Annotated Bibliography (10 pages)

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Table of contents

1. An Integral Approach to Substance Abuse[dagger]..................................................................................... 1

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Document 1 of 1 An Integral Approach to Substance Abuse[dagger] Author: Amodia, Diana S; Cano, Carol; Eliason, Michele J ProQuest document link Abstract: There is a pressing need in the substance abuse field for more comprehensive models of etiology and treatment that address the complex issues of addiction, including the biological, social, cultural, spiritual and developmental needs of individuals and groups. This article presents a theoretical framework for an integral approach to substance abuse that expands on the existing biopsychosocial model. One contribution of the model is an integrated approach to spirituality from a cross-cultural perspective. This integral approach examines substance abuse etiology and treatment from a four-quadrant perspective adapted from the work of Ken Wilber, and incorporates concepts from integrative medicine and transpersonal psychology/psychiatry. Implications of the model are explored. Links: Linking Service Full text: Headnote Abstract-There is a pressing need in the substance abuse field for more comprehensive models of etiology and treatment that address the complex issues of addiction, including the biological, social, cultural, spiritual and developmental needs of individuals and groups. This article presents a theoretical framework for an integral approach to substance abuse that expands on the existing biopsychosocial model. One contribution of the model is an integrated approach to spirituality from a cross-cultural perspective. This integral approach examines substance abuse etiology and treatment from a four-quadrant perspective adapted from the work of Ken Wilber, and incorporates concepts from integrative medicine and transpersonal psychology/psychiatry. Implications of the model are explored. Keywords-cross-cultural, spirituality, treatment philosophy Substance abuse has enormous costs to the nation, estimated at $143 billion dollars in 1998 (ONDCP 2001), and incalculable costs to the individual, family, and community. To adequately address this complex chronic relapsing disorder, an integrated system of treatment is desperately needed. Current systems of addiction treatment are limited and fragmented, focusing primarily on narrow behavioral treatments while at the same time the clients are increasingly presenting with co-occurring mental, emotional, spiritual, physical and transmissible diseases, and are culturally diverse. The typical client may go to different agencies for primary health care, HIV care, social service needs, and psychiatric medications, as well as a substance abuse treatment agency for social/behavioral treatments. Staff in these agencies often have very little, if any, training in addiction, cultural competency, or the holistic nature of addiction etiology or treatments. Clients with this degree of impairment have considerable difficulty negotiating these diverse agencies and systems that often give them mixed messages, culturally insensitive messages, fragmented care, or treatments that interfere with their addiction treatment. There is a critical need for integrated care of the whole client. The terms "integral," "holistic," "integrative, " and "mind-body" have been applied in the field of medicine (e.g. Gilbert 2003; Astin &Astin 2002) because "such care seeks to create health by engaging old and new approaches to health for the individual, system, community, and environment" (Sandman et al. 2002: 1). Within the field of mental health, this broadening of perspective and blending of new science and old wisdom traditions has occurred within transpersonal psychology and psychiatry, also called the human potential movement (Scotton 1996). These broader approaches recognize the essential role of attitudes, values, and spirit in health and illness. An integral approach to substance abuse treatment would include specific addiction treatment, mental health

