The Spirituality Group: a Search for the Sacred

This paper addresses the issue of integrating spirituality with substance abuse treatment by presenting the workings of the ‘‘Spirituality Group,’’ a therapy group for substance abusing veterans at a Midwestern Veterans Affairs Medical Center. Common themes from the group, case examples, and a discussion of working with group resistances are presented. The last 100 years have witnessed a variety of different attitudes and approaches to spirituality within the mental health community. In the past, mental health practitioners have at times viewed spirituality as integral, antithetical, or irrelevant to treatment. Many recent writings have documented an increased interest among psychologists in religiousness and spirituality (Emmons & Paloutzian, 2003; Hill et al., 2000; Miller & Thoresen, 2003; Shafranske, 2002; Tan, 2002–2003; Zinnbauer, Pargament, & Scott, 1999; Zinnbauer & Pargament, 2004), and presented ways in which to integrate religiousness and spirituality with mental health treatment (Ferrer, 2003; Griffith & Griffith, 2003; Hutchins, 2002; Ingersoll, 2002; Jerry, 2003; Miller, 1999; Richards & Bergin, 1997, 2000; Shafranske, 1996; Vaughan, 1995; Welwood, 2000; Zinnbauer & Pargament, 2000) and medical care (Cavendish et al., 2000; Krebs, 2001). In the field of addiction treatment, spiritual elements or traditions have long been associated with the path to sobriety and recovery, and this association remains prominent today (e.g. Alcoholics Anonymous World Services, 1976; Georgi, 1998; Gorski, 1991; Grof & Grof, 1993; May, 1994; Nixon, 2001; ‘‘Spiritus contra,’’ 1987). Despite this professional enthusiasm, however, few examples of how spirituality can be formally integrated into existing treatment programs have been presented in the professional literature. The purpose of this article is to present one such practical integration of spirituality with substance abuse treatment: The Spirituality Group. The specifics of this group will be discussed against the background of interest in spirituality within the fields of medicine and mental health in general and within the field of addiction treatment in particular. The group structure and process are similar to mainstream interpersonal therapy groups (e.g. Yalom, 1995), whereas the transpersonal approach described by Frances Vaughan (1979, 1991, 1993, 1995, 2001) has been used to interpret the group content and resistances. Email: [email protected] Copyright 2004 Transpersonal Institute The Journal of Transpersonal Psychology, 2004, Vol. 36, No. 1 50 A DEFINITION OF TERMS To find a single consensual definition of spirituality remains elusive even within the communities of researchers and adherents. Rather than elucidate this debate (for a discussion see Zinnbauer, Pargament, & Scott, 1999; Zinnbauer & Pargament, 2004), for this article we will use Pargament’s (1997) definition of spirituality as the search for the sacred. As such, it encompasses the various paths people take to find, conserve, and transform the sacred in their lives. As explained by Zinnbauer, Pargament, and Scott (1999): the sacred refers to the holy, those things ‘set apart’ from the ordinary, worthy of veneration and reverence. The sacred includes concepts of God, the divine, and the transcendent. However, it is not limited to higher powers. It also includes objects that become sanctified by virtue of their association with, or representation of, the holy. (p. 907) This definition does not resolve the debate over the content or function of spirituality, but it does have the advantage of remaining broad enough to include a diverse range of spiritual states and transpersonal experiences, while avoiding becoming so diffuse that it encompasses everything. For treatment providers, therefore, it is important to recognize that the search for the sacred is an active process that is not reducible to other needs or desires. The alcoholic who strives for sobriety may also pursue a spiritual awakening, but this does not mean that sobriety is solely a spiritual activity nor does it mean that spirituality is solely a product of addictions treatment or recovery programs. Rather, the alcoholic may pursue sobriety, spirituality, both, or neither. The upsurge of interest in various fields to integrate spirituality with patient care is therefore responding to the needs of those patients who wish to pursue both health and spirituality. The approach presented here recognizes that individuals recovering from substance abuse have access to internal and transpersonal resources (Vaughan, 1979, 1993, 2001) to assist their quest for health. SPIRITUALITY, MEDICINE, AND MENTAL HEALTH There is increasing sensitivity to spiritual issues within professional literatures of medicine and mental health. Interestingly, many health professionals are only now focusing on the importance of spirituality