ADDICTION AND SPIRITUALITY
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Jaime Grodzicki, M.D.
Associate Director Division of Alcohol and
Substance Abuse
Director of Substance Abuse Referral Program
(SARP)
NYU/Bellevue Hospital Center
OBJECTIVES
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 To improve the ability of physicians and other
mental health clinicians to understand the value of
spirituality and religious renewal in clinical
practice
 To position the role of spirituality as an effective
instrument of change in the treatment of
addictions
 To enhance the ability to integrate the elements of
spirituality into the overall treatment of patients
OVERVIEW
 Concepts in Addiction Psychiatry
 Framework of Spirituality
 Spirituality vs. religion
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Biological correlates
Spirituality in clinical practice
Spirituality and Substance Related Disorders
Spirituality and Alcoholics Anonymous
Spirituality as an instrument of change
Summary
WHAT IS AN ADDICTION?
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Addiction is a behavioral pattern of drug abuse
characterized by:
 Overwhelming involvement with:
 the use of a drug (compulsive use and loss of
control)
 The security of its supply
 High tendency to relapse after discontinuation.
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS AN ADDICTION?
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 Addiction is a
 Progressive
 Chronic
 Relapsing
 Primary
 Disease (potentially fatal)
 Characterized by
 Compulsion
 Loss of control
 Continued drug use despite adverse consequences
 Distortion in normal thinking
WHAT IS DRUG ABUSE?
_________________________________
Self–administration of any drug in a culturally
disapproved manner that causes adverse
consequences
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS DRUG DEPENDENCE?
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The physiological state of neuro-adaptation
produced by repeated administration of the
drug, necessitating continued administration
to prevent the appearance of the withdrawal
syndrome
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS TOLERANCE?
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Tolerance develops when after repeated
administration, increasing larger doses of a
drug must be administered to obtain the
effects observed with the original use
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS WITHDRAWAL?
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The psychological and physiological reactions to
abrupt cessation of a dependence-producing drug
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS REBOUND?
_________________________________
The exaggerated expression of the original condition
sometimes experienced by patients immediately
after cessation of an effective treatment
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
BRAIN REWARD PATHWAYS
Nucleus
accumbens
Ventral tegmental area
(VTA)

The VTAnucleus
accumbens
pathway is
activated by all
drugs of
dependence

This pathway is
important not
only in drug
dependence, but
also in essential
physiological
behaviors such
as eating,
drinking,
sleeping, and sex
RELAPSE AND CONDITIONING
Bed nucleus of the
stria terminalis
Prefrontal Cortex
Hippocampus



Nucleus
accumbens
Amygdala
Ventral tegmental area
(VTA)
Repeated substance
use has caused
“conditioning” to
occur in related
circuits
Now “cues”
associated with
substance use can
activate the reward
and withdrawal
circuit
This can evoke
anticipation of the
substance or
feelings similar to
withdrawal that can
precipitate relapse
in an abstinent
patient
Source:
Messing RO. In:
Harrison’s Principles of
Internal Medicine.
2001:2557-2561.
ADDICTION AFFECTS THE FOLLOWING
DOMAINS:
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PHYSICAL
SOCIAL
EMOTIONAL
COGNITIVE
SPIRITUAL
FAMILY
___________________________
“The greatest revolution of our generation is the
discovery that human beings, by changing the
inner attitudes of their minds, can change the outer
aspects of their lives”
William James (1852-1910)
GOALS OF TREATMENT IN ADDICTIONS
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Maximizing motivation for abstinence
Rebuilding a substance-free life style
Helping to maximize multiple aspects of life functioning
Optimizing medical functioning
Identifying and treating psychiatric symptoms and
disorders
Dealing with marital and other family issues
Enriching job functioning and financial management
Addressing relevant spiritual issues
Dealing with the homelessness
Relapse prevention
Schuckit, M Textbook of Substance Abuse Treatment. Am.Psych.Press (1994) pp. 3-10.
___________________________
“The greatest use of a life is to spend it on something
that will outlast it”
William James (1852-1910)
WHAT IS SPIRITUALITY?
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A part of a person that searches for transcendent
meaning and purpose in life and allows the person
to transcend his or her conflict or suffering
Puchalski, et al. Clin Geriatr Med 20 (2004) 689-714
A personal relationship between an individual and a
transcendent or higher being, force, energy or
mind of the Universe.
Whitfield,C. Alcoholism Treatment Q. 1:3-51 (1984)
WHAT IS SPIRITUALITY?
