The Spiritual Characteristics of New Zealanders Entering Treatment for Alcohol/Other Drug Dependence

This study describes the spiritual experiences, beliefs, and practices of New Zealanders entering intensive treatment for alcohol/ other drug dependence, and seeks to determine factors that influence spirituality in a clinical population. Ninety clients entering three residential treatment programs for alcohol and/or cannabis dependence were interviewed about their spiritual beliefs, behaviors, and experiences, using a broad selection of accepted measures.

A number of associations between aspects of spirituality and gender, ethnicity, age, employment, severity of dependence, and depression were found.

In particular, the more religiously active participants were less severely alcohol/other drug dependent, and depression was negatively associated with beliefs and activity related to 12-step participation.

Research; Michael P. Baker, J. Douglas Sellman, & Jacqueline Horn. The Spiritual Characteristics of New Zealanders Entering Treatment for Alcohol/Other Drug Dependence. Alcoholism Treatment Quarterly, Volume: 24 Issue: 4, 2006 Pages: 137 - 155

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Encouraging post-treatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients’ health care costs in the first year after treatment, but such initially impressive effects may wane over time.

This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n = 887 patients) or cognitive-behavioral (CB, n = 887 patients) treatment programs.

The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs.

The 2-year follow-up assessed patients’ substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

substantially higher abstinence rate among patients treated in 12-step

Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) in contrast to CB (37.0%) programs.

Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs.

30% lower costs in the 12-step treatment programs

In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p = 0.01).

Conclusions:

• Promoting self-help group involvement appears to improve post-treatment outcomes while reducing the costs of continuing care.
• Even cost offsets that somewhat diminish over the long term can yield substantial savings.
• Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Research; Keith Humphreys, and Rudolf H. Moos Alcoholism: Clinical and Experimental Research 2007; 31(1):64-68) - 1 This computation is in 2006 dollars, to which we converted for comparative purposes our prior findings, which had been originally reported in 1999 dollars (Humphreys and Moos, 2001).

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Spirituality/religiosity promotes acceptance-based responding and 12-step involvement.

BACKGROUND: Previous investigations have observed that spirituality/religiosity (S/R) is associated with enhanced 12-step involvement. However, relatively few studies have attempted to examine the mechanisms for this effect. For the present investigation, we examined whether acceptance-based responding (ABR) - awareness or acknowledgement of internal experiences that allows one to consider and perform potentially adaptive responses - accounted for the effect of S/R on 12-step self-help group involvement 2 years after a treatment episode.

METHODS: Data were collected as part of a multi-site treatment outcome study with 3698 substance-dependent male veterans recruited at baseline. Assessments were conducted at baseline, discharge, 1-year follow-up, and 2-year follow-up. We utilized structural equation modeling to examine the relationships among latent variables of S/R, ABR, and 12-step involvement over time.

RESULTS: In the final model, S/R was not directly related to 12-step involvement at 2-year follow-up. However, S/R predicted enhanced ABR at 1-year follow-up after accounting for discharge levels of ABR. In turn, ABR at 1-year follow-up predicted increased 12-step involvement at 2-year follow-up after accounting for discharge levels of 12-step involvement.

CONCLUSIONS: S/R promotes the use of post-treatment self-regulation skills that, in turn, directly contribute to ongoing 12-step self-help group involvement.

Authors: Carrico AW, Gifford EV, Moos RH. Spirituality/religiosity promotes acceptance-based responding and 12-step involvement. Drug Alcohol Depend. 2007 Jun 15;89(1):66-73

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Women and the Twelve Steps of Alcoholics Anonymous: A Gendered Narrative

This paper examines how women “work” the twelve steps of Alcoholics Anonymous (AA) from a gendered perspective.

Feminist critics of AA have

• challenged the language of AA’s Twelve Steps,
• the spiritual nature of the steps, and
• the male-dominated culture of the Twelve-Step program.

