Making Space for Spirituality While Treating Substance Use Disorders

As a graduate student new to addiction treatment, I have felt a growing curiosity about the degree to which spirituality is brought into psychotherapy. I attend a private religious university, thus my first therapy patients routinely spoke of God, recited scripture, or wrestled with interpretations of morality. This simultaneously became a sublime and perilous feature of my graduate work. Now, as a new intern at a Veterans Affair clinic, spirituality has taken on a new form as I work to make sense of addiction in the therapy room.

I will start with some definitions, although many variations exist, for spirituality and religion. The two are commonly intertwined but, at times, are intentionally separated. Nolan et al. (2011) provides a comprehensive definition of spirituality: “the aspect of humanity which refers to the way one seeks and expresses meaning, purpose, and connection to the moment, the self, others, nature, and the significant or sacred” (p. 87). Religion might be viewed as the hardware to this software; the beliefs, the customs, the culture, the rites, and rituals. Religion is not necessary for spirituality, but commonly connects an individual to a broader community and history through membership.

When it comes to treating addiction, we aim to help our patients move towards recovery; this stands as our desired outcome. The word recovery itself has many definitions within psychological literature (Worley, 2016). Despite the inevitable range of definitions, all reference a form of change or growth. The American Society of Addiction Medicine (2013) defines recovery as “the process of sustained action that addresses the biological, psychological, social, and spiritual disturbance inherent in addiction” (p. 2). The incorporation of the spiritual into the typical biopsychosocial model (Engel, 1980) is not always made. This seems pertinent to addiction treatment specifically. The recovery experience has remained riddled with themes closely or directly tethered to spirituality, including moving from shame to compassion, isolation to connection, death to life, listlessness to meaning, etc. Perhaps the spiritual is more necessary or unavoidable in this space compared to psychiatric others.

A defining feature and foundation of addiction treatment is, of course, Alcoholics Anonymous (AA). From its origin, AA has emphasized spiritual awakening and the importance of relying on a higher power (Alcoholics Anonymous World Services, Inc., 2001). One qualitative analysis of AA members identified love as the most frequently cited trait of patients’ Higher Power (Arnaud et al., 2015). Twelve-step programs have accrued empirical support for effectively treating those with substance use disorders, with noted short and long term benefits (Humphreys et al., 2014; Kelly, 2017; Tonigan et al., 2018). While spirituality is likely not an isolated mechanism of change for these desired outcomes, it is likely an integral aspect. Texts written by Bill Wilson, a co-founder of AA, highlights the spiritual fervor woven into the 12-step framework: “It was only a matter of being willing to believe in a power greater than myself. Nothing more was required of me to make my beginning” (Alcoholics Anonymous World Services, Inc., 2001, p. 12).

Systematic literature reviews of spirituality and substance use disorder (SUD) recovery have found significant links between the two, aiding individuals in achieving abstinence (Walton-Moss et al., 2013). Research has gone as far as to identify evidence for “spiritual struggles” as a possible risk for later development of addictive behaviors (Faigin et al., 2014; Stauner et al., 2019). It is important to note the more robust establishment of traumatic experiences a possible risk for addictive behaviors. It has been estimated that 30-50% of individuals seeking treatment for SUD have met criteria for post-traumatic stress disorder (PTSD) in their lifetime. In other words, individuals with PTSD are 4-5 times more likely to have a SUD compared to their peers without PTSD (Brady et al., 2020). The wounds of trauma can surely contribute to spiritual wounds. The latter, of course, is more elusive and not described within the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR; American Psychiatric Association, 2022).

