Spiritual mechanisms underlying substance abuse behavior change in faith based substance abuse treat by Emily Sandberg Gold

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Journal of Social Work Practice in the Addictions Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wswp20

Spiritual Mechanisms Underlying Substance Abuse Behavior Change in Faith-Based Substance Abuse Treatment a

James Alan Neff PhD and MPH & Samuel A. MacMaster PhD a

Department of Community and Environmental Health , College of Health Sciences

University of Tennessee, College of Social Work-Nashville Published online: 12 Oct 2008.

To cite this article: James Alan Neff PhD and MPH & Samuel A. MacMaster PhD (2005) Spiritual Mechanisms Underlying Substance Abuse Behavior Change in Faith-Based Substance Abuse Treatment, Journal of Social Work Practice in the Addictions, 5:3, 33-54, DOI: 10.1300/J160v05n03_04 To link to this article: http://dx.doi.org/10.1300/J160v05n03_04

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Spiritual Mechanisms Underlying Substance Abuse Behavior Change in Faith-Based Substance Abuse Treatment James Alan Neff Samuel A. MacMaster

ABSTRACT. Despite increasing interest in “faith-based” substance abuse treatment and HIV risk reduction interventions, there is little systematic evidence of the efficacy of explicitly spiritual interventions. However, fundamental to effective interventions is an explicit conceptualization of mechanisms underlying behavior change. This paper discusses the definition of faith-based organizations, specifically as they relate to substance abuse treatment programs, briefly reviews relevant behavior change theories to identify key variables underlying change, presents an integrative conceptual framework articulating linkages between spiritual intervention components, behavior change processes and substance abuse outcomes, and discusses how the mechanisms identified in our model can be seen in commonly used substance abuse interventions. Overall, the paper suggests that what happens in “faith-based” programs may not be so

James Alan Neff, PhD, MPH, is Professor and Associate Dean for Research, Department of Community and Environmental Health, College of Health Sciences. Samuel A. MacMaster, PhD, is Assistant Professor of Social Work, University of Tennessee, College of Social Work-Nashville. Addresses correspondence to: James Alan Neff, PhD, MPH, 205 Spong Hall, Old Dominion University, Norfolk, VA 23529 (E-mail: janeff@odu.edu) or Samuel A. MacMaster, PhD, 193 East Polk Avenue, Nashville, TN 37210 (E-mail: smacmast@ utk.edu). Journal of Social Work Practice in the Addictions, Vol. 5(3) 2005 Available online at http://www.haworthpress.com/web/JSWPA © 2005 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J160v05n03_04

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different from processes taking place in good social work practice in the addictions field. [Article copies available for a fee from The Haworth Document

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KEYWORDS. Faith-based programs, substance abuse treatment, spiritual change, behavior change models

INTRODUCTION “Faith-based” initiatives in areas of welfare-to-work, child care, and substance abuse treatment have recently received an increasing amount of public attention, both positive and negative (Johnson, 2002). However, particularly in the area of “faith-based” substance abuse treatment, there is little systematic evidence of the efficacy of interventions explicitly emphasizing spiritual or religious content (Johnson, 2002; Miller, 1997). Given that African American and Latino minorities are disproportionately impacted by substance abuse and substance abuse related HIV risk (CDC, 1999), there is a great need for culturally relevant and culturally competent interventions to motivate entry into (and retention in) substance abuse treatment (Longshore, Grills, & Annon, 1999). Faith-based approaches have been proposed as particularly relevant in this regard. The growing interest in faith-based approaches coincides with the increasing attention directed to conceptual and methodological issues surrounding spirituality, religiosity, and their implications for health and well-being (Fetzer Institute, 1999). Unfortunately, systematic empirical research regarding the efficacy of faith-based interventions for alcohol or substance abuse (i.e., those rooted in some spiritual or religious content) is sparse. However, while the evidence regarding efficacy of faith-based interventions is reviewed elsewhere (Johnson, 2002), an explicit conceptualization of mechanisms underlying behavior change is fundamental to understanding the effectiveness of any substance abuse intervention, whether faith-based or not. In short, while faith-based programs are viewed as providing a research setting in which the processes discussed here can be viewed in high relief, our argument regarding spiritual change and mechanisms underlying such change is more general.

