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ADDICTION AND SPIRITUALITY_________________________________
Jaime Grodzicki, M.D.
Associate Director Division of Alcohol and Substance Abuse
Director of Substance Abuse Referral Program (SARP)
NYU/Bellevue Hospital Center
OBJECTIVES_________________________________
To improve the ability of physicians and other mental health clinicians to understand the value of spirituality and religious renewal in clinical practice
To position the role of spirituality as an effective instrument of change in the treatment of addictions
To enhance the ability to integrate the elements of spirituality into the overall treatment of patients
OVERVIEW
Concepts in Addiction Psychiatry Framework of Spirituality
Spirituality vs. religion Biological correlates Spirituality in clinical practice Spirituality and Substance Related Disorders Spirituality and Alcoholics Anonymous Spirituality as an instrument of change Summary
WHAT IS AN ADDICTION?_________________________________
Addiction is a behavioral pattern of drug abuse characterized by:
Overwhelming involvement with: the use of a drug (compulsive use and loss of
control) The security of its supply
High tendency to relapse after discontinuation.Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS AN ADDICTION?_________________________________ Addiction is a
ProgressiveChronicRelapsingPrimaryDisease (potentially fatal)
Characterized byCompulsionLoss of controlContinued drug use despite adverse consequencesDistortion in normal thinking
WHAT IS DRUG ABUSE?_________________________________
Self–administration of any drug in a culturally disapproved manner that causes adverse
consequences
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS DRUG DEPENDENCE?_________________________________
The physiological state of neuro-adaptation produced by repeated administration of the
drug, necessitating continued administration to prevent the appearance of the withdrawal
syndromeStahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS TOLERANCE?_________________________________
Tolerance develops when after repeated administration, increasing larger doses of a
drug must be administered to obtain the effects observed with the original use
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS WITHDRAWAL?_________________________________
The psychological and physiological reactions to abrupt cessation of a dependence-producing drug
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
WHAT IS REBOUND?_________________________________
The exaggerated expression of the original condition sometimes experienced by patients immediately
after cessation of an effective treatment
Stahl, S. Essential Pharmacology, 2nd Ed, 2000
BRAIN REWARD PATHWAYS
The VTA-nucleus accumbens pathway is activated by all drugs of dependence
This pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex
Ventral tegmental area (VTA)
Nucleus accumbens
RELAPSE AND CONDITIONING Repeated substance
use has caused “conditioning” to occur in related circuits
Now “cues” associated with substance use can activate the reward and withdrawal circuit
This can evoke anticipation of the substance or feelings similar to withdrawal that can precipitate relapse in an abstinent patient
Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.
Ventral tegmental area (VTA)
Amygdala
Bed nucleus of the stria terminalis
Nucleus accumbens
Prefrontal Cortex
Hippocampus
ADDICTION AFFECTS THE FOLLOWING DOMAINS:
_____________________________________
EMOTIONALPHYSICAL
COGNITIVESOCIAL
SPIRITUAL FAMILY
___________________________
“The greatest revolution of our generation is the discovery that human beings, by changing the inner attitudes of their minds, can change the outer aspects of their lives”
William James (1852-1910)
GOALS OF TREATMENT IN ADDICTIONS
_____________________________________ Maximizing motivation for abstinence Rebuilding a substance-free life style Helping to maximize multiple aspects of life functioning Optimizing medical functioning Identifying and treating psychiatric symptoms and disorders Dealing with marital and other family issues Enriching job functioning and financial management Addressing relevant spiritual issues Dealing with the homelessness Relapse prevention
Schuckit, M Textbook of Substance Abuse Treatment. Am.Psych.Press (1994) pp. 3-10.
___________________________
“The greatest use of a life is to spend it on something that will outlast it”
William James (1852-1910)
WHAT IS SPIRITUALITY?_________________________________
A part of a person that searches for transcendent meaning and purpose in life and allows the person to transcend his or her conflict or suffering
Puchalski, et al. Clin Geriatr Med 20 (2004) 689-714
A personal relationship between an individual and a transcendent or higher being, force, energy or mind of the Universe.
Whitfield,C. Alcoholism Treatment Q. 1:3-51 (1984)
WHAT IS SPIRITUALITY?_________________________________
“Spirituality is recognized as a factor that contributes to health in many persons. This concept is found in all cultures and societies. It’s expressed in an individual’s search for ultimate meaning through participation in a religion, but it can be much broader than that, such as, belief in God, family, naturalism, rationalism, humanism, and the arts.”