This paper offers insight into how women in AA approach, interpret, and utilize the Twelve Steps to recover from alcoholism.

Through survey and narrative data, findings suggests

• that women working AA’s Twelve Steps become empowered and
• change for the better in spite of the male-dominated culture and language of the Twelve Steps and
• regardless of the difficulty they may have encountered in completing these steps.

In particular, the first three steps-the “surrender steps”-

• encourage women to let go of their alcoholic obsession and
• begin a spiritual path of recovery.

Steps Four through Nine require

• women to “clean house” and
• get rid of old self-destructive ways so that they may develop a new and stronger sense of self.

Finally, on completing Steps Ten through Twelve, women

• experience a spiritual awakening and
• then, in turn, “pass on” what they have learned from the Twelve Steps to other women in the program.

Woven throughout these women’s experiences is

• an acknowledgment of gender and
• the role it plays in how they work the Twelve Steps.

In the end, these women express a sense of personal empowerment that is particular to a gender-specific orientation to the Twelve Steps of AA.

Research; Jolene M. Sanders, Women and the Twelve Steps of Alcoholics Anonymous: A Gendered Narrative. Alcoholism Treatment Quarterly, Volume: 24 Issue: 3, 2006

Al-anon, Adult Children of Alcoholics, Gambler Anonymous, Narcotics Anonymous,

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Spirituality and Alcoholics Anonymous.

What can be confidently said about AA in general and about the role of spirituality in AA in particular?

• First, there is convincing evidence that alcoholism severity predicts later AA attendance.
• Second, atheists are less likely to attend AA, relative to individuals who already hold spiritual and/or religious beliefs. However, belief in God or a Higher Power before AA attendance does not offer any advantage in AA-related benefits, and atheists, once involved, are at no apparent disadvantage in deriving AA-related benefits.
• Third, the spiritually-based principles of AA appear to be endorsed in AA meetings regardless of the perceived social dynamics or climate of a particular meeting, eg, highly cohesive or aggressive.
• Fourth, significant increases in spiritual and religious beliefs and practices seem to occur among AA-exposed individuals.
• Fifth, in spite of much discussion to the contrary there is little evidence that spirituality directly accounts for later abstinence. We are finding, however, that spirituality has an important indirect effect in predicting later drinking reductions.

Specifically, in the past 20 years a number of effective methods have been developed to facilitate initial AA attendance (AA dropout is high, with some estimates ranging as high as 80%). Interventions that lead to initial increases in spirituality appear to lead to sustained AA affiliation, which, in turn, produces sustained recovery over time.

TSF and Brief-TSF are designed from studies such as this to facilitate AA attendance.

Research; Tonigan JS. Spirituality and alcoholics anonymous. South Med J. 2007 Apr;100(4):437-40.

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TSF for Dual Diagnosis

The role of 12-step programs and 12-step-oriented treatments for dually diagnosed individuals (DDI) remains unclear. Here are presented the results of a pilot study in a target population of 10 seriously mentally ill patients received an adjunctive modified 12-step facilitation (TSF) therapy emphasizing engagement of DDI in a specialized 12-step program for DDI.

Participants significantly increased their 12-step attendance and decreased their substance use during the 12 weeks of treatment.

Larger and longer-term studies are needed to assess the efficacy of modified TSF for DDI relative to other treatments, and to determine what forms of TSF are most effective in this population.

Research; Bogenschutz MP. Tucker NE Specialized 12-step programs and 12-step facilitation for the dually diagnosed. Community Ment Health J. 2005 Feb;41(1):7-20.

Brief-TSF can be adapted to serve these people.

Helping, spirituality and Alcoholics Anonymous

OBJECTIVE: The purpose of this study is to examine how helping activities and spirituality–perhaps key influences on sobriety–change over alcoholism recovery.

The study also explores interrelations among Alcoholics Anonymous (AA), helping and spirituality.

