A scoping review of spirituality in relation to substance use disorders: Psychological, biological, and cultural issues

Abstract

Background

Spirituality is a construct encompassing a diversity of strongly held beliefs and pursuits related to life’s meaning and purpose. Empirical studies in key domains of spirituality related to substance use disorder (SUD) can be valuable in guiding research, and potentially clinical care.

Objectives

To conduct a scoping review of research on the psychological, biological, and cultural dimensions of spirituality and their role in relation to SUD. To identify limitations in empirical findings within these domains and identify promising areas for related research.

Data Sources, Study Appraisal, and Synthesis Methods

Illustrative studies available in the empirical literature are reviewed in order to characterize these three key domains.

Results

Certain areas of importance stand out: On Psychology, attribution of SUD to a spiritual outlook; spiritual awakening; the relation of spirituality to drug craving; and spirituality in the context of psychedelic-assisted psychotherapy. On Biology, heritability of traits related to shared spiritual experience; neurophysiologic correlates of spiritually related experiences; and correlates in brain imaging; On Culture, spiritual aspects of SUD in different cultural settings; distinctions between spiritual and religious phenomena; roles that international organizations play; and context of acquiring recovery capital. The need for further research in each area is defined.

Conclusions

There is utility in examining the diversity of findings in the roles of psychology, biology, and culture in the SUD field. Further research, particularly applying randomization and clinical controls, would be useful in improving the effective application of the construct of spirituality in clinical care.

Keywords:

• Spirituality
• Alcoholics Anonymous
• Narcotics Anonymous
• biology
• psychology
• culture
• addiction

Introduction

Spirituality is a construct that has been used to encompass a diversity of strongly held beliefs and pursuits related to life meaning and purpose. It can be represented in issues like commitment to the welfare of others, esthetics, shared areas of personal interest, or personal redemption. It can also be embodied in certain aspects of a religious experience. In terms of compassionate medical care, it has been considered by caregivers to provide valuable support in helping patients who are confronting illness, including persons seeking recovery from substance use disorders (SUDs). The present scoping review explores psychological, biological, and cross-cultural aspects of spirituality in SUD recovery initiation and maintenance.

The importance of the spirituality construct in the SUD field has been widely recognized in positions taken by major international organizations. The World Psychiatric Association issued a position statement on its value overall in relation to mental health.¹ The World Health Organization designated it among resources that can serve as a basis for “discovering meaning and purpose in life” and as potential support for sustaining SUD rehabilitation.² Because spirituality is manifest in relation to SUDs in diverse cultural settings, the International Society of Addiction Medicine issued a position statement on its role within the field of addiction medicine.³

Spirituality in recovery experiences

The term “spiritual recovery movement” can be applied to socially grounded groups, developed outside the domain of empirical medicine, that claim to provide relief from disease, while ascribing their effectiveness to a spiritually grounded orientation. Attendance at religious services is often associated with an expectation of such relief, and there is empirical evidence that church attendance is associated with lower all-cause mortality rates⁴ and lower rates of SUDs.⁵ Such movements, however, need not be built around established religious practice. For example, apart from formal religious practice, spiritually oriented Twelve Step (TS) movements have been found to be associated with a decrease in addictive behaviors. Kelly and Eddie⁶ surveyed a large sample of persons who responded to a solicitation for persons who indicated that they had a problem with drugs or alcohol, but no longer did. Respondents selected items regarding how much each one helped them overcome the disorder. The most common item indicated as helping them the most was spirituality (and not religion). Krentzman et al.⁷ followed a sample of persons with alcohol use disorders (AUDs) over 5–30 months after treatment. They found that reduced drinking was associated with specific aspects of spirituality. Furthermore, in one recent review,⁸ seven studies reported that spirituality was a statistically significant predictor of decreased incidence of relapse in AUDs.

Nonetheless, there is difficulty in characterizing the role of spirituality in SUD as illustrated in the terminology employed. For example, Weinandy and Grubbs⁹ reviewed twenty-seven studies related to addiction or its treatment in which quantitative results were analyzed. These latter studies employed terminology related to spirituality, which was not employed across studies, nor with outcome measures where the term was defined, as well. Until measures used in this domain can be explicitly defined across such studies, generalizability will be limited.

