Substance Use & Misuse, 48:1157–1160, 2013Copyright C© 2013 Informa Healthcare USA, Inc.ISSN: 1082-6084 print / 1532-2491 onlineDOI: 10.3109/10826084.2013.820988

ORIGINAL ARTICLE

Perception of the Role of Spirituality and Religiosity in the AddictionTreatment Program Among the Italian Health Professionals:A Pilot Study

Valeria Zavan1and Patrizia Scuderi2

1Department of Addictions, ASL AL, Novi Ligure, Piedmont, Italy; 2Private Psychologistand Psychotherapist, Milano, Lombardy, Italy

In this pilot study, 69 health professionals workingin public and private programs treating drug usersand alcohol misusers in Italy were interviewed during2012 using the Vederhus and Laudet questionnaire asa framework to explore the importance of the conceptsof spirituality and religiosity and their possible roles inthe treatment through patient’s referral to mutual-helpgroups. The study’s limitations are noted.

Keywords addiction, treatment, aftercare programs, religion,Italian health-care system, mutual-help groups (MHG),spirituality, religiosity

INTRODUCTION

Research studying the interaction between professionaltreatment services for alcohol addiction and substance useand mutual-help groups (MHGs), like Alcoholic Anony-mous (AA) and other 12-Step groups, has documentedthat the spiritual principles typical of the 12-Step move-ment may sometimes be in conflict with the secular ap-proach of professionals (see e.g., Allamani, 2006). In-deed, according to a study with a sample of Norwegianaddiction clinicians by Vederhus, Kristensen, Laudet, andClausen (2009), the idea of spirituality, typical of MHGs,may be an obstacle affecting health professionals’ refer-ring patients to MHGs. This finding is significantly differ-ent from the results from a similar sample on US profes-sionals (Laudet, 2003; Laudet & White, 2005; Vederhus,Kristensen, Laudet, & Clausen, 2010). Only a few studieshave investigated this issue in the European context (Day,Gaston, Furlong, Murali, & Copello, 2005; Etheridge,Craddock, Hubbard, & Rounds-Bryant, 1999; Vederhuset al., 2009, 2010).

Address correspondence to Valeria Zavan, Via Ospedale 9, 15100 Novi Ligure (AL) Italy; E-mail: valeria.zavan@tin.it.

The treatment system stakeholders for alcohol addic-tion and illicit drug users in Italy are mainly representedby the secular (Addiction Treatment Services network),religious (Residential Therapeutic Community—TC net-works), and “spiritual” (MHGnetworks) philosophies thatcoexist and work with a variable degree of collaboration.The Italian public addiction treatment services are com-posed of multiprofessional teams. In 2010, there were 563programs, with 6,793 professionals, treating 172,211 drugaddicts and 65,360 clients with alcohol misuse-relatedproblems (Ministry of Health, 2011, 2012). The most im-portant TCs are organized in networks, mainly with resi-dential programs. Their programs are mostly inspired byCatholic principles, although they do not refer explicitlyto the Catholic faith. Their programs utilize pharmacolog-ical interventions, not always aiming at a drug-free treat-ment goal; their staffs aremostly professional workers and“recovered” patients. However, only 8.7% of alcohol anddrug addicts (about 16,000 subjects) were referred to a TCin 2010 (Ministry of Health, 2011, 2012).

Lastly, in addition to the 12-Step programMHGs, thereare CATs, i.e., “Club Alcologici Territoriali” (CommunityAlcohol Clubs: http://www.aicat.net), a type of commu-nity MHG system that is based on a social ecological ap-proach engaging family, and close friends. In Italy, thereare about 450 AA groups (www.aa.org) and about 2,000CAT’s; each type of group includes approximately 10,000alcoholic members (Allamani, 2007).

During 2009, 33.9% and 42.8% of the addiction treat-ment services reported collaborating with AA and CATgroups respectively; however, they referred only 7% (witha range between 2.8% and 13.9% by region) of alcohol de-pendents to the MHGs, with a decreasing trend over time(Ministry of Health, 2011). Thus most addicts are treatedwithin Italy’s public treatment system.

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Even though the issue of spirituality is an explicit as-pect of Italian MHG programs, and many rehabilitationprograms have a religious dimension, the issues of reli-giosity and spirituality (R/S) aspects of a person’s life,adaptation, and functioning apparently are not a usual fo-cus among professionals within the substance user treat-ment system. This might explain the under-utilization ofself- and MHGs.

Few studies about the interaction between MHGs andaddiction treatment professionals have been implementedin Italy (Allamani, 2007, 2008; Jean et al., 2004). Themost comprehensive information available is derivedfrom AA and NA national surveys. In two national AAsurveys in 2009 and 2011, AA members received theirinformation about AA from a health professional orwithin the addiction treatment program in less than 30%and 7% of cases, respectively (Alcolisti Anonimi Italia,membership survey, 2009 and 2011: http://www.alcolisti-anonimi.it). The only Italian Narcotics Anonymous (NA)survey documented that 26.5% and 13.6% of intervieweeshad been referred by the health professionals and by theaddiction service professionals, respectively (NarcoticiAnonimi Italia, Resources for Professionals section,2005: http://www.na-italia.org).