METHOD: Questionnaires were administered to recovering alcoholics (118 men, 80 women) recruited at AA and Women for Sobriety meetings, treatment programs and through personal connections. A helping scale measured Recovery Helping (8-item alpha = 0.78), Life Helping (12-item alpha = 0.62), and Community Helping (6-item alpha = 0.60). The Daily Spiritual Experiences scale assessed two components of spirituality identified by factor analysis: Theism and Self-Transcendence. Two components of an AA scale, Involvement and Achievement, were also treated separately on the basis of factor analysis.

RESULTS: Structural equation modeling revealed that

• longer sobriety predicted significantly more time spent on Community Helping,
• less time spent on Recovery Helping and
• higher levels of Theism, Self-Transcendence and AA Achievement.
• Model covariances revealed that both AA components were related to more Recovery Helping and higher Theism.
• Both spirituality components related to all forms of helping, with one exception.

CONCLUSIONS: The findings highlight important changes in helping with length of sobriety.

• As their sobriety accumulates, recovering alcoholics seem to devote less time to informal helping and more time to organized community projects–perhaps indicating evolving needs and abilities.
• The results also suggest roles for AA and spirituality in encouraging helping, and they indicate that some forms of spirituality relate to AA affiliation.

Future work might establish whether and when helping in different domains contributes to the maintenance of abstinence and to other drinking-related outcomes.

Research Report; Zemore SE, Kaskutas LA. J Stud Alcohol. 2004 May;65(3):383-91. Helping, spirituality and Alcoholics Anonymous in recovery.

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Spiritual assessment in biomedicine

The recent surge of interest in links between spirituality and health has generated many assessment approaches that seek to identify spiritual need and suggest strategic responses for health care practitioners.

The interpretations of spirituality made within health frameworks do not do justice to the way spirituality is understood in society in general.

Spiritual assessment should not impose a view or definition of spirituality, but should seek to elicit the thoughts, memories and experiences that give coherence to a person’s life.

Spiritual assessment tools should not be used without adequate exploration of the assumptions made. Assessment processes need to be adequately conceptualised and practically relevant.

In agencies organised according to biomedical priorities, spirituality is a personal coping mechanism that need not be incorporated into the health treatment plan.

Integration is the patient’s issue - patients must work out how to incorporate their experience of the biomedical system into the rest of their lives.

Social perspectives that regard spirituality as a means of social support view spiritual care as the responsibility of the cultural and religious communities supporting the patient.

Practitioners operating within a social model may be more intentional about involving these communities in care, but they still leave the decision to participate to the patient and family.

In both these approaches, it is for patients to decide whether they will seek spiritual care alongside the health care being provided.

However, spiritual care may be seen differently within a biopsychosocial framework. Here spirituality is related to quality of life and is thus one of the individual characteristics that shape health beliefs and motivations. It affects compliance and outcomes, and is thus legitimately an area of interest for clinicians.

Criteria for appropriate spiritual assessment

Spiritual assessment should thus not impose a view, let alone a definition, of spirituality, but should seek to elicit the thoughts, memories and experiences that give coherence to a person’s life. This implies taking seriously the idea that spirituality preserves identity and sense of self, particularly in professionalised environments, and ensuring that professional practice assessments are made within a framework that matters to the patient.

This means identifying spiritual needs and resources in ways that

• Respect patients’ perspectives and do not infringe privacy;
• Involve all members of the interdisciplinary team to the extent that they are able and willing to contribute;
• Permit clear documentation of needs, strategic responses to these needs, resources required, and outcomes;
• Integrate strategies into an overall care plan in ways that are readily understood by all members of the interdisciplinary team;
• Provide a shared framework for continuity of care between community agencies and inpatient services; and
• Provide a place for religious care but do not conflate spiritual issues with religious practice. While spiritual care in general may be provided by a team, specific religious care is best provided by a person from the same faith community, preferably one willing to participate in the team.

