Multicultural Considerations in the Assessment of Addictive Behaviors

Journal of Substance Abuse Tre

Special article

Assessment of spirituality and its relevance to addiction treatment

Marc Galanter, (M.D.)4, Helen Dermatis, (Ph.D.), Gregory Bunt, (M.D.),

Caroline Williams, (M.D.), Manuel Trujillo, (M.D.), Paul Steinke, (M.A, M.D.)

Division of Alcoholism and Drug Abuse, New York University School of Medicine, New York, NY 10016, USA

Received 13 April 2006; received in revised form 15 June 2006; accepted 16 June 2006

Abstract

The prominence of Twelve-Step programs has led to increased attention on the putative role of spirituality in recovery from addictive

disorders. We developed a 6-item Spirituality Self-Rating Scale designed to reflect a global measure of spiritual orientation to life, and we

demonstrated here its internal consistency reliability in substance abusers on treatment and in nonsubstance abusers. This scale and the

measures related to recovery from addiction and treatment response were applied in three diverse treatment settings: a general hospital

inpatient psychiatry service, a residential therapeutic community, and methadone maintenance programs. Findings on these patient groups

were compared to responses given by undergraduate college students, medical students, addiction faculty, and chaplaincy trainees. These

suggest that, for certain patients, spiritual orientation is an important aspect of their recovery. Furthermore, the relevance of this issue may be

underestimated in the way treatment is framed in a range of clinical facilities. D 2007 Elsevier Inc. All rights reserved.

Keywords: Substance abuse treatment; Spirituality; Alcoholics Anonymous; Psychometric scale

1. Introduction

Alcoholics Anonymous (AA) has been described as ba spiritual program for living,Q as bthere is no dogma, theology, or creed to be learnedQ (Miller & Kurtz, 1994). Dictionaries define spirituality with phrases such as bconcerned with or affecting the soulQ or bpertaining to GodQ (Berube, 2001). These connotations suggest that an approach to spirituality

can be framed relative to addiction recovery, as understood by

members of Twelve-Step programs.

To operationalize this construct for use in addiction

treatment settings, we developed a scale designed to assess

the degree to which a subject’s views reflect this orientation.

We have applied it to patients in a diverse group of treatment

programs and to medical caregivers and chaplaincy trainees.

0740-5472/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jsat.2006.06.014

Support for this project was provided by the Scaife Family Foundation.

4 Corresponding author. Division of Alcoholism and Drug Abuse,

New York University School of Medicine, 550 First Avenue, New York,

NY 10016, USA. Tel.: +1 212 263 6960; fax: +1 212 263 8285.

E-mail address: [email protected] (M. Galanter).

These results were then examined in relation to subjects’

views on substance abuse treatment and recovery. We present

here the psychometric properties of this Spirituality Self-

Rating Scale (SSRS), along with responses from these subject

groups on their views on substance abuse treatment and

recovery and their attitudes toward spirituality in relation to

recovery from addiction. Our findings suggest that further

attention needs to be paid to the importance of spirituality and

its value to patients relative to their recovery in diverse

settings where addicted people are treated.

There have been a number of studies on substance

abusers’spiritual orientation whose findings reflect a positive

relationship to recovery. Two were on methadone-maintained

patients: Avants, Warburton, and Margolin (2001) found that

a higher self-report rating on bspirituality or religious supportQ was an independent positive predictor of abstinence from illicit heroin and cocaine. Flynn, Joe, Broome, Simpson,

and Brown (2003) found that patients who indicated religion

or spirituality as a source of recovery support were almost

twice as likely as those who did not to be free from heroin and

cocaine at 5 years. Piedmont (2004) evaluated a group of

abstinent drug abusers who had entered a spiritually oriented

atment 33 (2007) 257–264

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264258

ambulatory program of 8 weeks’ duration. Of those who

completed the program, the ones who had higher pretreat-

ment on spirituality had higher scores on well-being and less

psychiatric symptomatology after completion (no indication

of final drug-free status was given). Polcin and Zemore

(2004) and Zemore and Kaskutas (2004) studied ambulatory

patients who were predominantly drawn from AA meetings

by applying a multidimensional measurement of religious-

ness/spirituality, and they found that those AA members who

had longer periods of sobriety reported a greater level of

spirituality at the time of evaluation. Magura et al. (2003)

reported that responses on a 12-item Spirituality Well-Being

scale were not associated with increased abstinence, but were

associated with health-promoting behaviors such as btaking care of yourselfQ and bgetting enough sleep.Q

Some studies on ambulatory patients on recovery,

however, did not show a relationship between spiritual

orientation and decreased use of drugs. Christo and Franey

(1995) evaluated a sample of patients attending Narcotics

Anonymous in London and found, on a 6-month follow-up,

no relationship between scores on a spiritual belief ques-

tionnaire and abstinence. Murray, Malcarne, and Goggin

(2003) studied members currently attending AA meetings

and found no relationship between belief in God or in a

higher power as a motivation to stop drinking and duration

of sobriety. Clearly, there is a need for an operational

definition for what investigators term bspiritualityQ relative to addiction recovery.