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care and medical/physical care, as well as address issues related to legal problems, housing, employment, education, and relationships, deal with clients within their familial, cultural, and broader societal contexts, and address spiritual needs. This model requires multidisciplinary team coordination, including at minimum specialists in addiction medicine, addiction psychiatry, psychology, substance abuse counseling, and case management. All of the team members need to be trained to address the whole person, including the cultural and spiritual components of care. The scientific literature on addiction treatment acknowledges this multidisciplinary nature of addiction by labeling it a biopsychosocial disorder; however, even this definition is limiting, as it neglects the cultural, spiritual, and societal influences. In addition, very few existing treatment agencies actually deliver their services in a biopsychosocial manner. Even the more comprehensive treatment systems often lack true coordination among the different aspects of care. Many lack the spiritual and cultural components of treatment and give only lip service to the transformational change needed for long-term recovery. Transformational change is often linked to spiritual practice or "quantum change" (Miller &C' de Baca 2001 ). Altering lifestyle behaviors of any type is difficult, whether it involves reducing or abstaining from cocaine use, quitting smoking, exercising daily, or changing dietary patterns. Only treatments that recognize the multifactorial nature of human behavior and provide skills or practices that enhance change are likely to be successful. Motivation for change has multiple components within the individual, agency, culture, and society, all of which must be considered in a comprehensive treatment approach. When culture is considered in treatment, it is often highly specific to generalities of one culture, denying the multicultural nature of society and the enormous variation within any given culture. What is needed is a cross- cultural approach that addresses the commonalities across culture, in much the same way that Huston Smith (1976) has identified the commonalities across all the great world religions, and Angeles Arrien (1993) has identified commonalities in human interactions and communication. There is strength in difference when common bonds can be identified-diversity can be honored even while searching for common ground. Angeles Arrien (2001: 1-2) noted: Diversity is known by many different names-pluralism, unity, harmony, tolerance, inclusion, conflict mediation, facilitation, equity, intercultural understanding, anti-bias, multi-cultural education, equal employment opportunities, affirmative action, cultural competence, global competitiveness, social justice, racial understanding, and being politically correct. This quote suggests how much confusion there is surrounding the meaning of the term "diversity." No wonder staff in substance abuse treatment agencies do not always know how to address cultural differences in their programs when there is no consensus about the meaning of diversity. Currently, programs often offer a spiritual component to treatment, particularly if they use a 12-Step approach to treatment or recommend 12-Step self-help groups to their clients. However, the spirituality of Alcoholics/Narcotics Anonymous stems from a narrow Christian religious focus and is not relevant or useful to all clients, who vary widely in their religious and spiritual backgrounds and worldviews. An integral approach to substance abuse would offer a broader view of spirituality that could bridge cultural and religious boundaries. THEORETICAL FRAMEWORK The integral approach to substance abuse was informed by the work of several theorists, but most notably Ken Wilber's Integral Model. Wilber (2000) outlined a four quadrant theory of human consciousness development that is the most comprehensive model available today, integrating the work of western and eastern philosophy and developmental psychology. Figure 1 illustrates the four quadrants in two dimensional form, but in reality the quadrants are multidimensional and the levels of development are nested holarchies (hierarchical and nonhierarchical forms of development where higher levels transcend and include the lower levels) which are spiral rather than linear. The upper left and right quadrants represent individual development and the lower left and right quadrants represent the collective. Within the upper left quadrant (the I) are contained the many lines

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of human development such as cognitive, affective, and moral, which are relatively independent of each other. Therefore, development can be uneven. Recognition that the level of development is important in how substance abuse is perceived, experienced, and expressed in the individual is an important component of a truly integral model of treatment. Every human behavior has correlates in all four quadrants, and change in one quadrant precipitates change in the other three in a dynamic interaction. For example, a change in brain chemistry may result in a feeling or emotional pattern that we call "depression" experienced by the individual as sadness and hopelessness, defined by the sociocultural context as a mental illness, and eligible for medications or psychotherapy by the economic health care systems of our nation. Another major contribution of Wilber's work is the attention paid to spiritual development. Wilber (2000) reviewed many different perspectives on spirituality and identified five common definitions of spirituality:

