Chair: Marc Galanter, MD, Professor of Psychiatry, New York University at firstname.lastname@example.org
Donald Kurth, MD, Subgroup Chair on Twelve Step
ISAM has designated certain Interest Groups in order to develop key areas of interest for its members. This Interest Group is designed to address the issue of spirituality and Twelve Step Groups with regard to addiction illness and recovery. This was undertaken because of:
(1) the Society’s definition of addiction, manifest in “biological, psychological, sociological and spiritual dimensions.”
(2) the diversity of our members’ cultural backgrounds that merit attention to the nature of spirituality in their respective national settings.
(3) the role of Twelve Step fellowships as spiritually-oriented programs dedicated to addiction recovery.
Areas of Focus
We will address different aspects of spirituality and Twelve Step recovery, which have been explored in both practice and research. Some examples are:
(1) Clinical Issues: These have been the focus of treatment for drug use recovery, and behavioral addiction.
(2) Cross-cultural studies: Application of recovery approaches are found in diverse national settings, among treatment professionals, and in religiously oriented programs7.
(3) Biology: Recent imaging studies have been undertaken to ascertain neurophysiologic concomitants of spirituality in relation to addictive disorders and their treatment.
(4) Twelve Step Programs: These are abstinence-oriented, organized, self-designated spiritual fellowships.
The Spirituality Interest Group Members are: Marc Galanter, MD (chair), Hamad Al Ghaferi, MD, PhD, Gregory Bunt, MD, John (Calvin) Chatlos, MD, Paul Earley, MD,Nady el-Guebaly, MD, Belle Gavriel-Fried, PhD, Helena Hansen MD, PhD, Jag Khalsa, MS, PhD, Donald Kurth, MD, Clayton McClintock, MTS, PhD, Lisa Miller, PhD, Marc N Potenza, PhD, MD, Stephen Ross, MD
Over many years, acts of deeply felt commitment have served as a basis for people trying to gain control over their substance use disorders (SUDs). Given the many settings in which this can occur, and the diverse, culturally-defined beliefs upon which individuals may draw, the generic term of spirituality can be applied to such phenomena. The International Society of Addiction Medicine includes a spiritual dimension, in addition to psychological and biological dimensions of SUDs, as in its definition of addiction and certification note1. Twelve Step programs are illustrative of the role of Spirituality in recovery from SUDs.
The current document presents information to clarify the role of spirituality within the addiction field, and includes how neuroscience, social science, and psychology can advance our understanding of spirituality and its role in recovery from addictions, and provides recommended actions. It complements the inclusion by the World Health Organization on religion and spirituality as a dimension of quality of life2, and the World Psychiatric Association’s guidelines for introducing religion and spirituality into the practice of psychiatry3.
Despite considerable advances in both pharmacologic and behavioral treatment
modalities, there is a worldwide deficit in the availability of professional treatment for SUDs. There is also a need for developing approaches to promote addiction recovery tailored to the diversity of respective national cultures by generating, evaluating and employing spiritually-oriented approaches that may help to address this deficit.
One aspect of securing sustained recovery is included under the concept of “recovery capital,” describing resources upon which a person with a SUD may draw. This term has been defined by the World Health Organization in the International Standards for the Treatment of Drug Use Disorders2 as the internal and external resources available to an individual to promote a sustained recovery, including peer-based and culturally-related support for discovering “meaning and purpose in life.” Consequences of a deficit in this aspect of recovery capital has been illustrated in an analysis by Case and Deaton4 in characterizing “deaths of despair,” which they specifically define as alcohol-related liver disease, drug overdose, and suicide. After controlling for obesity, income inequality, and poverty, they found that individuals’ limited options for achieving hope for the future was most common in demographic groups experiencing a rise in such deaths.