This is a preliminary study, aiming to explore the Ital-ian addiction treatment professionals’ attitude towardsthe issues of religiosity and spirituality that may con-cern their clients, and if this attitude affects their re-ferral to 12-Step groups. The authors anticipated that astraightforward investigation of R/S with professionalscould result in defensive and less than reliable answersand could be misunderstood or criticized as being an in-trusion into a private sphere. The Laudet and Vederhusquestionnaire, addressing questions about R/S and MHGsas well, appeared to be an acceptable approach to thistheme.

SAMPLE AND METHODOLOGY

The Laudet and Vederhus questionnaire was translatedinto Italian with the authors’ permission and accordingto the guidelines for cross-cultural adaptation (Beaton,Bombardier, Guillemin, & Bosi, 2000).

Further, in order to explore professionals’ R/S attitudewith clients, 11 items with a new Likert scale were addedto the Italian version of Vederhus and Laudet’s question-naire in a separate R/S appendix.

The questionnaire was initially sent via e-mail to 12key clinicians from nine relevant Italian addiction treat-ment institutions in Italy, during May–July 2012. The keyclinician forwarded the questionnaire to his/her staff pro-fessionals, suggesting that they return the completed ques-tionnaire to the researchers by e-mail. Participants wereguaranteed anonymity and could choose not to participate.Only 69 (39%) questionnaires were returned out of the176 that had been distributed, of which 25 (36%) werepartially incomplete.

RESULTS

Characteristics of the SampleThe 69 respondents (42 females and 25 males) were em-ployed in 50 public addiction treatment programs, or in19 TC programs. Their mean age was 47.2 years andtheir mean duration of work within the addiction area was9.33 years. Health professionals (mainly medical doctors)were 28, psychologists 19, social workers/educators 17,and other professionals 5.

Importance and Attitude of the ReferralFifty-one professionals (74%) indicated that they had re-ferred their patients to MHGs, while 11 did not refer andseven did not answer. The mean percentage of referralswas 36%, with an extremely wide range (0–100), medianvalue of 20%, and mode value of 10% (49 respondents).

Using Vederhus and Laudet’s 10-point scales, MHGsare considered useful or very useful even among thoseprofessionals who do not refer clients at all (average scoreof 7.5). The role of mutual help is believed to be very im-portant in the recovery process (7.4) and to be relevant inthe co-operation with the public treatment system (7.3).

R/S and Referral to Mutual-Help Groups (MHGs)Fifty-six percent of the respondents indicated that they didnot consider “the religious aspect of MHG as being anobstacle for many clients to attend,” while the perceptionof meetings as a “place in which people talk about God”by clients was considered as a client’s prejudice by threerespondents.

The MHGs’ concept of “powerlessness” was consid-ered as being not dangerous for the clients by the majorityof the respondents (53%).

Personal Beliefs About Religion and SpiritualityOnly 28 professionals answered the R/S questions. A neu-tral position prevailed in nearly all of the answers. Re-spondents were inclined to report that it may not alwaysbe useful to explore a client’s belief about his/her religiousfaith and spirituality, unless s/he introduced the topics andin case it was of great importance for the client’s life. Itwas noted that talking about spirituality, rather than reli-gion, could be of some help for the patient.

None of the respondents noted that spirituality and/orreligious faith were considered as being actual or potentialprofessional tools for treatment, or planned change, evenif they were recognized as being a key principle of theMHGs’ philosophy of recovery. Spirituality and/or faithwere viewed as being important in everyone’s life, likeany other relevant issue in the clients’ life.

The definition of spirituality involved for most an im-manent interpretation of one’s own life, and of everyone’slife, as a deep opportunity for growth (“a concept relatedto the soul,” “related to the research of the meaning oflife,” “a human need to raise himself,” “a sense of belong-ing to a greater thing, as nature or humanity”) that appearsunrelated to the religion. The latter was however perceivedas being a complex of norms, rituals, dogmas, and beliefs

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THE ROLE OF SPIRITUALITY AND RELIGIOSITY IN THE ADDICTION TREATMENT PROGRAM 1159

related to the Catholic Church and its organization (“goingto church on Sundays,” “belonging to a group,” “inheritedbelief,” “adaptation to some rules”). A few respondentsclaimed that spirituality (“presence of a high power,” “asearch for transcendence,” “belief in a God”) and religionare not different.

STUDY’S LIMITATIONS

This study’s limitations and limited generalizability in-clude: being a pilot study, based on an opportunistic sam-ple of 69 respondents who are not representative of Italy’ssubstance user treatment staffs who treat both in the publicand private treatment systems. Other drug user treatmentstakeholders, such as relevant policy makers, who can anddo play a critical role in the dimensions of Italy’s treatmentprograms, were not surveyed and should be considered forfuture needed research.

