Below is an edited version of the 300-level essay I submitted as part of my psychology degree back in 2014.The paper was Abnormal and Therapeutic Psychology Assignment. At the time, I was struggling with the focus placed on pathologizing peoples behavior—ascribing a sickness mindset, rather than looking at holistic and systemic issues that impacted people’s ability to heal, or not—so I took a ‘risk’ and wrote about something I was genuinely interested about and believed in—the power of spirituality to heal. I still love the opening quote—a powerful reminder that we are not powerless…we can (and do) heal ourselves…very often without drugs, expensive rehab and medical intervention.
Date: 25 September 2014
“Science has sometimes been at odds with the notion that laypeople can cure themselves” (Liotta, 2013). Sparking my interest in examining spiritual approaches to the treatment of alcohol addiction, Liotta’s article examines the success of the 12-step programme prescribed by Alcoholics Anonymous (AA) for the treatment of alcohol addiction. AA’s programme has a strong spiritual framework, and Liotta explores the premise that the programme’s success may eventually be empirically validated through medical and psychological science.
The relevance to the domain of abnormal and therapeutic psychology of spiritual approaches to the treatment of alcohol abuse is multi-faceted. For many people, their spirituality is a central part of who they are, and what they believe, and spiritual sources of healing are a major source of strength for many. For others, it may be an, as yet, untapped resource (Dowsett-Johnston, 2013; Miller et al., 2008).
Arguably, no therapeutic approach can be regarded as complete unless the spiritual dimension is attended to yet both history and current practice has shown that ignoring the role of spirituality, forbidding its practice (Bennett, 2009), or pathologising its existence, in favour of more cognitive, rational, or medical interventions is neglectful and can be harmful (Bennett, 2009; Langman, 2013; Miller, 1998). For example, A. Abraham, Prison Manager of Arohata Prison, was informed by forensic staff that they wanted to medicate a woman they thought was psychotic when she said she ‘saw spirit’ and talked to dead ancestors (personal communication, 17 July, 2014).
Importantly in New Zealand particularly, enabling spiritual approaches to the treatment of disease is also arguably evidence of honouring the commitments made in the Treaty of Waitangi, yet this is not always actively embraced and at times has been outlawed. (Bennet, 2009) cites the Tohunga Suppression Act, 1907 which threatened criminal conviction if a person allowed a Maori person to treat them using spirituality, “by professing or pretending to profess supernatural powers in the treatment or cure of any disease” (Bennet, 2009, p. 171)
Spirituality is difficult to define given the uniqueness of the experience for people, and differing orientations to spirituality – including a diverse range of religious beliefs (Miller, 1998). However, the view that spirituality is “that which gives people meaning and purpose in life” (Puchalski, Dorff & Hendi, 2004 as cited in Galanter, 2007, p. 266) appears to have a universally applicable meaning. Galanter (2007) also notes that spirituality is not something accessible only to people of religious orientation, or self-proclaimed spiritual orientation but accessible to all, including non-believers (often referred to as Agnostics) (Miller, 1998). This echoes the view of Carl Jung who believed spirituality was an intrinsic part of being human and that lack of connection to one’s spiritual self leads to dis-ease, including the disease of alcohol addiction (Galanter, 2007).
Alcohol addiction or alcoholism (also referred to as alcohol dependence) is defined by the American Medical Association (AMA) as “a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations” (Alcohol addiction, 2014). It is characterised by, “a prolonged period of frequent, heavy alcohol use; the inability to control drinking once it has begun; physical dependence manifested by withdrawal symptoms when the individual stops using alcohol; tolerance, or the need to use more and more alcohol to achieve the same effects; and a variety of social and/or legal problems arising from alcohol use” (The Free Dictionary, 2014).
Addiction (termed substance dependence by the American Psychiatric Association) was once defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:
1. Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of the substance.
2. Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance or (b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
3. The substance is often taken in larger amounts or over a longer period than intended.
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5. A great deal of time is spent in activities necessary to obtain the substance (such as visiting multiple doctors or driving long distances), use the substance (for example, chain-smoking), or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
DSM-IV criteria (The Diagnositic and Statistical Manual) for substance dependence include several specifiers, one of which outlines whether substance dependence is with physiologic dependence (evidence of tolerance or withdrawal) or without physiologic dependence (no evidence of tolerance or withdrawal). In addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3) sustained, and (4) sustained partial; on the basis of whether any of the criteria for abuse or dependence have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (such as methadone maintenance) or for those living in a controlled, drug-free environment. Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (Fourth Edition. Washington, DC: American Psychiatric Association, 2000.)