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A fundamental premise of this paper is that spiritual mechanisms underlying effective faith-based interventions may be conceptualized in terms of extant theoretical models of behavior change, which have considerable empirical support. Therefore, this paper will: (1) discuss the definition of faith-based organizations, specifically as they relate to substance abuse treatment programs, (2) briefly review relevant behavior change theories to identify key variables underlying change, (3) present an integrative conceptual framework articulating linkages between spiritual intervention components, behavior change processes and substance abuse outcomes, and (4) present a discussion of how the mechanisms identified in our model can be seen in commonly used substance abuse interventions. Overall, our goal is to suggest that what happens in ‘faith-based’ programs may not be so different from processes taking place in good social work practice in the addictions field. BACKGROUND The Definition of Faith-Based Organizations A critical starting point for this discussion is the definition of “faith-based” programs. Castelli and McCarthy (1997) define faithbased organizations broadly to include congregations, national networks (such as Catholic Charities or YMCA), freestanding religious organizations, or other urban or social ministries providing some community service (Vidal, 2001). A White House White Paper (2001) takes a broad view including both religious and secular organizations, referring to “faith-based grassroots groups . . . [involving networks] . . . of local congregations . . . small nonprofit organizations (both religious and secular) . . . and neighborhood groups that spring up to respond to a crisis” (p. 3). In contrast, Scott (2003) emphasizes: (1) the linkage of faith-based organizations to an organized faith community, (2) the presence of a particular religious ideology and (3) staff and volunteers drawn from a particular religious group. While such definitions provide useful reference points, an appreciation of the diversity of faith-based groups requires a broad, inclusive approach allowing for both secular and religious organizations. Thus, Sider and Unruh (1999) posit four types of faith-based providers: (1) secular providers who make no explicit reference to God or any ultimate values, (2) religiously affiliated providers who use standard non-religious techniques and approaches without religious content,

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(3) exclusively faith-based providers who rely on religious content and technologies to the exclusion of traditional non-religious approaches, and (4) holistic faith-based providers who combine religious and non-religious content and approaches. Thus, Sider and Unruh emphasize a combination of religious affiliation and religious content, similar to The Working Group on Human Needs and Faith-Based and Community Initiatives (2002), who emphasize the degree to which a program is imbued with religious and/or spiritual content (e.g., a continuum ranging from “faith-saturated” to “faith-secular partnership”). Thus, an approach encompassing a broad range of programs is a necessity, in particular, in examining faith-based providers of substance abuse treatment. We note that extant discussions of “faith-based” programs have addressed a variety of human and social service organizations and argue that faith-based substance abuse treatment programs represent a particular niche in this broader arena. In particular, with regard to defining faith-based substance abuse treatment programs, we downplay the importance of the religious or congregational affiliation of the organization itself, but rather emphasize the presence of some implicit or explicit religious or spiritual content underlying program activities. This follows from the fact that many substance abuse treatment programs, while not associated with or espousing any organized religion or set of religious beliefs, may endorse 12-step conceptions of spirituality and the existence of a Higher Power. Thus, while they may not constitute a religion per se, 12-step programs do promote practices such as prayer, meditation, confession, and penance (Connors & Derman, 1996) and, as well, involve elements of ideology and recruitment of volunteers and “staff” from existing 12-step members proposed as characteristics of faith-based organizations (Scott, 2003). In this sense, even a secular treatment program may have elements of a faith-based program. Another layer of complexity emerges with regard to the conceptualization of faith-based substance abuse treatment programs in that, as we will discuss in detail below, programs endorsing 12-step philosophy typically emphasize “spiritual transformation” (Albers, 1997; Alcoholics Anonymous, 1995) as a fundamental component of recovery. In this regard, a typological approach emphasizing the degree to which a program is imbued with religious and/or spiritual content (Sider & Unruh, 1999) becomes critical to the examination of substance abuse treatment programs where even a traditional program emphasizing conventional medical and psychosocial treatments may incorporate spiritual content to some extent.

