Spirituality in addictions treatment: wisdom to know…what it is

Substance Use & Misuse, 48:1203–1217, 2013Copyright C© 2013 Informa Healthcare USA, Inc.ISSN: 1082-6084 print / 1532-2491 onlineDOI: 10.3109/10826084.2013.800343

ORIGINAL ARTICLE

Spirituality in Addictions Treatment: Wisdom to Know. . .What It Is

Steve Sussman1, Joel Milam1, Thalida E. Arpawong1, Jennifer Tsai1, David S. Black2

and Thomas A. Wills3

1Departments of Preventive Medicine and Psychology, Institute for Health Promotion and Disease Prevention Research,University of Southern California, Los Angeles, CA, USA; 2Semel Institute for Neuroscience & Human Behavior,University of California, Los Angeles; 3Epidemiology Program, University of Hawaii Cancer Center

Spirituality has long been integrated into treatmentsfor addiction. However, how spirituality differs fromother related constructs and implications for recoveryamong nonspiritual persons remains a source of dis-cussion. This article examines ways in which spiritu-ality is delineated, identifies variables that might me-diate the relations between spirituality and recoveryfrom substance abuse disorders, describes distinctionsbetween spiritual and nonspiritual facets of addictionstreatment, and suggests means to assist in further clar-ification of this construct.

Keywords addiction treatment, spirituality, treatment,mind–body, substance misuse, recovery, mediators

INTRODUCTION

Spirituality has long been a topic of clinical interest inthe alcohol and other drug abuse addictions field, no-tably since the beginning of the 12-step recovery move-ment in 1935, and earlier, associated with advocacy forabstinence in some Christian groups (e.g., by FrancesWillard, cofounder of theWoman’s Christian Temperance

1The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can beabused. Editor’s note.2The reader is reminded that the concepts of “risk factors” as well as “protective factors” are often used in the literature, without adequately notingtheir dimensions (linear, nonlinear; rates of development; anchoring or integration, cessation, etc.), their “demands,” the critical necessary conditions(endogenously as well as exogenously; from a micro to a meso to a macro level) which are necessary for either of them to operate (begin, continue,become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are theory-driven,empirically-based, individual and/or systemic stake holder- bound, based upon “principles of faith,” historical observation, precedents and traditionsthat accumulate over time, conventional wisdom, perceptual and judgmental constraints, “transient public opinion” or what. This is necessary toconsider and to clarify if these terms are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities,“principles of faith,” and stakeholder objectives. Editor’s note.3The reader is asked to consider that the term “recovery” is an overloaded container concept which is bounded by culture, time, place, andstakeholder values. Although there is no consensualized definition by a range of involved deliverers of care and services for its targeted populationsa most recent effort to define it has resulted in the following definition: Recovery is defined as a voluntarily maintained lifestyle composed orcharacterized by sobriety, personal health, and citizenship. The Betty Ford Institute Consensus Panel, Journal of Substance Abuse Treatment 33(2007) 221–228. “Recovery” is most often associated with abstinence. Its dimensions, and the necessary internal and external, micro and macrolevel conditions for its achievement in treatment ideologies such as harm reduction, quality-of-life, and conflict resolution have yet to be delineated.Editor’s note.This paper was supported by a grant (DA020138) from the National Institute on Drug Abuse.Address correspondence to Steve Sussman, Ph.D., FAAHB, FAPA, Institute for Health Promotion and Disease Prevention Research, University ofSouthern California, Soto Street Building, 2001 North Soto Street, Room 302A, Los Angeles, CA 90033 USA; E-mail: [email protected]

Union in 1874; by Southern Baptists at their conventionin 1886) and as long-standing tenets of Islam and Bud-dhism; and in some works of such people as Dr. Ben-jamin Rush in the late 1700s (Alcoholics Anonymous,1976; Carroll, 1993; Hirsh, 1953; James, 1997; Kurtz,1982; Sussman & Ames, 2008; White & Whiters, 2005).In the published literature on the scientific study of re-ligion, Kass and colleagues (1991) described spiritual-ity as being one’s personal search for connection witha Higher Power (also referred to as “God,” “Ground ofBeing,” or “life force”) which, when successful, leads toreduction of anxiety and a sense of belongingness withother beings. This description appears to be the essenceof what spirituality generally means within alcohol anddrug abuse1 addictions treatment settings (Borras et al.,2010; Galanter, 2006; Green, Fullilove, & Fullilove, 1998;Miller, 1998; Sussman, 2010; Sussman, Skara, de Calice,Hoffman, & Dent, 2005; Sussman, Nezami, & Mishra,1997). Current research, most of which considers reli-gious and spiritual beliefs as overlapping or even in-terchangeable, indicates that spirituality is posited to beprotective2 from alcohol and other drug misuse, and isa unique component of recovery3 from substance abuse

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disorders4 (e.g., Borras et al., 2010; Galanter, 2006;George, Larson, Koenig, & McCullough, 2000; Miller,1998; Robinson, Krentzman, Webb, & Browere, 2011;Seaward, 1995; Sussman & Ames, 2008; U.S. DHHS,2012; Wills, Yaeger, & Sandy, 2003).

Concerns Regarding Spirituality in AddictionsTreatmentThe research concerning spirituality and addictions cre-ates debate regarding the options for recovery among ag-nostics or atheists (e.g., Tonigan, Miller, & Schermer,2002). Protagonists of a Higher Power concept suggest adifficult existence for nonbelievers. That is, persons thatequate spirituality with personal religion and transcen-dence may not believe that one who is an atheist or agnos-tic will be able to achieve spiritual solutions to alcoholismor drug addiction. One argument is that if one will not turntheir will and lives over to the care of a Higher Power,generally a Supreme Being, one will not be able to per-manently quit substance misuse (Alcoholics Anonymous,1976). In other words, to be a nonbeliever purportedly pre-vents one from ceasing problematic drug use.5 Alterna-tively, if one quits drug use without reliance on a spiritualsolution, generally a Supreme Being, a presumption mayexist that one will not be able to retain a sense of life bal-ance; that is, obtain (quality) sobriety, as opposed to mereabstinence. Also, theremay be the assertion that more reli-giously/spiritually devout persons are better or more purehumans, more deserving of sobriety (Sloan, Bagiella, &Powell, 1999). In other words, there may be a presump-tion that those persons who engage in prayer to a HigherPower, and engage in such practices as confessing theirsins to others, making restitution, and engaging in ser-vice work (e.g., 12-step work) are more deserving of re-ceiving a “gift” of sobriety, or of receiving moral supportfrom other people. Furthermore, spirituality sometimes isconsidered as being an essential, intrinsic component of

4The reader is reminded that the medicalizing and pathologizing of arange of human behaviors and adaptations and associated diagnoses oftypes of psychoactive substance use and selected users is relatively re-cent and is a consensus-based taxonomy which is not always empiri-cally informed. Editor’s note. American Psychiatric Association. Diag-nostic and Statistical Manual of Mental Disorders (DSM-IV), 4th ed.;American Psychiatric Association: Washington, DC, 1994.5The reader is asked to consider that with the advent of artificial scienceand its theoretical underpinnings (chaos, complexity, and uncertaintytheories), it is now posited that much of human behavior is complex, dy-namic, multidimensional, level/phase structured, nonlinear, law-driven,and bounded (culture, time, place, age, gender, ethnicity, etc.). Beinga believer or nonbeliever in a higher power—however, this concept isdefined and delineated—would be such a behavior/process. This is nota semantic issue. Distinguishing between one’s religion, religiosity andspirituality, and its posited association with an abstinent lifestyle can beaffected by dimensionalizing each of these three phenomena. There aretwo important issues to consider and which are derived from this: (1)Using linear models/tools to study nonlinear processes/phenomena canand does result in misleading conclusions and can, therefore, also re-sult in inappropriate interventions; (2) the concepts prediction and con-trol have different meanings and dimensions than they do in the moretraditional linear ”cause and effect” paradigms. (Buscema, M. (1998),Artificial Neural Networks, Substance Use &Misuse, 33(1–3). Editor’snote.

health, or at least an intrinsic component of a holistic con-ception of health (which has been considered by theWorldHealth Organization), closely aligned with psychologicaldimensions such as hope, optimism, and inner peace (e.g.,Chuengsatiansup, 2003; O’Connell & Skevington, 2010).Unfortunately, persons who do not consider themselvesas spiritual may be considered less healthy by definition(Koenig, 2008).

