Spirituality and Addiction

Many academicians and patients understand spiritualityas a loaded or, at times, intimidating concept; this is because they impute to it notions of sectarian religious indoctrination, mythology and superstition. In addition to the ambiguity of this concept, difficulties in measuring spirituality have discouraged mental health and social researchers from investigating its influence on physical and mental health. Ingeneral,mentalhealthspecialists involvedin the care of addicted patients are more aware of the role of spirituality in recovery. However, it continues to be a relatively neglected area of studyandresearchinthetreatmentofaddictions, despite growing evidence of its potential benefits to recovery. A growing number of accredited medical schools in the United States offer courses on spirituality in medicine (1), but they are still far from proposing a clear empirical understanding of the potential usefulness of spirituality in themedical field.Many academicians in higher education find themselves searching for meaning in their own lives but do not appear to acknowledge that search in their own students or patients. A challenge is ahead of us. How can we make our lives and the lives of our patients less fragmented and more authentic? Above and beyond the multiplicity of interpretations of spirituality, recognizing the search for values, meaning, purpose, and a sense of transcendence offers an opportunity for the realization of personal accountability, social integration, positive thinking and emotional balance. Clinicians in the field of addictions cannot ignore spirituality because many patients in the process of recovery report that spiritual experiences play a leading role in their path to recovery. A strong connection to a source of spiritual support is considered one of the main favorable prognostic factors (2). The most important, and best studied, source of knowledge on spiritual experiences in recovery is derived from studied on participation in 12-step programs such as Alcoholics Anonymous (AA). Clinicians working in addictions could effectively reduce their patients’ resistance by becoming more comfortable with the spiritual dimensions of healing (3).

Many academicians and patients understand spirituality as a loaded or, at times, intimidating concept; this is because they impute to it notions of sectarian religious indoctrination, mythology and superstition. In addition to the ambiguity of this concept, difficulties in measuring spirituality have discouraged mental health and social researchers from investigating its influence on physical and mental health. In general, mental health specialists involved in the care of addicted patients are more aware of the role of spirituality in recovery. However, it continues to be a relatively neglected area of study and research in the treatment of addictions, despite growing evidence of its potential benefits to recovery.
A growing number of accredited medical schools in the United States offer courses on spirituality in medicine (1), but they are still far from proposing a clear empirical understanding of the potential usefulness of spirituality in the medical field. Many academicians in higher education find themselves searching for meaning in their own lives but do not appear to acknowledge that search in their own students or patients. A challenge is ahead of us. How can we make our lives and the lives of our patients less fragmented and more authentic? Above and beyond the multiplicity of interpretations of spirituality, recognizing the search for values, meaning, purpose, and a sense of transcendence offers an opportunity for the realization of personal accountability, social integration, positive thinking and emotional balance.
Clinicians in the field of addictions cannot ignore spirituality because many patients in the process of recovery report that spiritual experiences play a leading role in their path to recovery. A strong connection to a source of spiritual support is considered one of the main favorable prognostic factors (2). The most important, and best studied, source of knowledge on spiritual experiences in recovery is derived from studied on participation in 12-step programs such as Alcoholics Anonymous (AA). Clinicians working in addictions could effectively reduce their patients' resistance by becoming more comfortable with the spiritual dimensions of healing (3).

RELIGION VS. SPIRITUALITY
Each person views her or his spirituality in a unique way. For some individuals, conven-tional religious beliefs are part of spirituality while for others such beliefs may play little or no part. The general definition of spirituality is therefore controversial. It is related to but not synonymous with religiousness. Religiousness displays specific behavioral, social, doctrinal and denominational characteristics because it involves a system of worship and doctrine that is shared by a group.
Within a broader construct, spirituality encompasses the individual's sense of self, sense of mission and purpose in life, and the personal meaning that each individual derives from her or his work. In contrast to religion, spirituality connotes a direct and personal experience of that which each individual considers sacred; this connotation is un-mediated by a particular belief system prescribed by dogma or by hierarchical structured defined by roles such as the priest, the minister, the rabbi, the gurus, or other defined leaders (4). A person may develop higher levels of spirituality without believing in God or practicing a religion.
Spirituality is described as referring to people who are concerned with metaphysical issues as well as daily life. Spirituality can be defined as a relationship between an individual and a transcendent or higher being, force, energy or mind of the universe (5). This relationship is personal and does not require affiliation with any religion. However, in the United States, organized religion provides the most common path to spiritual growth and development, and helps provide answers to spiritual questions (6).