James Alan Neff and Samuel A. MacMaster

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“Religiosity” vs. “Spirituality” in the Study of Faith-Based Treatment Another definitional issue with regard to our examination of “faithbased” substance abuse treatment programs concerns the somewhat traditional distinction between “religion” and “spirituality,” where-in religion is viewed as organized religious practice whether formal (as in church attendance) or informal (as in prayer). This is in contrast to “spirituality” which is viewed as involving the individual’s relationships with self, others, and some transcendent force (or higher power) (cf. Armstrong, 1996). Spirituality is said to represent an integrative force in the individual’s life (Ellison, 1983), providing “meaning,” core values, and principals for organizing one’s life. While the distinction between religiosity and spirituality is heuristically valuable, in the conceptual and empirical literature, this distinction may become somewhat blurred, reflecting perhaps the essential interconnectedness of the dimensions. Particularly, with regard to the study of “spiritual change” in faith-based treatment programs, both spirituality and religiosity dimensions must be examined. In terms of the conceptualization and measurement issue, it is noted that a variety of models and measures of religious and spiritual phenomena have evolved (cf. Chatters, Levin, & Taylor, 1992; Levin, Taylor, & Chatters, 1995), ranging from simple (“intrinsic vs. extrinsic,” Allport, 1958; “personal” vs. “institutional,” Moberg, 1971) to elaborate (“belief, experience, ritual, knowledge, and consequences,” Glock and Stark, 1965). Chatters and Taylor (1994) provide a useful distinction between organizational involvement (formal involvement such as church attendance), non-organizational involvement (informal involvement such as prayer and bible studies at home), and subjective religiosity (including such aspects as beliefs, knowledge, attitudes, and the perceived importance of religion in the individual’s life). This model differentiates subjective (spirituality) dimensions from formal and informal religious practices, though all are subsumed within the concept of “religious involvement.” While this may blur the distinction between religion and spirituality, the concept of “involvement” may be useful in highlighting the relationship between religious practices, such as ritual and prayer, and spiritual beliefs and experience. The fundamental interdependence of practices and belief is echoed in classic social theory, wherein Durkheim (1915) defines religion in terms of an “integrated system of beliefs and practices relative to sacred things . . . which unite in one moral community . . . all those who adhere

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to it.” Religion was thus defined in terms of beliefs and practices (rituals) that fulfilled basic collective social functions (Alpert, 1961) including: promoting self-discipline, social cohesion, “revitalizing” the social heritage of the group, and promoting well-being. In this sense, religious practices (prayer, singing, testifying, etc.) reinforce the underlying belief system and promote social solidarity and integration of the individual into the collective. Thus, while the religion vs. spirituality distinction has intuitive appeal, an appreciation of the essential social nature of the processes going on in faith-based substance abuse treatment requires a more integrative perspective acknowledging the interdependence of religious practices and spiritual beliefs. While not all faith-based treatment programs are necessarily tied to a “religion” per se, they may involve some constellation of practices and beliefs that serve to engage the individual into the collective process and to facilitate changes in values, beliefs, norms, coping behaviors, and ultimately changes in substance abuse behaviors. Thus, “spiritual transformation,” while involving transformation at an individual level, is viewed as taking place in the context of a social process (Rambo, 1993). Religion and Spirituality in Relation to Substance Abuse and Recovery In terms of what is known about spiritual and/or religiosity dimensions in relation to substance abuse and changes during treatment, recent reviews of literature (Gorsuch, 1995; Miller, 1997) yield the following conclusions: (1) religious or spiritual involvement may serve as a protective factor against the development of substance abuse problems (Gorsuch and Butler, 1976), (2) some spiritual changes appear to take place during substance abuse treatment, and (3) for some individuals for whom religion/spirituality is salient, spiritually based substance abuse interventions may be effective. Moreover, while there is some consistent evidence that religious or spiritual involvement is positively related to well-being and other dimensions, and that spirituality may be involved in substance abuse treatment and recovery, little is known about theoretical mechanisms underlying spiritual change in substance abuse treatment (Gorsuch, 1995; Miller, 1997). It is acknowledged that religion and spiritual influences upon wellbeing and substance abuse have received inadequate theoretical and empirical attention (cf. Ellison, 1993; Armstrong, 1996). Despite the otherworldly and ineffable connotation of the spirituality concept, the