Materials and methods

Our objective in conducting this scoping review is to lend clarity to how psychology, biology, and culture, three major domains on the nature of spirituality, relate to SUD. In order to do this, we have reviewed relevant peer-reviewed articles from major indexing services, such as PubMed, PsychInfo, and Social Sciences Citation Index. We then integrated the findings on key aspects of these domains. We also considered the limitations in our knowledge of each of these domains and described how further research could be directed.

Results and discussion

Psychology

A variety of psychologically grounded issues bear on the role of spirituality and SUD. These include how individuals attribute meaning to their experiences, the nature of spiritual awakening and of drug craving, and the way psychedelics can introduce spirituality into recovery. We will deal with them here.

One way to understand how an individual can gain a spiritual orientation is to employ the psychological model of attribution theory, namely the way people affix causation to their experiences.¹⁰ By employing this model, a change in one’s outlook can be understood by the way a person can come to attribute new meaning to their experiences. This can apply to the acquisition of a spiritual orientation by someone who has seen themselves as captive to the misuse of substances. This attribution to a new outlook can take place at a time when a person experiences little meaningful support in their circumstances, have poor prior explanatory information regarding their compromised situation, and has problems beyond their capability to resolve. Such a transition can then take place by resolving the cognitive dissonance between their prior outlook and a new one offered of recovery. That is to say, the acceptance of a spiritual orientation toward recovery can resolve the conflict between two identities, one from a person compelled to drink, and one who, with the aid of spirituality, can be relieved of the pressure to drink. The resolution of cognitive dissonance has in fact been manifest in the measurement of neural activity.¹¹

The experience of spiritual awakening is mentioned in the Twelve Steps, and it reflects on one of the ways this process of cognitive dissonance can be consolidated. This transformative phenomenon has parallels in psychological literature. William James, at the turn of the Twentieth Century, described dramatic experiences such as those under the rubric of “Varieties of Religious Experience,” and the term was later adopted by the founders of AA.¹² Miller and de Baca¹³ described such experiences under the rubric of “quantum change,” which they proposed to describe a variety of major, and singular, psychological transformations people may experience. Such transformational change experiences have been noted by White¹⁴ within the biographies of noted individuals recovering from a SUD. In the empirical literature, Zemore¹⁵ followed a sample of persons discharged from SUD residential treatment and found at follow-up that increased TS involvement predicted higher odds of involvement and that this outcome was partly explained by increases in spirituality through spiritual awakening. Additionally, participants treated in professional settings for SUD were found upon follow-up by Kaskutas et al.¹⁶ to have over a three times greater likelihood of abstinence if they reported having had a spiritual awakening after discharge.

Drug craving among persons with SUD is an important aspect of the psychology of these disorders, and it has been found to be associated with certain psychological traits. Among persons who underwent psychosocial treatment for AUD, those with higher levels of craving have been found to have a greater likelihood of relapse.¹⁷ Young people in AA who reported having a spiritual awakening were found to have lower levels of craving, but craving was greater among those who scored higher on depression.¹⁸ Craving has also been found to be diminished in the laboratory setting among smokers who actively attempted to suppress their responses to smoking imagery.¹⁹ This latter finding may suggest options for modifying the role of craving through cognitive intervention, and Verdejo-Garcia et al.²⁰ proposed that a cognitive training program may serve as an option for treatment of SUD.

A person’s misuse of a particular drug may hinge on subjective responses that vary across respective drugs.²¹ This is evident in why an individual may choose stimulants vs psychedelics, each of which elicits a very different subjective response. The issue is particularly relevant to the initiation of misuse and relevant to the choices a person may make in relation to the choice of recreational drugs.²²

These findings make clear that attention to spirituality does not preclude the role of other psychological models playing an important role in relation to SUD. Cognitive factors are clearly pertinent in the psychology of the disorder,²³ and extensive research has also been carried out in the cognitive domain, including some on its neurophysiologic correlates.²⁴ In one study, participants and therapists reported on a cognitive behavioral therapy study for AUD. Both groups reported that incorporating a component related to participants’ spiritual orientation enhanced their motivation in the treatment.²⁵ Further research bridging related psychological and biological interventions in the SUD domain is merited.

