Spirituality and Harmful or Hazardous Alcohol and Other Drug Use

Spirituality is recognized as a positive influence in the lives of individuals who engage in problematic alcohol and other drug use. Spirituality should be addressed in a patient-centered and respectful manner that honours boundaries and autonomy, and is integrated into evidence-based treatment practices. For some individuals, substance use may be inspired or motivated by spirituality, while for others spirituality may not be relevant or individuals may choose a secular perspective. For others, spirituality may be a source of shame or connected to past trauma. Professionals and programs that address substance use therefore need neutral and practical methods to assess and integrate spirituality into their work without turning substance use treatment into religious practice.

Why It Matters

A number of alcohol and other drug use “problems” are not within the purview of biomedical medicine. Many of the problems associated with alcohol and other drug use exist in the social, emotional and existential domains of human experience. For a number of individuals, spirituality and the search for meaning are critical components in coping with stress, making choices regarding use of drugs, and navigating the process of treatment. Appreciating these dimensions has the potential to augment the treatment process, reduce long-term medical and clinical care, and inform strategies of prevention.

Integration of Spirituality into Routine Health Care for Adults and Children: A Framework for Clinicians. Health care systems are constrained by decreasing budgets, thus striving to deliver high quality care while containing costs. Decisions about the integration of spirituality into health care practices have many practical and multiple ethical dimensions. Patients and clinicians must grapple with the process for assessing spiritual needs, and whether to refer patients to support that is faith-based or secular. Additionally, issues of coercion, stigma, and control over disclosure of spiritual information need to be taken into consideration. All of these factors in turn can influence decisions regarding the development of health care work force competencies for spirituality assessment and care; documentation systems and record keeping practices; payment for spiritual care services; and collaborations between health care systems and community or religious organizations.

The issue of equity needs to be considered. Spiritual supports are not all delivered through formal health care systems; many are delivered in places of worship, self-help groups, and informal social networks. Access to these resources can vary significantly by neighborhood, culture, and socioeconomic status. As a result, efforts to integrate spiritual support into health care systems must be structured in such a way that they do not compromise the rights of individuals and groups with differing belief systems. Instead, the goal should be the promotion of pluralism, and preventing one spirituality from being given primacy over others.

Who It Affects

This paper explores the experience of people who drink problematically, people who use illicit drugs and people at risk of hazardous drinking with reference to spiritual or religious worldviews and community participation. For some such individuals spirituality/religion and community participation are core aspects of identity and meaning making. For others spirituality is unimportant or even a source of shame, confusion or conflict. Clinicians need to be aware of such diversity and should not assume that for a particular individual spirituality is, or is not, important.

Healthcare providers from a variety of sectors and professions encounter the interface of substance use and spirituality in their work. Providers in sectors such as primary care, addiction treatment and recovery, mental health, and emergency services from professions such as medicine, nursing, social work, and the clergy are all affected by the interface of substance use and spirituality. Many of these providers are nurses, addiction counselors, mental health professionals, and chaplains/psychotherapists. While all of these providers support patients who use substances, nurses, social workers, chaplains, and peer recovery coaches are typically the most involved in supporting and assessing a patient’s spiritual resources. There are also a variety of community health systems and third party payers that must make decisions about whether to offer or support spiritual care services, whether to provide training and continuing education funds for providers to study substance use and spirituality, or whether to contract with community programs that support individuals with addiction and spiritual problems.

While there are many different stakeholders in the field of addiction treatment and recovery, clinicians are perhaps the most critical group. However, there are also many community stakeholders who play an important role in addiction treatment and recovery including individuals, groups and organizations representing various sectors of society including the faith-based sector as well as mutual-help and recovery ministries. These stakeholders can offer social support and meaningful engagement, as well as housing, employment, education and other resources. There is considerable variation in how different stakeholders choose to relate to clinicians including some who are motivated and able to support and cooperate with clinicians in the delivery of evidence-based treatment as well as those who are opposed to any treatment that is not strictly abstinence-based and withhold treatment to uphold their personal beliefs. Policymakers and regulators should work to support and foster those positive collaborations, while at the same time ensuring that the clinical needs of addicted individuals are being met.

What Changes

• Clinicians should routinely screen for spiritual needs and supports as part of a person-centered substance use assessment, using neutral, open-ended questions and documenting preferences without imposing beliefs.
• Care plans should treat spiritual resources as complementary to, not replacements for, evidence-based treatments — including counseling and medications for addiction — and include clear referral pathways to chaplaincy, peer support, or community spiritual groups when desired by the patient.
• Health systems should develop training and protocols that protect patient autonomy and confidentiality while enabling collaboration with community spiritual resources; this includes guidance on consent, boundary-setting, and when spiritual advice may be harmful or contraindicated.
• Policymakers and payers should consider supporting research, workforce development, and pilot programs that test respectful, noncoercive models for integrating spiritual care into prevention and recovery services, with attention to equity and measurable outcomes.