Appropriate process for spiritual assessment

Spiritual assessment must be a process, not merely an event, as it needs to take account of emergent insights and accommodate the patient’s exploration of particular issues if he or she so chooses.

The discussion here applies to health care contexts in which process is possible (such as general medical practice, community health or residential care), rather than the brief encounters of day surgery or the emergency room.

The process should begin with a form of screening, preferably one that maps significant relationships within the domain of spirituality. This screening can be carried out descriptively, noting connections as they emerge in taking patient histories and in general clinical and informal encounters by all members of the team.

For more information see; Bruce D Rumbold. A review of spiritual assessment in health care practice. Medical Journal of Australia 2007; 186 (10): S60-S62

Helping Helps the Helper

Aims; The helper therapy principle suggests that, within mutual-help groups, those who help others help themselves. The current study examines whether clients in treatment for alcohol and drug problems benefit from helping others, and how helping relates to 12-step involvement. Design Longitudinal treatment outcome.

Participants; An ethnically diverse community sample of 279 alcohol- and/or drug-dependent individuals (162 males, 117 females) was recruited through advertisement and treatment referral from Northern California Bay Area communities. Participants were treated at one of four day-treatment programs.

Measurements; A helping checklist measured the amount of time participants spent, during treatment, helping others by sharing experiences, explaining how to get help and giving advice on housing and employment. Measures of 12-step involvement and substance use outcomes were administered at baseline and a 6 month follow-up.

Findings; Helping and 12-step involvement emerged as important and related predictors of treatment outcomes. In the general sample, total abstinence at follow-up was strongly and positively predicted by 12-step involvement at followup, but not by helping during treatment; still, helping positively predicted subsequent 12-step involvement. Among individuals still drinking at follow-up, helping during treatment predicted a lower probability of binge drinking, whereas effects for 12-step involvement proved inconsistent.

Conclusions; Findings support the helper therapy principle and clarify the process of 12-step affiliation.

Research report; Sarah E. Zemore, Lee Ann Kaskutas & Lyndsay N. Ammon, In 12-step groups, helping helps the helper. Addiction; March 2004

Peer Support in Action: From Bystanding to Standing By

Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample.

OBJECTIVE: This descriptive and exploratory study investigated change in alcoholics’ spirituality and/or religiousness (S/R) from treatment entry to 6 months later and whether those changes were associated with drinking outcomes.

METHOD: Longitudinal survey data were collected from 123 outpatients with alcohol use disorders (66% male; mean age = 39; 83% white) on 10 measures of S/R, covering behaviors, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. Drinking behaviors were assessed with the Timeline Followback interview. Alcoholics Anonymous (AA) participation and attendance were also measured.

RESULTS: Over 6 months, there were statistically significant increases in half of the S/R measures, specifically the Daily Spiritual Experiences scale, the Purpose in Life scale, S/R practices scale, Forgiveness scale, and the Positive Religious Coping scale.

There were also clinically and statistically significant decreases in alcohol use.

• Multiple logistic regression analyses showed that increases in Daily Spiritual Experiences and in Purpose in Life scores were associated with increased odds of no heavy drinking at 6 months, even after controlling for AA involvement and gender.

CONCLUSIONS: In the first 6 months of recovery, many dimensions of S/R increased, particularly those associated with behaviors and experiences. Values, beliefs, self-assessed religiousness, perceptions of a Higher Power, and the use of negative religious coping did not change.

Increases in day-to-day experiences of spirituality and sense of purpose/meaning in life were associated with absence of heavy drinking at 6 months, regardless of gender and AA involvement.

The results of this descriptive study support the perspective of many clinicians and recovering individuals that changes in alcoholics’ S/R occur in recovery and that such changes are important to sobriety.

Robinson EA, Cranford JA, Webb JR, Brower KJ. Six month changes in spirituality religiousness and heavy drinking in a treatment-seeking sample. J Stud Alcohol Drugs. 2007 Mar;68(2):282-90.

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