Spirituality is a multi-faceted activity that permeates all we do in addiction.

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From Luke’s Journal October 2023  |  Vol.28 No.3  |  Mental Health I

The use of addictive agents (alcohol and/or other drugs (AODs)) is a common problem in clinical practice. The over-consumption of alcohol and tobacco are the most common problems, with illicit drug use less frequent. Iatrogenic addiction to opioids given for pain and benzodiazepines for anxiety and insomnia also occur.

Why do people take AODs? Sedatives like alcohol, benzodiazepines, opioids and marijuana are mainly taken for their calming effects, whereas stimulants like methamphetamine and cocaine are usually taken by driven people struggling to meet deadlines. Analgesics like opioids are given for acute and sometimes chronic pain. Each of these agents also stimulate the limbic system, making the user feel good. AODs can thus provide instant, artificial pleasure, a “chemical vacation from intolerable selfhood and repulsive environments”.¹ The effect, however, is temporary. Tolerance means that the user needs higher doses of the drug to achieve the same result. Sudden cessation in those with tolerance is often associated with withdrawal symptoms. These are worse for the sedating agents, but withdrawal symptoms can also occur with the stimulants.

Dependence and withdrawal are not the only ways in which these AODs can become problematic. Acute intoxication to alcohol can lead to several public health issues, including impaired driving ability, car crashes, domestic or social violence, injury, overdose and death. This primarily occurs with one-off or intermittent use when patients are reasonably naïve to the drug effects. Ironically, people who have built up a tolerance from regular use are somewhat protected from these acute effects. But tolerance can wane quickly. This is especially problematic for people trying to stop using. They can go through withdrawal but then lapse. The same dose that did little when the person was using regularly may be fatal when the person stops using.

“There is also behavioural addiction, such as gambling, the use of screens for entertainment, pornography, and online addiction. These, too, can stimulate the limbic system.”

There is also behavioural addiction, such as gambling, the use of screens for entertainment, pornography, and online addiction. These, too, can stimulate the limbic system. The phenomena of tolerance and salience can also occur. By salience, we mean that the behaviour becomes more important than anything else and thereby dominates all other behaviours. 

This raises questions about the purpose of living. If we are not living for our addiction – whether behavioural or AOD – what are we living for? What do our addictions prevent us from doing? What is the point of life anyway? These are spiritual issues of meaning and purpose, which can be explored with our patients.

Carl Jung, in a letter to Bill Wilson, the founder of the AA movement, describes, “Spiritus contra spiritum” – the Divine Spirit driving out the spirit of alcohol.² Here, spirituality is seen as a driver or an empowerment. In Hebrew and Greek, the word spirit means breath and liveliness. So a lively person is full of spirit, and a person with hope is inspired. In turn, a hopeless person is dispirited. A dead person has expired – there is no life or breath in them. AODs then can drive a person, but the drive of the Spirit can enhance recovery.

“Thus addiction can be regarded as a disease of relationships, with recovery involving social reconnection.”

Spirituality is more than meaning, purpose and drive. Why do we have a pleasure centre in the brain? What is the evolutionary advantage, for the individual and the species, of being designed with pleasure centres? Why are humans designed to feel good? I believe the pleasure centres enhance human bonding, sexually (with obvious reproductive benefits) and socially. There is pleasure in holding your baby, in conversations with family and friends, in raising children, in sitting around a campfire and planning your next hunt or harvest. The pleasure centre enhances socialisation. Thus addiction can be regarded as a disease of relationships, with recovery involving social reconnection. Humans are built to relate – to themselves, to family, to society, to the created order, and to God. Recovery will therefore involve connections in all these dimensions.

Meaning, purpose, and relationships equate to the big three Christian virtues: faith, hope and love. Plus, the power of the Spirit enables us to overcome where there was defeat before. Are there other dimensions to spirituality?

“Meaning, purpose, and relationships equate to the big three Christian virtues: faith, hope and love.”

One of the dimensions worth exploring is the transcendent dimension. This is unusual for medical practitioners, for we are trained to think purely within a naturalistic framework. Yet thought and imagination shape our behaviour, and our patients often have some sense of the divine in their lives. The spirituality gap describes the gap between a patient (with a spiritual orientation, awareness and resources) and a secular therapist (purely trained in worldly skills and who avoids their patient’s spirituality). The spirituality literature encourages trained practitioners to bridge that gap.  

