this aspect of recovery capital have been illustrated in an analysis by Case and Deaton ¹¹ in characterizing “deaths of despair,” which they specifically define as alcohol-related liver disease, drug overdose, and suicide. After controlling for obesity, income inequality, and poverty, they found that individuals’ limited options for achieving hope for the future were most common in demographic groups experiencing a rise in such deaths.

An approach to enhancing personally experienced spirituality, as embodied in the availability of culturally syntonic approaches, and thereby improving one's recovery capital, may serve to yield relief from the pressure to turn to substance misuse and addictive behaviors. Such approaches have been documented in diverse settings, such as recovery from gambling (a non-substance use) disorder in Israel ³ and multi-denominational, Christianity-based recovery programming. ¹² Similar approaches are also implicit in numerous culturally defined settings worldwide for achieving recovery, including Hinduism in India, Buddhism in South Asia, and Shi'ism in Iran.

Perhaps the most widely studied of such an approach has been undertaken in research on Twelve Step fellowships. The utility of these fellowships has recently gained additional validity after the release of a Cochrane Review ¹³ that demonstrates the substantial effectiveness of facilitating participation in Alcoholics Anonymous (AA) and other Twelve Step programs for alcohol use disorder. On a clinical level, it has been found that self-reports of spiritual awakening among AA members predicted improved drinking outcomes in subsequent follow-up.14

AA and Narcotics Anonymous are self-designated “Spiritual Fellowships,” and their members number in the millions worldwide. Two aspects of this self-designation are evident in the importance of spirituality and spiritual awakening among long-term members who attribute spiritual commitment to their experience of recovery. In fact, abstinence after discharge from professional treatment was found in one study to be three times as likely among patients who reported having had a spiritual awakening.15

Studies that delineate biological correlates of spirituality can be helpful in understanding mechanisms of recovery from addictions. In one set of studies, responses to a guided imagery neuroimaging task were evaluated. ^{16 , 17} Spiritual experiences were contrasted with those of neutral-relaxing and stressful experiences, and neural differences between the conditions were distinguishable by using functional magnetic resonance imaging. ^{16 , 17} Activation of the parietal cortex distinguished the three conditions, ¹⁶ resonating with prior structural studies linking religion and spirituality to parietal volume of this region. ¹⁸ A more sustained pattern of engagement of a ventral frontotemporal network was also specific to the spiritual condition, and the degree of engagement correlated with self-reported robustness of the spiritual experience as well as intrinsic spirituality, suggesting a functional neural network underlying spiritual experiences and tendencies. ¹⁷ Additionally, measures of intrinsic spirituality have been found to correlate inversely with cortical and subcortical brain regions during exposure to personally stressful cues. ¹⁹ Given that individuals with early life trauma or those with drug addictions (particularly women who are more likely to engage in addictive behaviors to alleviate stress or for other negative reinforcement motivations) have been found to over-activate these regions during similar exposures to stressful cues, ^{20 , 21} the findings suggest a biological mechanism by which spirituality may mitigate against stress and addiction risk. Another study ²² employed long-term AA members who had reported having had a spiritual awakening. They were exposed to alcohol-related images after reading either an AA-related prayer or neutral material. Their responses following the prayer condition, both on imaging and on subjective report, were correlated with the subsequent diminished craving that they reported. Such research suggests options to be pursued in studying neural networks reflective of spiritual experiences and how they may promote recovery from addictions.

Gardner and Kleinman note that an emphasis on biological research and pharmacological management has come to predominate over studies on “the interconnections of mind, body, and society” ²³ to the detriment of potentially beneficial integrative models. Spirituality is often culturally resonant with the medically underserved, including racial/ethnic minority groups, individuals of lower socioeconomic status, and women. Engaging spirituality and related community organizations in treatment is an important aspect of improving treatment access, outcomes, and equity for underserved groups.24

Gaining a better understanding of how spirituality is manifested in different cultures may also aid in better tailoring of treatment in specific settings. It may also enrich the ways patients with addictions can be approached by clinicians. Additionally, research on the neural mechanisms associated with spiritual experiences may lead to clarifying the complexity of brain networks that underlie neurally based schemas associated with addiction recovery.

The above-described approaches may aid in developing better personalized psychological and behavioral approaches for clinicians and may help keep patients engaged in medication-focused treatment programs. Neurobiological studies may aid in understanding differential responses of people with addictions to treatment (both positive or negative) and identifying mechanisms underlying active ingredients of treatments. Such information has significant potential to advance interventions and decrease suffering of individuals impacted by addictions.

Recommendations

In light of the above, we propose the following:

That the clinical evaluation of a patient with an addictive disorder (SUDs or behavioral addictions like gambling or gaming disorders) include an assessment of the role of spirituality in their personal history and the current manifestation of their addictive disorder.

That clinicians’ treatment planning include consideration of how issues related to spirituality can be employed in programming designed to increase the patient's recovery capital to fortify their recovery, such as an examination of which spiritually related experiences a patient might have previously encountered and ascertaining spiritually oriented resources in their community.

That spiritually oriented community-based resources that are appropriate for a given patient (such as culturally oriented facilities, religious institutions, ²⁵ and peer support groups, like Twelve Step fellowships) be considered for referral, and supporting the referral of patients to such resources.

That research be promoted to ascertain psychological, cross-cultural, and biological underpinnings on how drawing on spiritual resources can play a role in recovery from addictive disorders.