2. Method

2.1. Study samples

We conducted a series of cross-sectional studies on

cohorts of substance abusers in recovery-oriented programs

and on other cohorts not designated as substance abusers.

In the instruments employed, we included a scale designed

to assess their spiritual orientation and its relationship to

attitudes toward addiction treatment, and their views on

AA. Where specific procedures of subject selection and of

the administration of structured questionnaires were

reported previously, relevant references are cited below.

Participation of all subjects was voluntary, and responses

were recorded on answer sheets with identifiers removed

for subsequent analysis.

Patients in the following treatment settings were studied:

Dually diagnosed (DD) psychiatric inpatients (n = 101;

i.e., those who were diagnosed with both general

psychiatric disorders and substance-use Axis I disorders)

were interviewed. They had been admitted to an acute

inpatient general psychiatric service at Bellevue Hospital

because of their potential harmfulness to themselves or

to others. Individuals in this sequential series of

admissions were interviewed as soon as they were able

to respond effectively to structured questionnaire items

read to them (Goldfarb, Galanter, McDowell, Lifshutz,

& Dermatis, 1996).

Therapeutic community (TC) residents (n = 210) of the

Daytop Village Therapeutic Community Program at two

sites (Swan Lake and Parksville, NY) were studied. A

one-time cross-sectional survey adapted from our pre-

vious research (Dermatis, Guschwan, Galanter, & Bunt,

2004) was administered in a group setting at each site.

Patients on methadone maintenance (n = 110). Patient

chart numbers were selected at random from the New

York Bellevue Hospital Methadone Maintenance Clinic’s

roster of patients who were waiting to receive their

methadone doses.

Methadone Anonymous members (n = 52) in New-York-

City-based groups (Gilman, Galanter, & Dermatis, 2001)

were studied. Methadone Anonymous is a recovery-

oriented peer-led program for patients on methadone

maintenance that is based on the Twelve-Step group

format. It was established because many traditional

Twelve-Step groups exclude active participation of

patients on opiate replacement therapy.

Questionnaires were also administered to subjects who

were not in substance abuse treatment programs:

Medical students in their first year and second year (n =

119) at New York University Medical School who

volunteered for a survey on medical treatment: Subjects

in this sample completed a questionnaire on attitudes

toward spirituality and addiction treatment (Goldfarb

et al., 1996).

Medical addiction faculty (n = 34) drawn from the New

York University Medical Center and from an annual

meeting of the American Society of Addiction Medicine:

Members of this sample of convenience were asked to

participate in a study on addiction treatment (Fazzio,

Galanter, Dermatis, & Levounis, 2003).

Chaplaincy trainees (n = 19) at the Bellevue Interdeno-

minational Clinical Pastoral Education Program: Train-

ees were drawn from diverse religious and ethnic

backgrounds. All participants in the four sequential

cycles of a 2-month full-time training were administered

a written questionnaire.

University students (n = 180) presenting at New York

University Counseling Service (UCS) for mental health

consultation: This is clearly a clinical sample. Subjects

completed the questionnaire as part of their intake

assessment. This series of sequentially presenting stu-

dents consisted of 95 (53%) undergraduate and 85 (47%)

graduate students.

2.2. Instruments

Questionnaires administered to substance-abuser groups

were designed to ascertain aspects of their abuse and

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264 259

treatment, and were tailored to each treatment setting

relative to the objectives of the respective studies. Subjects

were told by the research staff that the survey was

undertaken to improve the understanding of addiction

treatment options; that responses were given anonymously,

with no review of individual respondents’ questionnaires

by clinical or educational staff; and that participation

was voluntary.

Each assessment battery that was administered to

substance-abuser cohorts consisted of about 150 multiple-

choice items and included demographic, drug use, employ-

ment, and treatment-related items, as well as self-rating

items reflecting attitudes toward spirituality. In each assess-

ment battery, the SSRS and additional spirituality-related

items were administered following questions concerning

sociodemographic characteristics, substance use, and prior

treatment characteristics. Administration of each of the

surveys for substance-abuser cohorts took an average of

30 minutes. Spirituality-related measures that are relevant to

this report are described here. Questionnaires completed by

nontreatment cohorts were briefer, contained the SSRS

described below, and required no more than 10 minutes

to complete.

2.3. The SSRS

Our previous research (Goldfarb et al., 1996; McDowell,

Galanter, Goldfarb, & Lifshutz, 1996) described the devel-

opment of a seven-item spirituality measure reflecting an

intrinsic (as opposed to a more external socially related)

orientation to spirituality, based on factor analyses con-

ducted in medical students and DD psychiatric inpatients.