Antagonists of a Higher Power concept provide severalconverse arguments. One assertion is that treatments withprima facie religious content (e.g., that refer to God orprayer) violate basic ethical and legal notions of freedomof speech, beliefs, and choice or, in the United States,“separation of church and state” (Ellis & Schoenfeld,1990; Sloan et al., 1999: Trimpey, 1996). Also, anecdo-tally, many persons in recovery6 assert that if they hadto endorse a Supreme Being as part of their treatmentplan, they would have been doomed in their effortsfor recovery (Christopher, 1988; Galaif & Sussman,1995; Horvath, 1999; Peele & Brodsky, 1992; Toniganet al., 2002; Trimpey, 1996). Some may simply desirea separation of religion or spirituality from recovery, orhold onto a scientific (data-based) worldview (Borraset al., 2010; Ellis & Schoenfeld, 1990). Others positthat Supreme Beings in various religions are judgmentalor punishing (Cotton, Zebracki, Rosenthal, Tsevat, &Drotar, 2006). Additionally, others will argue that overlyritualistic reliance on a Higher Power or religious-typerecovery group may, itself, reflect a substitute addiction(Sussman & Black, 2008; Sussman, Reynaud, Aubin, &Leventhal, 2011; Taylor, 2002), or reduction in individualsound judgment or self-reliance (Ellis & Schoenfeld,1990; Li, Feifer, & Strohm, 2000; Moos, 2010; Nicolaus,2012). Some also may be uncomfortable in intensive,sometimes distressful spiritual/religious-oriented groupexperiences, or may feel (or be) rejected by the group fornot expressing religious ideation (Galanter, 2006).

These spirituality-related concerns have led to adapta-tions that mitigate participation by atheists and agnostics.For example, Jim Burwell, one of the first 10 membersof Alcoholics Anonymous (A.A.), was a self-proclaimedatheist and identified with the A.A. Fellowship or with his“better self” as being his “Higher Power” (Burwell, 1968).Alternative Higher Power interpretations have includedthe presence of helpful others, the human experience,nature or forces or creation, Good Orderly Direction, con-science, and goodness (Chesnut, 2001; Green et al., 1998).These alternative interpretations may underlie a findingthat 12-step self-help group attendance has been found to

6The term “recovery” can be viewed as a binary process, recovered ornot recovered, whatever the criteria being used; as well as in a mannerconsensualized by the 12-step movement of an ongoing process, a dayat a time, which is achievable but is never fully achieved. These arenot simply semantic distinctions. The reader is referred to the work ofthe General Semanticists (The symbol is NOT the thing symbolized, themap is NOT the territory. The word is NOT the thing. S. I. Hayakawa) aswell as to Osgood’s thesis of the semantic differential, in which contextinfluences meaning. Editor’s note.

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ISSUE OF SPIRITUALITY IN THE TREATMENT OF ALCOHOL AND OTHER DRUG ADDICTIONS 1205

be associated7 with abstinence one year later (among alarge sample of substance abuse8 inpatients) regardless ofwhether or not participants believed in God (Winzelberg& Humphreys, 1999). This is consistent with the sugges-tion that spirituality is a multidimensional construct thatincludes many types of beliefs among its constituents(e.g., Berry, 2005; Hill et al., 2000; Miller, 1998; Miller &Thoresen, 2003). Before exploring different perspectivesof spirituality, mediators of the impact of spirituality onrecovery, or distinguishing spirituality from secularism,we attempt to differentiate spirituality from religion.

Defining Spirituality Versus ReligionSpirituality has historically been nested within the bound-aries of religion (e.g., one’s personal relation with a super-natural entity). That is, religion has been treated as havinga broader scope. Spirituality often has been treated as thepersonalization of religion (Kass et al., 1991), but more re-cently has also been treated as distinct from religion (Hillet al., 2000;Wink &Dillon, 2003; Zinnbauer et al., 1997).Religion pertains to a social collective of thoughts, feel-ings, and behaviors that arise from a search for the sacred.“Sacred” refers to (1) an existential worldview, (2) feel-ings of awe or respect or devotion, or (3) rituals that ex-press connection to a person, object, principle, or conceptthat transcends the self. Religion also includes goals ofgroup belongingness (e.g., church membership and struc-ture, attendance, and organized belief system). That is,religion involves institutionalization/legitimization of asearch for the sacred. Belonging to a religious group alsomay involve nonspiritual ends such as safety, personalcomfort, affiliation, or identity.

Spirituality involves the search for the sacred with-out the addition of group belongingness, and collectivelyorganized institutions, and sometimes does not invokea supernatural power (George et al., 2000; Hill et al.,2000; Zinnbauer et al., 1997). Spirituality might con-sider the sacred as being world-oriented (e.g., ecolog-ical, of nature) or humanistic (people-oriented) insteadof supernatural. Compared to religiosity, spirituality maybe more closely associated with well-being via personalgrowth or personal wisdom; whereas religion may bemore closely associated with well-being from positive re-lations, or other social-related activities (Wink & Dillon,2003). Still, one’s sense of spirituality is associated withone’s social world (see Ashmos & Duchon, 2000; Hill& Pargament, 2003; Holder, Coleman, & Wallace, 2010;Zinnbauer et al., 1997). For example, spirituality at theworkplace may be associated with being part of the workcommunity, working for something larger than oneself,feeling spiritually energized at work, and caring about

7The reader is referred to Hills’s criteria for causation which were de-veloped in order to help assist researchers and clinicians determine ifrisk factors were causes of a particular disease or outcomes or merelyassociated. (Hill, A. B. (1965). The environment and disease: Associ-ations or causation? Proceedings of the Royal Society of Medicine 58:295–300). Editor’s note.8This refers to the DSM-IV diagnostic category.

the spiritual health of coworkers (Ashmos & Duchon,2000).

Spirituality may even be defined more broadly than re-ligion (Holder et al., 2010; Koenig, 2008). That is, religionmay be defined as being only one example of spiritual ex-pression. However, as Koenig (2008) argued, it is not clearwhat construct spirituality is if one removes the search forthe sacred from its definition. Of course, what is defined assacred is embedded within a historical and social context(Hill et al., 2000). In other words, what is defined as sa-cred could change over time—if so, such impermanencemay reflect the relative importance of an experiential pro-cess as being preventive of relapse/promotive of recoveryas opposed to, for example, a static sacred object or ritual(e.g., Seaward, 1995).

Measurement of SpiritualityMeasurement of spirituality has consisted primarily ofthe use of four types of self-report items (Berry, 2005;Galanter et al., 2007; Koenig, 2008; Sussman et al., 2005),some of which are intimately tied to religion9.

• People might simply be asked how spiritual they are, orwhether they hold spiritual beliefs (Sussman, Nezami,& Mishra, 1997).

• Another type of item assesses a person’s participation inspiritual groups or events (Berry, 2005; Sussman et al.,2005).

