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Substance Abuse Treatment Modalities: Literature Review

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Spirituality is not considered to exist as a single treatment technique, but rather as a general orientation with which a person approaches drug or alcohol treatment. For example, Strachan (1982) suggests that spirituality is a type of lifestyle necessary for "whole recovery" of the alcoholic/addict. Likewise, Whitfield (1985) observed that the physical, mental and spiritual recovery in a program is a "way out" of needless suffering for all humankind.

Given its' existence as an orientation toward substance abuse treatment, there appears to be a variety of definitions of spirituality. Dollard (1983) defined spirituality as "concerned with our ability, through our attitudes and actions, to relate to others, to ourselves, and to God, as we understand him". Mikulas (1987) uses the term spiritual to refer to practices, insights, states of being and frames of reference that are most influenced by forces beyond and inclusive of the individual and his personal, interpersonal, and suprapersonal, or transcendent experiences. Brown and Peterson (1991) have defined spiritual progress as advancement toward or in the development, experience, integration, or acquisition of those ego-transcending behaviours, cognitions, values, attitudes , practices, or beliefs that are manifested in the personality change sufficient to bring about recovery from a previously maladaptive state of being. Although varied, the commonality among the definitions is that spirituality transcends all aspects of treatment and therefore provides a common link toward integrating treatment components and a general lifestyle supportive of drug and alcohol abstinence.

In defining spirituality, many experts are quick to point out that it is separate from religion, where the former is described as daily action and the later as conformity to a belief, doctrine or theology (Brown & Peterson, 1991; Brown et al., 1988). This distinction, or lack thereof, has been offered as the primary reason why some (e.g., Chiauzzi & Liljegren, 1993; Peele, 1989) question the utility of a spiritual treatment approach. Brown, Peterson and Cunningham (1988) have suggested that the confusion surrounding the distinction between spirituality and religion has resulted in the former being either avoided, presented in a manner offensive to a larger population of substance abusers or presented inadequately in content or method.

To clarify what actually constitutes spirituality, Brown & Peterson (1991) developed the Brown-Peterson Recovery Progress Inventory (B-PRPI); a measure of spirituality and spiritual practices that are common in "working" twelve step oriented programs. Across 3 separate samples of individuals attending twelve step programs, results showed a high consistency in the reported use of a number of spiritual practices. Over two-thirds of the normative sample reported having completed a "fourth" and "fifth" step, making amends, engaging in prayer, "telling their story", listening carefully, maintaining regular sleep habits, and avoiding "people, places, and things" not conducive to their ongoing recovery. A similar proportion reported more cognitive behaviours, such as admitting powerlessness, belief, trust, and faith in a Higher Power, "turning it over", accepting "life on life's terms", experiencing more real relationships with others, and experiencing freedom from "mental obsessions" about or with the "object of their dependency". The respondents reported viewing all of the above as constituting spirituality, leading the authors to conclude that spirituality and spiritual practices represent a "broad-based approach" in twelve step oriented treatment programs.

Although spirituality consists of a myriad of practices and lifestyles, the majority of substance abuse treatment programs that espouse a spiritual approach embrace the specific steps suggested within the original twelve steps of Alcoholics Anonymous (AA). A detailed description of the actual steps can be found elsewhere , but suffice it to say that the first step establishes the spiritual orientation by asking individuals to admit helplessness over their dependency and to appeal to a "Higher Power" to assist them in their recovery. The Higher Power need not represent God or indeed any form of religion, but rather is defined by the individual as his/her source of support in overcoming and abstaining from problematic substance use. As described by the co-founder of AA, Bill W., twelve-step spirituality requires a minimum of faith and allows a nearly unlimited choice of spiritual belief and action.

Brown, Peterson and Cunningham (1988) have proposed a three dimensional cognitive-behavioural approach to spirituality in achieving the twelve steps, but it has not as yet been examined for effectiveness among different groups of substance abusers. Emrick (1987) has examined the relationship between AA speaking, meeting attendance, sponsorship, taking steps Four and Five, and working on steps Six through Twelve to drinking outcomes in treatment graduates. Results showed support for following the behavioural guidelines of the AA program and higher success rates in recovery. The limitation of these findings is that no actual data was gathered on the spiritual practices of the subjects.

In terms of hard scientific evidence, there is little empirical evidence on the efficacy of spirituality in substance abuse treatment. We should caution, however, that there has not been a great deal of scientific investigation examining the link between spirituality and positive behaviour change. What does remain, however, are millions of the adherents to 12 step programs making powerful testimonies about the pivotal role that spirituality plays in the recovery process. Overall, regardless of current evidence on treatment outcomes, spirituality will remain a central component of most if not all traditional treatment approaches with anecdotal evidence (individual testimonies) pointing to the powerful relationship between spirituality and recovery.

References for Spirituality:

Brown, H., Peterson, J., & Cunningham, O. (1988), “Rationale and Theoretical Basis for a Behavioural/Cognitive Approach to Spirituality”, Alcoholism Treatment Quarterly, 5(1/2), 47-59.

Brown, H., & Peterson, J. (1991), “Assessing Spirituality in Addictions Treatment and Follow-Up: Development of the Brown-Peterson Recovery Progress Inventory (B-PRPI)”, Alcoholism Treatment Quarterly, 8(2), 21-45.

Chiauzzi, E., & Liljegren, S. (1993), “Taboo Topics in Addictions Treatment: An Empirical Review of Clinical Folklore”. Journal of Substance Abuse Treatment, 10, 303-316.

Dollard, J. (1983), Toward Spirituality: The Inner Journey, Center City, Minn.: Hazelden.

Emrick, C.D. (1987), “Alcoholic Anonymous: Affiliation, processes, and effectiveness as treatment”, Alcoholism: Clinical and Experimental Research, 11 (5), 416-423.

Strachean, J.G. (1982), Alcoholism: Treatable Illness. Center City, Minn.: Hazelden Foundation.

Whitfield, C.L. (1985), Alcoholism, other drug problems, & spirituality: A transpersonal approach. Baltimore, MD: The Resource Group.