Subsequent factor analyses of this seven-item measure in the

university, methadone clinic, and TC samples indicated a

unipolar factor structure, with six items having loadings

exceeding .35 in each of the three samples. These six items

are listed in Appendix A, and the SSRS reported here

consists of these six items. They were rated on a 5-point

Likert-type rating from 1 = strongly agree to 5 = strongly

disagree. The scale is scored by summing responses to the

six items. The items are recoded before calculating the sum,

with higher scores reflecting a higher level of spirituality

(range, 6–30; i.e., Score 1 is redesignated as 5, and Score 2

Table 1

Cronbach’s a reliability coefficients of the six-item spirituality scale, by

study sample

Study sample M SD Cronbach’s a

Medical students (n = 119) 17.23 6.03 .86

College/graduate students (n = 180) 17.61 6.33 .90

DD psychiatric inpatients (n = 101) 23.18 5.84 .87

Methadone clinic patients (n = 110) 23.34 5.66 .88

Methadone Anonymous attendees

(n = 52)

21.90 5.49 .82

TC residents (n = 210) 22.20 5.86 .91

Chaplain trainees (n = 19) 27.63 1.57 NA

Note. NA = not assessed.

is redesignated as 4). Cronbach’s a coefficients for this six- item version of the scale ranged from .82 to .91 (see

Table 1).

To evaluate the construct validity of the SSRS, on a

preliminary basis, we assessed the relationship of spirituality

to related constructs that are consistent with the Twelve-Step

conceptualization of spirituality. Spirituality-related per-

sonal characteristics that were available in DD patients

and medical students included one item drawn from a

Gallup (2002) poll report on religion in Americans:

Do you believe that God or a universal spirit is:

(a) a heavenly father who can be reached by prayer?

(b) an idea, not a being?

(c) an impersonal creator?

(d) I don’t know.

They also included one item that assessed the extent to

which they believed in a power greater than themselves,

which was rated on a 5-point Likert-type rating scale from

1 = never to 5 = always. Using the same Likert-type rating

scale to assess attitudes toward treatment, DD patients were

asked to rate the extent to which they wanted more groups

focused on spirituality in their treatment, and the TC sample

was asked to rate the extent to which they wanted

spirituality featured more in the TC program.

2.4. Other clinical issues

The following additional measures were applied to assess

treatment-related issues associated with spiritual orientation:

1. A 5-point Likert-type scale ranging from 1 = not at

all to 5 = very much was used for evaluating the

views of DD patients, TC residents, methadone

clinic patients, Methadone Anonymous members,

medical students, and addiction faculty members

regarding the importance of four issues to recovery

from addiction: spiritual orientation, AA meetings,

job, and outpatient treatment.

2. Medical students’ and faculty members’ perceptions

concerning their patients’ views were determined by

asking the medical students and the faculty to rate

what they perceived was the importance of the four

issues noted above to their patients.

3. Results

There was neither a significant difference in SSRS scores

on an analysis of variance across the four groups of

substance abusers (DD patients, TC residents, methadone

maintenance patients, and Methadone Anonymous mem-

bers) nor any significant difference between the mean scores

of UCS students and medical students (see Table 1).

Because of this, substance-abuser samples were combined

Table 2

The importance of issues to treatment: DD patients versus medical students and addiction faculty

Issue

DD patients (n = 101) Students (n = 119) Faculty (n = 34) ANOVA (df = 2, 251)

A B C D E

A � B � D A � C � E Own view

[M (SD)]

Own view

[M (SD)]

Patients’ view

[M (SD)]

Own view

[M (SD)]

Patients’ view

[M (SD)]

Spiritual orientation 4.48 (0.93) 2.95 (0.92) 3.03 (1.10) 3.38 (1.41) 2.65 (1.05) F= 65.2444 F = 68.7244

AA meetings 4.61 (0.80) 2.86 (1.13) 4.10 (0.85) 3.94 (0.86) 3.0 (0.98) F= 89.0144 F= 46.2144

Job 3.71 (1.56) 3.97 (1.15) 4.23 (0.92) 3.85 (0.91) 3.52 (1.23) F= 1.082 F = 6.6944

Outpatient treatment 4.29 (1.02) 3.99 (0.92) 4.30 (0.67) 4.45 (0.83) 3.16 (0.92) F= 4.324 F = 24.4744

4 p b .05.

44 p b .001.

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264260

into one group, and medical students and UCS students (a

clinical sample in effect) were combined into another group

for the following analysis. An independent t test was then

conducted to compare the two groups on the SSRS. The

substance abusers (M = 22.63, SD = 5.8) were significantly

more spiritual than were the students (M = 17.49, SD = 6.2;

t = 11.78, df = 770, p b .001). The distribution of spirituality

scores in the chaplain sample was restricted to the extremely

high end of the range (M = 27.63, SD = 1.57), reflecting

strong spiritual orientation.