• A third type of spirituality item assesses a person’sengagement in spiritual experiences, such as medi-tation and prayer, or trying to obtain solace from ahigher power (Carroll, 1993; Kass et al., 1991; Suss-man, Nezami, & Mishra, 1997).

• A fourth type of spirituality item taps subjective self-beliefs such as a sense of purpose, feeling peaceful, feel-ing a sense of harmony, sense of forgiveness, or senseof connectedness (Koenig, 2008; Underwood & Teresi,2002).

There are a variety of “spirituality”-related beliefs andpractices that may be predictive of recovery success,many of which are not explicitly reliant on existence ofa Supreme Being (Tonigan, Miller, & Schermer, 2002).However, there is often little explication regarding whatare the referents of self-reported “spirituality” (e.g., Berry,2005; Sussman, Nezami, & Mishra, 1997). For example,a measure may refer to a “spiritual force” in one’s life,but leave it up to the individual to determine the con-stituents (operationalization, causal mechanism) of thisforce (Berry, 2005). That is, spirituality terms are oftenused in a way left to be defined by the individual. Theyare not explicated. Thus, it is difficult to support or refuteinfluence of treatment organizations that promote spiri-tuality, or individuals who report guidance from spiritualforces, because of the variance (or vagueness) in the un-derstanding of what is “spirituality.”

9There are numerous specific measures of spirituality, and thisgoes beyond the scope of this paper (see Chuengsatiansup, 2003;Egbert, Mickley & Coeling, 2004; Koenig, 2008; Sussman, Nezami,& Mishra, 1997, for more examples).

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Mediation of the Impact of Spiritual Practiceson RecoveryEven if one makes explicit certain beliefs or practices thatare said to be spiritual in content, it is generally not statedwhat mediates the effects of these spirituality-based be-liefs or practices on recovery. That is, assuming a per-son meditates to receive support from a Higher Power,prays, goes to church, engages in a number of other “re-ligious” activities or, alternatively, states positive affirma-tions, meditates on a fixed object of self, focuses attention,engages in service work, or “smells the roses,” the utilityof these actions is contingent on what they actually do forthe person; how they translate into recovery behavior. Byengaging in some practice or manner of thinking (“spiri-tuality”), an intermediate effect is elicited (the mediator)which, in turn, impacts on later addictive behavior (alco-hol or drug misuse). We understand the causal mechanismunderlying the relations of spiritual practices or thoughtswith later alcohol or drug misuse by identifying themediators.

There are numerous potential mediators (e.g., Cottonet al., 2006), and these may vary within and across indi-viduals over time. Subjective statements of attachment toHigher Powers or supernatural entities are types of spiri-tuality related to a religious conceptualization. Five othermediators that do not appear to rely on a Supreme Be-ing conception include: (1) building a personal sense ofmorality (Sussman et al., 2005), (2) creating wellness, astable positive attitude or conscientiousness (Cotton et al.,2006; Sussman, Nezami, & Mishra, 1997), (3) strength-ening reliance on executive cognitive processes (Pribram,1999), (4) provision of social support or instruction inadaptive coping (Cotton et al., 2006), or (5) generation ofa placebo effect (Galanter, 2006).

Morality as a MediatorMorality refers to acting in the “right” or “good” way.Acting in the “wrong” way would serve to induce “guilt.”Sources of morality include cultural institutions (school,church, legal systems), and social groups (family, peers,clubs), and integration of these in one’s own experience(personal code). A majority of religions have positions onwhat is acceptable to put into the human body. These po-sitions vary from explicitly prohibiting use (abstinence),to not prohibiting use (moderation), to the incorporationof the spiritual use of a substance into various religiousrituals. Among the world’s largest religions (Christianity,Islam, Judaism, Buddhism), substance use is either pro-hibited or frowned upon when used for intoxicating pur-poses (pleasurable versus medicinal or spiritual), or othernon-normative reasons. Identifying with a religion canalter behavior by the prescription/subscription to nonus-ing values, and/or function as an external control; for ex-ample, through nonsubstance using social norms and in-teraction with nonusing peers (Amoateng & Bahr, 1986;Benda, 1997; Merrill, Salazar, & Gardner, 2001; Oetting,Donnermeyer, & Deffenbacher, 1998).

George et al. (2000) note that specific religion/spiritualgroup-based prohibitions against unhealthy behaviors

may explain the relation of spirituality with drugabuse prevention or cessation (also see McCullough &Willoughby, 2009). The generation of Alcoholics Anony-mous was influenced greatly by the Oxford Group,10

which asserted moral betterment (Galanter, 2006).Regarding empirical research that specifically exam-

ined morality as a mediator of the relations of spiritualitywith drug use, Sussman et al. (2005) found that a spiritual-ity practices-and-beliefs measure that included items tap-ping prayer and meditation practices, religious/spiritualgroup participation, and reliance on a Higher Power pre-dicted lower levels of drug use one year later amonga sample of 501 at-risk teens from 19 alternative highschools. However, when statistically controlling for ameasure of morality of drug use (which also predictedlater drug use) the spirituality measure no longer predictedlater drug use. Only the morality of drug use measure re-mained a significant predictor. The researchers inferredthat it may have been the alteration of one’s associationsof “guilt” or “right or wrong” with drug use that wasmore fundamental to changing behavior, rather than spir-itual beliefs and practices per se. Thus, the spiritual prac-tices may have provided the social learning setting withinwhich to establish cognitive associations of immoralitywith drug use.

Gryczynski & Ward (2012) studied the relations be-tween religiosity, heavy drinking, and social norms amonga large sample of U.S. adolescents, and found that re-ligiosity may exert an indirect protective effect againstheavy alcohol use, through nonpermissive drinking normsof parents, close friends, and peers.While this was a cross-sectional study, it also supports the potential mediatingeffect of social morality on the relations of spiritualityand drug use. Similar indirect effects of intolerance of de-viance, via friends’ substance use, on one’s own substanceuse, were found by Walker, Ainette, Wills, & Mendoza(2007).

Wellness Constructs as MediatorsThere are numerous wellness-related constructs that maymediate the relations of spirituality with substance use.First, spiritual beliefs or practices may work to decreasedrug misuse through eliciting statements of positive atti-tudes toward life (Daaleman, Cobb, & Frey, 2001; Georgeet al., 2000; Horvath, 1999; Salsman, Brown, Brechting,& Carlson, 2005; Sussman et al., 1997) which may be an-tagonistic to self-seeking, negativistic behavior. In otherwords, taking an optimistic life perspective may mediatethe effects of spiritual actions on drug use.

Because, lack of positive affect (i.e., anhedonia) isa significant predictor of substance use (e.g., Leventhalet al., 2012), spirituality/religiosity may impact addic-tive behaviors through increasing positive effect via more

10The Oxford Group was an organization founded in 1931 by FrankBuchman, an American Lutheran Christian minister and missionary,derived from Christian tenets but not a religion, guided by four “abso-lutes” (honesty, purity, unselfishness, and love), and spiritual principlesof confession, surrender, restitution, and doing God’sWill (Bufe, 1991).

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constructive pathways toward well-being. That is, reli-gious/spiritual sentiments include emotional and behav-ioral experiences (e.g., a “positive attitude” or caring forothers) that foster life satisfaction (Peterson, Ruch, Beer-mann, Park, & Seligman, 2007). To the extent that thesecharacter strengths are supported by religious institutionsor spiritual practices, they may help instill positive emo-tions though adaptive activities as opposed to substanceuse.