If spirituality is about finding God’s perspective on all there is, then there is more. Competent clinical care in all its dimensions is in itself a spiritual act. And in taking a compassionate history, we often find that the reasons our patients find themselves in strife with their addictions are fairly obvious. This should evoke compassionate care rather than judgmentalism – the vice which the Master found so exasperating in the religious leaders of the day.

“This should evoke compassionate care rather than judgmentalism – the vice which the Master found so exasperating in the religious leaders of the day.”

One of the dimensions of addiction care is to work out where the person is at in the cycle of change. Patients hiding their struggle with AODs will present to their GP with other conditions like indigestion, hypertension, insomnia, or anxiety. The astute GP will be alert to the possibility that AOD use might be an aggravating factor. They will take a gentle history of their AOD use and link the presenting symptom with that use. This moves patients from the pre-contemplative stage to the contemplative stage in the cycle of change.

The skill in helping a patient in the contemplative stage is to get them to articulate for themselves the pros and cons of their AOD use. This is not a lecture by the doctor to change the patient’s behaviour; rather, through sympathetic listening, it is the action of hearing the patient’s ‘reasons’ for and against their AOD use. This is not a rational discussion, for the pros of AOD use are often deeply emotional and personal. Patients themselves may have difficulty describing why they do it. Very often, it is the default option in their behaviour. The question is how confident they are of change and how easy it will be.

If the patient is ready for change, the practitioner will need to decide on how severe the withdrawal is likely to be, and the appropriate location for the withdrawal – home, detox centre or hospital. The management can be easy or difficult depending on the number of AODs the patient is withdrawing from and the medical and psychiatric comorbidities.

Once AOD use is stopped, the main challenge is to remain abstinent. The most common outcome of detox is relapse. Detox is easy, but relapse prevention is challenging. There are many relapse prevention strategies, including managing physical and mental co-morbidities, developing practical strategies to manage or avoid high-risk situations, prescribing anti-craving agents, and creating societal reconnections. The value of the 12-step program is debated by sceptical academics but embraced by those who believe. In my judgment, the data cannot provide knock-down proof of efficacy. On balance, the 12-step program can be very beneficial for some people. It provides fellowship and accountability and introduces people to a power beyond themselves. It facilitates forgiveness and empowerment and helps them to overcome a sense of shame that is so much part of those in addiction. I recall one patient from a Roman Catholic background who told me that his view of God has become bigger since he attended AA. “He is much more mysterious and much more loving than before.” That is spiritual growth.

What about the concept of harm minimisation? All of us, patients and therapists, are on a journey of self-discovery. If, on the way, we can create an environment of safety by offering safe injecting facilities, clean needles, or substitution pharmacotherapy while sorting out some of the deep issues that have led to AOD abuse in the first place, then we are helping. Like Jesus, we can meet people where they are and keep them safer on their journey to recovery. It is part of the hardness of heart ethic espoused by Jesus in Matthew 19:4. My own clinical experience has shown that premature detoxes with inadequate relapse prevention strategies in patients on opioids have been fatal. On the other hand, patients’ hard work in all the biopsychosocial dimensions of recovery can be associated with a very satisfactory outcome.

“Spirituality is a multi-faceted activity that permeates all we do in addiction. It is a journey that goes at the patient’s pace.”

Spirituality is a multi-faceted activity that permeates all we do in addiction. It is a journey that goes at the patient’s pace. Some are not ready for faith; some do not want or see the need for it. Those choices need to be respected and cannot be forced. However, even within a secular, pluralist society, we can help people explore issues of meaning, purpose, relationships, strength and empowerment. We can help them to explore the transcendent and, for the receptive, we can talk about Divine love and compassion, which can be transformative in a patient’s life.

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References

1. Huxley A.  The doors of perception 1954 Huxley, A 1954, The doors of perception, Harper & Brothers, viewed September 2007, http://en.wikipedia.org/wiki/The_Doors_of_Perception
2. Bill Wilson.  Originally in Carl Jung’s letter to Bill Wilson Jan 30 1961, best extracted from https://www.reddit.com/r/Jung/comments/aqbbfa/dr_carl_jungs_letter_to_the_cofounder_of/ (accessed 1 Oct 2023).  A Google search leads us in a number of interesting directions with a number of AA groups running commentary on this quote.