3.1. Relationship of SSRS scores to spiritually related

beliefs/attitudes

Respondents who believed that God is an entity reachable

by prayer had SSRS scores higher than the scores of those

who did not view God this way, in both DD patients (M =

24.71, SD = 4.59 vs. M = 20.03, SD = 6.9; t = 3.55, df = 46,

p b .001) and medical students (M = 21.42, SD = 4.91 vs.

M = 15.75, SD = 5.70; t = 15.75, df = 117, p b .001). Similarly,

respondents who believed in a higher power had a greater

level of spirituality than those who did not, in both DD

patients (M = 24.58, SD = 4.99 vs. M = 18.43, SD = 6.11;

t = 4.92, df = 99, p b .0001) and medical students (M = 20.52,

SD = 5.38 vs. M = 14.84, SD = 5.33; t = 5.71, df = 117,

p b .0001). SSRS scores were significantly correlated with

DD patients’ preference for more group treatment sessions

focused on spirituality (r = .440, p b .0001), and with TC

patients’ preference for more spirituality to be featured in

their program (r = .550, p b .0001).

3.2. Attitudes toward treatment

Paired t test analyses were carried out to ascertain the

degree to which DD patients considered two types of

experiences to be valuable for their recovery: spiritual issues

relative to nonspiritual ones. As seen in Table 2, both

bspiritual orientationQ and bAAQwere scored as more valuable than ba jobQ (paired t test = 4.04, df = 100, p b .0001; paired t test = 5.02, df = 100, p b .0001, respectively), and bAAQwas rated higher than outpatient treatment (paired t test = 2.66,

df = 100, p b .01).

Medical students, DD patients, and addiction faculty

were polled as to how valuable they thought each of the

same four issues was to a substance abuser’s recovery. As

shown in Table 2, the three groups differed in their attitudes

concerning the importance of spiritual orientation ( F =

65.24, df = 2,251, p b .001) and AA meetings ( F = 89.01,

df = 2,251, p b .001). Scheffe post hoc tests at the .05 level

of significance indicated that both the students and the

addiction faculty rated spirituality and AA meetings as

significantly less valuable than did DD patients. The

students and faculty were also asked to indicate what rating

they thought substance-abusing patients would give for each

of these issues. Student and faculty ratings of substance

abusers’ perceptions of the importance placed on spiritual

orientation ( F = 68.72, df = 2,251, p b .001) and AA

meetings ( F = 46.21, df = 2,251, p b .001) were

significantly different from ratings made by DD patients.

Scheffe post hoc tests indicated that medical students and

faculty members underestimated the value that DD patients

placed on spiritual orientation and AA meetings. Significant

differences in group perceptions concerning the importance

of a job ( F = 6.69, df = 2,251, p b .05) and outpatient

treatment ( F = 24.47, df = 2,251, p b .001) were obtained

with Scheffe post hoc tests indicating the following: (1)

medical students overestimated the importance that patients

placed on a job, and (2) faculty members underestimated the

importance that patients placed on outpatient treatment.

Although the residential TC program was neither

oriented toward spirituality nor included Twelve-Step

meetings, more than half of the respondents in the TC

sample (111 of 210; 53%) indicated that they wanted

spirituality to be featured in the program a lot or very

much (Scores 4 and 5). Furthermore, an appreciable

portion of TC respondents also gave scores of 4 or 5 on

how much they wanted the Daytop program to feature

more Twelve-Step meetings (96 of 210; 46%). Both the

members of Methadone Anonymous and the patients in the

methadone clinic cohort were asked to rate the degree to

which they regarded Twelve-Step programs as integral to

their recovery, and a large portion of these patients (33 of

52 [62%] and 41 of 110 [37%], respectively) indicated that

they regarded the programs as a lot integral or very much

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264 261

integral (Score 4 or 5) or fairly integral (Score 3) (14 of 52

[27%] and 33 of 110 [30%], respectively).

4. Discussion

4.1. Connotations of spirituality

The scale we developed was designed to draw on

connotations of this construct that are typically reflected in

AA members’ views (Galanter, 2005). We did not include

certain connotations employed in other studies that were not

oriented toward substance abusers, such as mystical

experiences (like a bloss of selfQ or bdistortion of time and spaceQ) (Hood, Morris, & Watson, 1993), items reflecting divine intervention in one’s daily life (Hall & Brokaw,

1995), aspects of religious rituals such as prayer (Saur &

Saur, 1993), provision of heavenly rewards (Moberg, 1980),

and appreciation of natural beauty (Galek, Flannelly, Vane,

& Galek, 2005). Additionally, the SSRS is different from

scales designed to assess AA involvement and affiliation,

but not spirituality as such (Humphreys, Kaskutas, &

Weisner, 1998; Morgenstern, Kahler, Frey, & Labouvie,

1996; Tonigan, Connors, & Miller, 1996).

