Chapter 6.0 Spiritual Considerations
Integrating spirituality and religion into substance use disorder assessment and treatment is complicated. While some find the integration affirming, others may feel indifferent or hurt by the historical judgement and discrimination connected to the moral model. Despite these limitations, most clients desire to have their spiritual or religious beliefs integrated into their counseling experiences. Counseling professional should be prepared to conduct spiritual assessment and integrate spiritually informed practices when indicated.
A moral model of substance misuse has been widely embraced at various times in American society. This explanatory model suggests that deceit and moral deficits are cardinal features of substance use disorders and a moral conversion is necessary to overcome addiction (Stoddard Dare and DeRigne, 2010). Contrasting the strength of the simplicity of this model, one important disadvantage to this theory is that it seems to negate the role of biological, psychological, and social forces in the development of substance use disorders and the need to address those issues (Lassiter and Spivey, 2018).
The blending of morality and substance misuse dates back to the founding fathers of the United States. Katcher (1993) reviews the work of medical professor Dr. Benjamin Rush, a coauthor of the Declaration of Independence. In the late 1700’s and early 1800’s, Rush developed and widely circulated a “moral thermometer” to rate an individuals’ temperance or intemperance (cited in Katcher, 1993). The temperance section of the scale lists specific beverages such as water, milk, cider and wine and paired those drinks with qualities such as “cheerfulness,” “health.” and “strength.” The intemperance section included beverages such as “strong punch,” “toddy,” and “rum.” Those drinks were mapped to “vices,” (lying, fraud and murder), “diseases” (puking, tremors, melancholy), and “punishments” such as debt, hunger, and jail (cited in Katcher,1993).
Rush’s thermometer came at a time liquor was believed to help laborers by providing energy and relief from extreme heat or cold (Katcher, 1993) so part of his intent was to convey that alcohol use could be problematic. Rush’s work highlights two important themes that have reoccurred over time. First, moral judgements are tied to substance use. Second, certain substances are considered acceptable, or more acceptable, while others are considered unacceptable.
Rush’s work was extended by a broad temperance movement and later Prohibition. As described by Lassiter and Spivey (2018), intertwined with a Christian message of morality and deepening a personal connection with God, the temperance movement, which spanned 1826-1919, focused first on reducing alcohol use, and later on total abstinence in order to curb social ills such as violence against women and children. Also, in the mid 1800’s opioid use increased substantially as it was viewed as a socially endorsed method to soothe children and reduce ailments. Societal acceptability of tobacco, alcohol, cocaine, and opioid use differed by race and class with racial minorities and individuals in lower socio-economic groups more likely to have their use classified as deviant or immoral. The passage of Prohibition in 1920 began a tremendous increase in the criminalization of alcohol and other drug use. Legislative activity (the Boggs Act 1951, the Narcotics Drug Act of 1956) continued through the 70’s (establishment of the Drug Enforcement Administration) and 80’s (Anti-Drug Abuse Act) which furthered a view that people who use illicit drugs are immoral and dangerous and should be incarcerated (Lassiter and Spivey, 2018). Racism was deeply ingrained in these policies as is evidence by the differential sentencing for crack and powder cocaine (https://www.aclu.org/other/cracks-system-20-years-unjust-federal-crack-cocaine-law).
Despite the complicated and sometimes damaging role of spirituality and religion, they also clearly can have a beneficial role to play in substance use, prevention, and treatment.
The Role of Spirituality and Religion in Prevention and Treatment of Substance Use Disorders
Grim and Grim (2019) provide an introduction to the role of spirituality and religion in substance use disorders. Edited excerpts from their open access publication follow as we,
1) “examine the empirical evidence illustrating faith’s contribution to preventing people from falling victim to substance abuse and helping them recover from it,” and
2) “introduce and flesh out a typology of faith-based substance abuse treatment facilities, recovery programs, and support groups (Grim and Grim, 2019, p 1751).”
This passage from the Journal of Religion & Health article “Belief, Behavior, and Belonging: How Faith is Indispensable in Preventing and Recovering from Substance Abuse” is by Brian J. Grim and Melissa E. Grim and licensed under a CC-BY 4.0 license.
Grim and Grim, 2019 (p. 1713-1750) state:
Along with the body and the mind, the spirit is also a central part of the continuum of addiction health care. Based on [a] review of extensive evidence-based research on addiction that follows, it is clear that religion and spirituality—which we refer to collectively as faith—are exceptionally powerful, integral, and indispensable resources in substance abuse prevention and recovery. This body of research shows that the efficacy of faith includes not only the behaviors people engage in (or don’t engage in) because of their faith and the support people find in belonging to faith communities, but also people’s religious and spiritual beliefs themselves.