SPIRITUALITY AND PHYSIOLOGICAL PATHWAYS
Spirituality may provide a cushion against both major and minor stressors through the modulation of physiologicalpathways. Through neuro-endocrine mechanisms (via cathecolamines, serotonin and cortisol), negative emotions have been associated with pathogenic mechanisms including myocardial ischemia (7); arrhythmias (8) increase platelet aggregation (9) and suppressed immune system function (10). Spiritual practices elicit a relaxation response, as opposed to a stress response reducing muscle tension, decreases activity of the sympathetic branch of the autonomous nervous system and reduces activity of the anterior pituitary-adreno-cortical (10) axis, blood pressure and heart rate. In addition spiritual practices improve oxygenation and alter brain wave activity and function. Biological studies on meditation showed an inverse correlation between levels of spirituality and 5HT receptor density, suggesting an active role of spiritual practices in the serotoninergic system in the brain (11).

SPIRITUALITY AND STRESS
Social affiliation enhances the stress relief effect of spirituality; this is because spirituality and social connectedness act synergistically. Social relationships serve as positive reinforcement for continued affiliation to and compliance with group norms. Social connectedness and absence of depression have been associated with improved information about health care resources, better compliance with health care regimens and quicker response to acute health crises (12). Stress is well known to compromise physical health. A variety of diseases are related to high levels of stress; these range from cardiovascular illness to rheumatic, dermatologic, digestive, psychiatric and immunologic illnesses. Spiritual practices have been used for centuries in several cultures to prevent stress and emotional disconnections. Meditation, prayer, relaxation techniques, better time management and maintaining a sense of meaning and purpose are proven as effective resources to cope with stress.

SPIRITUALITY IN SUBSTANCE USE DISORDERS
Several studies support a relationship between spirituality and positive outcomes in substance use disorders. Moreover, religiousness and spirituality may protect against disease indirectly by association with a healthy lifestyle. The association between moderation and control in alcohol or drug use and religiousness is well established. Highly religious people are consistently less likely to abuse drugs or alcohol than less religious people. Studies suggest that spirituality may be an important di-mension of patient experience to assess in future addiction outcome research (13).

SPIRITUALITY AND ALCOHOLICS ANONYMOUS (AA)
AA includes a spiritual experience with a higher power in its 12-step fellowship program. A fellowship is " a friendly relationship or companionship; community of interests, feeling etc.; an association of persons having similar interests." AA defines its purpose and vision as a "fellowship of men and women who share their experience, strength and hope with each other, that they may solve their common problem and help others to recover from alcoholism" (14). AA is not a religion. In fact, Bill W's departure from "preaching" followed the discovery that a religious approach did not work for most alcoholics. The 12-step program can be considered the product of field research, the effectiveness of which continues to be supported by recent clinical research (13). Learning from AA's method of delivering spiritual care interventions could help design a practical model to apply and generalize the spiritual dimension to other recovery modalities.
AA does not require learning any theology, creed or catechisms; atheists are welcome and do well in the program. Most patients in AA approach the spiritual journey as a needed element in their recovery. As specialists in addiction psychiatry and medicine, and as educators in substance abuse, we should understand and transmit to colleagues and patients the usefulness of spiritual experiences in the recovery process.
Other spiritual fellowships that recognize and incorporate the spiritual dimension in recovery are Narcotics, Cocaine, Nicotine and Methadone Anonymous (15).

WHAT ARE THE BENEFITS OF SPIRITUALITY?
Why should an individual make an effort to develop spirituality? We are all seeking for something. Naturally and intrinsically, whether we are aware or not, the tendency to achieve something declares a purpose. The purpose of existence is different for different individuals. Yet, the common denominator is the purpose.
The spiritual experience provides a calm or peaceful state of mind and a sense of harmony or internal integration that stimulates positive thinking; it also provides a high level of sensitivity and a degree of stability necessary for inner contentment. William James, the father of modern psychology, stated that 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." In comparison to the literature in the fields of general psychiatry and medicine, the literature in the field of addiction treatment is rich with references to spirituality. However, research is needed in order to systematicallystudy the relationship between spirituality and recovery. McDowell et al. (16) showed that patients view spirituality as essential for their recovery and highly prioritize spiritual programs in their treatment. This is because the spiritual aspect of the treatment is concerned with meaning and purpose, and it includes concepts of one's sense of connection to something bigger than the self. It is also concerned with the belief that we are here to help others by sharing and enriching each other's lives. Spiritual growth embodies a powerful connection to people, the world, or the universe. It may stimulate high values like compassion, generosity, creative self-expression, trust, faith, respect, hope, self-awareness, and it usually brings about self-acceptance.
In summary, there is clear evidence that spirituality plays a significant role in physical and mental health recovery. Its influence should be researched in a more systematic way. Clinicians in the field of addictions might benefit from skillful use of the spiritual dimension in the treatment of addictive disorders.