Integrating Spirituality Dimension in Middle Eastern Countries Addiction Treatment Services: Regional and Cultural Perspectives
Spirituality is now an established & essential dimension of holistic addiction treatment interventions. There has been a slow integration of this valuable resource into treatment and rehabilitationservices in Middle Eastern countries where the concept is underdeveloped with minimal uptake. A search of the academic libraries and databases was conducted to establish the extent of this “avoidance” & this was supplemented by a questionnaire distributed to selected focus groups, enquiring specifically about the topic.This article summarizes the findings of the search, analyses the causes, and recommends adopting culturally appropriate operational definitions of spirituality, conducting more research and integrating the dimension it into the addiction treatment philosophies utilized in these countries. Religion and spirituality in many cultural groups are deemed important for the provision of comfort, joy, pleasure, and meaning to life as well as be means to deal with death, suffering, pain, injustice, tragedy, andstressful experiences in the life of an individual or family .
Keywords: Spirituality, Addiction, Psychiatric, Stress, Mental health, Addiction medicine, Rehabilitation
An important disclaimer is necessary at the outset. This article is not about religious or theological dimensions. It specifically addresses the issue of spirituality as an intervention, a fourth dimension, added to the biological, psychological & social dimensions that currently form the pillars of addiction treatment and rehabilitation services worldwide.
Miller beautifully lays the foundation of understanding spirituality summarizing the work of various expert panels stating “Spirituality is not interchangeable with religion; it is one principle area of concern for religion, but religions also have other non-spiritual goals and purposes. Spirituality is not a commodity that is present or absent, or one that is possessed in amount.
Spirituality is multidimensional. Every person can be located somewhere within the multidimensional space of spirituality. The assessment of spirituality has to do with understanding the person’s location along the multiple dimensions.” (Miller, 2003).
Neurobiologists, sociologists and psychologists all insist it is within their remit and lay claim on the concept. Neuroscientists have been using brain imaging studies to look at the anatomical correlates of spirituality/religiosity and mental health issue and also making new discoveries, expanding the definitional terrain, like the default mode network. Psychologists have already gained territories by laying claim on mindfulness, metacognitive therapy, Acceptance and Commitment Therapy (ACT), etc. International guidelines have all recommended inclusion of spirituality in treatment of mental illness (e.g. American Psychiatric Association, Australian psychological society, The Royal college of Psychiatrists UK) (Arnold, et al., 2002; Miller et al., 2014).
The difficulty of addressing the topic is compounded by the lack of a universally approved definition (Hanegraaff, 2000).
Linguistically, in Arabic language, spirituality translates to two different adjectives, Roohi and Rohani. The former would give a weaker signal when looking at relevance and correctness of the meaning pertaining to our topic. Still, many use it as a synonym of the latter. Rohani is the correct adjective for the purposes of our topic.
It is not within the remit of this article to delve into how each of the adjectives are used to address a range of topics like healing with the Qur’an or Ruqia, exorcism, possession by jinn, which all appear as top hits when one searches for the two words namely roohi and Rohani, in Arabic. It is, however, pertinent to state that neither term is relevant to the concept.
Another linguistic dilemma pertains to the intervention mode. Is it spiritual treatment or counseling? So, is it Ilaj Rohani (which means in Arabic spiritual treatment or Irshad Rohani (spiritual counseling)?
This is an easier question to answer as the only one that separates is counseling or Irshad Rohani, as far as our topic “Spirituality” is concerned.
This is a highly charged topic. An imminent Muslim scholar, Sheikh Waseem Yousif, was asked in a call-in TV show about the topic. He shrugged the question of stating, “What do we know about the soul (Rooh)? The Quran tells us it is only Allah who knows all about the soul, so there is nothing to say about it”. Another well-respected and erudite authority, the late sheikh Alsharawi also condemned the spiritual healers calling them cheats and fraud. Both comments are available to the public on YouTube.
At one level, the two words, soul and spirit, even in English, can be confusing as “spirit refers to the immaterial part of man, whereas soul refers to both material and immaterial aspects of humanity”. www.gotquestion.org.