At the start, it is useful to provide a working definition that differentiates religion from spirituality, both of which we categorize as aspects of faith because the two frequently overlap…
Spirituality is defined as an openness to God, nature or the universe where one can experience harmony with truth, feelings of love, hope and compassion, inspiration or enlightenment with a sense of meaning and purpose in life, an individual’s connection with God or the Transcendent.
On the other hand, religion is viewed as the corporate expression of that connection, where one mediates their relationship to God and the community through an organized system of beliefs and practices (Burnett 2014, pp. 28–29).
Empirical Evidence of Faith’s Contribution to Preventing Substance Abuse and Helping People Recover from It
An emphasis on the biological aspect of healing has provided us with advanced diagnostics… and an extended lifespan; the benefits have been extraordinary. However, these achievements often …disregard the important role of the inner, spiritual aspects of healing…However, this is changing. Writing in the American Medical Association Journal of Ethics, Robert Orr notes that “there is an increasing recognition in modern Western medicine of the importance of patient spirituality in treatment and healing” (2015, p. 414). The recognition of the significance of the spiritual aspects of healing has been growing, particularly since the 2001 mandate by the Joint Commission on Accreditation and Healthcare for the administration of a spiritual assessment by healthcare providers for patients and their families (Hodge 2006; The Joint Commission n.d.).
Hundreds of evidence-based studies demonstrate the positive impact of faith on health and well-being (e.g., Duke University n.d.; Koenig 2005, 2008, 2011, 2018; George et al. 2002; Johnson et al. 2002; Koenig et al. 2012; Rew and Wong 2006; Schoenthaler et al. 2018; VanderWeele 2017; Zemore 2008), and, as we will show in this section, nowhere is this positive impact more evident than in the recovery of people who are suffering from substance abuse. We should emphasize that the benefits of faith to health can be seen in a variety of religious contexts, including monotheistic and nontheistic faiths and beliefs.
For instance, Chan et al. (2002) noted that the inner, spiritual aspects of healing are common in the Eastern philosophies of Buddhism, Taoism, and traditional Chinese medicine. Their research demonstrates significant improvements in patients when taking the body–mind–spirit integrated model of intervention.
We should also note that in more than any other area of modern health care, substance abuse treatment embraces the traditional paradigm of treating body, mind, and spirit (Borkman 2008; Polcin and Borkman 2008). This is not to say that all people with addictions benefit from faith content in recovery, but many do.
- For example, 84% of the clients in addiction counseling expressed a desire for a greater emphasis on spirituality in treatment (Hodge 2011).
- Johnson and Pagano (2014) found that spiritual support and religious involvement can be an integral part of dealing with substance abuse, pertaining to both prevention(i.e., young adults involved in religion are less likely to become addicted to drugs) and recovery (i.e., addicts in spiritual programs such as the 12-step fellowships pioneered by Alcoholics Anonymous (A.A.) have a lower risk of relapse).
Dr. Elinore F. McCance-Katz, Assistant Secretary of Health and Human Services for Mental Health and Substance Use, outlines three necessary steps to successfully combat and treat substance abuse in the long run: clinical care, social intervention, and social support. She highlights the strength of faith-based communities and organizations, especially in regard to social intervention and support (US Department of Health and Human Service, 2017, September 28).
Government leaders recognize that the federal and state agencies are logistically unable to effectively and comprehensively confront the substance abuse epidemic on the local front where faith-based organizations work (Acker 2017; Hein 2014). By their nature, faith-based substance abuse recovery programs, particularly at the congregational level, reach beyond the addict and engage their family and community in the recovery process (White et al. 2012). As a clear indication of the US government’s ongoing recognition of the important role of faith-based communities in addressing substance abuse, the Department of Health and Human Services’ Center for Faith-Based and Neighborhood Partnerships recently published an Opioid Epidemic Practical Toolkit: Helping Faith and Community Leaders Bring Hope and Healing to Our Communities (US Department of Health and Human Services, 2018a, August 3).
We will now specifically look at the evidence-based research on
(a) how faith generally relates to substance abuse,
(b) how faith relates to youth and substance abuse, and
(c) how faith relates to adults and substance abuse; we will also provide an overview of the available evidence-based studies on the effectiveness of faith-based substance abuse recovery support programs.
Faith’s Relationship with Substance Abuse in General
Evidence-based studies point to the instrumental contribution of faith to substance abuse prevention and recovery.