This definition which provides a psychological stance rather than a medical one, was altered in 5th edition of the DSM. As compared to DSM-IV, the DSM-5’s chapter on addictions was changed from “Substance-Related Disorders” to “Substance-Related and Addictive Disorders” to reflect developing understandings regarding addictions.6 The DSM-5 specifically lists nine types of substance addictions within this category (alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; and tobacco). These disorders are presented in separate sections, but they are not fully distinct because all drugs taken in excess activate the brain’s reward circuitry, and their co-occurrence is common.
Problem drinking that becomes severe is given the medical diagnosis of “alcohol use disorder” or AUD in the DSM-V. AUD is a chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using. An estimated 16 million people in the United States have AUD. Approximately 6.2 percent or 15.1 million adults in the United States ages 18 and older had AUD in 2015. This includes 9.8 million men and 5.3 million women. Adolescents can be diagnosed with AUD as well, and in 2015, an estimated 623,000 adolescents ages 12–17 had AUD.
To be diagnosed with AUD, individuals must meet certain criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Under DSM–5, the current version of the DSM, anyone meeting any two of the 11 criteria during the same 12-month period receives a diagnosis of AUD. The severity of AUD—mild, moderate, or severe—is based on the number of criteria met.
To assess whether you or loved one may have AUD, here are some questions to ask. In the past year, have you:
“If you have any of these symptoms, your drinking may already be a cause for concern. The more symptoms you have, the more urgent the need for change,” say professionals.
This brief research paper examines recent research that reveals the significant role of spirituality on mental and emotional health, and therapeutic approaches to the treatment of alcohol addiction. However, as Galanter (2007) notes, it is difficult to measure empirically many of the elements that make spirituality an effective part of treatment. He advocates for “a new model of recovery from addiction that is compatible with the spiritual orientation espoused by many members of AA” (Galanter, 2007, p.265). The new model he defines is, “ based on accounts of substance dependent individuals’ own subjective experience. These experiences are not directly observable by the clinician but are available only as reported through the prism of the person’s own introspection and reflection.” (Galanter, 2007, p.265). Miller (1998) support’s this view and argues that spiritual constructs and measures can be used in addiction research as: “predictor, dependent, covariate, and independent variables” (Miller, 1998, p.982). “Clear hypotheses can be derived and tested in these areas, assuming the reliable measurement of spiritual variables” (Miller, 1998, p.982). However as Miller, Forcehimes, O’Leary, and LaNoue’s (2008) clinical research shows, differences in interpretations, meanings, and values ascribed to definitions may impact reliability and validity.
Galanter, Dermatis, Bunt, Williams, Trujillo, and& Steinke, P. (2006) developed a 6-item scale, the Spirituality Self-Rating Scale (SSR), which attempted to operationalize spiritual constructs and measure patients’ subjective spiritual beliefs. However conceptualising spirituality is challenging, and people may ascribe different meanings to words, and thus misunderstandings and misinterpretations may skew results. For example, one question asks, “Do you believe God or a universal spirit is: c.) an impersonal creator” (Galanter et al., 2006, p.259). The word ‘impersonal’ may suggest a non-caring person. The inability of researchers to always clearly and consistently define constructs may impact reliability and may not be applicable across cultures. And this is a limitation of such measures.
Nevertheless, while defining spirituality and its mechanisms, and evidencing spirituality empirically may be problematic, a body of research suggests common themes, or key mechanisms core to spiritual approaches to successful treatment. These spiritualty dimensions include: the role of attitudes and beliefs; meaning and purpose; community; self-awareness, forgiveness; attachment to God/a higher Power, control, and daily spiritual practice as a source of strength (Lyons, Deane, & Kelly, 2010; Galanter et al., 2006; Miller, 1998).