We were mindful, however, of the mention of God in the

Twelve Steps, as embodied in the words of the AA

cofounder Bill W., who experienced an epiphany in 1935

heralding the beginning of AA. This was expressed when

his plea for redemption from alcoholism was answered by

ba wind not of air, but of spirit . . . so this is the God of the preachers!Q (Alcoholics Anonymous, 1975; Chappel, 1993). Three years later, the Twelve Steps were modified to add a

phrase following the term God (God bas we understood himQ), respecting the fact that members may define spirituality as separate from denominational religion.

4.2. Relevance to treatment readiness

Spirituality is not generally assessed in studies related to

engagement and progress in treatment; issues such as self-

efficacy and desire for help (Joe, Broome, Rowan-Szal, &

Simpson, 2002), or acknowledgement of one’s problem

(Prochaska & Diclemente, 1986) is more often considered.

bPatient attributes,Q as an overall entity, may be considered as a nonspecific term within an overall conceptual frame-

work for treatment, as employed by Simpson (2004) in a

model he developed. Nonetheless, spiritual orientation may

play a unique role in promoting an attitude that facilitates

some patients’ openness to change, particularly in the

context of programs that draw heavily on Twelve-Step

groups. It may also be influential in a patient’s choice of a

given treatment program or in promoting adherence to the

program’s behavioral expectations. Additionally, a low level

of spirituality may suggest relatively better acceptance of a

program that is not heavily oriented toward Twelve-Step

recovery when referral is considered. Further investigation

is needed to ascertain if this applies in a useful way to

abstinence after treatment.

In our substance-abuser samples, spiritual orientation to

recovery was apparently considered relatively important.

Vocational training is often considered as a means of

improving clinical outcome for patients, but limited

empirical evidence validating this assumption has been

reported, at least in studies on methadone maintenance

programs (Staines, Blankertz, Magura, Cleland, & Bali,

2005). Indeed, our DD patients rated spiritual orientation as

more important to their recovery than a job. They also rated

AA meetings as more important than outpatient treatment.

They further indicated that they had wanted greater

emphasis on spirituality and Twelve-Step programs in their

treatment. Many of the residents of the TC we studied also

indicated a preference for more of a spiritually oriented

approach in their treatment. Altogether, these findings

support the view that some substance-abusing patients in

treatment programs would prefer more activities associated

with spiritual aspects of recovery than are provided.

4.3. Limitations

The six-item SSRS was found to have a unidimensional

factor structure within the university, methadone, and TC

samples and an acceptable internal consistency reliability

for all samples. Preliminary support for the validity of the

measure was limited to the nature of significant correla-

tions with spirituality-related beliefs (i.e., belief in God as

an entity reachable by prayer, belief in a higher power, and

preference for spirituality in treatment, as well as high

scores demonstrated by the chaplain sample). Due to

constraints in the length of the assessment battery, other

spirituality measures, which could have strengthened the

evidence for the concurrent validity of the measure, were

not included. Further evaluation will be needed to ascertain

the scale’s validity by making use of established markers

of spirituality.

There are a number of limitations as to whether our

findings can be generalized to diverse populations with

substance-use disorders and as to the degree to which they

can be applied in framing clinical management. Substance

abusers may experience spirituality in different ways

relative to their recovery, given their respective life

experiences, cultural backgrounds, and religious affiliations.

We attempted to frame a scale that was sufficiently general

in nature to address this diversity, but specific individuals

may differ from each other on this count. In addition, the

literature cited above on the role of spirituality in the

maintenance of abstinence is certainly not conclusive.

Our subjects were recruited in the greater New York area

and may not be representative of patient and nonpatient

groups in other parts of the country. For example, Bellevue

Hospital serves a relatively indigent urban population, and

New York University may attract students whose orientation

is different from that of some other educational institutions.

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264262

The substance abusers studied may also reflect the

particular populations of the programs from which they

were drawn, but not other programs of similar designation.

Thus, although Daytop Village’s regimen is largely in

conformity with classical descriptions of TC (De Leon,

1997), other programs may have somewhat different

orientations. Some do employ, or at least encourage,

Twelve-Step attendance.

Finally, not all the patients self-identified themselves

with high scores on the SSRS, and a demand characteristic

of any addiction treatment setting may be to promote unduly

positive responses to a spirituality measure. Given all this,

care must be taken not to alienate or even compromise some

patients who would be distressed if more activities related to

spirituality were included in their treatment programs.

Clearly, no patients should be pressed to participate in such

exercises if they prefer not to do so.

4.4. AA and remission from chronic disease

McLellan, Lewis, O’Brien, and Kleber (2000) have

pointed out similarities between drug dependence and

chronic general medical illnesses, based on issues of its

duration, problems in treatment adherence, and possibility

of relapse. They emphasized the need for the availability of

long-term support for the maintenance of remission in all

such illnesses. Given current constraints on medical

expenditure, however, it is important that approaches to

maintaining stable remission should be relatively low in cost

if they are to be adopted. Options that employ patients’ own

spiritual orientation may therefore be useful for certain

patients. In such cases, an underlying Twelve-Step philos-

ophy, with its nondenominational spiritual orientation, may

be beneficial for sustaining recovery-oriented behaviors.