Why is it important to integrate spirituality in addiction treatment? (Waters & Shafer, 2005)
Spirituality has become an important topic in today’s world for many reasons. There is an overwhelming consensus and evidence for incorporating it in many aspects of human life. It has become part of the “whole person” model of care and has established itself as an essential part of psychiatric assessment and management. The following are examples and are not an exhaustive list of the evidence for its effectiveness:
Spirituality influences the course and outcome of medical and psychological ailments. Spiritual/religious practices such as prayer, contemplation, Yoga, Zen and transcendental meditation affect physiological processes in the brain. This list can be expanded to include introspection, self-help movements, pursuit of the inner child, various 12 Step approaches (Piedmont, 2001).
Meditation of various kinds has been found to be helpful in health promotion (Martin & Carlson, 1988), and has been applied in the prevention and treatment of addictive behaviors (Miller, 1998). Cognitive approaches using spiritual content have been demonstrated to be effective with both Muslims and Christians (Azhar et al., 1994).
Project MATCH found that higher baseline scores on the Religious Background and Behavior Scale predicted better drinking outcomes at the one-year follow-up (Zemore & Kaskutas, 2004). Six-Month Changes in Spirituality and Religiousness in Alcoholics Predict Drinking predict outcomes at Nine Months, even when controlling for AA involvement (Robinson et al., 2011). It is a protective factor against substance misuse (Kulis et al., 2012). Higher levels of religious faith and spirituality predicted a more optimistic life orientation, greater perceived social support, higher resilience to stress, and lower levels of anxiety (Pardini et al., 2002). Substance abusers who practice the 12 Steps are more likely to remain abstinent than those treated with other types of non-spiritual therapy Miller (1998). Among treatment seekers, individuals who reported a spiritual awakening as a result of their AA involvement were nearly four times more likely to be abstinent three-years post-treatment than individuals who reported never having had a spiritual awakening (Kaskutas et al., 2004).
Levels of incorporation of spirituality in everyday life and in treatment services. At the macro level, spirituality is part of the interventions that “promote mental health and well-being, alongside the treatment of mental illness”, according to Sheila Hollins, a past president of the Royal College Psychiatrists, UK. She sees this as a responsibility of everyone, including social care, criminal justice and education sectors and faith-based organizations. This should according to her, assert the centrality of mental health in society, thus aiding indirectly in the prevention of mental illness and in supporting individuals with mental disorders (Cook, 2009). At the micro level, the concept is diverse, controversial and needs to be broken down to components to be read in conjunction as follows:
Component 1: spirituality is being “concerned with matters of meaning and purpose in life, truth and values”.
Component 2: Human beings are a composite of essential parts- Physical, emotional, social and, spiritual working interchangeably to comprise balance and harmony in the whole person (Fiske, 2002).
Component 3: The term spirituality generally refers to the human longing for a sense of meaning and fulﬁllment through morally satisfying relationships between individuals, families, communities, and religions
Component 4: Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions. It may be experienced as a relationship with that which is intimately “inner”, immanent and personal, within the self and others, and/or as relationship with that which is wholly “other”, transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth and values (Modified from Cook, 2004) (Table 1).
|Till the 17th century||Moral model’ of addiction. (Compared to adultery, theft etc.).|
|18th century||Enlightenment movement: Reason and science, remnants of the above model still prevalent.|
|19th century||Popularity of the disease model aided by the scientific underpinnings.|
|20th century||Alcoholics Anonymous (AA) adopted the disease model, in a modified form, with particular influence over the perception of addiction as a spiritual problem.|
|21st century||American Society of Addiction Medicine defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations” (ASAM, 2011).|
Table 1. The changing views about addiction over time.
To navigate through a treacherous terrain, linguistically, conceptually and culturally, I involved as many people as I could, and asked them all one question: what does spirituality mean to you? The whole exercise was completed August-October 2017. It formed the basis of a workshop presented at the International Society of Addiction Medicine, Abu Dhabi, UAE. Participation in the questionnaire, focus groups was completely voluntary and anonymity was guaranteed (Bond et al., 2003).
This I put to:
A patient’s focus group. N=54
A group of colleague’s focus group N=8
Snowballing to groups of professionals through social media. N=140
AA/NA group members.