Second, a desire to be of assistance to others may beanother wellness-type mediator (Sussman et al., 1997).Bogg & Roberts (2004) conducted a meta-analysis of 194studies, and found that conscientiousness-related traits areuniformly negatively related to unhealthy behaviors in-cluding substance use. As an example of inducing com-passion for others, mindfulness meditation often includesloving-kindness meditation that can bolster feelings ofcompassion toward all living beings (e.g., Fredrickson,Cohn, Coffey, Pek, & Finkel, 2008). In loving-kindnessmeditation, practitioners first focus compassionate inten-tions on a relatively easy target, such as a child. Thepractitioner then expands this bubble of compassion to-ward more difficult relationships, such as those who havecaused him or her harm in the past. Finally, this awarenessis gradually expanded to all sentient beings. By doing this,the participant becomes aware of the interconnected suf-fering of all living beings. This practice can draw forthfeelings of interconnectedness as well as a sense of mean-ing though virtuous emotions such as love, empathy, andgenerosity.

Third, sense of coherence (SOC) may be a media-tor of the relations of spirituality with recovery (Georgeet al., 2000). SOC is a wellness-type construct that re-flects an individual’s worldview and methods of cop-ing with challenging stimuli. SOC is composed of threecomponents: (1) comprehensibility—stimuli that confronta person make cognitive sense, (2) manageability—theperson has resources at his disposal that are capableof meeting the demands posed by the stimuli, and (3)meaningfulness—that problems posed in life are worthcommitting to (Antonovsky, 1993). Individuals who havea strong SOC tend to have more positive life attitudes, bet-ter coping mechanisms, less perceived stress, better qual-ity of life, and are more spiritual (Antonovsky, 1993). Ina study of 93 Israeli inmates recovering from drug ad-diction, Chen found that SOC played a positive, mediat-ing role in the relationship between spirituality and addic-tion recovery. Also, of the inmates that participated in theintervention programs, those that received a supplemen-tary spirituality-related treatment component in additionto social support demonstrated a higher SOC and a less-ening of negative emotions (e.g., anxiety, depression, andhostility) than their counterparts who received social sup-port only (Chen, 2006). Thus, there is evidence of SOCas a mediator of the relations between spirituality andrecovery.

In some research studies, religious participants con-fronted with a chronic illness began to question their be-lief system and their “God(s)” (Delgado, 2007; Strang &

Strang, 2001). In such cases, nonsupernaturalmeans to en-hance SOC might be relatively effective at bringing aboutmeaning in life. That is, possibly, when the search for “thesacred” as a Supreme Being is removed, the role that “thesacred” plays may be considered instead as a commitmentto find meaning in life (Daaleman, Cobb, & Frey, 2001).

Finally, one other possible mediator of the relations be-tween spirituality and stress-related drug misuse is termedpost-traumatic growth (PTG). Spiritual beliefs and prac-tices are commonly reported as major sources of strengthfor surmounting both the daily and major stressors oflife (Ano & Vasconcelles, 2005; Shaw, Joseph, & Linley,2005). These beliefs and practices may serve a protectivefunction on stress-related drug misuse. PTG is the relativechange in one’s psychosocial health after having experi-enced an extremely stressful event, integrating the new-found strength as well as heightened sense of vulnerabilityinto the reconstruction of meanings for the self, one’s pur-pose, role of social relationships, appreciation for and pos-sibilities in life, and sense of spirituality (Tedeschi & Cal-houn, 1996). As a result of change endorsed in these areasof PTG, an individual may be compelled to alter health-related behaviors, including those involving substance useand recovery.

Increased spirituality and the development of PTGhave been demonstrated. For instance, in a review byShaw, Joseph and Linley (2005), results of 11 studiessummarized the extent to which spirituality is helpful topeople in dealing with the trauma-related circumstances,and to discern the relationship between spiritualityand PTG. Both positive religious/spiritual coping (e.g.,active religious surrender, seeking spiritual connectionor religious direction, religious conversion) and nega-tive religious/spiritual coping (e.g., demonic reappraisal,marking religious boundaries, pleading for direct interces-sion) were related to PTG, as was nonreligious/spiritualcoping (e.g., active coping, receiving social support, ac-ceptance, emotional venting, denial) but not as strongly.Findings suggest that turning to one’s faith or spiritualitymay be part-and-parcel of the overall process in makingsense of the circumstances surrounding the trauma.

Several researchers have assessed the statistical rela-tionship between PTG and substance use in a wide rangeof samples. Among high school students, who had experi-enced various stressful events, PTG was inversely relatedto a substance use index (Milam, Ritt-Olson, & Unger,2004). In another study conducted among middle schoolstudents exposed to stress from the events of September11, authors reported a positive relationship between PTGand identification with religion, and an inverse relation-ship between PTG and alcohol use (Milam, Ritt-Olson,Tan, Unger, & Nezami, 2005). More recently, Dunlop andTracy (2013) found that self-redemption statements (as-sessed through narratives coded for statements on positivepersonality change resulting from past traumatic expe-riences, such as “becoming stronger”) was significantlymore common among those who were able to maintainsobriety four years or more versus those who weresober for less than six months, and that the perception

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of self-redemption, or positive personality change, atthe first assessment point was able to predict sobrietyat second assessment several months later. Collectively,these studies suggest that individuals may seek toachieve congruence between thought and action such thathaving undergone positive psychological transformationfollowing extreme stress manifests in less substance use.

Koenig (2008) provided a warning regarding vari-ous measures of spirituality that focus on wellness at-titudes/positive psychological states, including purposeand meaning in life, connectedness with others, peaceful-ness, sense of harmony, and well-being. He argued thatby including indicators of mental health in the defini-tion of spirituality, an association between the two con-structs is assured. That is, there is the danger of a falsedichotomy by considering wellness practices as spiritualpractices, and it does suggest a potential confounding be-tween ratings of being spiritual and being of good men-tal health. Researchers perhaps should attempt to sepa-rate spirituality from such wellness variables as havingpositive attitudes toward life, conscientiousness, SOC, orPTG. Koenig argues for a specific definition of spiritual-ity; that should be measured using questions about pub-lic and private religious beliefs, practices, rituals, cere-monies, attitudes, and degree of commitment. Spiritualitymay foster wellness variables that foster sobriety.

Neuro-Cognitive Function as a MediatorWhat have been referred to as spiritual practices mightstrengthen (1) attentional focus and (2) executive cogni-tive processes (decision-making and inhibitory control ofbehavior). That is, it is possible that fine-tuning of neu-rocognitive function may mediate the impact of spiritual-ity on recovery. For example, some researchers and practi-tioners have suggested that mindfulness-related cognitivetechniques might alternatively be referred to either as at-tentional retraining-type strategies (bottom-up processingof salient stimuli), as means of executive control enhance-ment (top-down modulation of responses to discomfort),or as spiritual practices (Borras et al., 2010; Cleveland& G., 1992; Galanter, 2006; Pribram, 1999; Sussman &Ames, 2008; Witkiewitz, Lustyk, & Brown, 2012).

In recent years, mindfulness meditation has been ofspecific public and scientific interest. A cursory Inter-net search of “mindfulness meditation” will provide anidea of how ubiquitous the practice is today. In termsof research on the topic, in the year 1990 only five re-search studies were published on mindfulness comparedto the 397 papers published in 2011 (Black, 2010). Mind-fulness means “paying attention in a particular way: onpurpose, in the present moment, and nonjudgmentally”(Kabat-Zinn, 1994, p. 4). Practicing mindfulness in dailylife is believed to alleviate the psychological suffering co-occurring with most health ailments and medical condi-tions. This belief is based on the notion that unnecessarysuffering is often created by negative thoughts that aggra-vate real or perceived symptoms. Given that mindfulnessmeditation stems from a rich historical mixture of easternhealing and spirituality, it is no surprise that those who

practice mindfulness meditation report enhanced spiritualwell-being (Carmody, Reed, Kristeller, &Merriam, 2008)and the experience of spiritual events (Greeson et al.,2011). Increase in one’s spiritual experience (awarenessof and relationship with the transcendent), which may as-sist in recovery, may be partially mediated by practice ofmindfulness and related neurobiological changes (atten-tion, present-moment focus, awareness, and nonjudgment(Carmody et al., 2008; Greeson et al., 2011).