despite the over 30 years of work within transpersonal psychology, and the century of research and writing within the psychology of religion dating back to William James (1902/1961) and Edwin Starbuck (1899). A brief survey of the nursing and medical literature reveals a theoretical, practical, and research interest in spirituality. For example, Emblen (1992) has investigated the meanings nurses attribute to spirituality. Spirituality has also been identified as integral to nursing’s holistic philosophy (Cavendish et al., 2000; Krebs, 2001) and to holistic hospice care for both patients and caregivers (Chandler, 1999). Nursing has additionally advanced the integration of spirituality and patient care with regard to diagnoses. As discussed in Cavendish et al. (2000), there are currently three approved The Spirituality Group: A Search for the Sacred 51 nursing diagnoses related to spirituality: Spiritual distress, risk for spiritual distress, and potential for enhanced spiritual well-being. Qualitative research to clarify the nursing diagnosis of spiritual distress has also been conducted (Smucker, 1996). Recent publications within transpersonal psychology continue to focus on spirituality, especially on issues of spiritual distress and proposals for more holistic diagnoses. Just a few examples include: differentiating spiritual crises from transformative experiences (Grof & Grof, 1989), distinguishing prerational from transrational states (Wilber, 1995), the importance of making differential diagnoses of transpersonal phenomena (Jerry, 2003), and Integral approaches to multiaxial psychiatric diagnosis (Ingersoll, 2002). Moreover, Hutchins’ (2002) proposed ‘‘Gnosis Model,’’ provides a complementary expansion to each diagnostic axis of the DSM-IV to include positive aspects, such as a person’s gifts, goals, strengths, and supports, rather than focusing exclusively on a person’s problems. A focus on optimal health and human potential has been a cornerstone of transpersonal psychology since its inception (Tart, 1983; Walsh & Vaughan, 1980), and numerous investigations of the relationship between religiousness, spirituality, and physical health have been conducted within the past decade (see Miller & Thoresen, 2003; Pargament, 1997; Powell, Shahabi, & Thoresen, 2003; Seeman, Dubin, & Seeman, 2003). In their summaries of empirical research, Miller and Thoresen (2003) and Powell et al. (2003) conclude that religiousness and spirituality are common ways in which individuals cope with illness and life stress, and there is strong evidence that church/service attendance reduces the risk of mortality. They also report that religiousness and spirituality may protect against cardiovascular disease, and that being prayed for may improve physical recovery from acute illness. Investigators have likewise examined links between religiousness, spirituality, and mental health. For example, Gartner, Larson, and Allen (1991) concluded from their review of the literature that religious attendance is positively related to physical health, longevity, marital satisfaction and well-being, and lower rates of suicide, drug use, alcohol abuse, and delinquency. Pargament (1997) concluded from his review that religiousness and spirituality show positive, though modest, relationships with mental health. Further, specific religious/spiritual coping variables predict positive and negative coping outcomes. In particular, those variables related to better adjustment included feeling supported and guided by God, feeling supported by one’s religious congregation, feeling like a partner with God in solving problems, and attributing stressful life events to the will of God. In contrast, poorer outcomes were associated with feeling abandoned or at odds with God or one’s congregation, and attributing stressful life events to a punishing God. Given the various ways in which spiritual phenomena can impact health and healing, it is no surprise that mental health practitioners have argued for the inclusion of spirituality with treatment (e.g., see Griffith & Griffith, 2003; Walsh & Vaughan, 1993; Zinnbauer & Pargament, 2000). Recent writings in this vein include topics such as spirituality as a resource in couple’s therapy (Anderson & Worthen, 1997; Wolf & Stevens, 2001), and the importance of including spirituality in culturally appropriate treatment with Native Americans (Bristol, 2001; ‘‘Healing circle,’’ 1999; Voss, Douville, Soldier, & Twiss, 1999), and African Americans (e.g., Brome, The Journal of Transpersonal Psychology, 2004, Vol. 36, No. 1 52 Owens, Allen, & Vevaina, 2000; Thomas, 2001). Researchers have likewise documented that mental health consumers desire to discuss religious and spiritual issues in counseling (Rose, Westefeld, & Ansley, 2001; Quackenbos, Privette, & Klentz, 1985, 1986). The inclusion of spirituality in mental health work has also been described for treatment groups. For example, Genia (1990) described her creation of a spiritual encounter group for the exploration of participants’ spiritual experiences in a group discussion format. Psychodramatists have also used action methods with individuals and groups to help co-dependent clients find internal spiritual understanding and develop ego strength (Miller, 2000; Winters, 2000). An integration of spirituality with holistic long-term care has been described by Durkin (1992) as the ‘‘Community of Caring.’’ This is the title of her group approach to integrate the spiritual dimension into patients’ personal lives, attitudes towards treatment, and relationships with one another. Finally, Kehoe (1999) described a long-term psychotherapy group she formed to focus on spiritual issues relevant for patients with chronic mental illness. Kehoe presents the value of the group in terms of the opportunities patients have to reflect on the meaning of their difficulties, to use their faiths in order to cope with their mental illnesses, and to consider ways in which their beliefs may contribute to their suffering. SPIRITUALITY AND ADDICTIONS TREATMENT Perhaps the most explicit integration of spirituality in patient care is evident in treatment programs for substance abuse. It is well documented that spiritual growth is a core element of the AA ideology and the path to recovery through AA is often described as a ‘‘spiritual program.’’ Likewise, authors have described the relationship between problematic spirituality and relapse (Gorski, 1991), have advocated for spiritual psychotherapy in addiction medicine (Georgi, 1998), have characterized addictions in terms of spiritual crises or unfulfilled spiritual cravings (Grof & Grof, 1993; ‘‘Spiritus contra,’’ 1987), and have identified spirituality as a resource for parents in recovery (DiLorenzo, Johnson, & Bussey, 2001). This emphasis on spirituality within some programs of substance abuse treatment has led authors such as May (1994) to argue that ‘‘the single most important event for an addict or alcoholic to experience in early recovery is the beginning of a distinct spiritual focus for living’’ (p. 35). Whereas numerous programs for substance abuse treatment do not include a spiritual focus (Trimpey, 1996), research does appear to support the contention that spiritual belief and practice are helpful to some individual adherents. For example, Galanter’s (1999) investigations into the ‘‘spiritual orientation’’ in substance abuse treatment concluded that spiritual belief may positively reinforce AA group affiliation and provide relief from psychological distress. Spiritual beliefs have also been identified as influential in the ways in which individuals cope with disease and perceive recovery from substance abuse (Tangenberg, 2001). Brome, Owens, Allen, and Vevaina (2000) found spirituality to be associated with positive self-appraisals, active coping, and social support for African American women in recovery. Brush and McGee (2000) concluded that spirituality was an important personal activity as The Spirituality Group: A Search for the Sacred 53 well as a recovery activity for homeless men in recovery from substance abuse. Green, Fullilove, and Fullilove (1998) documented the reported positive life transformations of persons in recovery who embrace a Higher Power. Pardini, Plante, Sherman, and Stump (2000) found that among recovering individuals, higher levels of spirituality and religious faith were associated with optimism, greater perceived social support, higher resilience to stress, and lower levels of anxiety. Finally, in his review of research, Miller (1998) found that spiritual/religious involvement was associated with decreased risk of alcohol/drug use, and may also facilitate the process of recovery. Given the need and the enthusiasm to integrate spirituality with patient care, one might assume that proposals and program descriptions would abound in the professional literatures. Unfortunately, except for some notable articles such as Prezioso’s (1987) proposal for integration of spirituality into an inpatient chemical dependence treatment program, and Kehoe’s description of group psychotherapy to address spiritual issues with the chronically mentally ill, there is a dearth of such program descriptions. It was in this background of interest and need that a psychotherapy group was created by the authors to address spiritual issues as part of the Substance Dependence Program (SUDEP) at a Midwestern Veterans Affairs Medical Center. We have called it the Spirituality Group. THE SPIRITUALITY GROUP We begin with an excerpt from the fliers for the group: ‘‘[The Spirituality Group] focuses on exploring personal values, discussing spirituality and spiritual beliefs, and examining spiritual conflicts or concerns about one’s faith. This is not a Bible study group or a group that endorses any particular religious system or set of spiritual beliefs; rather, it is a group that encourages personal exploration and understanding of how veterans confront existential and spiritual issues in life.’’ The Spirituality Group was created in 1998. It has run since that time for one hour each week with an average attendance ranging from 3–15. The group is voluntary and open by referral to members of the SUDEP programs, including patients from the residential, outpatient, dual diagnosis, and opiate substitution programs. Group membership is open, and the group often differs in size and membership from one week to the next. Whereas most military veterans utilizing the VA hospital system are male, female veterans have also attended the Spirituality Group. The group’s central values include tolerance, an emphasis on discussion and personal sharing, and a pluralistic approach to spiritual issues. As discussed in Zinnbauer and Pargament (2000) and Vaughan (1995), the pluralistic approach recognizes and values diversity in the expression of spiritual beliefs, values, and practices. There are multiple effective spiritual approaches to life and recovery, as well as multiple ineffective or problematic approaches. The pluralistic approach encourages individual and group exploration of common sources of suffering for addicts and alcoholics in treatment, and the particular ways in which these The Journal of Transpersonal Psychology, 2004, Vol. 36, No. 1 54 individuals wrestle with issues of faith, treatment, and recovery. As the group members work to achieve sobriety and understand their patterns of addiction, the Spirituality Group encourages them to find, re-discover, practice, or explore the sacred in their lives. The Spirituality Group encourages the movement of the substance abuser from a state of suffering and psychological imprisonment to increased freedom, self-awareness, and growth. The basic structure and process of the group overlap in many ways with mainstream therapy groups. In particular, the ways in which the group functions therapeutically and the tasks of the group leaders (see Yalom, 1995) are common to both general interpersonal groups and the Spirituality Group. For example, generating and maintaining hope, understanding the universality of suffering and human experience, sharing information, altruistic behavior among group members, interpersonal learning and feedback, opportunities for corrective emotional experiences, generating group cohesion, affective expression and catharsis, and exploring existential issues are readily apparent in both types of groups. Likewise, therapist tasks of unifying and setting boundaries within the group, setting group norms and using group process as the agent of change, and an emphasis on working in the ‘‘here and now’’ (Yalom, 1995) are fundamental to both general therapy groups and the Spirituality Group. The chief difference that sets the Spirituality Group apart from other groups is its focus on spiritual and transpersonal issues. To understand and frame this specific content, and to work with the particular resistances that this material can generate in a group, we have relied on the work of Frances Vaughan (1979, 1991, 1993, 1995, 2001). As presented by Vaughan, a transpersonal context in psychotherapy is one that affirms the importance of spiritual issues for psychological health and explicitly values spiritual and transpersonal experiences as potentially healing and valid rather than pathologizing or discounting them (Vaughan, 1993). Further, there is an emphasis on increasing personal awareness, practicing virtues (e.g. altruism, compassion) with others, and integrating spiritual experience and understanding into everyday life. For the Spirituality Group, it is not enough to have superficial discussions or debates about religious tenets or scriptural interpretation. We actively encourage participants to share personal spiritual experiences, emotions, peak or mystical experiences, existential angst, and spiritual distress. Spiritual strengths are highlighted as vital aids for recovery from substance abuse, and participants are encouraged to take insights gained in the group and actively practice them in their daily lives. After 6 years of experience, a number of specific themes have emerged from the group, as well as several common problems or challenges for the group process. The group themes can be folded into 5 general categories: a) seeking to understand the nature of spirituality; b) reconciling anger and spirituality; c) understanding the meaning of the spiritual path; d) coping with loss or death; and e) forgiveness. Seeking to Understand the Nature of Spirituality The most common reason given by participants for attending the Spirituality Group is curiosity about the nature of spirituality and the relevance of spirituality to recovery. The Spirituality Group: A Search for the Sacred 55 As discussed by Vaughan (1995), authentic spirituality may manifest either inside or outside of traditional forms of religion. When a given search for the sacred loses meaning or becomes a hindrance to spiritual growth, a change is needed. Donald: A seeker. New members frequently ask, ‘‘What is the difference between spirituality and religion?’’ Donald, a bright and curious man working hard in early recovery, would ask a variation of that question near the beginning of each session he attended. Raised in a traditional, somewhat fundamental religious family, Donald’s beliefs were shaken by his negative experiences with cocaine abuse. The old belief system no longer had relevance for him. He bumped up against it each time he tangled with other group members who found satisfaction in their ‘‘old time’’ religion. Gradually his weekly questions sharpened. He was less interested in arguing with others than in clarifying his own beliefs. Ultimately he joined the Quaker Church where he was able to grow spiritually without reliance on rigid dogma. He remains an active group member and is a steadying influence who looks for the divine light in each of us. Reconciling Anger and Spirituality Another common theme in the group is reconciling anger and resentment with the dictates of one’s spiritual life. Anger at God, anger at clergy, or anger at oneself often comes into focus as substance-abusing individuals struggle to understand themselves and to remain clean and sober. Vaughan (1995) describes anger as soul loss and states, ‘‘healing is obstructed whenever anger is suppressed or denied. Buried rage is a prison for the soul.’’ (p. 169) Walsh: Vengeance is Mine. Walsh was the kind of open-faced man who would be chosen to play Santa Claus, the kind of man who would enter a burning building to save the people inside. Polysubstance dependent for years, he had numerous treatments, each one followed by a relapse. His stance on joining the group was twofold. He was obsessed with his plan to avenge his daughter’s murder 10 years earlier, and he was enraged with God for allowing that death. He counted the days until the murderer’s release so he could kill him. He interpreted the past murder as God’s punishment for his drug problems and for his being under the influence of drugs and away from the house the night of the crime. He began to reflect and probe deeper into himself only after the group members confronted him and accused him of grandiosity for interpreting a grisly murder as an act of God custom-designed to punish his addiction. The group members demonstrated their caring for him week after week. They refused to be intimidated by his rigidity. Gradually he began to trust them. The week after their confrontation, he confessed his secret. Complicating his guilt over his daughter’s murder was his guilt about having assaulted two women while under the influence of drugs. He saw himself as the special object of divine retribution. His extreme guilt and shame kept him stuck in drug dependency because he did not believe he deserved better. The group’s accepting him despite his past crimes helped him remove the first chink in his armor of addiction. If he could be forgiven by others, maybe he could forgive The Journal of Transpersonal Psychology, 2004, Vol. 36, No. 1 56 himself. He decided that recovery from drug dependence was his responsibility and would require life-long maintenance. This knowledge has been a relief and a blessing. Walsh is no longer under a life sentence of guilt, self-loathing, and vengeance. Instead he has committed himself to a life of daily struggles, joys, and decisions. He has joined a non-denominational church, volunteers at an elementary school, and is working an active recovery program. He believes there is goodness in the world and even in him. Understanding the Meaning of the Spiritual Path Many come to the Spirituality Group with a long history of spiritual strivings and experiences. Their participation often seems less about content than process. A metaphor often used by these believers is that of the ‘‘Spiritual Path.’’ The metaphor of the path as a representation of spiritual growth is cross-cultural, and can include various meanings such as the unfolding relationship with God, an intimate and personal journey, or progress towards wholeness (Vaughan, 1995). Teddi and Smokie: Polar Bears in Hell. Two women: one African-American (Teddi), one Latina (Smokie); one IV heroin dependent, the other crack cocaine dependent. Both are HIVþ. Both felt condemned to Hell by their diagnosis. Smokie is in her mid-forties. She lost her mother to death when she was ten years old. More recently she ‘‘lost’’ her ten-year-old only daughter first to foster care, then later to adoption because the courts deemed her an unfit mother. She has had no contact with her daughter since then and does not even know where she is. Smoldering with silent