Addressing issues related to addictive behaviors and diagnoses
Substance use disorders (SUDs) are chronic health disorders with exacerbation rates of approximately 50%, which are similar to rates for other chronic health disorders, such as diabetes, hypertension, and chronic obstructive pulmonary disease (National Institute on Drug Abuse, 2018). Spirituality has been identified as a factor that can improve recovery rates in people with SUDs (Walton-Moss, 2013; Worley, 2017).
A variety of definitions of spirituality have been proposed across several disciplines, including philosophy, theology, nursing, and medicine. Spirituality can be described as a connection to something bigger than ourselves, to something sacred in relation to finding meaning in life often involving an experience of a sense of aliveness and interconnectedness (University of Minnesota, 2016). The European Association of Palliative Care defines spirituality as the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, self, others, nature, and the significant or sacred (Nolan et al., 2011). When writing on nursing concepts in relation to health promotion, nurses Ruth Beckmann Murray and Judith Proctor Zentner (1989) describe the spiritual dimension as that which tries to be in harmony with the universe; strives for answers about the infinite; and comes into focus when the person faces emotional stress, physical illness, or death. Another often cited older reference for the definition of spirituality comes from the authors of The Spiritual Brain, describing it as any experience that is thought to bring the experiencer into contact with the divine (Beauregard & O'Leary, 2007). Although there are some similarities between spirituality and religion in regard to beliefs, they are distinct in that religion has a focus on practices, rites, and rituals and answers questions about what is right and wrong versus spirituality, which focuses on finding meaning, connection, and value (University of Minnesota, 2016). Mindfulness is an example of how spirituality can be practiced and experienced outside of a religion-based framework.
The purpose of the current article is to examine the evidence supporting the relationship between spirituality and recovery and provide strategies for nurses to incorporate spirituality principles in their work with patients with SUDs.
The term recovery in relation to SUDs implies a change or growth related to lifestyle and interpersonal and social characteristics but has no universally accepted definition (Worley, 2017). One definition that is often cited is from the Substance Abuse and Mental Health Services Administration (2015), which defines recovery as a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. The World Health Organization (2016) defines recovery related to SUDs as the maintenance of abstinence from alcohol and/or other drug use by any means. The American Society of Addiction Medicine (2013) defines recovery as the process of sustained action that addresses the biological, psychological, social, and spiritual disturbance inherent in addiction. The Betty Ford Institute Consensus Panel (2007) defines recovery as a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. An expert in the field of addictions, William L. White (2007) conducted an analysis of the concept of recovery and determined a working definition of recovery as the experience (a process and a sustained status) through which individuals, families, and communities affected by severe alcohol and other drug (AOD) problems heal the wounds inflicted by AOD-related problems; actively manage their continued vulnerability to such problems; and develop healthy, productive, and meaningful lives.
Spirituality and Recovery from Substance Use Disorders
For some time, spirituality has been shown to be positively associated with recovery (Worley, 2017). In a systematic review of the relationship between spirituality or religion and recovery, researchers examined 29 studies that had abstinence as the most common outcome and found a beneficial relationship between spirituality or religion and recovery from SUDs (Walton-Moss et al., 2013). In another study, researchers looked at the National Institute of Drug Addiction Treatment Outcome Study dataset to examine relapse rates among 2,947 participants and found an association between spiritual/religious beliefs and practices and remission from substances (Schoenthaler et al., 2015). In another study of Narcotics Anonymous members who had at least 10 years of abstinence, spiritual development was identified as having had a positive impact on their recovery and was also associated with a more hopeful outlook on life (DeLucia et al., 2015). Positive religious coping was studied by researchers who found that in 331 participants, greater positive religious coping was associated with significantly greater mutual-help participation, fewer days of drug use prior to admission, and was significantly associated with lower drug craving and, therefore, might modify the course of SUD recovery (Medlock et al., 2017).
Spirituality without a religious association has also been identified as being positively associated with recovery. In a study of 332 participants in self-help recovery groups, belief in a higher power as a universal spirit was predictive of the absence of cravings (Dermatis & Galanter, 2016). Mindfulness meditation, with origins as an ancient spiritual practice with an aim to still the mind by eliminating negative thoughts and induce a state of relaxation (Lazaridou & Pentaris, 2016), has been found to positively impact recovery from SUDs. Researchers who conducted a systematic review and meta-analysis of research on mindfulness as a treatment for SUDs found that mindfulness treatments reduce the frequency and severity of SUDs, the intensity of cravings, and stress severity (Li et al., 2017). In another randomized controlled trial (RCT) with 200 women with SUDs who engaged in mindfulness, those in the mindfulness group had improved class attendance, improved distress tolerance, and a more positive affect than the control group (Black & Amaro, 2019). Researchers who conducted a RCT with 35 incarcerated youth with SUDs found that those who received mindfulness training had significant increases in self-esteem and decision-making skills and concluded that mindfulness can play an important role in improving well-being and decreasing recidivism (Himelstein et al., 2015).