Positive changes in brain structure and function as-sociated with recovery are found in response to mind-fulness meditation, indicating the program’s applica-bility to addictions treatment (Brewer et al., 2010;Galanter, 2006; Witkiewitz, Lustyk, & Bowen, 2012).Sustained concentration and focused-breathing in thepresent moment—skills practiced during mindfulnessmeditation—can modulate the somatosensory bridge be-tween mind and body, leading to feelings of calm, relax-ation, and wholeness.

Furthermore, the practice of observing thoughts, emo-tions, and sensations from a decentered meta-awareness,and contemplating on their ephemeral nature can lead to asensation of being larger than a single constricted mind orego. Moreover, this decentered stance inherently dampensstrong ties to distracting mental chatter, allowing for indi-vidual consciousness to merge with a more global senseof universal consciousness (Walsh, 1999). The Westernemphasis—even obsession—with thoughts and thinkingoften stymies the potential for these types of spiritualopportunities. Therefore, the broadened mental perspec-tive cultivated in mindfulness meditation can enliven spir-itual feelings such as awakening, personal insight, andliberation.

It should also be mentioned, however, different frommindfulness meditation, that there are other contempla-tive practices that involve purposeful self-talk (e.g., to aHigher Power), which may strengthen deliberate social-informational processing. Purposeful self-talk may becontrasted with overly ritualistic contemplative practices(e.g., over-learned prayers) that reflect more primitive orautomatic processing and may be counterproductive interms of assisting recovery (Shariff & Norenzayan, 2007;Sussman et al., 2011).

Social Support and Adaptive Coping as MediatorsSpirituality or religious involvement might also operatethrough providing a channel of building supportive bondswith significant others and liaisons, and identificationwith prosocial others (George et al., 2000; Moos, 2010;Wu & Witkiewitz, 2008). In addition to social group-enforced morality as a mediator, previously discussed,social support may involve assistance with materialneeds, reinforcement of one’s value as a person, or com-panionship, all of which could mediate the relations of re-ligious/spiritual group involvement and drug abuse or lifesatisfaction (e.g., Nealon-Wood, Ferrari, & Jason, 1995;Salsman et al., 2005). For example, 134 male residents ofa sober living facility (Oxford House) reported compan-ionship (fellowship) as amain reason for attendance at AA

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meetings (Nealon-Wood, Ferrari, & Jason, 1995), whichappeared to lead to longer lasting sobriety. Likewise, Wuand Witkiewitz (2008) found that alcoholics in treatmentwho had pretreatment social networks supportive of drink-ing demonstrated better outcomes in the 12-step Facilita-tion condition of Project MATCH than theMotivation En-hancement or Cognitive Behavioral Therapy conditions.Thus, social support may be a mediator of the relationsof spiritual group involvement with drinking or drugoutcomes.

One important type of adaptive coping is self-control.McCullough & Willoughby (2009) reviewed literaturesuggesting that self-control, self-monitoring, and self-regulation may mediate the relations between religiousexperience and health/well-being. Likewise, Walker et al.(2007) found that religiosity/spirituality predicted lateradolescent substance use indirectly in part through goodself-control. The impact of mindfulness meditation prac-tices also may be on strengthening the operation ofexecutive cognitive function that, in turn, would serveto strengthen inhibition of impulsive, substance misuse-related behavior (Witkiewitz et al., 2012).

Related adaptive coping mechanisms might be estab-lished as well, involving development of more responsiblebehavior, sense ofmastery via cognitive coping, or achiev-ing pleasure through relatively harmless means (Moos,2010). Interestingly, one type of cognitive coping methodmight be “spiritual acceptance,” or affinity for serendip-itous phenomena. Spiritual acceptance is associated withincreased serotonin turnover (Borg, Andree, Soderstrom,& Farde, 2003; Galanter, 2006), the neurotransmitter in-volved in maintenance of pleasurable feelings, and mightbe protective against drug misuse. Thus, social supportand adaptive coping may mediate the relations of spiri-tuality and substance use via behavioral, cognitive, andneurobiological changes.

The Placebo Effect as MediatorThe placebo effect has been defined as a reduction insymptoms resulting from one’s belief in the effective-ness of a therapeutic intervention (Vase, Riley, & Price,2002). The term “placebo” may connote ”sham” treat-ments or cultural folklore; however, empirical and clini-cal evidences suggest that mind-body effects of placebotreatments may have lasting significant effects. As earlyas 1955, Beecher demonstrated that 16%–60% of patientsshowed benefit from having received a placebo for pain,cough, drug-induced mood change, headaches, seasick-ness, or the common cold (Beecher, 1955).

Spiritual beliefs may, in and of themselves, resultin psychological or neurobiological changes that mightfacilitate staying sober, possibly reflecting operation ofa placebo effect (Galanter, 2006). As is the case withother mediators of the relationship between spiritualityand recovery, the placebo effect may occur through neu-ropsychophysiological processes that are influenced bycharacteristics such as expectations, optimism, or otherrelated motivational states (Giordano & Engebretson,2006; Giordano&Kohls, 2008). These neuropsychophys-iological processes are initiated by spiritual experiences

that elicit hierarchical activation of peripheral and centralneuraxes, which, in turn, initiate a chain of complexsignal processing through various regions of the brain toaffect cognitive and emotional perceptions and ideation(Kohls, Sauer, Offenbacher, & Giordano, 2011).

The process may result in altered neurochemistry inbrain systems also involved in addiction (e.g., activation ofendogenous opioids and serotonin), and inhibition of thebeta-adrenergic sympathetic nervous system (Benedetti,Mayberg, Wager, Stohler, & Zubieta, 2005; Kohls et al.,2011). In short, common regions of the brain appear tobe involved in the interpretation of spiritual experiences,placebo responses, and effects of substances.

Summary of Mediation of Spirituality and Implicationsfor the Secular-MindedThere are numerous potential mediators of the re-lations between spirituality and recovery from drugabuse, including morality-based attitudes, wellness con-structs (positive attitudes, conscientiousness, SOC, PTG),strengthening of cognitive function and mindfulness, so-cial support or involvement in adaptive coping, or due to aplacebo effect. Table 1 provides a summary of these con-structs. The challenge for the secular-minded could be toidentify nonspiritual/non-Supreme Being means of ma-nipulating the same mediators. Then, treatment for the ad-dictions might be repackaged in a way that is more ac-ceptable to people of different metaphysical orientations.Indeed, 12-step programs have been reconceptualized torefer to understanding and support of others in the groupor to spiritual resources rather than to a Supreme Being(e.g., Cleveland & G., 1992). If people in recovery canidentify with a healing process that will help them, it maynot matter which route is taken. A healing route may beone they choose to label as religion, spirituality, or rationalrewiring.

Context-Determined Meanings of SpiritualitySpiritual beliefs and practices derive meaning withinsocio-environmental contexts (Moos, 2010; Stokols,1990). Modern terrorism, Satanism, Cult Suicides, Pagan-ism or other such phenomena arguably could be said toreflect the operation of spirituality within unique contexts(e.g., Bowman, 1995; Swatos, 1992). As such, it is possi-ble for spirituality to be employed as a means to promotedrug use or misuse, rather than ameliorate drug use or mis-use (Galanter, 2006; Sussman et al., 2006).