The growing interest in integrating clients’ spiritual and religious beliefs into addiction treatment is explored by Galanter et al. (2007), who assessed the role of people’s attitudes and orientation toward spirituality and how this affected their views of addiction treatment. The SSR was administered to three distinct groups: a diverse range of patients currently in treatment programmes; doctors and other medical caregivers; and trainee chaplains. It was also administered to people who were not in treatment programmes. Administering the test to a control group was a strength of their research, highlighting that spirituality was rated more highly by those in treatment, than those not suffering from addictions. Despite issues of reliability I have already discussed the strength of their research was also the finding that “medical students and faculty members underestimated the value patients placed on spiritual orientation.” (Galanter et al,, 2007, p. 260). This finding is also shared by other research which highlights the untapped reservoir of help many helping professionals fail to tap into it (Miller et al, 2008).
Empirical research on spirituality and alcoholism reveals that prior to participating in AA’s 12 step programme all participants reported admitted feeling a sense of powerlessness over their alcohol dependency (Brown & Peterson, 2008). During the completion of their 12-Steps they gained a stronger sense of control over their lives and their drinking (Brown & Peterson, 2008; Bliss, 2007; Liotta, 2013). The studies of Robinson et al (2011) controlled for AA involvement, and reported decreases in alcohol abusers previous coping strategies, such as judging, and condemning, and these changes were associated with a greater sense of control and improved drinking outcomes. However these findings were not supported by Miller et al. (2008) which found no changes (Miller et al, 2008). A possible explanation could be the strong religious association with Miller et al.’s study and the negative religious associations participants may have had, especially given the directive nature of the research. Robinson (2011) found that participants who felt judged, abandoned, or punished by God “were less likely to feel in control of their lives than those who had a ‘benevolent perception of and relationship to a deity” (Robinson et al, 2011, p. 660). Moreover differences in the two findings may also be explained by Miller et al.’s use of video recordings and monitoring of sessions where Robinson et al. did not use these techniques.
Langman and Cheung Chung (2013) widened the focus of their research, exploring the impact of co-existing conditions (e.g. trauma) among people with addiction, but their findings still confirm the “degree of symptoms varying depending on specific coping resources such as spirituality” (Langman & Cheung Chung, 2013, p.15).
However, given all but five of the 81 participants, either in treatment or service users, were Caucasian, the potential for bias limits the generalizability of their findings. In addition, 84% of participants were unemployed, and that the majority were single also introduces the potential for biased results. A possible lack of intimacy, and stress associated with unemployment potentiality limits the applicability of results only to people with similar life histories.
Langman and& Cheung Chung’s study suggests that spirituality and forgiveness are beneficial, while “guilt is detrimental to relapse management” (Langman & Cheung Chung, (2013, p.12). These views are also shared by Lyons et al., (2010) who suggest anger and resentment (non spiritual constructs) towards self or others, can predict negative health outcomes.
However, in contrast, in a more diverse and larger sample of 364 people, Robinson, Krentzman, Webb, and& Brower (2011) found no significant relationship for forgiveness of others, but did find increases in forgiveness of self was a predictive factor in reduced drinking outcomes. Their study, contrasting with Langman and & Cheung Chung’s (2013) also provided longitudinal evidence (9 months) that significant changes were sustained.
Robinson et al.’s (2007) research found that a positive change in drinking outcome was linked with alcoholics’ spirituality and/or religiousness (S/R) and that having a sense of meaning and purpose of life, in particular was predictive of abstinence. Conducting a longitudinal survey over six months, on a survey group of 123 outpatients with alcohol use disorders “(66% male; mean age = 39; 83% white) they used a range of questionnaires to assess 10 measures of S/R, covering behaviours, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. (Robinson et al, 2007. P.). Other statistically significant findings included the predictive role of meaning and purpose in reducing drinking outcomes was also found by Brown and& Peterson, (1991); and Langham, (2012). The high mean age of Robinson et al.’s research and high percentage of white participants, are limitations of their research, and may negate the applicability of this research to younger addicts in particular, for whom a sense of meaning and purpose may not be significant.
A habitual practice of daily spirituality was found by Robinson et al, (2007) to be associated with the absence of heavy drinking at six months, regardless of gender or involvement in other group support activities such as involvement at AA. The results of their study support the view of many clinicians and individuals recovering from alcohol abuse and addiction that changes in alcoholics’ spirituality, and the adoption of practices such as prayer, meditation, and reading spiritual books, and being involved in a spiritual community are important to sobriety (Brown & Peterson, 1991).