Another important limitation is that the Vederhus andLaudet questionnaire used in this study proved to be onlya partially useful adaptation of this tool to the Italian con-text, even though it had been successfully implementedin the Norwegian and US cultures. One explanation forthis might be that this questionnaire principally addresses12-Step MHGs, but not other types of MHGs, which arealso co-operating with Italy’s formal treatment programs,and have a different approach to the treatment of addictedpeople.

CONCLUSIONS AND FUTURE NEEDED RESEARCH

This pilot study is an attempt to investigate how Ital-ian addiction treatment professionals refer their patientsto MHGs and how they are informed about their princi-ples, particularly 12-Step groups, and their personal be-liefs about spirituality and religion. Notwithstanding thestudy’s limited and unrepresentative sample, the level ofinformation about AA and the other 12-Step groups is no-ticeable, when compared to earlier investigations in the1980s (Allamani, 2007). Although spirituality and reli-gion are perceived as being the principles of how 12-Stepgroups function, Italian professionals working in the ad-diction area appear to be “lukewarm” about these pro-cesses. The issues of spirituality, and even more so ofreligion, are perceived as pertaining more to the privatethan to the public dimension of their own approach tothe treatment of “addictions.” The public health system inItaly is still regarded as being the main treatment for drugusers and alcoholics, although referral to 12-Step groupsis considered as being one of the options. The other mostcommon choice is the referral to the social-oriented CATgroups.

One should not be surprised with the tepid attitude ofaddiction professionals towards the issues and processesof religion and also of spirituality. In fact while mostItalians are of Christian Catholic denomination, a greaterpart of the population does not actively practice, and therelationship between the individual, the religious expe-rience, and the Church is “marked by personal timing

and rhythms.” This relationship allows personal beliefs,low attendance and participation in religious practices, aswell as disagreement with many precepts, while not ques-tioning belonging as being part of one’s identity (Garelli,2013).

Even if the findings cannot be generalized to the opin-ions and attitudes of the universe of Italian addiction treat-ment professionals, they suggest that spirituality and reli-giosity are considered as being general principles, albeitwith little or no relationship with a formal professional-based treatment, although their appropriateness is ac-knowledged for MHGs.

Declaration of InterestThe authors report no conflicts of interest. The authorsalone are responsible for the content and writing of thearticle.

THE AUTHORSValeria Zavan, M.D. (Italy),is toxicologist, motivationaltrainer—Nonalcoholic (ClassA) Board’s Trustee of theAlcoholics Anonymous, Italy.She is director of the AddictionUnit of ASL AL in Novi Ligure(Piedmont), and has beenworking in the addiction field forthe last 20 years with a particularinterest in self-help.

Patrizia Scuderi, Ph.D. (Italy),is a private psychologist andpsychotherapist in Milano, Italy,and a clinician trained in EMDR.She has graduated in clinicalpsychology from the Universityof Padova, Italy, and specializedin Junghian analytic psychology.She is also involved in teamwork for addictions.

GLOSSARY

Club Alcologico Territoriale: The Club System forTreated Alcoholics (CAT) was developed in 1964 inZagreb by the Croatian psychiatrist Vladimir Hudolinand was introduced soon after into Trieste and is cur-rently operating in 34 other countries. The Family Clubsystem is based on a social ecological approach thatengages the entire family, including close friends andassociates. All have a key role to play in the treatmentprocess. A Club has to meet on a fixed day and time and

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it is compulsory that the members of the Club attendweekly meetings regularly. The highest importance isgiven to the family, because the family as a whole isconsidered to be the most important bio-social systemfor each individual person. This results in the “tagged”alcoholics remaining within, and being treated inside,their family environment. The underlying basic princi-ple being that no change in behavior or lifestyle can beachieved outside of this biosocial system. This modelwas developed with an abstinence orientation but it canalso be implementedwith a harm-reduction, quality-of-life, wellness, as well as conflict resolution ideologicalunderpinnings.

Faith: An assent of thought and feeling that constitutes thestarting point for any believer who is part of a religiousorganization. It is a dogmatic act that allows the senseof belonging and is closely related to the religious as-pects.

Professional educator: Is a social worker and healthcare personnel in possession of a qualifying univer-sity degree, implementing specific educational projectsand rehabilitation as part of a multidisciplinary treat-ment plan developed by a team aimed at a balanceddevelopment with the educational objectives of thepersonality/relationship in the context of participationand recovery of daily life, and cares for the positivepsycho-social integration or reintegration of disadvan-taged person.

Religion: A set of values, beliefs, dogmas, rules, and or-ganized rituals, collectively recognized as related to aspecific interpretation of a higher entity and to the rela-tionship with that entity. The person who makes refer-ence in those rules, rituals, and organizations identifieshim/herself with a sense of belonging.

Spirituality: A set of values, sensitivities, and feelings thatare perceived subjectively and that are related to a re-flection and to an individual research of the immanent.

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