The option of using a psychological intervention combined with a pharmacologic one is promising. This was shown to be associated with relief of depression and anxiety in terminal cancer patients.²⁶ A diversity of subjective experiences similar to spiritual ones was reported in this latter study.²⁷ Bogenschutz et al.²⁸ described similar spiritually related experiences among patients receiving psilocybin-assisted psychotherapy for AUD as compared to psychotherapy alone. Follow-up demonstrated a greater decrease in alcohol use than in the control group. In a similar intervention, participants described subjective experiences that were defined as spiritual in nature.²⁹ Psilocybin administration in combination with cognitive behavioral therapy has also shown promise in facilitating smoking cessation in persons with nicotine use disorder.³⁰

Further research would be valuable in:

1. Defining the commonality across subjective experiences that individuals ascribe to spirituality.

2. Replicating studies to show that combined psychological and biological interventions, as with psilocybin, can generate spiritual experiences that can alter the course of SUD.

3. Defining the impact of spirituality on self-efficacy and on interpersonal relationships in persons being treated for SUD.

4. Defining the role of spiritually-based treatment for different misused substances.

Biology

The issue of spirituality can be a source of misunderstanding between biologically oriented and spiritually oriented clinicians. Certain findings related to neurobiology, however, can help to conceptualize a relationship between spiritual experience and its underlying biology, characterizing the role of sociobiology in defining spirited, recent neurophysiologic findings, and biology related to spiritual experience.

One such model is sociobiology. It is a discipline that proposes certain behavior patterns (and not only the morphology of somatic components) are grounded in individuals’ innate biological complement.³¹ This model of sociobiology was developed on the basis of observations of specific prosocial behavior patterns in respective species, and how they may have become heritable by natural selection. This transformation is understood to have taken place because these behaviors have had adaptive value over generations of evolutionary time.

Two key aspects of the genetic basis of a social trait can be considered in this regard. One is that the heritability of certain social traits is not only based on the fitness it provides an individual but also on the adaptive advantage it provides the group in which that individual shares a genetic complement, e.g. family, primitive clan members. This has been termed inclusive fitness.³² This can be considered to reflect the capacity for acquiring shared spiritual experiences, which can constitute a cognitive and affective basis for supporting adaptive behavior.

A second biologically based social trait is that persons can support each other’s capacity for survival by altruistically aiding each other, termed reciprocal altruism. This latter trait may be seen in the shared support among people who participate in a spiritually oriented recovery program. Manifestations of sociobiologically grounded traits across groups of individuals within a species (such as affiliative orientation or intellectual capacity), are, however, primarily due to environmental, rather than genetic differences.³³

Neurophysiologic findings can serve to clarify the adaptive nature of biologically grounded, shared spiritual beliefs. Rim et al.³⁴ reviewed studies on neurobiologic correlates of religion/spirituality, including a wide range of regional settings. They did this with encephalography or structural and functional neuroimaging. Their findings suggest that certain patterns of brain function that are associated with the way spiritual (or related religious) experiences are distinct in the sites where they are detected. Such findings can be useful in considering neurobiologic phenomena at the interface between the subjective experience of spirituality and of phenomena associated with SUD. While the evidence emerging from such studies is preliminary in many respects, it can be useful in characterizing that interface.

Recent brain imaging techniques have facilitated research on aspects of cognition and affect that can shed light on phenomena analogous to spiritual experience in substance use. For example, human mutuality with others, as in mentalization, can serve as a basis for shared subjective experiences. These are distinguishable on imaging of specific brain loci³⁵ and could be associated with shared spiritually related perspectives. Measurements have been made on physiologic correlates of the acquisition of memories and attitudes, which can take place outside the awareness of a given individual. In this respect, group-based social experiences can be visualized³⁶ and cognitive disposition can then come to be related to the acquisition of certain attitudes (such as spirituality). An individual’s innate inclination toward the experience of genetically grounded cognitive traits³⁷ has also been found to facilitate the acquisition of specific values. Such traits can be considered for potential association with spiritually related experiences. Such phenomena could also secondarily become a substrate for spiritually grounded ritualistic behaviors, as in religious practice³⁸ or culturally based activities reflecting spiritual values.