In addition, some writers assert that people mayuse drugs as a means of spirituality enhancement (e.g.,Aldrich, 1977; Stafford, 1977), in search of transcendenceor divine contact (Galanter, 2006). That is, there existspiritual practices facilitated by drug use (Sussman et al.,2006). For example, the “Peyote Religion” (Native Amer-ican Church) is adhered to among some American Indiantribes (e.g., Apache, Navajo), and involves imbibing thehallucinogen, peyote, to connect with Higher Powers,strengthen decision-making, obtain a sense of culturalpride, release negative emotions, enhance forgiveness,and even to treat alcoholism (e.g., Albaugh & Anderson,1974).

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TABLE 1. Mediators between spirituality and recovery from substance use

# Variable name Variable description Possible mediating mechanism Research considerations

Building a personal sense of morality1. Morality Refers to acting in the “right” or

“good” way, whereas acting inthe “wrong” way would induce“guilt.”

Cultural institutions, social groups,or personal code dictates viewson substance use, whether forpersonal or spiritual use orreligious ritual.

Religion serves as external control,source for social norms;group-based prohibitions mayexplain the indirect effect.

Creating wellness, a stable positive attitude or conscientiousness2. Positive attitudes

toward lifeEncompasses optimism or positiveaffect

Religious institutions or spiritualpractices may help instill positiveemotions through adaptiveactivities in lieu of substance use.

Emotional and behavioralexperiences generated throughpositive attitudes may foster lifesatisfaction.

3. Desire to be ofassistance toothers

Often assessed asconscientiousness-related traits(CRTs)

Brings forth feelings ofinterconnectedness with all livingbeings and sense of meaningthrough love, empathy, andgenerosity.

Inducing compassion for others,through loving-kindnessmeditation, bolsters compassiontoward all living beings and otherCRTs.

4. Sense ofcoherence(SOC)

Reflects one’s method of copingwith challenge; defined bycomprehensibility, manageablity,and meaningfulness.

Strong SOC includes positive lifeattitudes, better coping methods,and less perceived stress.

Fostering SOC may be effective atfinding meaning in life, whetheror not related to a SupremeBeing.

5. Post-traumaticgrowth (PTG)

Positive change in one’spsychosocial health after havingexperienced an extremelystressful event

PTG encompasses greater sense ofpersonal strength, purpose,meaning, appreciation forpossibilities in life, andspirituality.

Related to positivereligious/spiritual coping;synonymous with stress-relatedgrowth and benefit finding

Strengthening reliance on executive cognitive processes6. Mindfulness “Paying attention in a particular

way: on purpose, in the presentmoment, and nonjudgmentally”(Kabat-Zinn, 1994, p. 4)

Mindfulness meditation may lead tofeelings of calm, relaxation, andwholeness while strengtheningcognitive function.

May confer enhanced well-beingand experience of spiritualevents. Mindfulness and relatedneurobiological, attentional, andself-regulation changes mayfacilitate recovery.

Provision of social support or instruction in adaptive coping7. Building

supportivebonds withothers

Involves identification withprosocial others, and maintainingthe relationships.

Social support may involveassistance with material needs,companionship, and positivereinforcement of one’s value as aperson.

Example: Benefit of companionshipat AA meetings may lead tolasting sobriety.

8. Adaptive coping Encompasses components ofself-control, self-monitoring,self-regulation, and “spiritualacceptance” (a type of cognitivecoping).

Adaptive coping may result in thedevelopment of more responsiblebehavior, sense of mastery (viacognitive coping), or achievingpleasure through means otherthan substance use.

“Spiritual acceptance” is related toincreased serotonin turnover.Serotonin is the neurotransmitterinvolved in maintenance ofpleasurable feelings.

Generation of placebo effect9. Placebo Reduction in symptoms resulting

from one’s belief in theeffectiveness of a therapeuticintervention

Spiritual beliefs may, in and ofthemselves, result inpsychological or neurobiologicalchanges that might facilitatestaying sober.

Neuropsychophysiological changesmay be influenced bycharacteristics such asexpectations, optimism, or otherrelated motivational states.

As a second example, it is well known that one ofthe founders of Alcoholics Anonymous used the drug,LSD (d-lysergic acid diethylamide) in the 1950s, to tryto achieve spiritual growth and healing (Dyck, 2006;Sussman et al., 2006). Alan Watts (1968) describedpsychedelic drugs as producing mystical, religious, orcosmic experiences. He admitted that there are “drugged”persons who are dimmed in consciousness, fogged in

judgment, or deprived of will, and he asserted that alcohol,opiates, and barbiturates are of that type. Also, he assertedthat one should not engage in irresponsible behavior (e.g.,driving a car) on any drug. However, he also stated that theuse of two types of drugs, marijuana and hallucinogens,were helpful in inducing spiritual-type experiences. Theseexperiences include a slowing down of time (presentfocus), awareness of interdependence among things,

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awareness of relativity in the relations among things, andawareness of eternal energy. He argued that oppositionto drug use is due to a religious orientation repelled bya sense of “oneness with the universe,” and which viewsspirituality in terms of Supreme Beings apart from oneself(also see Clark, 1970; Pahnke, 1966; Smith, 1964).

As a third example, Sussman et al. (2006) found thata drug use-specific spirituality measure (e.g., self-reportitems include “drug use can help you find your trueself” and “drug use promotes personal growth and en-lightenment”) was positively predictive of cigarette smok-ing and hallucinogen use one year later among a sam-ple of 501 at-risk teens from 18 alternative high schools.Thus, the context within which “spirituality” operatesmay define or moderate the effects of related beliefs andpractices on substance use. Certainly, it is possible thatdrug use-related spirituality may become self-destructive(Bastos, 2010), as might non-drug-use-related spirituality(Galanter, 2006).

The ethno-cultural context underlying spirituality alsomay alter its relations with drug use. For example, in astudy of 362 adolescent ethnic Russians and ethnic non-Russians (mostly Islamic), spirituality failed to be as-sociated with recent cigarette smoking or alcohol use.Cigarette and alcohol use intentions were associated withspirituality, but only among ethnic non-Russians. Rather,the importance placed on health as a value was inverselyassociated with substance use among all youth. Thesefindings suggest that spirituality may be irrelevant insome ethnicities, if not associated with religions that areproscriptive against cigarette and alcohol use (Pokhrel,Masagutov, Kniazev, & Sussman, 2012; Pokhrel et al.,2012).

In brief, spirituality “is”what spirituality “does.” It maybe protective or facilitative of drug use, or fail to be foundto be related to drug use, depending on what contexts andpractices are associated with the term. Practices that directone’s thoughts and behavior away from drug use, and per-haps provide one with a stable sense of a positive self, ap-pear to be fundamental for recovery. These practices maybe termed as religious, transcendent, spiritual, mindful,moral, conscientious, secular, or as cognitive reparation orcognitive coping (e.g., “centering,” “emptying,” “ground-ing,” and “connecting”; Seaward, 1995). Regardless ofthe label as being spiritual or nonspiritual, if consumersand change agents promote individualized pathways ofhealing or “treatment matching” (e.g., individualized con-sideration of need of family therapy, vocational counsel-ing, psychiatric services, or nondrinking social networks),great strides in substance user treatment11 will be made(e.g., McLellan et al., 1997; Wu & Witkiewitz, 2008).

