ADDICTION AND SPIRITUALITY _________________________________

1. 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

2. 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

3. 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

4. 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

5. WHAT IS AN ADDICTION?_________________________________ • Addiction is a • Progressive • Chronic • Relapsing • Primary • Disease (potentially fatal) • Characterized by • Compulsion • Loss of control • Continued drug use despite adverse consequences • Distortion in normal thinking

6. 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

7. 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 syndrome Stahl, S. Essential Pharmacology, 2nd Ed, 2000

8. 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

9. WHAT IS WITHDRAWAL?_________________________________ The psychological and physiological reactions to abrupt cessation of a dependence-producing drug Stahl, S. Essential Pharmacology, 2nd Ed, 2000

10. 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

11. Nucleus accumbens Ventral tegmental area (VTA) 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

12. Bed nucleus of the stria terminalis Prefrontal Cortex Hippocampus Nucleus accumbens Amygdala Ventral tegmental area (VTA) 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.

13. ADDICTION AFFECTS THE FOLLOWING DOMAINS:_____________________________________ EMOTIONAL PHYSICAL SOCIAL COGNITIVE SPIRITUAL FAMILY

14. ___________________________ “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)

15. 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.

16. ___________________________ “The greatest use of a life is to spend it on something that will outlast it” William James (1852-1910)

17. 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)

18. 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.

19. 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.

20. 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)

21. SPIRITUALITY AND RELIGION

22. “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._________________________________

23. MYSTICAL EXPERIENCE_____________________________________ “An uplifting sense of genuine spiritual union with something larger than the self” Underhill, 1999; Essentials of Mysticism.

24. 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)

25. BIOLOGICAL CORRELATES_____________________________________ NONSPECIFIC AROUSAL: Epinephrine can result in happiness or malaise (Schacter S, Singer JE. Psychol Rev 69:319, 1962) HEMISPHERIC DISSOCIATION: Severed corpus callosum and right hemisphere stimulation: epileptic patient waves his hand and creates an explanation Gazzaniga MS. Bisected Brain 1970 DEPRESSED young monkeys are given either imipramine or are introduced to peers: depression resolved Suomi S et al. Arch Gen Psychiat 35:321, 1978

26. 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

27. 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

28. 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.

29. 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)

30. PRACTICE GUIDELINES FOR PSYCHIATRIC EVALUATION INADULTS_____________________________________ “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.

31. Cultural Assessment for Diagnosis and CareDifferential Diagnosis_____________________________________ • Religious/spiritual phenomena • Religious/spiritual problem • Culture-bound syndrome • Mental disorder • Possibility of concurrent diagnosis

32. Cultural Assessment for Diagnosis and CareTreatment Plan_____________________________________ • Biomedical • Psychological • Socio-cultural • Spiritual/Religious

33. Spiritual/Religious treatment plan includes: • Ongoing assessment and formulation • Respect, empathy and boundaries • Modification of psychotherapy when indicated • Spiritual/Religious interventions when indicated

34. 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

35. 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

36. IMPORTANCE TO RECOVERY (RANK ORDER)__________________________________________ Medical Students’ View Patients (N=119) (N=101) of Students of Patients Inner Peace 1 8 7 Medical Services 2 3 3 Belief in God 3 9 11 AA 4 11 5 Outpatient Tx 7 4 2 Gov’t Benefits 9 2 9 Goldfarb L et al., Am J Drug Alcohol Abuse, 1996; McDowell D et al., J Addic Dis, 1996

38. 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

39. ALCOHOLICS ANONYMOUS (AA) AND SPIRITUALITY_____________________________________

40. THE HOUSE OF SOBRIETY(From: Recovering, How to Stay Sober, Mueller and Ketcham 1987). SPIRITUAL PHYSICAL MENTAL EMOTIONAL ABSTINENCE (THE FOUNDATION)

41. 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

42. SPIRITUAL BEHAVIOR_____________________________________ • Prayer • Meditation • Walking in nature • Reading poetry/sacred texts • Lighting a candle • Listening to music • Smelling incense

43. 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

44. 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.

45. 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

46. 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.

47. THANK YOU