* Spirituality involves the highest levels of any of the developmental lines (e.g., the highest level of cognitive or moral development, for example). * Spirituality is the sum total of the highest levels of the developmental lines. * Spirituality is itself a separate developmental line with a sequential stage-like unfolding. * Spirituality is an attitude (such as openness or love) that one can have at any stage (this is perhaps the most common definition of spirituality). * Spirituality involves peak experiences that can occur at any level of development. The first two definitions imply that psychological development must be complete or far advanced in certain lines of development before spirituality can emerge. On the other hand, one can demonstrate spirituality in the expression of unconditional love or acceptance in a nonhierarchical fashion. All of the definitions appear to have some validity. Spirituality in the context of addiction treatment will be discussed in a later section. Another important theoretical contribution to the integral approach to substance abuse comes from the work of cultural anthropologist Angeles Arrien (1993) who proposed a number of concepts and tools aimed at bridging cultural differences. This work suggests that the multiple, fragmented, culturally specific practices currently in existence can be unified via a cross-cultural approach to individual growth. That is, instead of having separate treatment programs for every diverse population, there are universal bridging concepts that both honor diversity and teach common principles of human conduct and communication. These bridging concepts are drawn from centuries of writing in indigenous wisdom traditions. After 25 years of hands-on experience with indigenous cultures around the world, Arrien found that 80% of them shared common values of communication (Arrien 2005; see also the work of Joseph Campbell 1973 and Huston Smith 1976). Learning these cross-cultural bridging techniques better prepares clients for dealing with the stresses of a diverse society. The integral approach suggests a fresh way of looking at the etiology and treatment of substance abuse, one that honors and expands on the biopsychosocial model. Figure 2 highlights the etiologic factors in each quadrant, as well as the treatment components that are suggested by each quadrant. Ideally, treatment involves actions taken in all four quadrants; change in one quadrant causes change in the other three. For example, a

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change in welfare regulations in the mid 1990s (lower right quadrant: LR) led to increased poverty (LL), particularly among women and children, which lead to a greater likelihood of drug-dealing for survival (LL) and drug use to self-medicate negative consequences of poverty (UL and UR). This led to a greater number of children in the foster care system (LL), changes in brain functioning (UR), greater cognitive impairments (UR), increases in symptoms of depression, anxiety, shame, and guilt (UL), increased stigmatization of drug-addicted women (LL), and stricter policies which increased the incarceration rate of drug-addicted women (LR). Figure 2 is not comprehensive, but offers some examples of etiologic and treatment variables that could be considered in designing integral programs. Inner Substance(TM) is a specific treatment approach that integrates the four quadrants and offers a way of bridging the left hand quadrants while addressing spirituality from a crosscultural perspective (for further information see Amodia &Cano 2002).

APPLICATION OF THE FOUR QUADRANT THEORY TO ADDICTION TREATMENT This section reviews in more detail the components of each quadrant, and their contribution to a more holistic or integral substance abuse treatment model. Although each quadrant is presented separately, it is important to keep in mind that the integral approach serves to integrate all four quadrants to promote transformational (positive, life-affirming) change via the process of providing access to spirit using cross-cultural bridging concepts. The Upper Left Quadrant (I) The upper realms of the integral approach to substance abuse (the individual level) have been studied the most extensively, and therapies dealing with cognitive, affective, and social development have been designed. However, three areas of individual development suggested by the integral approach have been somewhat neglected in the research on substance abuse etiology and treatment: the dynamic and uneven nature of human development (that is, the role of developmental stage or level), spirituality, and crosscultural issues. Lip service is given to individualizing treatment to meet the developmental level of the client, but because of lack of