These programs provide acculturation into an approach to

abstinence associated with peer support, a positively

oriented philosophy based on enhanced personal meaning,

and an altruistic orientation toward helping other addicted

people. In this latter regard, a secondary analysis of Project

MATCH data showed that recovering substance abusers

who helped other substance abusers maintain sobriety were

better able to sustain their own (Pagano, Friend, Tonigan, &

Stout, 2004).

Motivation for recovery from addictive illness based on

Twelve-Step involvement is therefore a subject of interest

for some investigators. In a 1-year follow up on a 28-day,

Twelve-Step-based, Minnesota model inpatient program,

Isenhart (1997) found that affiliation with AA and accep-

tance of an AA sponsor (independent of scores on the

SOCRATES scale for motivational readiness) were found to

be predictive of a subsequent decrease in the quantity and

frequency of alcohol consumption. Ouimette, Moos, and

Finney (1998) found that self-selection for participation in

Twelve-Step ambulatory aftercare groups was also associ-

ated with improved outcome at 1-year follow-up. Hum-

phreys and Moos (2001) contrasted between patients

attending programs that emphasized Twelve-Step treatment

and those oriented toward cognitive–behavioral approaches;

the former required less subsequent inpatient hospitalization

than those in the latter treatment programs. AA may also be

useful as a model for approaches to promoting recovery that

are not grounded on spiritual philosophy, such as a peer

support program (e.g., Rational Recovery; Galanter, Egelko,

& Edwards, 1993). To draw on the benefits of mutual

support for abstinence, we developed a secularly grounded

peer-based approach applied in ambulatory care. This draws

on behavioral modeling familiar to many patients from

Twelve-Step groups, and this approach is not embedded in a

spiritually grounded philosophy (Dermatis et al., in press;

Galanter, 2002). In some settings, Twelve-Step-based

rehabilitation programs employ alumni groups that draw

on an AA spiritually oriented format that sustains recovery-

oriented behaviors after discharge.

4.5. Outside the spiritually oriented treatment community

The institutional settings studied here, where a large

portion of addicted people are treated, do not typically focus

on spiritual renewal. Methadone maintenance is built around

a pharmacological agent complemented by counseling over

pragmatic issues, such as job training and avoidance of

secondary drug use. Therapeutic communities emphasize

the bcommunity as methodQ (De Leon, 1997) for promoting character change, although some TCs do employ Twelve-

Step groups or encourage attendance. Additionally, on

general psychiatric units, although the comorbidity of

substance use and mental illness is quite high, the emphasis

is on psychopharmacological treatment and maintenance of

adaptive behaviors. Programs that are medically grounded,

ranging from HMOs (Mertens, Lu, Parthasarathy, Moore, &

Weisner, 2003) to state hospitals (Haugland, Siegel,

Alexander, & Galanter, 1991), also encounter large numbers

of patients with substance-use disorders. Recognition by

clinical staff of the importance of spirituality in any such

settings may therefore have clinical utility.

It has also been shown that individual physicians can

play an important role in addressing alcohol-use disorders in

their patients in office practice with brief educational

interventions (Fleming, Barry, Manwell, Johnson, & Lon-

don, 1997). When we compared the attitudes of both

medical students and teachers of addiction medicine to those

of DD patients, we found that these two medical cohorts

regarded spiritual orientation toward recovery as relatively

less important than the pragmatic issues of a job and

outpatient treatment. The patients, however, indicated

otherwise in their responses. Equally important, the two

medical cohorts underestimated the degree to which the

patients would rate spiritual orientation and AA as important

to recovery. This is significant relative to the strong

orientation toward religion and spirituality, as noted in the

aforementioned polling data drawn from the general

population (Gallup, 2002). These findings suggest that there

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264 263

is a need for further attention to enhancing physician

understanding of the relevance of spirituality to substance-

abusing patients.

In conclusion, spirituality, however difficult to define in

operational terms, likely constitutes an important motivator

for recovery for some (perhaps many) substance-dependent

people. More clarity is needed on how patients experience

it and the degree to which it can constructively be given

voice in their course toward recovery in conventional

treatment settings. It does appear, however, that many of

the patients we studied ascribed importance to it and that

they were apparently desirous of its playing a larger role in

their treatment. Clearly, more study is needed regarding

how this construct affects certain patients’ acceptance of

sobriety and not others’, and how it may play relative to

treatment outcome in a field where evidence for therapeutic

modalities is essential.

Appendix A. Spirituality Self-Rating Scale

Below is a list of statements. Using the following rating

scale, indicate the number that best indicates your agree-

ment with the statement.

1. It is important for me to spend time in private

spiritual thought and meditation.

( )

2. I try hard to live my life according to my religious

beliefs.