11Treatment can be briefly and usefully defined as a unique, planned,goal-directed, temporally structured, multidimensional change process,of necessary quality, appropriateness, and conditions (endogenous andexogenous), which is bounded (culture, place, time, etc.) and can be cat-egorized into professional-based, tradition-based, mutual –help-based(AA, NA, etc.) and self-help (“natural recovery”) models. There are nounique models or techniques used with substance users—of whatevertypes and heterogeneities—which aren’t also used with nonsubstanceusers. Whether or not a treatment technique is indicated or contraindi-cated, and its selection underpinnings (theory-based, empirically-based,

Alternatives to Spirituality for Recovery: SecularApproachesVarious researchers and practitioners have presentedexplicitly secular, nonspiritual alternatives to recoveryfrom drug misuse that also do not rely on the 12-steps(e.g., Galaif & Sussman, 1995; Humphreys, 1997; White& Kurtz, 2006; White & Nicolaus, 2005). Secular-basedrecovery emphasizes harnessing rational self-direction,adaptive coping (e.g., problem solving, assertivenessskills) and resilience, resistance of more primitiveaspects of self (and self-control skills), assertion ofself-reliance, and processing of empirical information,and may discourage self-labeling (White & Kurtz, 2006;White & Nicolaus, 2005). One may think of secularrecovery approaches as (1) not invoking a SupremeBeing and (2) encouraging self-integration as opposedto self–other integration. Several organizations tendto promote these attributes (e.g., Rational Recovery,Secular Organizations for Sobriety—Save Our Selves[SOS], SMART Recovery, LifeRing; Christopher, 1988;Galaif & Sussman, 1995; Galanter, Egelko, & Edwards,1993; Horvath, 1999; Nicolaus, 2012; Trimpey, 1996;White & Kurtz, 2006). Another means of recovery,contingency management interventions, which provideincentives yoked to periodic assessments of drug absti-nence, are effective and might be considered secular inconstruction (e.g., Petry, Martin, Cooney, & Kranzler,2000).

Of course, secular and spiritual variables may impacteach other. The set of previously considered mediatorsof the relation between spirituality and recovery maybe considered secular in contents (e.g., morality instill-ment, wellness enhancement, neurocognitive function im-provement, and so on). Thus, spirituality (e.g., attemptsat transcendence from self) may impact secular vari-ables (e.g., which bring about self-integration) that impactrecovery.

Conversely, secular variables may also impact one’sspirituality. One family of approaches, often consideredsecular (though some people consider them spiritual

principle of faith-based, tradition-based, etc.) continues to be a genericand key treatment issue. In the West, with the relatively new ideologyof “harm reduction” and the even newer Quality of Life (QOL) andwell-being treatment-driven models, there are now a new set of goalsin addition to those derived from/associated with the older traditionof abstinence-driven models. Conflict-resolution models may stimulatean additional option for intervention. Each ideological model has itsown criteria for success, as well as failure. Treatment is implementedin a range of environments; ambulatory as well as within institutionswhich can include controlled environments. Treatment includes a spec-trum of clinician–caregiver–patient relationships representing variousforms of decision-making traditions/models: (1) the hierarchical modelin which the clinician-treatment agent makes the decision(s) and the re-cipient is compliant and relatively passive; (2) shared decision-makingwhich facilitates the collaboration between clinician and patient(s) inwhich both are active; and (3) the ”informed model” in which the pa-tient makes the decision(s). Substance users, who represent a hetero-geneous group of people and patterns of use, continue to be treatedin ”specialized” programs which are distanced from the mainstream ofthe treatment of nonusers—”NORMED TREATMENT OF NORMEDDISEASES”—all-too-often manifest imparity in availability and deliv-ery of needed services, utilize policies which are stakeholder -drivenand not evidence-based and may be ethically insensitive. Editor’s note.

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activities), under the auspices of the National Institutesof Health (NIH) called complementary and alternativemedicine (CAM), is increasingly being used to treat healthailments as well as address spiritual needs. Many CAMtreatments derive from Eastern perspectives that central-ize the importance of spirituality in the healing process.For example, nonpharmaceutical CAM treatments includemeditation, deep breathing exercises, yoga, bodywork,tai chi, progressive relaxation, and other techniques thatunify the mind and body and enhance spiritual well-being.Sustained meditative states can activate psychobiologicalprocesses that drive perceptions of euphoria, minor hallu-cinations, and out-of-body experiences, which are oftenreported as spiritual encounters (Newberg & Iversen,2003).

Other approaches, which are “ordained” as being of asecular foundation, also may produce effects/experiencesone may term spiritual. For example, it is feasible that theself-empowerment emphasized and experienced throughsuch approaches as LifeRing (Nicolaus, 2012) may be ex-perienced as transcendent and inspired. So, it is feasiblethat spiritual and secular approaches might be (1) discrim-inable and (2) impact each other. Yet, there are variationsin the breadth of definitions of spirituality (varying from asearch for the Sacred or Divine to a search for the Essencesof the Human Condition and Wellness), which, as previ-ously mentioned, may complicate our understanding ofthe concept (Koenig, 2008).

If spirituality is defined as personal religion—creatinga connection with Higher Powers—spirituality-basedrecovery would appear quite distinct from secularnonspiritual-based recovery, the latter being based onappeals to rational thinking, adaptive coping, or self-empowerment. On the other hand, if spirituality is definedas having a sense of being in the presence of a life force,and of having a sense of well-being and connection withthe world around oneself, then secular approaches andspiritual approaches likely do overlap (Koenig, 2008), un-less secular approaches are defined narrowly, only fromthe perspective of the self, regardless of nonsupernat-ural outside powers (e.g., culture, nature/environment,society).

Clarification of Spirituality as an Empirical Concept:Consideration of Necessary and Sufficient Conditions,and Family ResemblancesAs generally used in practice, spirituality is not consideredto be an empirical concept. That is, it tends not to be con-sidered something observable; rather it is viewed as beinga metaphysical construct (Galanter, 2006). As such, it isdifficult to confirm or disconfirm the operation of spiritu-ality on behaviors such as alcohol or other drug misuserecovery (e.g., as a supernatural phenomenon, there is novalidated measure of detecting the presence of the sacred).Of course, as such, the existence and impact of spiritualityon behavior may be questionable. Certainly, there are the-oretical constructs that, at one time, were not measurable,

or theoretical constructs that weremeasured—but actuallyweremeasuring something else (see Churchland, 1981, oncommonsense psychology). Also, there is much currentresearch that is attempting to delimit and operationalizethis construct. At the very least, future research will needto disentangle specific elements/features of spirituality inorder to establish better scientific and practitioner consen-sus in assessment of this construct, and determine its im-pact from these features.

One way to think about spirituality is as a theoreti-cal construct with “necessary” and “sufficient” features.That is, one may say that spirituality is a “real” con-struct because it contains certain features and, consider-ing enough features, one need not consider more (e.g.,see http://plato.stanford.edu/entries/necessary-sufficient/;accessed on September 24, 2012). Perhaps, there mustbe a search for transcendence to something beyond ev-eryday experience for one to be considered on a spiri-tual trek. This may be a necessary condition. Also, afterconsidering transcendence along with also obtaining newmeaning in life as another feature, perhaps, spiritualitymay be considered fully defined. This may be a sufficientdefinition.

An alternative way to think about spirituality is as atheoretical construct composed of some family of fea-tures that one may agree the construct possesses. Here,one would only assert that spirituality is being demon-strated given certain features that may or may not overlapacross people and time (e.g., see Zinnbauer et al., 1997).In other words, this is a gentler means of trying to under-stand the concept by merely looking for common featuresin a set. Elements of spirituality may include: (1) existen-tial meaning (e.g., ultimate concerns, appreciation of themystery of creation), (2) grounding or integrating featureswithin a person (e.g., sense of wholeness, pertaining to thetruth or authenticity [e.g., higher or loftier values], self-forgiveness), (3) transcendence (reaching beyond self toa Supreme Being, Greater Self, or other “hidden world”),(4) a sense of mission or destiny in life (idealism, personalpractices), (5) a sense of awe with life and everyday expe-rience, and (6) a sense of connectedness with other enti-ties (e.g., God, nature, people, social justice) (Elkins et al.,1988; Hill et al., 2000).