A large majority of cases show that religious and spiritual beliefs and practices lead to lower levels of substance abuse, including reduced likelihood of using various drugs, in the course of a lifetime (Degenhardt et al. 2010; Herman-Stahl et al. 2007; Moscati and Mezuk 2014; Palamar et al. 2012).
- For instance, a study by Lyons et al. (2010) found that up to 82% of clients who experienced a spiritual awakening during substance abuse treatment and recovery were completely abstinent at a 1-year follow-up compared with 55% of non-spiritually awakened clients.
- Koenig et al. (2012) identified at least 278 quantitative studies that attended to the relationship between alcohol abuse and faith prior to 2010.
- Of these, 86% found that faith reduced the risks associated with alcohol use, abuse, or dependence; only four studies (1.4%) found that faith contributed to alcohol use, abuse, or dependence, with the rest being neutral.
It is possible that the findings reported on the positive role of faith were arrived at through less rigorous methods. However, to test this, the authors looked separately at only 145 research of highest quality among the 278 evidence-based studies. Among these, 131 (90%) found that faith reduced the risks of alcohol use, abuse, or dependence, while only one found that faith contributed to alcohol use, abuse, or dependence.
Koenig and colleagues (op. cit.) also reviewed the studies that examined the relationship between faith and drug use, abuse, or dependence, and…they obtained similar results.
- Of the 185 studies identified, 84% found that faith reduced the risks of drug abuse and only two (1.4%) found that faith contributed to drug abuse.
- These findings echo those of Rew and Wong (2006) who found that, among 43 studies, most (84%) showed that religiosity, i.e., the intensity of religious involvement and practice, and/or spirituality had positive effects on health attitudes and behaviors.
- The results are similar to an earlier review by Moody-Smithson (2001) of more than 100 studies prepared for the Center for Substance Abuse Treatment (CSAT), which found that 90% of the studies reported that substance abuse was less common among more religious people.
The inclusion of faith-based elements in otherwise secular programs has also been shown to be effective. For example, Nemes et al. (1999) studied two 12-month substance abuse treatment programs and found that the clients who completed all the components of treatment, including faith-based elements, reported less substance use at subsequent follow-ups.
Some of the studies with neutral or negative findings include those with mixed results.
- For instance, a study by Yeterian et al. (2018) found that among adolescents being seen in an outpatient SUD program, higher baseline spirituality predicted a lower likelihood of heavy drinking at follow-up, even more so than religiosity. However, higher levels of religion and spirituality at the baseline were related to increased marijuana use at the 6-month follow-up, as participants reported that they felt more spiritually connected when they were high on marijuana.
- Another recent mixed-results study of 1565 young black homosexual men in Houston and Dallas showed that participation in spiritual and religious activities is an important source of resilience, albeit a risk for these men (Carrico et al. 2017).
- On the one hand, the odds of substance use diminished when the men had higher levels of “spiritual coping” (i.e., the ability to tap into spiritual support and look for meaning in a traumatic situation).
- On the other hand, more engagement in spiritual and religious activities was also found to be associated with greater odds of substance use because of the huge stigma associated with being black and gay.
Faith’s Relationship with Substance Abuse Among the Youth
Evidence-based studies have found that youths who are spiritually active, participate in a faith community, and invest in a prayerful relationship with their God are less likely to use or abuse drugs and alcohol and engage in related criminal activity (Johnson et al. 2015, 2016a, b; Lee et al. 2014, 2017; Post et al. 2015, 2016). A seminal 2-year study by The National Center on Addiction and Substance Abuse (2001) at Columbia University, directed by Joseph A. Califano Jr., the former US Secretary of Health, Education, and Welfare in the Clinton administration, found that
- the teens who did not consider religious beliefs important were almost three times more likely to smoke, five times more likely to binge on alcohol, and almost eight times more likely to use marijuana compared with the teens who strongly appreciated the significance of religion in their daily lives.
- The study also found that, compared with the teens who attended religious services at least weekly, the teens who never attended services were twice more likely to drink, over twice more likely to smoke, over three times more likely to use marijuana or binge on alcohol, and four times more likely to use illicit drugs.
A host of studies show that faith among adolescents and young adults can act as a powerful deterrent against drug and alcohol abuse, even when controlling for other contributory factors (e.g., depression).
One of the largest studies on drug and alcohol abuse among American youth aged 12–17 analyzed data from the National Survey on Drug Use and Health (Ford and Hill 2012); the study found that
- higher degrees of religiosity reported, including religious attendance, involvement, and reliance on religious beliefs in decision making, were associated with several benefits, such as limited depression and negative attitudes toward substance abuse. After controlling for depression, religiosity was still found to be associated with less cigarette smoking, heavy drinking, and prescription and illicit drug abuse.