Spirituality in the Health Care Environment
In past centuries, medicine was a profession attending to body and spirit, with physicians viewed as secular priests, and nurses and hospitals were often affiliated with religious organizations (Capparelli, 2005; Puchalski, 2001). In time, there was a shift in the focus of health care from a caring, service-oriented model to a technological, cure-oriented model; however, over the past few decades there has been a renewed emphasis on holistic care involving the whole person—body, mind, and spirit (Puchalski, 2001). Spiritual care can be incorporated into health care practice by showing compassion by being fully present and attentive to patients and showing support for their physical, emotional, and spiritual suffering; listening to patients' fears, hopes, pain, and dreams; obtaining a spiritual history; being attentive to all dimensions of patients and their families (i.e., body, mind, and spirit); incorporating spiritual practices as appropriate; and involving chaplains or religious leaders as members of the interdisciplinary health care team when applicable (Puchalski, 2001). The goal in addressing spirituality is to listen and offer support but to defer in-depth spiritual counseling to religious professionals as well as to not overstep professional boundaries, such as by suggesting specific religious or spiritual beliefs to a patient (Puchalski, 2001).
Health care providers may be reluctant or experience barriers to discussing spirituality with their patients. Researchers who conducted a qualitative study with 55 health care providers, including nurses at a Veterans hospital, found that providers had concerns about whether spirituality could be discussed in the workplace. Time constraint was identified as a significant problem limiting them from discussing spirituality as was an overall reticence to discuss it because they did not know how or wish to discuss spirituality with their patients (Fletcher, 2004). Other researchers have examined this topic and found that patients are willing and want to discuss spiritual issues with their providers but it often does not occur and barriers exist (Bergamo & White, 2016; Best et al., 2015; Wittenberg et al., 2017).
A barrier to health care providers' including spirituality as a component of their care is lack of training. In nursing education, programs may not always include content on spirituality, as it is often not presented in nursing textbooks, and there are limited studies on effective strategies to teach this content (Connors et al., 2017). In one literature review of evidence related to spirituality in nursing education from 1993 to 2017, knowledge and practice gaps were identified, including lack of support and environmental constraints, uncertainty about curriculum structure related to the topic, unprepared faculty, and lack of competencies for faculty to prepare nursing students in spirituality (Ali et al., 2018).
Spiritual Assessment Instruments
Because spirituality is associated with improvement in recovery, spiritual assessment should be included, using validated instruments, when working with patients with SUDs. In addition, the Joint Commission on Accreditation of Health Care Organizations has determined that religion and spiritual beliefs, values, and preferences should be addressed in patients receiving psychosocial services for the treatment of SUDs (Ehman, 2018). The Faith and Belief, Importance, Community, and Address in Care (FICA©) Spiritual Assessment Tool was developed by consensus and later found to be a feasible and effective measure of spirituality (Borneman et al., 2010; Puchalski & Romer, 2000). The instrument has been used in numerous studies, is free, available online, and comprises 11 items measured in four categories: (a) faith, belief, and meaning; (b) importance and influence; (c) community; and (d) address in care (Puchalski & Romer, 2000). Another free online tool is the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale (FACIT-SP), which has been found to be psychometrically sound and used extensively in research studies on spirituality (FACIT, 2010; Peterman et al., 2002). This 12-item scale includes items related to purpose, faith, spirituality, and peacefulness (FACIT, 2010).
Spirituality is foundational to a comprehensive, holistic treatment approach when working with patients with SUDs. Nurses should take steps to gain an understanding of spirituality, how it can be assessed, and how they can help patients strengthen their spirituality to improve their recovery. Spirituality has been studied by numerous researchers and high-level evidence indicates that spirituality is associated with higher recovery rates and overall wellness. Validated spiritual assessment instruments are readily available and should be used to open communication and increase patients' awareness of their strengths and areas for growth concerning spirituality. It is appropriate for nurses to engage in discussions on this topic while keeping in mind the need to respect professional boundaries and the patient's point of view. To help prepare nurses to feel comfortable and competent to engage in discussions related to spirituality, nursing schools should enhance their content on spirituality in nursing programs, including spirituality related to content on SUDs. Nurses can also make an impact in this area by advocating for spiritual leaders to be part of integrated care teams so that they are available to patients.
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