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staff training, funding priorities, and other issues, most often all clients are subjected to the same generic treatment. This issue of lifespan development is too complex to explore here, but requires much more study. The determination of level of development is complicated by effects of drugs on many developmental functions such as attention, memory, higher cognitive functions, and moral decision making. Whereas the most widely used form of treatment, the 12-Step approach, is a spirituality based model (derived from a particular Christian religious perspective), many scientists have rejected the concept of spirituality as an unmeasurable, idiosyncratic factor (Miller 1998). Why has spirituality been such a central feature of actual treatment, but so rarely addressed in the research literature? As Wilber noted, there are many quite different definitions of spirituality, and many people have difficulty separating spirituality from religion (Working Group 1999; Miller 1998). Because the form of spirituality proposed by the 12-Step philosophy is so closely tied to a Protestant religious worldview, the entire concept of spirituality within the addiction treatment field has been linked to religion in the minds of many clinicians, clients, and scientists. Focusing on spirituality from only one religious perspective is as limiting as focusing on treatment from only one cultural perspective. Clients in substance abuse treatment often express an interest in obtaining spiritually based treatments and/or report that their recovery involved spiritual transformational change (Arnold et al. 2002; Miller 1999; Green, Fullilove &Fullilove 1998), yet many so-called evidence-based treatmerits focus on single lines of development (cognitive, behavioral, social) and ignore the spiritual aspects. There is a great need for treatment models that help clients access spirituality from a cross-cultural perspective, honoring the diversity in the specific paths or tools used to achieve transformational change. Whether spirituality is viewed as a separate line of development, dependent on other lines of development, or as a unique behavior, attitude or experience, thousands of years of wisdom traditions have identified methods of accessing spirit, ranging from prayer to meditation to ancestor rituals to acupuncture to nature experiences (Murphy 1992). Western science is just recently recognizing the health benefits of these indigenous traditions (e.g., Gilbert 2003; Robinson, Matthews, &Witek-Janusek 2003; Astin 1998, 1997; Kabat-Zinn et al. 1992). There is growing attention in the substance abuse treatment literature to the development of self and identities, particularly those social identities related to race, ethnicity, nationality, religion, sex/gender, sexual identity, and class. These social identities bridge the quadrants. One cannot identify with a gender, racial/ethnic, sexual, or religious identity in isolation of a social, cultural, or broader societal context. Some identities are based on the recognition of societal oppression (LR), whereas others are based on shared interests or beliefs (LL). To deal with these identities only on the individual level is limiting. The way that these identities should be addressed in treatment is not clear. How does an agency deal with the various identities of clients? What happens when one individual has multiple identities, such as a 65-year-old African-American Jewish woman? Clearly there is a need for a cross-cultural paradigm that honors cultural and subcultural differences but allows for identification of universal themes. Social identities are experienced by the individual (UL), but are rooted in the sociocultural (LL) and broader dominant ideologies (LR), thus cross-cultural bridging concepts are needed to expose these connections. In conclusion, most substance abuse treatment focuses on the upper left quadrant functions, but only pays attention to a fraction of the developmental lines, such as the cognitive and/or behavioral lines. There is a need for a more comprehensive view of the developmental and integral nature of addiction, particularly approaches that include spiritual development and cultural identities. Lower Left Quadrant (We) The substance abuse treatment literature points out the role of the social and cultural environment, recognizing the power of these social entities in relapse risks. For example, AA/NA slogans about the need for "new playmates, new playgrounds" recognize the power of family and peers. In addition, there are growing numbers of culturally-specific treatment programs, tailored for people based on their social identities (by race, sex/gender, age, sexual identity, or religion, for example). These programs, while offering a safe haven and