- Adolescents who frequently attend religious services, who are involved in faith-based activities, and who place a high value on spirituality exhibit greater resilience when facing the stressors that can lead to the formative use of drugs and alcohol as a coping mechanism.
A web-based survey of 5217 students in grades 6–8 at parochial private schools in the Baltimore Area, conducted at Johns Hopkins School of Public Health and Center for the Prevention of Youth Violence (Debnam et al. 2016), examined the associations between stress, spirituality, and substance abuse.
- The research found that, while stress was a predictor of substance abuse, it even had a stronger correlation with substance abuse for students who reported lower spiritual beliefs.
- Similarly, a study of Native American youths in grades 7–8 revealed that involvement in religious practice and native culture helped them better integrate into society and protect themselves against substance abuse (Kulis et al. 2012).
Investigators at the University of Virginia, Johns Hopkins School of Public Health, and Cedars-Sinai Medical Center in Los Angeles (Debnam et al. 2018) examined the moderating effect of spirituality on the relationship between psychological stress and substance use among 27,874 high school students from the state of Maryland.
- They discovered that higher spirituality was related to lower substance abuse in both males and females and further moderated the effect of stress that would have otherwise culminated in substance abuse by males.
- Moreover, youths and teens who have been religiously active and who have made prayer and belief in God an integral part of their lives have better coping mechanisms when attending drug rehabilitation programs and better outcomes after the programs end. For instance, a controlled study of substance-dependent youths revealed that those who had been assessed at the baseline with preexisting greater lifetime religious involvement were more likely at the end of the treatment to be regularly engaged in abuse recovery activities and behaviors, predicting greater recovery outcomes (Kelly et al. 2011).
These are not isolated findings. There is overwhelming evidence that religious involvement and/or religiosity are associated with reduced risk of substance use among adolescents (Bahr and Hoffmann 2008; Bartkowski and Xu 2007; The National Center on Addiction and Substance Abuse 2003; Metzger et al. 2011; Steinman and Zimmerman 2004; Wallace et al. 2007).
- The teens who attend religious services weekly are less likely to smoke, drink, use marijuana or other illicit drugs (e.g., LSD, cocaine, and heroin) than the teens who attend religious services less frequently (Brown et al. 2001; The National Center on Addiction and Substance Abuse 2010; Longest and Vaisey 2008; Steinman et al. 2006; Wills et al. 2003).
- Further, religious practice among teens discourages them from taking highly dangerous drugs (Adlaf and Smart 1985; Thompson 1994). In their study, Chen and VanderWeele (2018) found that people who attended religious services at least weekly in childhood and adolescence were 33% less likely to use illegal drugs.
Adolescents also benefit from their mothers’ higher levels of religious practice, controlling for factors that also influence the level of drinking (e.g., the adolescents’ peer associations) (Foshee and Hollinger 1996).
Higher teenage religiosity was also related to other factors related to a decrease in drug use, such as good family relations, high academic performance in school, having anti-drug attitudes, and socializing with friends who do not take drugs (Johnson 2002). Moreover, teens themselves tend to cite their peers’ religious and spiritual inclinations as reasons that discourage their peers from drinking and taking drugs (The National Center on Addiction and Substance Abuse 2011).
Faith’s Relationship with Substance Abuse Among Adults
The 2001 National Center on Addiction and Substance Abuse study found that the
- adults who do not consider religious beliefs important are more than three times more likely to binge on drinks and almost four times more likely to take illicit drugs.
- The study also found that, compared to those who attend religious services at least every week, the adults who never attend religious services are more than five times more likely to take illicit drugs and almost seven times more likely to binge on drinks.
- The study found that people “with strong religious or spiritual beliefs are healthier, heal faster and live longer than those without them” and that “religion and spirituality can play a powerful role in the prevention and treatment of substance abuse and in the maintenance of sobriety” (The National Center on Addiction and Substance Abuse 2001, p. ii).
Faith protects both women and men against substance abuse. A study of over 11,000 women, aged 18 and older, found significant reductions in alcohol and drug use by more religiously active women, including lesbian and bisexual women (Drabble et al. 2016). Acheampong et al. (2016) showed that women and men who use prescription opioids and who are actively religious and spiritual are less likely to engage in simultaneous polysubstance use (SPU). The protective feature of religious engagement against alcohol abuse can have a lasting impact. For example, Koenig and Vaillant (2009) found that frequent religious attendance at midlife (ages 45–47) was protective against alcoholism and predicted a significant increase in subjective well-being by the age of 70, independent of other predictors and baseline well-being.