Some empirically based examples can be helpful in illustrating these findings. Neurophysiologically based studies illustrate how spiritually related stimuli can either modify or suppress participants’ subjective responses to sensory input, and the content of such studies can be considered analogous to the impact on the subjective experience of craving.⁸ In one study, Scheinele and colleagues³⁹ monitored the resting state functional activity of religious subjects who believed in the healing aspects of visiting Lourdes. Participants were asked to describe the sensations they experienced with sacred water labeled as originating in Lourdes. Their responses to tap water labeled as coming from Lourdes were compared to those that had tap water with no such label. The former samples generated contrasting patterns of subjective sensations associated with neurophysiologically related measurements.

Responses to biologically grounded subjective experiences can be informative as well. Miller and colleagues⁴⁰ studied individuals for genetically based familial risk for developing depressive illness. They found that a relationship with higher importance of religiosity/spirituality among subjects was associated with relatively greater cortical thickness, which itself was associated with a lower risk for depressive illness. Similarly, Panier et al.⁴¹ followed EEG patterns on subjects at familial risk for depressive disorders over five to ten years of follow-up. They found that the greater importance of religiosity/spirituality was associated with a lesser incidence of depression. Furthermore, in one large sample of participants, a significant negative association was found between negative cortical thickness and binge drinking.⁴²

Findings relating spirituality/religion to biological measures of personal prayer can also be informative. In one study of self-identified religious subjects, recitation of prayer was found to generate specific patterns of neural activation suggestive of specific cognitive processes.⁴³ In another study, a distinction between formalized and improvised prayer was observed to be associated with respective patterns of neural response.⁴⁴

Observations have also been made with regard to specific substance-related phenomena. In one study, subjects were engaged in different types of guided imagery to achieve stress relaxation. Neural findings related to the spiritually oriented conditions were found to be associated with a distinct functional neural network.⁴⁵ The pattern of spiritual experience observed in this latter study was considered by the investigators to be useful for the future study of the role of spirituality in recovery from compulsive behavioral disorders. In another experimental setting, craving related to addictive disorders was studied in long-term AA members. Participants were presented with alcohol-related stimuli and were found to experience lower alcohol craving associated with a distinct neural response pattern when reciting Twelve Step-related prayer, as compared to when reciting neutral text.⁴⁶

These studies may provide a basis for considering biologically grounded spirituality and its relationship with SUD. As a group, however, they suggest that further investigation along the following lines is merited:

1. Comparing neural responsivity to trigger stimuli in persons who participate in a variety of spiritually related practices to those who do not.

2. Comparing neurobiological correlates of spiritually-based treatment across different cultural settings.

3. Studying neurobiological correlates of spiritually-based treatment for SUD by combining quantitative findings with associated qualitative findings.

4. Examining neurophysiological aspects of spiritually-based treatment in contrast to matched controls from secular treatment programs.

Culture

An openness to spiritually related experience can be considered from both psychological and biologic perspectives. Its manifestations, however, can be quite different in diverse cultural settings. For example, in a residential recovery program for ex-prisoners in Wales, the promotion of spiritually based coping mechanisms was found to buffer a sensation of hopelessness that detracted from SUD recovery.⁴⁷ Spiritually based programs may be adapted to encompass contemporary, empirically based techniques, such as the modification of Japanese Daisuki Zen Buddhist practice which has been modified to accommodate empirically based medical practice.⁴⁸ In Islamic Iran, an increased spiritual orientation among university students was found to be associated with less potential for addictive behaviors.⁴⁹

There are diverse examples of spiritually based cross-cultural issues in the US where a background of Christian practice has been wedded to organizations promoting recovery and is similarly wedded to contemporary adaptations of secular practice.⁵⁰ “Fourth and Fifth Step Groups,”⁵¹ a spiritually grounded format adapted from AA has gained a following among Latinos of Mexican descent, particularly in California. In Oxford House residential programs, predominately African American residents combine spiritually oriented AA with a supportive group structure.⁵² In work done by Venner et al.⁵³ about American Indian/Alaskan people, spiritual practices were integrated into the delivery of medication-based treatment. In the US territory of Puerto Rico, a spiritually based Pentecostal approach, employed in certain programs, served as the basis for addiction recovery.⁵⁴ There are examples of culturally informed addiction treatment, where spirituality is integrated into care in the provision of established evidence-based treatment (e.g., cognitive behavioral therapy), in the Black church in the US.⁵⁵