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cultural specificity, may not prepare the client to return to a culturally diverse world. In addition, they may make assumptions about the homogeneity of a particular cultural group that has little basis in reality. For example, a program based on traditional Chinese values may not be beneficial to all Asians, or even all Chinese individuals. Programs that have a mixture of clients have struggled with ways to make their staff and programs culturally specific or culturally sensitive. There has been little clarity in the field about how to do this, or how to assess whether an individual or a program has achieved cultural competency. Individuals must unlearn prejudice and stereotypes, recognize common cultural differences, eventually learn to honor or value diversity, and offer safe and inclusive services to all clients. However, the typical cook-book approach to diversity education has always been problematic. Making blanket statements about the characteristics of any socially- constructed group sets one up for stereotypical thinking (which led to prejudice in the first place). Merely replacing negative stereotypes with positive stereotypes has been more harmful than useful. Instead, a cross- cultural bridging paradigm that is able to deal with universal themes across cultures could be potentially revolutionary. For example, diversity textbooks often state "Hispanics value family." While true (stereotypes are almost always based in some level of truth), there is no cultural group on earth that does not value family. The differences lie in how family is defined, what cultural myths or archetypes about family have been passed down generationally, and what social roles an individual is expected to play in their family. The need for family is a universal cross- cultural bridging concept, whereas the specific behaviors related to one's family may be culturally specific. When diversity textbooks make statements about the characteristics of some group of people, they are broad generalizations based on the "typical" members of the group and ignore the wide diversity in the individual, such as degree of assimilation into the dominant culture, age, immigration status, language and religion, and many other differences. To group all people of one racial group or even one ethnic group together and ignore the intragroup variations has been referred to as "ethnic gloss" (Trimble 1995), and is an important limitation of culturally-specific treatment interventions. Diversity education has been ineffective, largely because it has been based on the assumption that lack of attention to culture is due to lack of knowledge. Therefore, diversity education programs focused on the cognitive aspects of human development and stereotypical characteristics of large groups of people, and ignored the fact that cultural differences are rooted in sociocultural assumptions and stereotypes (LL) and dominant ideologies (LR) that have cognitive, affective, moral, religious, and spiritual ramifications for the individual. Education alone is rarely effective in changing individual attitudes or cultural ideologies. Rather than continue to educate based on differences, the integral approach begins with cross-cultural bridging concepts, or similarities. Once interpersonal relationships are built across cultures, different perspectives and practices can be shared and a sense of community can emerge. Upper Right Quadrant Hundreds of studies have examined the biological correlates of addiction, including genetic transmission, neurochemical systems, metabolism of substances, and physical effects of substances on organ systems and bodily structures and functions (such as studies of intoxication, withdrawal, and their short and long-term effects on the physical body). Western science has effected a drastic separation from philosophy and religion (Austin 1998; Kabat-Zinn et al. 1992), that values empirical (observable) science over all else. Many authors have called for contemporary science to broaden its focus and begin to integrate wisdom traditions with the best of new science. In particular, many authors have called for the incorporation of spiritual care back into health care (Miller &Thoresen 1999). Biological researchers often work in isolation of those providing direct services, making policies, or dealing with the ravages of substance abuse in local communities. Biological findings take years to be translated into treatment approaches. An integral approach to addiction treatment would encourage biological researchers to translate their findings so that they are more quickly applied in the field, and clinicians would help researchers

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identify and prioritize research agendas that would provide a greater good to the field. An integral approach would also broaden the perspective of biological treatments to include concepts of fitness, nutrition, and biological effects of alternative and complementary treatments such as meditation and acupuncture. Until recently, biological studies have tended to treat human bodies as though they were all alike, thus the same medication or medical treatment was considered to be appropriate for all patients/clients. However, there is growing recognition that bodies do differ in terms of metabolism of drugs and responses to treatment, leading to subspecialities in sex/gender differences and ethnopsychopharmacology. For example, women have lower blood volumes, higher body fat, greater bioavailability and slower drug clearance than men (Robinson 2002; Kandall 1998), and African Americans, Asians, Caucasians, and Mexican Americans have genetic differences in enzymes involved in drug metabolism (Ruiz 2000). Some cultural differences appear to have underlying biological underpinnings whereas others are related to sociocultural differences. As one example of a cultural difference, in some groups, physicians are viewed as the ultimate authority and patients will follow instructions to the letter whereas in other groups, western physicians are viewed with distrust. Treatment philosophies are another example of subcultural differences. In spite of major changes in the past few years, some health care providers who recovered from their own substance abuse using 12-Step programs still believe that clients must be completely free of any mood-altering substance, and discourage clients from getting medications. This cultural attitude, or ideology, affects the treatment of clients with co-occurring mental illnesses. The integral approach recognizes the impact of all four quadrants and advocates for simultaneous (integrated) treatment. Drug effects on the physical body (UR) can create or mimic reactions in the Upper Left quadrant that we experience (UL) and interpret (LL) as love, mania, paranoia, or some other emotion. Practitioners who are not trained in an integral approach to addiction may misdiagnose the stimulant abuser as schizophrenic or in the manic phase of bipolar disorder, or misdiagnose the alcoholic as depressed. Of course, these mental disorders or symptoms often do coexist with substance abuse, but misdiagnosis can lead to ineffective and costly treatment. In the past hundred years, medicine has focused on curing illness. This emphasis stemmed from the mind-body separation and development of medical technologies that fostered rapid advancement of science, but the focus on physical health in isolation has been limiting. There is growing recognition of the interdependence of physical health with emotions, attitudes, values, and cultural belief systems. In addition, many physical health problems, including addictions, are chronic illnesses that cannot be cured. An integral approach emphasizes healing rather than curing, using techniques drawn from all four quadrants in a holistic fashion. Studies have shown that over 80% of cancer patients use complementary and alternative medicines (Montbriand 1993), many of which are drawn from old wisdom traditions, including yoga, meditation, acupuncture, herbal treatments, and so on. Many of these have been incorporated into addiction treatments, although there has been very little study of their effectiveness as of yet. Lower Right Quadrant The treatment field often comments on the politics of substance abuse treatment, but this information is rarely incorporated into the actual treatment models used in practice. For example, incarceration of substance abusers is related to contradictory societal myths-health care discourse labels substance abuse as a chronic illness whereas the legal/regulatory discourses label it criminal activity. Dominant religious discourses have varied responses to addiction, from labeling it as sin or lack of moral fortitude or as curable by religious conversion, to developing compassionate programs that support people suffering from addictions. The ever-changing political climate means that funding for substance abuse treatment waxes and wanes, depending on whether major policy makers are more responsive to supply or demand rhetoric, whether the nation is waging a war on drugs or a war on drug users, and whether the prevailing view is to scapegoat substance abusers for societal ills, or to promote compassionate care. The differences in political messages about drugs given by previous first ladies