Research also indicates that religious engagement can be especially useful for minority populations in the USA. In their analysis of the cross-sectional data from a nationally representative sample of 868 Latinos of Mexican origin from the National Latino and Asian American Study (NLAAS), Moreno and Cardemil (2018) found that religious attendance was linked to lower lifetime prevalence of depressive disorder, anxiety disorder, and SUD.
A qualitative study by Cheney et al. (2013) delved into some of the religious and spiritual dimensions of reducing and abandoning cocaine use among African–Americans in rural and urban areas of Arkansas. Their analysis suggested four ways in which religion could have an impact.
First, the participants situated substance use in religious and spiritual frameworks.
Second, participation in organized religious activities helped many of the participants cut down on or briefly stop cocaine use at some point in their substance use history. These activities ranged from attending church and Bible studies to singing in the choir, which they identified as a steadying force that helped reduce cocaine use.
Third, the participants cited their personal relationship with God as a factor in reducing cocaine use and placing them on the road to recovery.
And fourth, many participants expected God to step in.
Research shows that a person’s effective use of the spiritual resources from their faith tradition—positive religious coping (PRC)—contributes to better substance abuse recovery outcomes. Religious coping may range from prayer to convictions of religious faith and belief itself (Elmholdt et al. 2017; Schjødt et al. 2008, 2009; Jegindø et al. 2012; Yu et al. 2016). People who use PRC tend to seek spiritual support and meaning when inflicted by traumatic events; by contrast, people who resort to negative religious coping (NRC) can have a hard time recovering, as they experience spiritual complications and express doubt about the issues of God and faith. For instance, Medlock et al. (2017) found that PRC had a positive correlation with a patient’s reduced cravings and increased productive participation in 12-step meetings, whereas patients who relied on NRC suffered withdrawal symptoms more acutely and benefited less from the 12-step meetings.
PRC has been shown to help maintain sobriety during the postdrug rehabilitation period. Martin et al. (2015) followed participants in alcohol outpatient treatment from 2 weeks until 6 months after enrollment; they found that those participants who relied on religion to help them cope were less likely to drink heavily and had fewer drinks per day than those who believed in no religion or resorted to NRC. PRC has also been found effective when dealing with opioid dependence—an addiction with high rates of relapse. While there are pharmacotherapies, such as methadone and buprenorphine, which are effective in reducing relapse, they are not effective enough in isolation for treating the whole person. Puffer et al. (2012) found that increased PRC was associated with less frequent opioid use and more frequent 12-step participation. They also found that patients who were able to decrease NRC were less prone to relapse. International studies provide corroborative support for US findings, linking religious participation and a personal prayerful connection with God (or spirituality) to fewer addictive behaviors (e.g., Szaflarski 2001; Gomes et al. 2013; Haug et al. 2014).
Effectiveness of Selected Faith-oriented Substance Abuse Recovery Support Programs
Religion–based substance abuse recovery programs include those that are carried out by such groups as the Salvation Army and Teen Challenge (Adult and Teen Challenge USA 2018), and spirituality–based programs include those carried out by such groups as A.A. and Narcotics Anonymous (N.A.).
A survey of the Salvation Army’s Harbor Light Center in Washington D.C. (Wolf-Branigin and Duke 2007) found that participants who chose engagement in spiritual activities improved their chance of successfully completing their treatment program.
In 2017, Teen Challenge USA helped, on average, 5826 individuals in their US residential programs each day (Teen Challenge 2018, p. 1). A 7-year study on Teen Challenge’s effectiveness found that, in contrast to those who had dropped out of the program, the program’s graduates had significantly managed to alter their behavior (Bicknese 1999). A Teen Challenge survey (Owen et al. 2007) revealed that the top two factors in maintaining sobriety after rehabilitation were staying connected to God (58%) and family (34%). At the time of the follow-up contact, an average of 2.7 years after graduation, 45% of the participants stated they had not had a single relapse; …83% said that their drug use was “a lot less” than before Teen Challenge. The results of this research are further supported by a follow-up Teen Challenge survey (Hardeman et al. 2011) that found that the top three factors in maintaining sobriety after rehabilitation were “staying connected to God” (62%), “family” (36%), and “hanging out with positive people” (22%). The graduates in general found the faith-based elements most useful for helping them recover.
