ADDICTION AND SPIRITUALITY_________________________________

Jaime Grodzicki, M.D.

Associate Director Division of Alcohol and Substance Abuse

Director of Substance Abuse Referral Program (SARP)

NYU/Bellevue Hospital Center

OBJECTIVES_________________________________

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 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?_________________________________

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?_________________________________ Addiction is a

ProgressiveChronicRelapsingPrimaryDisease (potentially fatal)

Characterized byCompulsionLoss of controlContinued drug use despite adverse consequencesDistortion 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?_________________________________

The physiological state of neuro-adaptation produced by repeated administration of the

drug, necessitating continued administration to prevent the appearance of the withdrawal

syndromeStahl, S. Essential Pharmacology, 2nd Ed, 2000

WHAT IS TOLERANCE?_________________________________

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?_________________________________

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

The VTA-nucleus 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

Ventral tegmental area (VTA)

Nucleus accumbens

RELAPSE AND CONDITIONING 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.

Ventral tegmental area (VTA)

Amygdala

Bed nucleus of the stria terminalis

Nucleus accumbens

Prefrontal Cortex

Hippocampus

ADDICTION AFFECTS THE FOLLOWING DOMAINS:

_____________________________________

EMOTIONALPHYSICAL

COGNITIVESOCIAL

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

_____________________________________ 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?_________________________________

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_________________________________

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_____________________________________

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

Involves a sense of self, mission and purpose.

Unrelated to a specific dogma, belief system or defined roles

BOTH

Sense of trascendence

Basis of meaning and purpose in life and work

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.

_________________________________

MYSTICAL EXPERIENCE_____________________________________

“An uplifting sense of genuine spiritual union with something larger than the self”

Underhill, 1999; Essentials of Mysticism.

BIOLOGICAL CORRELATES_____________________________________

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_____________________________________NONSPECIFIC AROUSAL: Epinephrine can resultin happiness or malaise

(Schacter S, Singer JE. Psychol Rev 69:319, 1962)

HEMISPHERIC DISSOCIATION: Severed corpuscallosum and right hemisphere stimulation: epilepticpatient waves his hand and creates an explanation

Gazzaniga MS. Bisected Brain 1970

DEPRESSED young monkeys are given eitherimipramine or are introduced to peers: depressionresolved

Suomi S et al. Arch Gen Psychiat 35:321, 1978

OUT OF BODY EXPERIENCE_____________________________________

. . .“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_____________________________________

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_________________________________

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

__________________________________________

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

_____________________________________

“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 CareDifferential Diagnosis

_____________________________________ Religious/spiritual phenomena Religious/spiritual problem Culture-bound syndrome Mental disorder Possibility of concurrent diagnosis

Cultural Assessment for Diagnosis and CareTreatment Plan

_____________________________________ 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_____________________________________

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)

_____________________________________ 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)__________________________________________ Medical Students’ ViewPatients (N=119)(N=101) of Students of Patients

Inner Peace 1 8 7Medical Services 2 3 3Belief in God 3 9 11AA 4 11 5Outpatient Tx 7 4 2Gov’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

_____________________________________ 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

_____________________________________

THE HOUSE OF SOBRIETY(From: Recovering, How to Stay Sober, Mueller and Ketcham 1987).

ABSTINENCE(THE FOUNDATION)

PHYSICAL

MENTAL EMOTIONAL

SPIRITUAL

SPIRITUAL CONCEPTS_____________________________________

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_____________________________________

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

_____________________________________ 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

_____________________________________ 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_____________________________________ 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