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Betty Ford and Nancy Reagan illustrate these political vagaries. The message that substance abuse is a treatable disease (Ford) versus the "just say no" campaign (Reagan) influenced millions of citizen's attitudes about substance abuse. Political policy has always been more closely tied to dominant ideologies and philosophies of those in power than it has to science or empirical research. For example, in spite of evidence that treatment reduces crime and other costs to society much more effectively than incarceration, the 2002 federal drug budget allocated $2.304 billion to SAMHSA (about 20% of the total budget), part of which funds treatment, whereas 53% of the budget went to law enforcement efforts (ONDCP 2003). An integral approach to substance abuse would need to address the political climate in treatment. For example, social justice approaches to treatment put individual problems into their political context (for example, the feminist philosophy that the personal is political), helping clients to recognize the social, economic, and political circumstances that contribute to substance abuse, such as poverty, child abuse, and the proliferation of liquor stores in minority neighborhoods.. The recognition of racism, classism, sexism, heterosexism, and other forms of oppression can be empowering. This is not to take a victim stance, but to adopt a social justice orientation that equips clients with knowledge and skills to understand the political climate as it impacts their individual lives. In addition, physicians and other professionals need to take advocacy roles for the disempowered patient populations with which they work. CONCLUSIONS The integral approach to substance abuse presented in this article expands on the biopsychosocial model and proposes integrating knowledge from western, eastern, and indigenous wisdom traditions. The need for bridging paradigms has been widely acknowledged in many fields in recent years, from theories in science such as chaos and systems theories that recognize the interdependence of all life, re-affirming wisdom traditions from around the world, to the integration of medicine using combinations of new science and ancient practices for healing. The integral approach to substance abuse addresses the major gaps in current substance abuse treatment, as summarized by the six overlapping points below: 1. The need for multidisciplinary teams. An integral approach requires true collaboration among practitioners of different disciplines, as well as alliances with researchers and policy makers to be truly effective. No one isolated discipline is sufficient to address a complex, multifaceted problem like addiction. 2. The need for multimodal therapies. Cross-cultural techniques, combining the knowledge of modern science with thousands of years of indigenous wisdom, particularly in methods to access spirit, are likely to produce the conditions needed for transformative and long-lasting change. 3. The need for cross-cultural bridging paradigms. There is a need for highly specific treatment programs which target particular communities, and some communities with large numbers of such clients can sustain separate programs. However, many treatment programs must serve a diverse community and cannot afford to specialize. These generic programs need cross-cultural approaches that are based on common ground rather than difference. Even the culturally specific treatment programs could benefit from incorporating a cross-cultural perspective, as most clients will live and work in diverse communities when they finish treatment. 4. The need to consider individual development. Identifying the individual's developmental stages or levels, and recognizing the multiple lines of development is a first step to truly individualizing treatment and identifying the tools that are best suited for growth at that stage (Wilber 2001). 5. The need to address spirituality from a cross-cultural perspective, separate from any specific religious worldview. Spirituality is a key component to physical and mental health and appears to be necessary for the transformative change required for recovery from substance abuse. Providing tools for accessing spirituality that are inclusive of all cultures and religions will reach more clients than current approaches. 6. Those involved with substance abuse treatment needs to concentrate more attention to the lower right quadrant and work toward policy change and social justice. It is necessary to create a means through which clinicians can learn to be more effective policy advocates for the clients with which they work.