A.A. is not only the most widely used spirituality-based support/mutual aid group for people recovering from alcoholism, but also provides inspiration for a multitude of other addiction recovery support groups (BBC Magazine 2015; Laudet 2008). Although some have questioned the usefulness of A.A. (Anderson 2015; Cunha 2015; Dodes and Dodes 2014; Ferri et al. 2006), the effectiveness of its approach has solidly been established in an edited volume by Galanter and Kaskutas (2008) for the American Society of Addiction Medicine and the Research Society on Alcoholism.
The volume provides an overwhelming body of theoretically informed and evidence-based empirical research, demonstrating the effectiveness of A.A. and its original spirituality-based 12-step approach as well as spirituality’s general role in addiction recovery. The volume also shows that A.A. has significantly informed and influenced how alcoholism is professionally treated today (Slaymaker and Sheehan 2008).
There are numerous other empirical studies on A.A.’s effectiveness. First, based on a 13-item A.A. Involvement Questionnaire of the extent of participants’ involvement in A.A. (Tonigan et al. 1996), the level of participation in A.A. is a determinant of a patient’s treatment outcome (Montgomery et al. 1995). Additionally, for adults who struggle with addiction, The National Center on Addiction and Substance Abuse (2001) found that the individuals who had received both professional treatment and attended spirituality-based support programs like A.A. or N.A. were far more likely to stay sober than if they had received professional treatment alone.
Kaskutas et al. (2003) examined the role of religiosity in A.A. involvement and long-term sobriety in a representative sample of 587 men and women interviewed upon entering treatment and re-interviewed one and 3 years later. Those who reported a spiritual awakening at Year 3 had had the highest chance of continued sobriety for the past year, a state that would not be equally extended to mere religious self-definition. The study also found that an increase in A.A. activities, besides just attending A.A. meetings (e.g., sponsorship), between the baseline and the first-year follow-up was also associated with greater likelihood of sobriety. For instance, the supportive, helping behaviors encouraged by A.A. were seen by members as an expression of spirituality in the recovery context (Zemore et al. 2004). White and Kurtz (2008) observed that a defining moment in the history of A.A. was connected to the realization of psychoanalyst Carl Young who, after providing the best treatment that psychiatry and medicine could offer, still saw a patient he treated relapse (Galanter and Kaskutas 2008). He then observed that patients maintained sobriety successfully through religious and spiritual experiences.
Hsu et al. (2008) also showed how the mindfulness and meditation inherent in the 12-step approaches are natural features of Buddhism and Buddhist approaches to addiction recovery.
Built into A.A. is the idea that all members are recovering from alcoholism and none has moral superiority (White and Kurtz 2008), with all unified by a single membership criterion—the desire to stop drinking.
Since volunteering and helping others are associated with positive health outcomes (Yeung et al. 2017), substance abuse recovery programs dependent on volunteering, such as those offered in A.A. and congregation-based groups, have a built-in advantage for success.
More specifically, volunteering and helping others is found to be instrumental in addiction recovery (Lee et al. 2016; Johnson et al. 2016a, b; Pagano et al. 2015; Post et al. 2015, 2016). From the perspective of social identity theory (Dingle et al. 2015), recovery is aided, and perhaps necessitated, by the presence of a consistent reference group of individuals who can help patients reconstruct their new identity as “nondrinking alcoholics,” that is, someone who is prone to abuse alcohol but decidedly no longer drinks (Borkman 2008). In fact, those overcoming a troubled past can be a limitless source of help and inspiration for those still struggling (Zemore and Pagano 2008).
It’s important to note that being vaguely spiritual is not itself indicative of behavior change (Jang and Franzen 2013): spirituality needs concrete beliefs (religious or religion-like), behaviors, and/or belongings in order to change outcomes. A.A. has all three elements in the form of a set of beliefs summarized in its Big Book, behaviors expected of members such as cessation of drinking, and belonging, such as all encouraged to have a home group (Alcoholics Anonymous n.d.).
Therefore, to better understand the role of spirituality, religion, and faith-based interventions in substance abuse treatment and recovery, we propose a typology for treatment and recovery programs and support groups along the vertical axis of spirituality and the horizontal axis of religiosity… This typology aids in understanding how religion and spirituality are related phenomena and not mutually exclusive (e.g., Hodge 2011; Koenig et al. 2001; Richards et al. 2009). Spirituality is also comfortable to many who have a secular orientation. For instance, A.A. Agnostics of the San Francisco Bay Area (2018) considers its branching communities as “spiritual” programs…
Furthermore, religion in its own right can serve as a repository and center of spirituality, such as Ignatian spirituality nurtured by the Society of Jesus (the Jesuits n.d.), mysticism as practiced in Sufi Islam (Cook 2015), or the exercise of Buddhist meditation techniques (Amihai and Kozhevnikov 2015). With this in mind, addiction treatment and recovery programs can range from the ones that are
(a) spiritual but not religious,
(b) religious and spiritual,
(c) religious but not spiritual, or
(d) neither religious nor spiritual.