rage, she was friendless until she met Teddi. A regular member of the Spirituality Group for months, she has not shared her HIV status with the other members. Perhaps because she feared that once she started talking she would reveal the medical condition that caused her shame, she rarely spoke or made eye contact. She remained an enigma to the others. Her approach to spiritual practice was to read her Bible from beginning to end, and then start over, in hope of enlightenment that would alleviate her pain. She seemed clueless as she expressed hopelessness about ever feeling at peace or finding redemption. Teddi, in contrast, came into the group kicking and screaming, demanding that attention be paid. A non-IV, crack cocaine user, she steadfastly maintained that she never traded sex for drugs. From her perspective she ‘‘did everything right,’’ so why had God cursed her with this terrible disease? Unfortunately, her boyfriend/drug dealer neglected to tell her he was HIVþ. Her initial reaction to her diagnosis made her situation even worse by increasing her use of alcohol and drugs. Her lively intelligence and ability to reflect, however, pushed her away from suicidal thoughts and toward an intense effort to find personal meaning in a chaotic universe. She stopped using alcohol and cocaine and even quit smoking. She reluctantly moved back with her conventional, religious parents who made clear their expectation that she would lead a respectable life. During one group session, after being asked once again why she was so angry with God, she unexpectedly shared her HIV status and told how she felt the ground of a previously safe universe give way after learning of her diagnosis. She talked about The Spirituality Group: A Search for the Sacred 57 her struggles since then to understand life in a seemingly capricious universe and to accept the likelihood that she will become very sick some day and will die young. She regards God as a divine parent, someone with whom you can become angry but you cannot reject. Childless by choice, she recently visited her two-year-old niece who was humming along to a Barney tape. When the child suddenly shouted ‘‘Sing it, Barney!’’ Teddi burst into tears and experienced an epiphany: what happened yesterday and what may happen tomorrow is less important than what is happening right now; we have these hours to live as well and as gracefully as we can. Teddi and Smokie, who daily experience the hell of their medical conditions, have moved to polarized positions. Smokie is in spiritual limbo. Teddi is discovering moments of heaven on earth. They are inseparable and cherish the growth of their friendship. Smokie wants to be like Teddi. Teddi, knowing she doesn’t want to return to Smokie’s hell, encourages her friend to join her on the journey to find meaning in everyday life. Coping with Loss or Death The ultimate existential issue is another frequent theme in the group. Death, and all the mystery and terror associated with it, is often wrestled with (or avoided) by the group. The loss of friends through war, the death of family members, and one’s own mortality are discussed by individuals who are familiar with the life and death struggles of addiction. Whereas encounters with death have the potential to spur spiritual awakening and movement towards completing unfinished business (Vaughan, 1995), they can also illuminate the limitations of one’s spiritual and emotional life. Ben: The prodigal son. The most erudite member of the group with an advanced degree in theology, Ben was an African American Southern gentleman. Almost a Renaissance man, he had been a talented basketball player and was a gospel musician in addition to being the beloved minister of his Church. He had a wicked sense of humor and a wicked addiction. Born into a family of serious alcoholics, he vowed never to let alcohol touch his lips. True to his word, he had not counted on becoming dependent on pain pills after unexpected major surgery following an accident. Ben was quick to admit he loved opiates as much as he loved God. His favorite Bible story was the Prodigal Son. If he could stay clear of the unholy trinity of Percoset, Percodan, and Demerol, he could be forgiven by a merciful God. Ben’s clean times did not last. Although he longed for the mercy shown by the father of the Prodigal Son, he cringed at the wrath of the God who sent plagues and lightning bolts. Ben never mentioned his deceased father who died a suicidal alcoholic. Group members suspected that God the Father of us all and God the father of Ben were confused in Ben’s mind. When asked about the relationship between him and his father, the usually ebullient Ben retreated into a scowling silence. Trapped by his rigid beliefs, his guilt and shame distance him from the God of his yearning. For now he is a spiritual orphan. The Journal of Transpersonal Psychology, 2004, Vol. 36, No. 1 58