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In conclusion, substance abuse treatment, like other specialized forms of health care, could benefit from an integral approach that takes into account all etiologic factors, and blends the treatment approach with the best of contemporary science and the wisdom of centuries of indigenous traditions. This framework for an integral approach to substance abuse serves as a guide for developing these holistic services. Footnote [dagger] The authors wish to thank Angeles Arrien for her inspiration and guidance in applying cross-cultural techniques to the treatment of addiction and mental illness. References REFERENCES Amodia, D.S. &Cano, C. 2002. Inner Substance(TM). San Francisco, CA: Inner Substance, LLC. Arnold, R.M.; Avants, S.K.; Margolin, A. &Marcotte, D. 2002. Patients' attitudes concerning the inclusion of spirituality into addiction treatment Journal of Substance Abuse Treatment 23: 319-26. Arrien, A. 2005. Personal communication. Arrien, A. 2001. Introduction to "Working Together." In: A. Arrien (Ed.) Working Together: Diversity as Opportunity. San Francisco: Berrett-Koehler Pub. Inc. Arrien, A. 1993. The Four-Fold Way: Walking the Paths of the Warrior, Teacher, Healer, and Visionary. San Francisco, California: HarperSanFrancisco. Astin, J.A. 1997. Stress reduction through mindfulness meditation. Psychotherapy and Psychosomatics 66: 97- 106. Astin, J.A. &Astin, W.W. 2002. An integral approach to medicine. Alternative Therapies 8 (2): 70-75. Austin, J. 1998. Zen and the Brain. Cambridge, Massachusetts: MIT Press. Campbell, J. 1973. The Hero with a Thousand Faces. Princeton, NJ: Princeton University Press. Gilbert, M.D. 2003. Weaving medicine back together: Mind-body medicine in the twenty-first century. Journal of Alternative and Complementary Medicine 9 (4): 563-70. Green, L.L.; Fullilove, M.T. &Fullilove, R.E. 1998. Stories of spiritual awakening: The nature of spirituality in recovery. Journal of Substance Abuse Treatment 15: 325-31. Kabat-Zinn, J.; Massion, A.O.; Kristeller, J.; Peterson, L.G.; Fletcher, K.E.; Pbert, L.; Lenderking, W.R. &Santorelli, S.F. 1992. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry 149: 936-43. Kandall, S.R. 1998. Drug Addiction Research in the Health of Women. Rockville, Maryland: NIDA. Miller, W.R. 1999. Integrating Spirituality into Treatment. Washington, D.C.: American Psychological Association Press. Miller, W.R. 1998. Researching the spiritual dimensions of alcohol and other drugs. Addiction 93 (7): 979-90. Miller, W.R. &C' de Baca, J. 2001. Quantum Changes: When Epiphanies and Sudden Insights Transform Ordinary Lives. New York: Guilford. Miller, WR. &Thoresen, C. 1999. Spirituality and health. In: W.R. Miller (Ed.) Integrating Spirituality into Treatment. Washington, D.C.: American Psychological Association Press. Montbriand, M.J. 1993. Freedom of choice: An issue concerning alternative therapies chosen by patients with cancer. Oncology Nursing Forum 20 (8): 1195-1201. Murphy, M. 1992. The Future of the Brain: Explorations into the Further Evolution of Human Nature. Los Angeles, CA: Tarcher, Inc. Office of National Drug Control Policy (ONDCP). 2003. National Drug Control Strategy. Washington, D.C.: Office of the White House. Office of National Drug Control Policy (ONDCP). 2001. The Economic Costs of Drug Abuse in the United States, 1992-1998. Washington, D. C: Office of the White House. Robinson, P.P.; Mathews, H. &Witek-Janusek, L. 2003. Psychoendocrine-immune response to mindfulness-