Then, a search of academic libraries and databases (PubMed, Medline) was conducted, looking for scholarly articles and contributions. The terms used were: Islamic, spirituality, addiction treatment, Middle East (Van Wormer & Davis, 2003) (Table 2).
|Patient focus groups||N=54||The majority understand the term as a religious concept.|
|Colleagues focus group||N=8||The majority understands it as in the 4 components, but cannot define it in Arabic.|
|Colleagues survey (social media)||N=140||Majority (responding in English) went for transcendent, transpersonal, non-materialistic definitions.|
|AA/NA contacts||2 representatives of each group responded||Standard responses from their literature: “attitude and gratitude”, classic 12 steps.|
|PubMed/Medline+all databases search of the concept in Islamic terms||42 hits only at the end of October 2017||The relevant results are summarized below.|
Single question: what does spirituality mean to you?
The overwhelming majority of responders were Muslim patients and colleagues working mainly in mental health and addiction treatment in the region.
As shown in Table 2 above, 9 books and 42 articles were retrieved. Only the following articles were highly relevant to our topic and need mentioning here in some detail:
Alghaferi et al., state that there is a dearth in research in published literature of substance use and addiction in the Islamic countries and the Middle East. According to the authors, their study was the first to explore if the biopsychosocial & spiritual model of addiction treatment was relevant to an addicted population in treatment. They concluded that the model fitted well but spirituality was not explored and further study of spirituality versus religious practice was recommended (Alghaferi et al., 2017).
Abdel Mawgoud et al. (1995) provide an insightful experience in developing a treatment program of addiction in an Arabic Muslim Society. The three major waves of knowledge and methodology are reviewed in historical perspective at Al Amal Hospital, Dammam, Kingdom of Saudi Arabia (K.S.A). The first phase resulted in a massive consumption of controlled drugs exposing patients to iatrogenic dependence. The second introduced a wider concept of treatment using a bio-psycho-social model in the context of the 12 steps program of the AA. This approach did not reflect positively on patients’ care due to the resistance of both patients and staff. The third phase addressed the causes of this resistance and formulated the basis for a comprehensive treatment program for addiction that relies on a clear philosophy and defined treatment stages. During the three phases, hospital records showed a progressive decrease in the amount of medications consumed (>90%) and dropouts (24%- 2.8%) Abdel Mawgoud et al., 1995).
Heydari et al. (2016), do not explore the spirituality in addiction treatment but in nursing practice from the view point of Islam. They propose a definition of spiritual health as follows: “In nursing, spiritual health is a dynamic process of approaching Allah, through which the patient gives meaning to the disease by communicating scholarly, wisely, and lovingly to the creator, the self, and others. This continuum to provide transcendence consists of love of the Creator, a duty-based life, religious rationality, and attention to the afterlife. The patient has different degrees, situations, and qualities on this continuum. Spiritual health causes psychological balance and actualized spirit like attributes of the Creator (Allah)”. The authors conclude: Islam has a unique perspective on spiritual health as it encompasses all aspects of human beings. Thus, it is necessary to carefully study the difference between the Islamic concept of spiritual health and that of other religions and ideologies to design suitable and useful nursing care for Iranian patients that satisfy their spiritual needs.
Another author, Rassool, questions whether the western paradigm to nursing care and management are applicable to Muslims and non-Muslims in both Islamic and non-Islamic countries. What is lacking in some of the conceptual frameworks and models of care is not only the fundamental spiritual dimension of care, but also the significance of spiritual development of the individual towards healing (Rassool, 2000).
Adib SM concludes: In the late 1960s, Islamist thinkers started proposing “Islamic medicine” as an alternative to the encroachment of the “Western” biomedical model within Arab and Muslim nations. In Islamic medicine, disease is attributed to lack of attention to the spiritual dimension of human beings, yet intermediate causal pathways are not provided. Alongside “orthodox” concepts, Islamic medicine promotes some herbal remedies, in addition to faithhealing through prayer and the recitation of holy verses. While most of those practices may be beneficial, they may cause some harm to patients if they entail delaying or denying timely recourse to “orthodox” medical care. There are currently no Islamic medicine training programs in any Arab country, and Islamic medicine has not emerged as a comprehensive health alternative comparable to other non-Western health models (Adib, 2004).