In a contrasting study, Forcehimes, O’Leary and& LaNoue (2008) tried a more directive approach, where rather than assess patients subjective experience of spirituality, people who were fresh from a detoxification programme received a 12-session manual-guided spiritual guidance (SG) intervention during and after inpatient treatment. The SG intervention was “hypothesized to influence substance abuse outcomes by increasing spiritual functioning on three measures: Daily Spiritual Experiences, Meaning in Life, and Private Religious Practices” (Miller at al., 2008, p.439). Contradictory to expected outcomes SG had no effect on spiritual practices or substance use outcomes at any follow-up point. A potential strength of their study was a wider range of cultures, Hispanic (50%), White non-Hispanic (35%), and Native American (12%), however this is somewhat negated by the high drop out rate (43%) and the failure to find an effect.
While the participants in Robinson et al.’s (2007) research are predominately Caucasians, a predictive link between daily spiritual practices and reduced alcohol consumption was found. Relatedly perhaps, a potential limitation of Miller et al.’s (2008) approach, unlike the other research cited previously, may have been the prescriptive, interventionist approach and the focus on techniques drawn from the Judeo-Christian tradition (Miller et al., 2008). While the authors claim this is the most common religious background in the US population this may have only been substantiated in census reports and not representative of the participants’ beliefs. In addition religiousness and spirituality are different constructs and experienced uniquely (Miller, 1998).
While the authors say they anticipated potential resistance to their approach, other than say they incorporated a clinical style of motivational interviewing, they do not specifically address how they overcame this resistance. Significantly 43% of participants dropped out after attending between 1-3 sessions and this is not accounted for. Potential strengths of this research and it’s failure to find an effect are summed up by the authors, “If spiritual formation is a developmental phenomenon that unfolds naturally over time, like cognitive or moral development, it may not be amenable to acute interventions designed to speed up the process” (Miller et al, 2008, p.440).
(Motivational interviewing is a specific technique to overcome resistance).
In the beginning psychology was interested in studying the psyche – the “human soul, spirit or mind” (Dictionary.com, 2014); however cognitive and rationally oriented mind therapies appear to have dominated therapeutic practice in modern times. Recent research re-establishes the importance of spirituality as an important therapeutic intervention, and integrates it into the mainstream of empirical psychological practice. The research confirms supports the theory that understanding this core dimension of human functioning, evaluating, understanding, and responding to the spiritual aspects of clients’ lives is an essential skill for health professionals who wish to understand this core dimension of human functioning, and tap into this reservoir of inner strength. “Comprehensive addictions research should include not only biomedical, psychological and socio-cultural factors but spiritual aspects of the individual as well” (Miller, 1998, p. 985).
While the research reveals the ongoing challenges in defining and measuring the elements of spirituality that make it an effective intervention, including differences in meaning and spiritual values, the desire to find ways of integrating clients spiritual beliefs and practice into the treatment of alcohol addiction continues to grow.
Future research could explore how spirituality could be incorporated into treatment/ therapy programmes, but practitioners should be wary of trying to impose spirituality on others, or to rush the pursuit of spiritual transcendence. As Miller et al. note, “Many people recovering from substance use disorders, including members of AA, report transformational experiences that seem to occur spontaneously rather than as the product of an intervention and that often have substantial spiritual or even mystical features” (Miller et al., 2008, p 440).
A tendency of the research presented to dominate their studies with middle-aged Caucasians is a limitation of their research, however this is helpful in illuminating a path other researchers may wish to explore. This is especially relevant for practitioners in New Zealand, treating Māori and other cultures for whom faith and spirituality are either embraced, or have been neglected – potentially opening the door to new forms of healing and treatment.
Regardless of issues presented in trying to empirically validate spirituality the research still confirms supports the view that spirituality is an important aid in helping people either currently or in the past abusing alcohol (Langman & Cheung Chung, 2013).
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Robinson, E. A. R., Krentzman, A R., Webb, J. R., & Brower, K. J. (2011, July). Six-Month Changes in Spirituality and Religiousness in Alcoholics Predict Drinking Outcomes at Nine Months.* Journal of Studies on Alcohol Drugs, 72(4): 660–668. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125889/
Psyche (2014), In Dictionary.com. Retrieved from http://dictionary.reference.com/browse/psyche?s=t
Well done with your assignment Cassandra. You have a nice writing style and chose an interesting topic. You reviewed the literature well and critically analysed identifying both conflicting and supporting information. Try and avoid using so many quotes at this level the majority of your writing should be paraphrased. A few referencing errors to improve on. Best of luck with your future studies
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