Spirituality in the world of therapy for co-occurring disorders is often left unaddressed or under-addressed. Perhaps this is due to its being viewed as a scary “hands-off” area better left to the religious person than to the tightly scheduled, objective, evidence-based therapist. So too, however, I find many religious people would rather have the therapist work with a person with co-occurring disorders, perhaps because of clergy’s own discomfort with the issue of how some symptoms of addiction and mental illness present themselves.
Spirituality is not a clinical football to be tossed to the most credentialed or the least bothered—it is an essential part of wellness and it needs to be treated openly by clinical professionals. There are many spiritual examples to cite where we could find clinical factors to discuss:
- In group therapy, I remember talking with a recovering patient about getting down on his knees to pray every morning and evening. After group ended, the co-leading therapist pulled me aside and said she would never say this sort of thing to a patient because she is Jewish and Jews don’t kneel.
- While working on an inpatient psychiatric unit, I remember with horrible vividness how long I became stuck in discussing spirituality with the first alcohol detoxifying patient with bipolar disorder I ever met. Unknown to me at the time, this man had a very actively psychotic, religious delusional thought disorder. Once was enough for me to try to have a conversation with him about God while he was in a manic state. Once he was stabilized on medications, he became a delight to see in outpatient practice. (I understood why it is far easier to avoid the topic of spirituality, or merely to offer it a passing clinical nod, when working with individuals with co-occurring disorders.)
- A priest angrily announced among a group of care providers, “I hated dealing with him, and tried to avoid his calls. He was just an annoying alcoholic who called the rectory all the time in the middle of the night obviously drunk, asking for a place to stay.” (Please note: I am aware that assisting people in their healthy relationship with God is something that some religious people are not any more comfortable in dealing with than some therapists are sometimes.)
- A person sat crying in therapy with me because she believed she had sinned against God in that she was not naturally able to have children, and went through a fertility process. Now, years later and with several wonderful children, she is facing serious problems in her life. She believes the problems are her fault because she had decided to have children years ago, thereby sinning against God and the “natural” wishes of her body. She never had told anyone because of her fear of having “gone against God.”
- While I was chatting during the social hour after Sunday morning worship, I heard people saying, “That person is crazy.” I turned and watched a man, with dirty hands and an inquisitive gaze, go from person to person and look at them quietly while listening in on the conversations. Not one individual in the large group of people in this affluent church turned to say hello to the poorly dressed man who appeared to be homeless.
In short, many people, let alone therapists, don’t offer individuals a safe place to learn about spirituality because of their own doubts around issues of differences; a lack of religious knowledge; dogmas and traditions; and cultural differences. To invite ongoing clinical conversation on the topics of one’s beliefs, faith and spirituality is scary. So too, it is tremendously difficult to document such issues in behavioral language for our clinical progress notes, especially when such topics may never have been discussed openly in our own homes, educational studies, or places of worship.
Religion and spirituality
I believe there are four areas to explore and balance in the wellness of sobriety. The process of physical wellness includes learning how to stop using, to eat, to sleep, to exercise, and to properly eliminate (for instance, opiate addicts can get constipated and alcoholics can get diarrhea). There is the area of intellectual wellness in which a person needs to learn everything he/she can about addiction. There is the emotional aspect in which a person needs to understand what a feeling is and how to control it. Finally, there is the spiritual aspect to wellness.
It is also important to understand the time frame of sobriety. I paraphrase others (such as Father Joseph Martin and distinguished psychiatrist Joseph Pursch, MD) in saying that the first year of sobriety is spent learning how not to relapse. By the second year the work shifts to identifying feelings and learning how to control them, rather than the feelings controlling you. And by the third year on, the time is spent developing spiritually.
It is important right from the beginning of treatment to explore both religion and spirituality, because they can be quite different. I find it is upon examining these differences that a person begins to risk opening up and sharing deeper details of their journey in health.
I keep the distinction very simple. Spirituality is a relationship based in three parts: a relationship with oneself, with others around us, and with a higher power. When we were using, it was an unhealthy relationship. Once we are clean and sober, it is one where we are learning how to be healthy. Religion is a man-made institution based upon a myth, in which ritual and tradition is practiced. “What do you believe?” is quite different from “What sort of relationship do you have?” Both can be important, however.