It is well worth noting that Heydari quoted above, used a hybrid model modified from Schwartz et al. (1993), in their methodology and differ from this article’s methodology in that the authors worked as a team and had access to articles through academic institutions. Their search key words were in line with and their search yielded 52 articles and 20 books.
At another level the western concept, according to a 2004 review of the literature pertaining to spirituality in substance misuse treatment describes the confusion and uncertainty as “universal” (Cook, 2004). In his review, he states that “the lack of clarity and the diverse definitions lead to identifying 13 conceptual components involving multiple dimensions”. I compared those components to the answers I received. Table 3 shows the comparison results, simply checking if our sample responses included his components.
|Domain||Cook’s review component||Concurrence/comments|
|Being ‘concerned with matters of meaning and purpose in life, truth and values’.||Transcendence
|Very High concurrence mostly affiliated to religion.|
|Human beings are a composite of essential parts—Physical, emotional, Social and, spiritual.||Non materiality Wholeness.||Moderate concurrence.|
|The human longing for a sense of meaning and ful?llment.||Core/force/soul
|A distinctive, potentially creative and universal dimension of human experience.||Relatedness
Non-religiousness) (explained as opposition of spirituality to/or identity to religion).
Table 3. Concurrence of respondents’ views and a standard definition/terminology.
Discussion And Conclusion
Addiction treatment and rehabilitation services in Middle Eastern countries need to start a dialogue and explore avenues to incorporate spirituality dimension into their treatment and rehabilitation philosophies. This is becoming an acute need specially that today’s world witnesses new challenges to the field of addiction treatment, example include the behavioral addictions and new psychoactive substances that are having devastating effects on the brain. The menu of interventions offered to our patients needs to be guided by evidence and practice based guidelines and courageous and visionary champions are desperately needed to lead the way. Academic institutions and pioneering services need to invest in research in the field and allocate budgets to invest in elucidating and structuring guidelines from the great heritage of Islam. I am sure the great scholars that provided humanity with the foundations of our current scientific and philosophical underpinnings of current knowledge have left a legacy and treasures waiting to be discovered. The following points summarize my conclusions and some are humble suggestions/recommendations:
A unifying concept defining spirituality in Islamic treatment and rehabilitation services, as a psychological intervention, should be adopted. This is not intended to treat patients differently on the basis of belief or faith but should tap into the resources of the faith. The term Irshad Rohani should be a useful term, its neutrality and the meaning it carries “guidance” are suited to the intended intervention.
A sophisticated approach could be designed around the mosques routine, through structuring religious and spiritual sessions with an Islamic context for countries in the regions and training Imams to deliver basic awareness and educational sessions in the sermons. This can be delivered after prayer times that a Muslim needs to observe, specially the two evening prayers “Salat al Maghreb” and “Salat Al Isha”.
Unedited Quotes from the questionnaire responses:
• Spirituality is non-materialistic part of human. It can be a state where a person feel completely connected to God, fulfilling all required religious obligation with certain believe in unseen things and reach a state of peace and acceptance of all things he likes or he does not like.
• Spirituality means to me joy, happiness, satisfaction with everything that I have. It means to me constant, continuous and eager longing to meet the almighty, the merciful Allah. The world of spirituality is a wonderful world with endless powers, but not everyone is lucky enough and blessed to have the key to enter the world.
• Spirituality is love. Love the entire universe and stay there in the ecosystem as long as I can. i.e., pantheist. As a rational entity I have to transcend this cosmos i.e. pantheist. It’s also called Nirvana.
• Spirituality is the real investment towards a straight and steady life. It is simple as that.
• Spirituality to me is a feeling of well-being and comfort emanating from non-physical source which in a way is relayed to the soul and inner belief.
• It means to me a connection with the higher source. Treating individuals by looking at their souls NOT background or beliefs. Accepting others despite our differences. Understanding our souls & living in harmony with our bodies & minds. Peacefulness.
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