Puchalski,C. In: Carter R, editor. Caregiving book series. Americus (GA): Rosalyn Carter Institute for Human Development, Georgia Southwestern State University: 2003.
SPIRITUALITY_________________________________
Encompasses the individual’s sense of self, sense of mission and purpose in life
It connotes a direct and personal experience of what each individual considers sacred and it is not mediated by a particular belief system prescribed by dogma or by hierarchical structure
It is not defined by roles such as priests, ministers, rabbis, gurus, or other defined leaders
Berenson, DA J. of Strategic and Systemic Therapies 1990;9(1):59-70.
SPIRITUALITY AND RELIGION_____________________________________
94% of Americans believe in God or a Higher Power
75% of Americans say religion is central to their lives
62% of Americans claim to be a member of an organized religion
9% of Americans stated that they have no religion preference
(N=1037 adults; December 1999; Gallup/CNN; USA today)
SPIRITUALITY AND RELIGION
SPIRITUALITY
Involves a sense of self, mission and purpose.
Unrelated to a specific dogma, belief system or defined roles
BOTH
Sense of trascendence
Basis of meaning and purpose in life and work
Help give meaning to suffering
Extend individual’s copying resources.
RELIGION
Displays specific behavioral, social, hierarchical, doctrinal characteristics.
Involves a system of worship and doctrine shared by a group
Involves an authority or leader (priest, ,rabbi, guru, minister, iman)
“A person may develop higher levels of spirituality without believing in God or
practicing a religion”
Gorsuch,RL Research on Alcoholics Anonymous, Rutger Center for Alcohol Study, New Brunswick, NJ, 1993,pp.301-318.
_________________________________
MYSTICAL EXPERIENCE_____________________________________
“An uplifting sense of genuine spiritual union with something larger than the self”
Underhill, 1999; Essentials of Mysticism.
BIOLOGICAL CORRELATES_____________________________________
Meditation: apnea, EEG changes (Corby AH, et al., Arch Gen Psychiatry, 1978)
Out of body experience: right angular gyrus: sees self “floating above the bed”
(Blanke O et al., Nature, 2002)
5HT-1A receptor density inversely correlated with spiritual acceptance scale
(Borg J et al., Am J Psychiatry 2003)
BIOLOGICAL CORRELATES_____________________________________NONSPECIFIC AROUSAL: Epinephrine can resultin happiness or malaise
(Schacter S, Singer JE. Psychol Rev 69:319, 1962)
HEMISPHERIC DISSOCIATION: Severed corpuscallosum and right hemisphere stimulation: epilepticpatient waves his hand and creates an explanation
Gazzaniga MS. Bisected Brain 1970
DEPRESSED young monkeys are given eitherimipramine or are introduced to peers: depressionresolved
Suomi S et al. Arch Gen Psychiat 35:321, 1978
OUT OF BODY EXPERIENCE_____________________________________
. . .“a person’s consciousness seems to become
detached from the body”
Right angular gyrus stimulation: to find a
temporal lobe seizure focus. Patient reports
she sees herself “floating 2 meters above the bed –
Her legs appeared to be moving toward her face”Blanke O et al. Nature 419:269,2002
SEROTONIN AND RELIGIOSITY_____________________________________
5HT-1A receptor density measured by ligand binding on PET study; correlated with
Temperament and Character Inventory,
2 scales:
(a) self-transcendence (religious behavior) and (b) spiritual acceptance (of phenomena not explained by objective demonstration)
Borg J et al. Am J Psychiatry 160: 1965, 2003
THE RELIEF EFFECT_________________________________
Social and spiritual affiliation produces a relief in distress symptoms. The relationship serves as an
operant reinforce for continued affiliation and compliance with group norms
Galanter, M. Psychiatric Services 2002 ; 53: 1072-1074.
RELIGION AND SPIRITUALITY IN CLINICAL PRACTICE
__________________________________________
DSM-IV – V62.89 : Religious or Spiritual Problem
(i.e. distressing experiences that involves loss or questioning of faith, conversion to a new faith, questioning of spiritual values)
PRACTICE GUIDELINES FOR PSYCHIATRIC EVALUATION IN ADULTS
_____________________________________
“The process of psychiatric evaluation must take into consideration and respect the diversity of American subcultures and must be sensitive to the patient’s ethnicity and place of birth, gender, social class, sexual orientation and religious/spiritual beliefs”
APA Practice guidelines, 1995.