( )

3. The prayers or spiritual thoughts that I say when I

am alone are as important to me as those said by me

during services or spiritual gatherings.

( )

4. I enjoy reading about my spirituality and/or my

religion.

( )

5. Spirituality helps to keep my life balanced and

steady in the same ways as my citizenship, friend-

ships, and other memberships do.

( )

6. My whole approach to life is based on my

spirituality.

( )

Strongly

agree

Strongly

disagree

1 — 2 — 3 — 4 — 5

Scoring instructions: Prior to computing the sum, each

of the items is recoded, with higher scores indicating greater

endorsement of the item (i.e., a score of 5 becomes 1; 2

becomes 4; and so forth). Responses to the six items are

then summed to yield a total score for spiritual orientation.

The higher is the total for the six items, the higher is the

level of spiritual orientation, with a scoring range of 6–30.

References

Alcoholics Anonymous. (1975). Alcoholics Anonymous comes of age. New

York7 Alcoholics World Services.

Avants, S. K., Warburton, L. A., & Margolin, A. (2001). Spiritual and

religious support in recovery from addiction among HIV-positive

injection drug users. Journal of Psychoactive Drugs, 33, 39–45.

Berube, M. S. (Ed.). (2001). Webster’s II new college dictionary (p. 1065).

Boston: Houghton Mifflin.

Chappel, J. (1993). Long-term recovery from alcoholism. Psychiatric

Clinics of North America, 55, 177–187.

Christo, G., & Franey, C. (1995). Drug users’ spiritual beliefs, locus of

control and the disease concept in relation to Narcotics Anonymous

attendance and six-month outcomes. Drug and Alcohol Dependence,

38, 51–56.

De Leon, G. (1997). Community as method: Therapeutic communities for

special populations and special settings. Westport7 Praeger.

Dermatis, H., Galanter, M., Trujillo, M., Rahman-Dujarric, C., Ramaglia,

K., & LaGressa, D. (in press). Evaluation of a model for the treatment

of combined mental illness and substance abuse: The Bellevue model

for peer-led treatment in systems change. Journal of Addictive

Diseases.

Dermatis, H., Guschwan, M. T., Galanter, M., & Bunt, G. (2004).

Orientation toward spirituality and self-help approaches in the

therapeutic community. Journal of Addictive Diseases, 23, 39–53.

Fazzio, L., Galanter, M., Dermatis, H., & Levounis, P. (2003). Evaluation of

medical student attitudes toward Alcoholics Anonymous. Substance

Abuse, 24, 175–185.

Fleming, M. F., Barry, K. L., Manwell, L. B., Johnson, K., & London, R.

(1997). Brief physician advice for problem alcohol drinkers. A

randomized control trial in community-based primary care practices.

Journal of the American Medical Association, 277, 1039–1045.

Flynn, P. M., Joe, G. W., Broome, K. M., Simpson, D. D., & Brown, B. S.

(2003). Recovery from opioid addiction in DATOS. Journal of

Substance Abuse Treatment, 25, 177–186.

Galanter, M. (2002). Healing through social and spiritual affiliation.

Psychiatric Services, 53, 1072–1074.

Galanter, M. (2005). Spirituality and the healthy mind: Science, therapy,

and the need for personal meaning. New York7 Oxford University Press.

Galanter, M., Egelko, S., & Edwards, H. (1993). Rational Recovery:

Alternative to AA for addiction? American Journal of Drug and

Alcohol Abuse, 19, 499–510.

Galek, K., Flannelly, K. J., Vane, A., & Galek, R. M. (2005). Assessing a

patient’s spiritual needs: A comprehensive instrument. Holistic Nursing

Practice, 19, 62–69.

Gallup, G. H. (2002). Religion in America. Princeton, NJ7 Princeton

Religious Research Center.

Gilman, S., Galanter, M., & Dermatis, H. (2001). Methodone Anonymous:

a 12-step program for methodone maintained heroin addicts. Substance

Abuse, 22, 247–256.

Goldfarb, L., Galanter, M., McDowell, D., Lifshutz, H., & Dermatis, H.

(1996). Medical student and patient attitudes toward religion and

spirituality in the recovery process. American Journal of Drug and

Alcohol Abuse, 22, 549–561.

Hall, T. W., & Brokaw, B. F. (1995). The relationship of spiritual maturity

to level of object relations development and God image. Pastoral

Psychology, 43, 373–391.

Haugland, G., Siegel, C., Alexander, M. J., & Galanter, M. (1991). A

survey of hospitals in New York State treating psychiatric patients

with chemical abuse disorders. Hospital and Community Psychiatry,

42, 1215–1220.

Hood, R. W., Morris, R. J., & Watson, P. J. (1993). Further factor analysis of

Hood’s Mysticism Scale. Psychological Reports, 73, 1176–1178.