How each of these elements contribute to a family ofconstituents of spirituality is not clear. Each of the el-ements alone, or in any combination with one or moreof the others may be a necessary or sufficient conditionof spirituality. It is also possible that different elementsmay exist in different people and yet both individuals maybe said to be spiritual. For example, one person may beon a search for ultimate meanings, and express transcen-dent experiences. A second person may express feelinggrounded, having a sense of destiny, and feeling connectedwith others. Both of these people may be labeled as spir-itual, but share none of the same elements in common. Inaddition, the same person may utilize different elementson different occasions but think of all of them as spiritualelements.

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CONCLUSIONS

“Spirituality” is a word, an experience of being, and aprocess. Words achieve their meanings by their usage in agiven time and place. Generally, spirituality is somethingthat one seeks rather than avoids. It appears to apply toa process, the end result of which, if achieved, is deeplysatisfying. A key “ingredient” appears to be in a searchfor the sacred. “Sacred” refers to that which underliesexistence, produces devotion, and permits an individualto connect to Higher Powers of some kind (Hill et al.,2000). There may be many different types of HigherPowers—and it is in reference to Higher Powers thatpossibly the most ambiguity in the term may reside. Ingeneral, Higher Power refers to a supernatural entity (e.g.,God). Sometimes it may refer to such entities as Forcesof Nature, about which one can feel an interconnectionand strength. “Secularism” avoids mention of HigherPowers. We assume that appeals to “science” are anexample of secularism; of course, one may argue that ifscience is treated with reverence as a Higher Power, theadherence to which leads to better life engagement, thenpossibly the scientific “experience” might be considereda spiritual one. In general, though, the thinking is thatone may obtain a connection with the world around themthrough such mechanisms as adaptive coping, but not asa source of personal worship, according to the secularperspective.

Through some means, which are not totally clear inthe literature, spirituality is posited to exert a protectiveimpact on drug misuse. A smorgasbord of potentialmediators, perhaps different ones for different people,or the same person at different times, may operate inresponse to spiritual practices to induce a therapeuticeffect. Besides the mediator of Supernatural Action (e.g.,praying to and receiving a response from God to relievean experienced craving or desire to drink alcohol oruse drugs), these mediators appear secular in contentand could stem from other secular as well as spiritualpractices.

Thus, care should be taken in the inclusion of poten-tial confounders versus potential mediators in the studyof the impact of spirituality on recovery. Simply statis-tically controlling for additional constructs in search ofthe unique variance of religiosity/spirituality on substanceuse, or abstinence, may mask important underlying causalpathways. Finally, it is important not to explain away thebreadth of this construct by saying that it is multidimen-sional. It is imperative to try to more fully understand(or appreciate) its necessary and sufficient conditions andlimits in terms of its family of constituents.

Declaration of Interest

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

THE AUTHORSSteve Sussman, Ph.D.,FAAHB, FAPA, received hisdoctorate in social-clinicalpsychology from the Universityof Illinois at Chicago in 1984.He is a Professor of preventivemedicine and psychology atthe University of SouthernCalifornia. He studies etiology,prevention, and cessationwithin the addictions arena,broadly defined. He has over420 publications. His programs

include Project Towards No Tobacco Use, Project TowardsNo Drug Abuse, and Project EX, which are considered modelprograms at numerous agencies (i.e., CDC, NIDA, NCI, OJJDP,SAMSHA, CSAP, Colorado and Maryland Blueprints, HealthCanada, U.S. DOE). He received the honors of Research Laureatefor the American Academy of Health Behavior, and Fellow of theAmerican Psychological Association (Division 50, Addictions).He is the current Editor of Evaluation & the Health Professions(SAGE Publications).

Joel Milam, Ph.D., is anAssistant Professor of PreventiveMedicine at the Keck Schoolof Medicine, University ofSouthern California, wherehe studies the psychologicaland behavioral adaptationto stress and disease. Hisresearch involvement includesprojects examining healthpromotion interventionsamong adolescents, cancersurvivors, and people living

with HIV/AIDS.

T. Em Arpawong, MPH, is adoctoral candidate in PreventiveMedicine/Health BehaviorResearch at the Universityof Southern California, KeckSchool of Medicine. Em’sresearch career began througha pre-doctoral fellowship at theNational Cancer Institute. Shecontinues to focus her work ondisease prevention through theexamination of psychosocialadjustment to stressful life

experiences, both positive and negative, the factors that influencesuch adjustment, and the impact on health outcomes, includingrisk behaviors and addiction, cancer, and chronic illnesses thatdevelop across the lifespan. Em’s current work is being fundedby a Tobacco-Related Disease Research Program dissertationaward.

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Jennifer Tsai, MPH, isa doctoral student at theInstitute for Health Promotionand Disease PreventionResearch, University ofSouthern California. Herinterests involve substance useprevention interventions amongadolescents, and translationalresearch. She received herMPH from the Keck Schoolof Medicine, University ofSouthern California.

David Black, Ph.D., is apostdoctoral research fellowat the University of CaliforniaLos Angeles Semel Institutefor Neuroscience and HumanBehavior, specializing in thepsychoneuroimmunology ofmindfulness, meditation, andother mind–body integrativemedicine interventions. He isthe author of more than 25 peer-reviewed publications, includingarticles in JAMA Pediatrics,

Journal of Adolescent Health, Pediatrics, and other leadingjournals. He is the Editor of Mindfulness Research Monthly, abulletin providing the forefront of research on mindfulness. Heis currently Principal Investigator on a randomized controlledtrial examining the effects of mindfulness training on sleep andpro-inflammatory markers in older adults with insomnia.

Thomas Wills, Ph.D., is aHealth Psychologist whoseresearch interests are in theetiology and prevention ofadolescent substance use. Atpresent he is a Faculty Memberin the Epidemiology program atthe University of Hawaii CancerCenter. His general theoreticalinterest is in multiple pathwaysfor risk and protection, with aspecific interest in dual-processmodels of self-regulation. He has

worked with adolescent populations in both New York and Hawaiiand has conducted studies linking religiosity and good self-controlin adolescence.

GLOSSARY

Addiction treatment: For the purposes of the present paper,this refers to treatment of alcoholism and other drugmisuse. However, spiritual and secular treatment-basedprinciples are being applied to other addictions, includ-

ing gambling, overeating, and sex, which may also bea source of concern (Sussman & Black, 2008).

Religiosity: This refers to one’s degree of commitment to areligious view. It may be differentiated from “religion,”which only indicates affiliation with an organized body,but not the extent of involvement with that body or itspractices.

Secular-based recovery: “Secular” is used interchange-ably with “nonspiritual” or “nonreligious” in our pa-per. One may envision a type of recovery programthat does not pertain to God or religious ideation (i.e.,“worldly”), but is in some sense spiritual (e.g., en-dowed with a “life force”). However, in most cases,“spiritual” is taken to mean one’s personal religion.These terms can be used in different ways, so therecould be confusion in usage.

Spirit: Vital essence, supernatural, not of matter, prin-ciple that stirs one to action, or sense of syn-ergy (http://www.definitions.net/definition/spirit; ac-cessed February –6, 2013).

Spiritual-based recovery: Perspectives on what might bedefined as “spiritual” is one of the topics of this paper.In general, as a tool of recovery, usage is of a personalreligion, or transcendent experiences (e.g., revelationof a sense of connection to the universe), as opposedto appeals to rational thinking or resolving cognitiveequivocation.

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