This section will describe and provide examples of each. It is important to note that not every scenario neatly fits each quartile; some may cross over and overlap others, hence “crossovers” in the center of the taxonomy.
Spiritual but Not Religious Substance Abuse Recovery (Ex. 12-Step Programs)
The vast majority of state-of-the-art substance abuse treatment and recovery programs in the USA include a key component that is spiritual but not necessarily religious (i.e., the 12-step recovery assistance program that A.A. and N.A. have developed and popularized). Our analysis of the Substance Abuse and Mental Health Services Administration (SAMHSA) database shows that 73% of the behavioral health substance abuse treatment services in the USA include a 12-step program or option. Although A.A. and N.A. are neither faith-based nor religious organizations, seven of their 12 steps explicitly mention God, a Higher Power, or spirituality. In fact, A.A. has clear roots in Protestant and Catholic Christian thought and practice (Burnett 2014; Chesnut 2014) and is predicated on the need for a Higher Power to help alcoholics become and remain sober. While this Higher Power is God for many members of the 12-step programs and fellowships, atheists and other nontheistic A.A. participants may define their Higher Power as the collective strength and support provided in their group meetings.
Twelve-step recovery programs are common across all substance abuse treatment programs, including programs serving vulnerable populations, such as persons who have experienced sexual abuse or persons living with HIV/AIDS.
As our typology suggests, A.A. and N.A. groups can range from those with no religious content, such as A.A. Agnostics of the San Francisco Bay Area, mentioned above, to those that have overt religious content such as closing with the Lord’s Prayer. The only requirement for A.A. membership is a desire to stop drinking. All A.A. and N.A. groups are self-supporting and do not accept contributions from non-A.A. members, and, most importantly, because they are locally administered, each group may have a slightly different character.
While A.A. and N.A. groups are not religious organizations, they frequently meet in spaces provided by local congregations at a low or no cost. In effect, many of the nearly 130,000 US congregations that have alcohol and drug abuse recovery groups (Grim and Grim 2016) either host A.A. or N.A. meetings or offer their own version of the 12 steps. When a church hosts an A.A. meeting, even though it has no programmatic oversight, churches still consider this as something the church is facilitating. This is an example of the same activity crossing over from one type of program to another, as shown in the typology above… For instance, our review of the A.A. meetings in Nashville, Tennessee, suggests that, of the 64 different facilities hosting A.A. groups, 51 (80%) are churches or other religious properties (A.A. Nashville n.d.). This is not surprising, given that the majority of people in the Nashville Area are members of some religious denominations (Grammich et al. 2012); less expected, though, is the fact that in Seattle, Washington, where the majority of people are religiously unaffiliated, by our analysis, 29 (54%) of the 54 facilities hosting A.A. groups are churches or other religious properties (A.A. Seattle n.d.)…The 160 weekly meetings…represent more than half (57%) of the 281 A.A. meetings held in the Annapolis Area each week (Annapolis Area Intergroup 2017). It is also not unusual for some congregational properties to serve as a hub for A.A. in a region. In historic downtown Annapolis, one of the buildings on the campus of the First Presbyterian Church, known as the Red House, serves as a permanent place for A.A. meetings in the area and holds the offices of the area’s A.A. Intergroup (akin to a regional organizing committee). Although these A.A. meetings occur inside the church buildings, the programs offered are spiritual and not religious; in other words, they are not based on the religion or religious oversight of the churches hosting the groups.
Religious and Spiritual Substance Abuse Recovery (Ex. Religion-Based 12-Step Programs)
A number of religion-based 12-step programs have taken the spiritual elements of A.A. and made them overtly religious. For example, Monty Burks, the Director of Faith-Based Initiatives at the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS), noted in our interview with him that across Tennessee there is a widespread use of Celebrate Recovery, a 12-step recovery assistance program adapted from A.A. and N.A. Celebrate Recovery, developed at Saddleback Church in southern California, offers an explicitly evangelical Christian version of the 12-step program. To date, over 5 million individuals are reported to have completed a Celebrate Recovery Step Study (Celebrate Recovery n.d.).
