Religion and Spirituality in Psychiatry

120 Alyssa A. Forcehimes and J. Scott Tonigancaptured in the famous “serenity prayer” that hasbeen adapted and widely used within AlcoholicsAnonymous: “God grant us grace to accept withserenity the things that cannot be changed,Courage to change the things which should bechanged, And the wisdom to distinguish theone from the other.” Also included in the disciplineof acceptance is the forgiveness of the selfand others and the act of submission, giving upindependence for a proper dependence on God.According to Lin and colleagues, (33) individualsrandomized to an adjunct forgiveness interventionreported lower depression, anxiety, and substanceuse at a four-month follow-up.Other than these studies that have examinedthe role of specific spiritual disciplines in thetreatment of addictions, many other specific spiritualpractices have not been studied empirically.Research is still in the early stages in determiningwhich spiritual disciplines may predict positiveoutcomes better than others.5. WHAT ROLE DOES SPIRITUALITYPLAY IN SUBSTANCE USE REDUCTION?Spirituality has been studied from distinct perspectives,and it is extremely important to distinguishthese perspectives when describing therole of spirituality in recovery. Spirituality has, forexample, been investigated as it directly affectssubstance use (independent variable). In contrast,spirituality has also been investigated as an outcomearising from prescribed practices intendedto reduce substance use (dependent variable).Third, spirituality has also been studied as a moderatingvariable in which people with some faithcharacteristic are more (or less) likely to acceptspiritual interventions. And, finally, spiritualityhas been investigated as a mediator or mechanismvariable that explains why particular behaviorsare predictive of substance use reductions.5.1. Spirituality as an IndependentVariableSpirituality has received mixed support as havinga direct effect on later substance use. In arecent book, Sober for Good (2001), Fletcher (34)discussed pathways to sobriety and noted,“Comments related to spirituality were amongthe five most frequent responses to open-endedquestions about key things … used to get soberand stay sober” (p. 239). Additionally, Flynn, Joe,Broome, Simpson, and Brown (35) reported that63 percent of their sample indicated that strengthfrom spirituality was reported as an importantfactor in the recovery from cocaine dependence,and Koski-Jannes and Turner (36) found thatspirituality was a factor associated with bettermaintenance of treatment gains.Evidence of the importance of spiritualitywithin an addiction population was alsosupported in a study conducted by Robinson,Brower, and Kurtz.(21) Results of this studyincluded the background finding that 54.4% ofpatients entering treatment for alcohol problemshad experienced, at some time in their lives, alife-changing spiritual or religious experience,compared to 39.1 percent in a large national survey.Participants in the Robinson et al.(21) studyalso rated their spirituality higher than their religiosity,and higher than did the national sample.Most important, after statistically controlling forself-reported frequency of AA attendance, positivegains in spiritual beliefs and practices significantlypredicted reduced substance use.It is important to note that, although patients’endorsement of the importance of spiritualitytends to be high in case studies and the empiricalliterature, there is a larger body of work to thecontrary. For example, the magnitude of the relationshipbetween spirituality/religiosity scoresmeasured at intake among an alcohol dependentsample (N = 1,726) and abstinence from alcohol(at a twelve-month follow-up) in an examinationof Project MATCH participants was smalland not clinically meaningful (37) albeit statisticallysignificant. Finally, Miller, Forcehimes, etal.(38) conducted the first two systematic evaluationsof the impact of a manual-driven interventiondesigned to explore and foster the practiceof spiritual disciplines on addiction treatmentoutcomes. The authors anticipated that spiritualguidance would enhance spiritual experience