_________________________________
“Spirituality is recognized as a factor that
contributes to health in many persons. This
concept is found in all cultures and societies. It’s
expressed in an individual’s search for ultimate
meaning through participation in a religion, but it
can be much broader than that, such as, belief in
God, family, naturalism, rationalism, humanism,
and the arts.”
Puchalski,C. In: Carter R, editor. Caregiving book series. Americus (GA): Rosalyn Carter
Institute for Human Development, Georgia Southwestern State University: 2003.
SPIRITUALITY
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 Encompasses the individual’s sense of self, sense
of mission and purpose in life
 It connotes a direct and personal experience of
what each individual considers sacred and it is not
mediated by a particular belief system prescribed
by dogma or by hierarchical structure
 It is not defined by roles such as priests, ministers,
rabbis, gurus, or other defined leaders
Berenson, DA J. of Strategic and Systemic Therapies 1990;9(1):59-70.
SPIRITUALITY AND RELIGION
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 94% of Americans believe in God or a Higher
Power
 75% of Americans say religion is central to their
lives
 62% of Americans claim to be a member of an
organized religion
 9% of Americans stated that they have no religion
preference
(N=1037 adults; December 1999; Gallup/CNN; USA today)
SPIRITUALITY AND RELIGION
SPIRITUALITY
BOTH
Involves a sense of self, Sense of trascendence
mission and purpose.
Basis of meaning and
Unrelated to a specific purpose in life and
dogma, belief system or work
defined roles
Help give meaning to
suffering
Extend individual’s
copying resources.
RELIGION
Displays specific
behavioral, social,
hierarchical, doctrinal
characteristics.
Involves a system of
worship and doctrine
shared by a group
Involves an authority
or leader (priest, ,rabbi,
guru, minister, iman)
“A person may develop higher levels of
spirituality without believing in God or
practicing a religion”
Gorsuch,RL Research on Alcoholics Anonymous, Rutger Center for Alcohol Study, New
Brunswick, NJ, 1993,pp.301-318.
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MYSTICAL EXPERIENCE
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“An uplifting sense of genuine spiritual union
with something larger than the self”
Underhill, 1999; Essentials of Mysticism.
BIOLOGICAL CORRELATES
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 Meditation: apnea, EEG changes
(Corby AH, et al., Arch Gen Psychiatry, 1978)
 Out of body experience: right angular gyrus: sees
self “floating above the bed”
(Blanke O et al., Nature, 2002)
 5HT-1A receptor density inversely correlated with
spiritual acceptance scale
(Borg J et al., Am J Psychiatry 2003)
BIOLOGICAL CORRELATES
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NONSPECIFIC AROUSAL: Epinephrine can result
in happiness or malaise
(Schacter S, Singer JE. Psychol Rev 69:319, 1962)
HEMISPHERIC DISSOCIATION: Severed corpus
callosum and right hemisphere stimulation: epileptic
patient waves his hand and creates an explanation
Gazzaniga MS. Bisected Brain 1970
DEPRESSED young monkeys are given either
imipramine or are introduced to peers: depression
resolved
Suomi S et al. Arch Gen Psychiat 35:321, 1978
OUT OF BODY EXPERIENCE
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. . .“a person’s consciousness seems to become
detached from the body”
Right angular gyrus stimulation: to find a
temporal lobe seizure focus. Patient reports
she sees herself “floating 2 meters above the bed –
Her legs appeared to be moving toward her face”
Blanke O et al. Nature 419:269,2002
SEROTONIN AND RELIGIOSITY
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 5HT-1A receptor density measured by ligand
binding on PET study; correlated with
 Temperament and Character Inventory,
2 scales:
(a) self-transcendence (religious behavior) and
(b) spiritual acceptance (of phenomena not
explained by objective demonstration)
Borg J et al. Am J Psychiatry 160: 1965, 2003
THE RELIEF EFFECT
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Social and spiritual affiliation produces a relief in
distress symptoms. The relationship serves as an
operant reinforce for continued affiliation and
compliance with group norms
Galanter, M. Psychiatric Services 2002 ; 53: 1072-1074.
RELIGION AND SPIRITUALITY IN CLINICAL
PRACTICE
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DSM-IV – V62.89 : Religious or Spiritual Problem
(i.e. distressing experiences that involves loss or
questioning of faith, conversion to a new faith, questioning
of spiritual values)
PRACTICE GUIDELINES FOR PSYCHIATRIC
EVALUATION IN ADULTS
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“The process of psychiatric evaluation must take into
consideration and respect the diversity of
American subcultures and must be sensitive to the
patient’s ethnicity and place of birth, gender,
social class, sexual orientation and
religious/spiritual beliefs”
APA Practice guidelines, 1995.