In relation to SUDs, there is value in distinguishing the role of spirituality from that of religion, and the history of AA illustrates this distinction. Some persons with AUD who were involved in the founding of AA attended, but later left, the Oxford Group, a society where personal renewal was based on Christian practice. AA then served as a model for the development of the Twelve Step-based approach. Early AA members designated their spiritual, but not religious, Twelve Step program for recovery.⁵⁶

In more recent years, one program addressing SUDs, Celebrate Recovery, employed Christian religious practice with the spiritual orientation of AA in a format that is oriented to achieving spiritual growth.⁵⁷ Another example of a theistic religious orientation with a non-religious orientation was found among polling members of the Twelve Step program Narcotics Anonymous.⁵⁸ They were evenly divided among those who saw “God as we understood Him” in the Twelve Steps as defined in traditional Christian religion, and those who identified that term otherwise as a non-theistic universal spirit.

The World Health Organization has designated sources of support termed “recovery capital” for achieving rehabilitation from SUDs; among them is the discovery of meaning and purpose in life.² Empirical findings on the role of spirituality among the components of recovery capital are therefore useful in understanding its role in recovery. This is relevant to the concept of “deaths of despair” developed by Case and Deaton.⁵⁹ They studied demographic data related to increased alcohol-related liver disease, drug overdose, and suicide among working-class Caucasians in certain American locales, particularly the Appalachian region of the US. In controlling a number of potential causes for this increase in morbidity, such as physical and economic factors, they found that a sense of meaninglessness and an unfulfilling life played a key role in the origin of these diseases in that population. Spirituality relevant to one’s own subculture, however, can be considered to encompass a variety of intangible commitments to provide meaning in life. Promotion of enhanced spiritually related experiences can serve as one component of recovery capital that can counter such vulnerabilities.

There are examples of this issue. Gavriel-Fried et al.⁶⁰ studied predictors of improvement in gambling disorder and found that intrinsic spirituality significantly contributed to symptom improvement. Laudet and White⁶¹ studied a sample of polysubstance users at different stages of remission and found that spirituality, among other components of recovery capital, served as a predictor of remission. Tonigan et al.⁶² studied persons attending AA meetings and found that gains in spiritual practice significantly mediated findings on improvement, relative to days abstinent and drinks per day.

Clearly, there is a great diversity in spiritually related practices, each within its own cultural setting. Further research is therefore needed on:

1. Comparing spiritual practices in different subcultures related to the terminology they employ and measuring the intensity to which participants adopt that terminology.

2. Developing the means to compare spiritually based practices for treating SUDs in the cultures in which they are practiced.

3. Expanding the culture of clinical education to assure that trainees encountering patients with SUD can be introduced to the role of spirituality relative to their disorder.

4. Comparing ethnic groups to clarify how social and economic bias such as race-based factors⁶³ can influence the relative outcome of spiritual practice.

Conclusion

The construct of spirituality encompasses a diversity of researchable areas that relate to recovery from SUD. We examined empirical findings in three key domains of this: psychology, biology, and culture. We then undertook this scoping review to help in understanding mechanisms that underlie the way spirituality plays a role in each of these domains.

Importantly, these findings suggest options for further research to generate an improvement in clinical care. Examples of these options include the role of spiritual awakening in establishing abstinence for some people with SUD; the way spiritually based practices can promote stability in long-term recovery; how neurobiology plays a role in altering the subjective experience of craving; ways for developing optimal techniques for combining psychedelics with psychological interventions; and the development of treatment approaches based on underlying commonalities in spiritually-based practice across diverse cultures. Going forward, studies in areas such as these may allow for improving our capacity to address the major public health problem of SUD.

Declaration of interest

The authors report no conflicts of interest.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.