An approach to enhancing personally-experienced spirituality, as embodied in the availability of culturally-syntonic approaches, and thereby improving one’s recovery capital, may serve to yield relief from the pressure to turn to substance misuse and addictive behaviors. Such approaches have been documented in diverse cultures, including such a recovery from gambling disorder in Israel5 and multi-denominational Christianity-based recovery programming.6 Similar approaches are also implicit in numerous culturally-defined settings worldwide for achieving recovery, including Hinduism in India, Buddhism in South Asia, and Shi’ism in Iran.
Perhaps the most widely studied of such an approach has been undertaken in research on Twelve Step fellowships. The utility of these fellowships has recently gained additional validity after the release of a Cochrane Review7 that demonstrates the substantial effectiveness of facilitating participation in Alcoholics Anonymous (AA) and other Twelve Step programs for alcohol use disorder.
Members of AA and Narcotics Anonymous are self-designated “Spiritual Fellowships,” and their members number in the millions worldwide. Two aspects of this self-designation are evident in the importance of spirituality and spiritual awakening among long-term members who attribute spiritual commitment to their experience of recovery. In fact, abstinence after discharge from professional treatment was found in one study to be three times as likely among patients who reported having had a spiritual awakening.8
Studies that delineate biological correlates of spirituality can be helpful in understanding mechanisms of recovery from addictions. In one set of studies, responses to a guided imagery neuroimaging task were evaluated9,10. Spiritual experiences were contrasted with those of neutral-relaxing and stressful experiences, and neural differences between the conditions were distinguishable by using functional magnetic resonance imaging.9,10 Activation of the parietal cortex distinguished the three conditions,9 resonating with prior structural studies linking religion and spirituality to parietal volume of this region.11 A more sustained pattern of engagement of a ventral frontotemporal network was also specific to the spiritual condition, and the degree of engagement correlated with self-reported robustness of the spiritual experience as well as intrinsic spirituality, suggesting a functional neural network underlying spiritual experiences and tendencies.10 Another study12 employed long-term AA members who had reported having had a spiritual awakening. They were exposed to alcohol-related images after reading either an AA-related prayer or neutral material. Their responses following the prayer condition, both on imaging and on subjective report, were correlated with the subsequent diminished craving that they reported. Such research suggests options to be pursued in studying neural networks reflective of spiritually-related experiences and how they may promote recovery from addictions.
Gardner and Kleinman note that an emphasis on biological research and pharmacological management has come to predominate over studies on “the interconnections of mind, body, and society”13 to the detriment of potentially beneficial integrative models. Spirituality is often culturally resonant with the medically underserved, including racial/ethnic minorities, those with lower socioeconomic status, and women. Engaging spirituality and related community organizations in treatment is an important aspect of improving treatment access, outcomes and equity for underserved groups.14
Gaining a better understanding of how spirituality is manifested in different cultures may also aid in better tailoring of treatment in specific settings. It may also enrich the ways patients with addictions can be approached by clinicians. Additionally, research on the neural mechanisms associated with spiritual experiences may lead to clarifying the complexity of brain networks that underlie neurally-based schemas associated with addiction recovery.
The above-described approaches may aid in developing better personalized psychological and behavioral approaches for clinicians and may help keep patients engaged in medication-focused treatment programs. Neurobiological studies may aid in understanding differential responses of people with addictions to treatment (both positive or negative) and identifying mechanisms underlying active ingredients of treatments. Such information has significant potential to advance interventions and decrease suffering of individuals impacted by addictions. The following points can be useful in applying the findings noted here: In the clinical evaluation of a patient with an addictive disorder (SUD or behavioral addiction like gambling or gaming disorders) it is useful to include an assessment of the role of spirituality in their personal history and the current manifestation of their addictive disorder. Treatment planning is enhanced by including consideration of how issues related to spirituality can be employed in programming to increase the patient’s recovery capital to fortify their recovery. Spiritually-oriented community-based resources that are appropriate for a given patient (such as culturally syntonic facilities, religious institutions15, and peer support groups, such as Twelve Step fellowships) should be considered for referral. Research is important to ascertaining psychological, cross-cultural, and biological underpinnings on how spirituality plays a role in the etiology of addictive disorders and in recovery, and how Twelve Step movements promote recovery.