Cultural Assessment for Diagnosis and Care
Differential Diagnosis
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Religious/spiritual phenomena
Religious/spiritual problem
Culture-bound syndrome
Mental disorder
Possibility of concurrent diagnosis
Cultural Assessment for Diagnosis and Care
Treatment Plan
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Biomedical
Psychological
Socio-cultural
Spiritual/Religious
Spiritual/Religious treatment plan includes:
 Ongoing assessment and formulation
 Respect, empathy and boundaries
 Modification of psychotherapy when
indicated
 Spiritual/Religious interventions when
indicated
Ethnic and Cultural Considerations
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Diagnostic assessment can be especially
challenging when:
 a clinician from one ethnic & cultural group
uses the DSM IV classification to evaluated an
individual from a different group
 a clinician who is unfamiliar with the nuances
of the individual’s cultural frame of reference
may incorrectly judge as psychopathology
SPIRITUALITY IN SUBSTANCE USE
DISORDERS (SUD)
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 Direct correlation between spirituality and
positive outcomes in SUD
 Patients in recovery often prioritize spiritual
programs in their treatment
 Spirituality is an essential part of the
recovery process
IMPORTANCE TO RECOVERY (RANK ORDER)
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Medical Students’ View
Patients
(N=119)
(N=101)
of Students of Patients
Inner Peace
1
8
7
Medical Services 2
3
3
Belief in God
3
9
11
AA
4
11
5
Outpatient Tx
7
4
2
Gov’t Benefits
9
2
9
Goldfarb L et al., Am J Drug Alcohol Abuse, 1996; McDowell D et al.,
J Addic Dis, 1996
ALCOHOLICS ANONYMOUS (AA) AND
SPIRITUALITY
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 AA includes a spiritual experience with God or a
Higher Power in its 12-step fellowship program
 AA includes a spiritual journey as a needed
element of recovery
 AA integrates the spiritual dimension as an
essential method of delivering care
 AA is not a religion
 AA success is the product of field research
supported by clinical research
ALCOHOLICS ANONYMOUS (AA) AND
SPIRITUALITY
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THE HOUSE OF SOBRIETY
(From: Recovering, How to Stay Sober, Mueller and Ketcham 1987).
SPIRITUAL
MENTAL
EMOTIONAL
PHYSICAL
ABSTINENCE
(THE FOUNDATION)
SPIRITUAL CONCEPTS
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Spiritual belief: “God or Higher Power can restore him/her to
sanity”AA – Step 2
Spiritual principles: Code of conduct or frame for action that
moves people toward the realization of values
Spiritual values: Qualities or ideals culturally derived, highly
regarded by a group or society leading to self-acceptance
Spiritual experience:Moment of clarity or a felt sense of
wonder, elation, peace or fulfillment
Spiritual growth:Embodies a powerful connection to people,
the world or the universe
SPIRITUAL BEHAVIOR
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Prayer
Meditation
Walking in nature
Reading poetry/sacred texts
Lighting a candle
Listening to music
Smelling incense
HOW TO INCORPORATE SPIRITUALITY AS AN
EFFECTIVE INSTRUMENT OF CHANGE
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 Assess and understand patient’s spiritual beliefs
 Acknowledge respect and listen carefully to patient’s
beliefs
 Explore emotions and make empathic statements
 Elicit spiritual themes
 Stimulate spiritual narrative
 Connect spirituality with social affiliation and recovery
 Mobilize support
PITFALLS IN DISCUSSIONS ABOUT
SPIRITUAL ISSUES
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 Trying to solve the patient’s problems or resolve
unanswerable questions
 Going beyond the clinician’s expertise and role
 Imposing the clinicians spiritual religious beliefs
on the patient
 Argue with patient’s view point or spiritual
beliefs.
OVERVIEW
 Definition of addiction
 Definition of spirituality
 Spirituality vs. religion





Biological correlates
Spirituality in clinical practice
Spirituality in substance related disorders
Spirituality in Alcoholics Anonymous
Spirituality as an instrument of change
SUMMARY
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 The ability of addicted people to establish a substance-free
recovery draws on their ability to achieve a meaningful,
spiritually-grounded life for themselves.
 Ability to inquire about the religion and spiritual life of
patients is an important element of our clinical and
psychotherapeutic competency.
 Millions achieve recovery status through the spiritual
fellowship of AA.
 An integrated medical, psychosocial and spiritual treatment
is a much needed model to achieve recovery in addicted
patients.
THANK YOU