Tennessee also offers an example of a close working relationship between faith communities and a state government, aimed at addressing substance abuse. TDMHSAS’ Office of Faith-Based Initiatives engages communities of faith across the state and certifies them as being qualified to meet the recovery needs of the people in their pews and in their area (TDMHSAS n.d.). As of 2017, about 250 recovery churches or congregations have been certified by TDMHSAS in Tennessee and about 50 others are in the process of becoming certified (Morris 2017). Across Tennessee’s 95 counties, a church or faith-based organization is the only civic institution common in all counties: “So, we figure that’s a perfect vehicle to drive information into the community and teach people that you don’t have to be an addiction counselor to help somebody who’s an addict,” said Monty Burks (in Vance 2016, paragraph 21).
Another religious adaptation of the A.A.’s 12-step recovery program is the Addiction Recovery Program of The Church of Jesus Christ Latter-day Saints. Unlike A.A. or N.A. programs, the Latter-day Saint’s program invites people who are struggling with all forms of addiction (e.g., drugs, alcohol, pornography, gambling, eating disorders, etc.) to attend the same meeting together. The program has adapted the 12 steps of A.A. into the framework of the doctrines, principles, and beliefs of the Church (The Church of Jesus Christ Latter-day Saints 2018).
Christian groups are not the only faith traditions to adopt and adapt the A.A.’s 12-step approach. Beit T’Shuvah, a residential 140-bed Jewish addiction treatment center and congregation, incorporates Jewish spirituality into its 12-step program. Millati Islami World Services, founded in Baltimore, Maryland, is a 12-step recovery program based upon Islamic principles (Ali 2014; Millati Islami World Services n.d.). Millati Islami reports that its modified 12 steps and traditions, which incorporate Islamic principles, are of great benefit to Muslims in recovery.
A.A.’s spirituality-infused 12-step recovery programs have inspired numerous nontheistic programs as well. Native American communities have used modifications of the steps to address the historical trauma they have experienced that contributes to their increased rates of depression, drug use, and addiction (see Acker 2017). The Wellbriety Movement (n.d.), for example, is a 12-step program that incorporates Native American cultures and spirituality (Sacred Connections n.d.). Another nontheistic adaptation of A.A. approach are Mindfulness and 12 Steps, weekly meetings that explore the basic teachings of the Buddhist practice of mindfulness and the participants’ own reflections in the twelve steps (Buddhist Recovery Network n.d.).
Religious but Not Spiritual Substance Abuse Treatment (Ex. Faith-Based Hospitals)
CHI St. Gabriel’s Health Opioid Program in rural Minnesota is a classic example of a religious but not spiritual substance abuse treatment and recovery program. St. Gabriel’s is recognized nationally for leading a faith-based charge against opioid abuse (American Hospital Association n.d.; Oosten 2018; Rioux 2018). The hospital does not advertise its Catholic identity in its name, although CHI is an acronym for Catholic Health Initiatives. And when hospital staff were interviewed for this study, the program was not described in spiritual terms but in medical and community terms, as a manifestation of its overall Catholic approach. The Catholic identity of the hospital is summarized in its mission statement: “The mission of CHI St. Gabriel’s Health is to nurture the healing ministry of the Church …. Fidelity to the Gospel urges us to emphasize human dignity and social justice as we create healthier communities” (CHI St. Gabriel’s Health n.d.).
Being “religious but not spiritual” is common to many religion-based institutions receiving government funding. Another example is the For My Baby and Me program, launched by Trenton Catholic Charities in December 2017 with a $1 million New Jersey Department of Health grant (Diocese of Trenton 2018). In our interviews, the program staff pointed to the type of population that is served as a direct result of their Catholic mission to serve the most vulnerable and neglected. For My Baby and Me seeks to meet critical needs pregnant, addicted women because very few recovery programs accept pregnant women, who require complex, specialized care (Capital Health n.d.)…
Substance Abuse Recovery Programs with Little or No Religious or Spiritual Content
While we are primarily focused on bringing to light religious and spiritual contributions to substance abuse recovery, we also believe that programs without these elements are valuable and helpful to many people, including religious people. The Secular Organization for Sobriety (S.O.S.) is an alternative to the 12-step model of recovery but “welcomes the attendance of religious, as well as nonreligious persons” (Secular Organization for Sobriety n.d., paragraph 3). LifeRing, also a secular program, reports that about 40% of their participants attend a house of worship, according to a 2005 survey (LifeRing n.d.). In general, these programs, including SMART Recovery, focus on an individual’s ability to take charge of their recovery, as suggested by the term “SMART” in SMART Recovery, which is an acronym that stands for “Self-Management and Recovery Training.” As with LifeRing and S.O.S., participants can be religious; however, “if you do not believe in a religion or spirituality, that’s fine” (SMART Recovery n.d., paragraph 1).