- About the Certification. International Society of Addiction Medicine. https://isamweb.org/isam-products/international-certification-addiction-medicine/. Accessed May 10, 2020.
- The United Nations Office on Drugs and Crime. International Standards for the Treatment of Drug Use Disorders 2017. https://www.who.int/substance_abuse/activities/msb_treatment_standards.pdf
- Moreira-Almeida A, Sharma A, Janse van Rensburg B, Verhagen PJ, Cook CCH. WPA position statement on spirituality and religion in psychiatry. World Psychiatry. 2016;15(1):87-88.
- Case A, Deaton A. Deaths of Despair and the Future of Capitalism. Princeton, NJ: Princeton University Press, 2020.
- Gavriel-Fried B, Moretta T, Potenza MN. Associations between recovery capital, spirituality, and DSM-5 symptom improvement in gambling disorder 2020;34(1):209-217.
- Brown AE, Tonigan JS, Pavlik VN, et al. Spirituality and confidence to resist substance use among Celebrate Recovery participants. J Relig Health 2013;52(1):107-113.
- Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12-step programs for alcohol use disorder. Cochrane Database Syst Rev 2020;3:1-98.
- Kaskutas LA, Ammon L, Delucchi K, et al. Alcoholics Anonymous careers: Patterns of AA involvement five years after treatment entry. Alcohol Clin Exp Res 2005;29:1983-1990.
- Miller L, Balodis IM, McClintock CH, Xu J, et al. Neural correlates of personalized spiritual experiences. Cerebral Cortex. 2019;29(6):2331-2338.
- McClintock CH, Worhunsky PD, Xu J, Balodis IM, et al. Spiritual experiences are related to engagement of a ventral frontotemporal functional brain network: Implications for prevention and treatment of behavioral and substance addictions. J Behav Addict 2019;8(4):678-691.
- Miller L, Bansal R, Wickramaratne P, Hao X, et al. Neuroanatomical correlates of religiosity and spirituality: A study in adults at high and low familial risk for depression. JAMA Psychiatry. 2014;71(2):128-135.
- Galanter M, Josipovic Z, Dermatis H, et al. An initial fMRI study on neural correlates of prayer in members of Alcoholics Anonymous. Am J Drug Alcohol Abuse 2017;43(1):44-54.
- Gardner C, Kleinman A. Medicine and the mind – The consequences of psychiatry’s identity crisis. N Engl J Med 2019;381:1697-1699.
- Substance Abuse and Mental Health Services Administration (SAMHSA). Chapter 6: Substance abuse among specific population groups and settings. In Treatment Improvement Protocol (TIP) 51. 2015. US Department of Health and Human Services, Rockville, MD.
- Chen Y, Koh HK, Kawachi I, Botticelli M, VanderWeele TJ. Religious service attendance and deaths related to drugs, alcohol, and suicide among US health care professionals [published online ahead of print May 6, 2020]. doi: 10.1001/jamapsychiatry.2020.0175.
Marc Galanter, M.D.
Research Professor of Psychiatry
NYU School of Medicine
550 First Avenue, Room NBV20N28
New York, NY 10016
Phone: 212-263-6960; Fax: 212-263-8285
The purpose of the group is to increase and improve the capability and capacity of addiction medicine to pursue further human science related research and education.
This group will be composed of individuals working in the field of addiction interested and or specialists in the fields of philosophy, anthropology, psychology, sociology and history.
Professor Georges Brousse, Md, PhD, HdR
Doctor Eric Peyron, MD, PhD
Sarah Namirembe (Uganda) <email@example.com>;
Tomohiro Shirasaka (Japn) <firstname.lastname@example.org>;
Soumitra Pathare (India) <email@example.com>