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based stress reduction in individuals with HIV: A quasi-experimental study. Journal of Alternative and Complementary Medicine 9 (5): 683-94. Robinson, G.E. 2002. Women and psychopharmacology. Medscape Women's Health eJournal 7(1). Available at www.medscape.com/ viewarticle/423938 Ruiz, P. 2000. Ethnicity and psychopharmacology. In: J. Oldham &M. Riba (Eds.) Review of Psychiatry, Volume 19. Washington, D.C.: APA Press. Sandman, G.; Bezold, C.; Jahnke, R.; Wisneski, L.; Snider, P.; Dumoff, A.; Weeks, J.; Schmidt, T.; Whitworth, G.C. &clay, E. 2002. Design principles for healthcare renewal: Draft. Special Supplement to Alternative Therapies 8 (2): 1. Scotton, B. 1996. Introduction and definition of transpersonal psychiatry. In: B. Scotton; A. Chinen &J. Battista (Eds.) Textbook of Transpersonal Psychiatry and Psychology. New York: Basic Books. Smith, H. 1976. The Forgotten Truth: The Common Vision of the World's Religions. San Francisco, California: HarperSanFrancisco. Trimble, J. 1995. Toward an understanding of ethnicity and ethnic identity, and their relationship to drug use research. In: G. Botvin; S. Schinke &M. Orlandi (Eds.) Drug Abuse Prevention with Multiethnic Youth. Thousand Oaks, California: Sage. Wilber, K. 2001. JVo Boundary: Eastern and Western Approaches to Personal Growth. Boston: Shambala Press. Wilber, K. 2000. Integral Psychology: Consciousness, Spirit, Psychology, Therapy. Boston, Massachusetts: Shambala Publications. Working Group of NIA/Fetzer Institute 1999. Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research. Available at: www.fetzer.org. AuthorAffiliation Diana S. Amodia, M.D.*; Carol Cano, B.A.** &Michele J. Eliason, Ph.D.*** AuthorAffiliation * Co-Medical Director, State of California Office of Alcohol and Drug Programs; Visiting Researcher, UCSF Institute for Health and Aging, San Francisco, CA. ** Substance Abuse Counselor and Certified Eastern Practitioner, California Pacific Medical Center, Institute of Health and Healing, San Francisco, CA. *** Associate Professor, University of Iowa, Iowa City, Iowa, and UCSF Institute for Health and Aging, San Francisco, CA. Please address correspondence and reprint requests to Dr. Diana S. Amodia, UCSF Institute for Health and Aging, 3333California Street, Suite 340, San Francisco, CA 94118. MeSH: Humans, Models, Theoretical (major), Substance-Related Disorders (major), Substance-Related Disorders (major) -- etiology, Substance-Related Disorders (major) -- psychology, Substance-Related Disorders (major) -- therapy Publication title: Journal of Psychoactive Drugs Volume: 37 Issue: 4 Pages: 363-71 Number of pages: 9 Publication year: 2005

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Publication date: Dec 2005 Year: 2005 Publisher: Haight Ashbury Publications Place of publication: Oxford Country of publication: United States Publication subject: Drug Abuse And Alcoholism, Medical Sciences--Psychiatry And Neurology, Pharmacy And Pharmacology ISSN: 02791072 CODEN: JPDRD3 Source type: Scholarly Journals Language of publication: English Document type: Journal Article Accession number: 16480163 ProQuest document ID: 207972353 Document URL: http://ezp.waldenulibrary.org/login?url=http://search.proquest.com/docview/207972353?accountid=14872 Copyright: Copyright Haight Ashbury Publications Dec 2005 Last updated: 2012-11-14 Database: ProQuest Central,Nursing & Allied Health Database

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