So, where do we begin? Engagement with spirituality/religion inevitably leads to a myriad of big questions; and often, the biggest questions. Measurement-based care is proposed to be an effective starting point for clinicians hoping to incorporate spirituality into their therapeutic care (Connery & Devido, 2020; Worley, 2020). This approach has gained momentum as an ideal clinical process that allows for routine incorporation of patient-reported data (collected via a standardized assessment tool) into treatment decisions. This process of gathering and analyzing information better allows clinicians to make an informed conceptualization as well as engage the patient in their care. Suggested instruments include the Spirituality Self-Rating Scale (Galanter et al., 2007), the Brief Multidimensional Measure of Religiousness/Spirituality (Stewart & Koeske, 2006), the Index of Core Spiritual Experience (INSPIRIT-R; Heinz et al., 2007), the Spiritual Transcendence Scale (Piedmont, 2004), and the Spiritual Well-Being Scale (Ellison, 1983). These measures can aid in information gathering, provide a starting point for discussions, and gauging patient willingness and openness to discussing certain topics. Assessment of a patient’s spiritual/religious history and challenges, allows us to function as culturally considerate clinicians. It has also been recommended for the development of a therapeutic alliance to precede discussions about these topics (Post & Wade, 2009). It is additionally crucial to appreciate religious/spiritual diversity and be careful to not impose one’s own beliefs onto patients (Johnson et al., 2007). While those struggling with addiction could be more willing to explore this portion of their identity, it should not be assumed that all are interested or willing to do so.

It is worth noting that the more abstract or vast the construct, the more error we are subject to in our reduction for the sake of measurement. The question of whether it is theoretically possible to conceptualize complex constructs with sufficient accuracy remains relevant today (McGrath, 2005). If there were to be a construct impossible to capture through measurement, spirituality might be at the top of the list. While we work as a field to improve the measurement of psychosocial phenomena, measurement of spiritual phenomena might be outside our wheelhouse at times. I would be remiss to not reference how Western, Educated, Industrialized, Rich, and Democratic (WEIRD) this point of view is to begin with; my point of view and maybe yours too (Henrich et al., 2010). This is especially pertinent when working with patients who may not identify with a WEIRD experience. I can’t help but think about the degree of spiritual practice  Western society has destroyed or delegitimized throughout history. Unfortunately, clinical judgment worsens as the religious beliefs of a patient become more unfamiliar (O’Connor & Vandenberg, 2005). At times, clinicians can even misinterpret certain religious beliefs as pathological. For example, O’Connor & Vandenberg (2005) found that American mental health professionals were more apt to rate Islamic beliefs as pathognomonic, contrasting significantly from interpretations of Christian beliefs. Acknowledging the flaws and biases in our field is critical in order to avoid perpetuating harm.

Regardless of its complexity, spiritual diversity is commonly viewed as a neglected dimension when considering multicultural competency. It is estimated that up to 89% of mental health professionals agree that clinicians should receive training in religious/spiritual competencies (Vieten et al., 2023). This same research estimated that 47% of mental health professionals had not received much training of this nature at all. Generally, there is a lack of research on providers’ spiritual landscapes and interactions with their clinical work. Given the complexity and controversy of this cultural component, this is not surprising. Hollins (2008) proposed that clinicians should explore their own beliefs in order to best help patients. Yet, it is uncommon that therapists are encouraged to explore religious/spiritual beliefs and biases in graduate school (Hage et al., 2006). There is also evidence that the majority of individuals did not discuss their beliefs with their colleagues given worries about the potential for conflict (Pelechova et al., 2012). If not in graduate school and if not in our careers, where is the space to reflect on these features of identity and diversity? On both a micro and macro level, we should aim to increase our tolerance for discussion and difference.

Reviewing the literature and discussing this topic feels a bit as if I’ve entered the Wild West. I am aware of that sublime and perilous feeling referenced earlier. This space of religion/spirituality can become convoluted with biases, overstepping, and boundary crossing. Pelechova et al. (2012) beautifully shed light on the common conflict between science/academia and religion/spirituality. There is often an overt or covert dichotomous distinction between the two. The first being objective and evidence-based and the latter as anecdotal and illusive, thus leading to questions about the possibility of integration. Maybe the best thing we can do to improve our efficacy as professionals is to reflect on our own integration of spirituality and academia. Or, maybe the best thing we can do is gain insight into our resistance to do so.

I am sure most of us have felt in over our heads when confronting spirituality/religion in the therapy room. I am also sure most of us have felt in over our heads when confronting the complexities and challenges of addiction. Merging the two is quite the feat. Keep in mind, we are therapists and not clergy, let alone shamans. While we do not need to be spiritual leaders, we can exist as fellow travelers (Yalom, 2002). Through open personal reflection and interpersonal deliberation, we can improve our understanding as individuals and a whole.