Cultural Assessment for Diagnosis and CareDifferential Diagnosis
_____________________________________ Religious/spiritual phenomena Religious/spiritual problem Culture-bound syndrome Mental disorder Possibility of concurrent diagnosis
Cultural Assessment for Diagnosis and CareTreatment Plan
_____________________________________ Biomedical Psychological Socio-cultural Spiritual/Religious
Spiritual/Religious treatment plan includes:
Ongoing assessment and formulation Respect, empathy and boundaries Modification of psychotherapy when
indicated Spiritual/Religious interventions when
indicated
Ethnic and Cultural Considerations_____________________________________
Diagnostic assessment can be especially challenging when: a clinician from one ethnic & cultural group
uses the DSM IV classification to evaluated an individual from a different group
a clinician who is unfamiliar with the nuances of the individual’s cultural frame of reference may incorrectly judge as psychopathology
SPIRITUALITY IN SUBSTANCE USE DISORDERS (SUD)
_____________________________________ Direct correlation between spirituality and
positive outcomes in SUD Patients in recovery often prioritize spiritual
programs in their treatment Spirituality is an essential part of the
recovery process
IMPORTANCE TO RECOVERY (RANK ORDER)__________________________________________ Medical Students’ ViewPatients (N=119)(N=101) of Students of Patients
Inner Peace 1 8 7Medical Services 2 3 3Belief in God 3 9 11AA 4 11 5Outpatient Tx 7 4 2Gov’t Benefits 9 2 9
Goldfarb L et al., Am J Drug Alcohol Abuse, 1996; McDowell D et al., J Addic Dis, 1996
ALCOHOLICS ANONYMOUS (AA) AND SPIRITUALITY
_____________________________________ AA includes a spiritual experience with God or a
Higher Power in its 12-step fellowship program AA includes a spiritual journey as a needed
element of recovery AA integrates the spiritual dimension as an
essential method of delivering care AA is not a religion AA success is the product of field research
supported by clinical research
THE HOUSE OF SOBRIETY(From: Recovering, How to Stay Sober, Mueller and Ketcham 1987).
ABSTINENCE(THE FOUNDATION)
PHYSICAL
MENTAL EMOTIONAL
SPIRITUAL
SPIRITUAL CONCEPTS_____________________________________
Spiritual belief: “God or Higher Power can restore him/her to sanity”AA – Step 2
Spiritual principles: Code of conduct or frame for action that moves people toward the realization of values
Spiritual values: Qualities or ideals culturally derived, highly regarded by a group or society leading to self-acceptance
Spiritual experience:Moment of clarity or a felt sense of wonder, elation, peace or fulfillment
Spiritual growth:Embodies a powerful connection to people, the world or the universe
SPIRITUAL BEHAVIOR_____________________________________
Prayer Meditation Walking in nature Reading poetry/sacred texts Lighting a candle Listening to music Smelling incense
HOW TO INCORPORATE SPIRITUALITY AS AN EFFECTIVE INSTRUMENT OF CHANGE
_____________________________________ Assess and understand patient’s spiritual beliefs Acknowledge respect and listen carefully to patient’s
beliefs Explore emotions and make empathic statements Elicit spiritual themes Stimulate spiritual narrative Connect spirituality with social affiliation and recovery Mobilize support
PITFALLS IN DISCUSSIONS ABOUT SPIRITUAL ISSUES
_____________________________________ Trying to solve the patient’s problems or resolve
unanswerable questions Going beyond the clinician’s expertise and role Imposing the clinicians spiritual religious beliefs
on the patient Argue with patient’s view point or spiritual
beliefs.
OVERVIEW
Definition of addiction Definition of spirituality
Spirituality vs. religion
Biological correlates Spirituality in clinical practice Spirituality in substance related disorders Spirituality in Alcoholics Anonymous Spirituality as an instrument of change
SUMMARY_____________________________________ The ability of addicted people to establish a substance-free
recovery draws on their ability to achieve a meaningful, spiritually-grounded life for themselves.
Ability to inquire about the religion and spiritual life of patients is an important element of our clinical and psychotherapeutic competency.
Millions achieve recovery status through the spiritual fellowship of AA.
An integrated medical, psychosocial and spiritual treatment is a much needed model to achieve recovery in addicted patients.