Humphreys, K., Kaskutas, L. A., & Weisner, C. (1998). The Alcoholics

Anonymous Affiliation Scale: Development, reliability, and norms for

diverse treated and untreated populations. Alcoholism: Clinical &

Experimental Research, 22, 974–978.

Humphreys, K., & Moos, R. (2001). Can encouraging substance abuse

patients to participate in self-help groups reduce demand for health

care? A quasi-experimental study. Alcoholism: Clinical & Experimental

Research, 25, 711–716.

M. Galanter et al. / Journal of Substance Abuse Treatment 33 (2007) 257–264264

Isenhart, C. E. (1997). Pretreatment readiness for change in male alcohol

dependent subjects: Predictors of one-year follow-up status. Journal of

Studies on Alcohol, 58, 351–357.

Joe, G. W., Broome, K. M., Rowan-Szal, G. A., & Simpson, D. D. (2002).

Measuring patient attributes and engagement in treatment. Journal of

Substance Abuse Treatment, 22, 183–196.

Magura, S., Knight, E. L., Vogel, H. S., Mahmood, D., Laudet, A. B., &

Rosenblum, A. (2003). Mediators of effectiveness in dual-focus self-

help groups. American Journal of Drug and Alcohol Abuse, 29,

301–322.

McDowell, D., Galanter, M., Goldfarb, L., & Lifshutz, H. (1996).

Spirituality and the treatment of the dually diagnosed: An investigation

of patient and staff attitudes. Journal of Addictive Diseases, 15, 55–68.

McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug

dependence, a chronic medical illness: Implications for treatment,

insurance, and outcomes evaluation. Journal of the American Medical

Association, 284, 1689–1695.

Mertens, J. R., Lu, Y. W., Parthasarathy, S., Moore, C., & Weisner, C. M.

(2003). Medical and psychiatric conditions of alcohol and drug

treatment patients in an HMO. Archives of Internal Medicine, 163,

2511–2517.

Miller, W., & Kurtz, E. (1994). Models of alcoholism used in treatment:

Contrasting AA and other perspectives with which it is often confused.

Journal of Studies on Alcohol, 55, 159–166.

Moberg, D. O. (1980). Social indicators of spiritual well-being. In J. A.

Thorsen, & T. C. J. Cook (Eds.), Spiritual well-being of the elderly (pp.

20–37). Springfield7 Charles C. Thomas.

Morgenstern, J., Kahler, C. W., Frey, R. M., & Labouvie, E. (1996).

Modeling therapeutic response to 12-step treatment: Optimal respond-

ers, nonresponders and partial responders. Journal of Substance Abuse,

8, 45–59.

Murray, T. S., Malcarne, V. L., & Goggin, K. (2003). Alcohol-related God/

higher power control beliefs, locus of control, and recovery within the

Alcoholics Anonymous paradigm. Alcoholism Treatment Quarterly, 21,

23–39.

Ouimette, P. C., Moos, R. H., & Finney, J. W. (1998). Influence of

outpatient treatment and 12-Step group involvement on one-year

substance abuse treatment outcomes. Journal of Studies on Alcohol,

59, 513–522.

Pagano, M. E., Friend, K. B., Tonigan, J. S., & Stout, R. L. (2004). Helping

other alcoholics in Alcoholics Anonymous and drinking outcomes:

Findings from Project MATCH. Journal of Studies on Alcohol, 65,

766–773.

Piedmont, R. L. (2004). Spiritual transcendence as a predictor of

psychosocial outcome from an outpatient substance abuse program.

Psychology of Addictive Behaviors, 18, 213–222.

Polcin, D. L., & Zemore, S. (2004). Psychiatric severity and spirituality,

helping, and participation in Alcoholics Anonymous during recovery.

American Journal of Drug and Alcohol Abuse, 30, 577–592.

Prochaska, J. O., & Diclemente, C. C. (1986). Toward a comprehensive

model of change. In W. R. Miller, & N. Heather (Eds.), Treating addic-

tive behavior: Processes of change (pp. 3–27). New York7 Plenum.

Saur, S. R., & Saur, W. G. (1993). Transitional phenomena as evidenced in

prayer. Journal of Religion and Health, 32, 55–65.

Simpson, D. D. (2004). A conceptual framework for drug treatment process

and outcomes. Journal of Substance Abuse Treatment, 272, 99–121.

Staines, G. L., Blankertz, L., Magura, S., Cleland, C. M., & Bali, P. (2005).

Evaluating vocational rehabilitation programs for substance users:

Issues in designing and implementing randomized studies. Evaluation

and Program Planning, 28, 61–68.

Tonigan, J. S., Connors, G. J., & Miller, W. R. (1996). Alcoholics

Anonymous Involvement (AAI) Scale: Reliability and norms. Psychol-

ogy of Addictive Behaviors, 10, 75–80.

Zemore, S. E., & Kaskutas, L. A. (2004). Helping, spirituality, and

Alcoholics Anonymous in recovery. Journal of Studies on Alcohol, 65,

383–391.