While background and clinical context are important, it is also important to make a few key distinctions regarding the terms spirituality and religion. First, a distinction needs to be made between religious practices (i.e., attending church) and spiritual practices (i.e., meditation and/or prayer). Second, it is important to make a distinction between religion and spirituality. Spending a few minutes at the beginning of treatment discerning whether the patient’s spirituality is something that will support their treatment goals, possibly contraindicated by their treatment plan, or even a source of social capital can be done with some finesse and asking the right questions.

Clinicians can help their patients benefit from spiritual resources by linking these resources with the patient’s values. Spiritual support can empower patients by enhancing social support, providing structure and meaning, combating feelings of isolation and loneliness and motivating change. In addition to peer led and mainstream faith based support groups and/or meetings, many individuals and their families would also benefit from the support and guidance of a trained chaplain or spiritual care provider as they process feelings of guilt, grief and moral injury related to addiction. Healthcare professionals need to know that these resources are available to their patients.

Of course there are also less-than-ideal scenarios and actual risks and trade-offs. Many spiritual/religious communities today stigmatize the use of mind-altering substances, or view addiction as moral failing, thereby actively discouraging persons and families from seeking help for addiction. There are also some treatment programs that actively discourage effective medical interventions in the name of spiritual advancement and recovery, putting individuals at risk for serious harm. So clinicians should be aware of how spirituality might reduce access to life-saving treatments, and advocate for an evidence-based approach when appropriate.

Clinical staff face a host of challenges in meeting the spiritual needs of their patients. This briefing addresses three of the most significant challenges faced by clinical staff: first, the feeling among many clinicians that they receive little training on safely and effectively addressing spirituality; second, the challenge of documenting spiritual assessment information in the electronic health record; and third, the legal and ethical boundaries that health care organizations must be aware of when considering partnerships with religious organizations or individuals.

This report describes the current state of the policy and reimbursement environment related to spiritual care and development. While chaplaincy, behavioral health with an existential orientation, and supportive community for individuals or small groups are all offered outside of the regular program structure in a gray area between billable services and non-program services, the report discusses some of the considerations, successful strategies and boundary setting guidelines that would need to be developed and monitored in order to offer these services in a way that is accessible to participants, but does not compromise their decision-making or create pressure or obligation to participate against their will.

Assess whether or not a patient wishes to have spiritual support included in their care; how their spirituality is supporting or hindering their treatment plan; and whether they would like referrals for spiritual support. Document patient’s preferences for spiritual support. Develop plan of care that includes spiritual goals if patient requests. Build vetted referral list of local spiritual support providers that offer alternative spiritual approaches and secular perspectives for patients who do not identify with any religious affiliation. Provide staff training on cultural humility, and educate staff on when providing spiritual advice could potentially place a patient in harm’s way and how to avoid those situations.

In the months and years that follow, health systems will need to support and fund an integrated approach to spiritual care, enabling individuals to make choices about whether or not they would benefit from such support. Initial models such as funding a spiritual care worker in addiction teams will need to be tested and scaled up where they have been shown to achieve good engagement and support recovery and subjective wellbeing for people who use drugs. However, there is also a need to evaluate the potential of digital platforms to signpost to a range of spiritual and secular resources to support recovery for those who use drugs, in the most disadvantaged areas and populations.

While significant progress has been made in several of these areas, there are still several important research gaps that need to be addressed including the need for better ways to assess spiritual needs, more research on what constitutes a “spiritual intervention,” and the best ways to incorporate spiritual aspects of substance use treatment into traditional medical models. Future studies would also benefit from increased representation of diverse populations and measures of outcome that are meaningful to clients, “more than abstinence” such as overall wellness, social/vocational functioning, and reduction of other harms.

Introduction: The inclusion of Spirituality in care for harmful or hazardous alcohol and other drug use must highlight the positive contribution that meaning, connection and belonging can bring to care whilst at the same time demonstrating that it will not compromise good quality care, patient autonomy or equality of access to a range of evidence based interventions for reducing or stopping alcohol and other drug use. When carried out well the inclusion of positive and growth oriented spiritual themes and interventions can be a useful adjunct to mainstream treatment and care for people who use alcohol and other drugs. The aim of poor spirituality is to cause harm and deny access to interventions that are backed by evidence. An initial goal for practitioners and managers of health and addiction care services would be to make clear to people who use alcohol and other drugs the choice or pathway that they can take to develop their own spiritual care.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC1526775/ https://pubmed.ncbi.nlm.nih.gov/33767804/