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process of “spiritual change or transformation” in faith-based substance abuse treatment programs may usefully be examined from the perspective of social and psychological processes involved in the attribution of meaning, causation, and efficacy as they relate to behavior change. Thus, work by Ellison (1993) and Pargament (1997) are seminal in analyzing spirituality in terms of core social-psychological processes of adaptation to life change and coping. Similarly, Miller’s (1997) discussion of spiritual change as a parallel to processes involved in effective substance abuse counseling emphasizes the importance of “forgiveness and salvation,” the influence of positive role models, availability of social support, and acceptance, “agape” or empathy in the therapeutic relationship. Such an approach may help demystify the concept of spiritual intervention, suggesting that effective faith-based interventions might share elements common to effective interventions in general. Thus, a growing body of literature supports the idea that therapeutic empathy, involving a “supportive” rather than a “confrontational” counselor style is associated with greater treatment engagement (Miller, Taylor, and West, 1980; Fiorentine, Nakashima, and Anglin, 1999) and other treatment outcomes (Miller, Benefield, and Tonigan, 1993; Fiorentine and Hillhouse, 1999). To the extent that a faith-based treatment program incorporates an empathic, accepting, supportive treatment approach, more positive outcomes might be anticipated. In this paper, we seek to clarify conceptually the behavior change mechanisms underlying faith-based substance abuse treatment. Specifically, we examine faith-based interventions from the standpoint of behavior change theories such as the Health Belief Model, the Theory of Reasoned Action, and the Social Learning Theory. The development of an integrative model combining these conceptual elements can be useful in explaining how spiritually based interventions can drive the change process. Viewing Change in Faith-Based Treatment from Dominant Behavior Change Models While there is some general agreement that some form of spiritual “transformation” takes place (Albers, 1997) involving a shift from negative, punishing to positive, forgiving views of spirituality and God (Miller, 1997), there has been little effort to formalize a model of the process. Based upon our previous discussion, we acknowledge that “faith-based” substance abuse treatment programs may be diverse in the extent to which they emphasize religious or spiritual content and that

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the process of spiritual transformation does not occur in a vacuum. That is, our discussion of the interdependence of religious practice and spirituality dimensions might suggest that faith-based programs would place heavy emphasis upon group practices and ritual to integrate the individual into the group to facilitate the adoption of group values, norms, beliefs, and to foster both spiritual and behavioral changes. In this section, we turn more specifically to address the possible mechanisms underlying spiritual change and behavior change in a faith-based context. We propose an organizing framework viewing faith-based interventions and change in substance abuse behaviors during treatment as involving changes at several levels. This model is graphically summarized in Figure 1. The factors involved at different stages of the model are discussed below: Individual Attributes: The starting point for the model involves what the individual brings to the program. People differ at the outset in terms of FIGURE 1. Integrative Conceptual Model of Spiritual Mechanisms Underlying Substance Abuse Behavior al iu s iv ute d In trib At m ra ts og en Pr lem E

Initial Treatment Readiness

Initial Level of Spirituality

Elements of Faith-Based Interventions Empathy

al ci ing s So arn sse Le oce Pr

Acceptance

Forgiveness

Meaning: Spirituality

Discipline

g tin t ita en t i m l ci ag Fa ng E

Role Modeling

View of God Punishing -> forgiving

Forgiveness: Self/Others

Self Acceptance: Self-Worth

Norms

Support

Social Reinforcement

Coping: Positive

Social Intergration

Enhanced Behavioral Intention

Spiritual Transformation Process

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or vi e ha ng e a B h C

Movement through Stages of Change

Substance Abuse Behavior Change: Recovery

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James Alan Neff and Samuel A. MacMaster

spiritual history, current level of spirituality, and general readiness for treatment. Substance abusers may be particularly likely to be disenfranchised–not only from key societal institutions, but also from their religious institutions. Further, as roughly 85% of drug users are out-oftreatment at any given time (Needle and Coyle, 1997), levels of readiness for treatment may be low. The typical individual may not be contemplating a change in their substance abuse. Program Elements: Given a potentially disenfranchised population, the critical issue is how a faith-based program can engage and retain the individual in the program and in the recovery process. Values regarding empathy, acceptance, and forgiveness (described by Miller, Taylor, and West, 1980) as characteristic of effective substance abuse counselors), may be critical in a faith-based intervention. Moreover, because out-oftreatment substance abusers may well have been living rather chaotic lifestyles, elements providing structure and discipline are crucial components of a program. Thus, daily routines, individual or group chores, and rules prohibiting drug use or “street talk” contribute to a sense of order. Further, following from Durkheim (1915) and Alpert (1961), rituals and group activities promoting social cohesion are central. These activities may involve group bible study (or 12-step study), prayer/meditation, testifying or witnessing regarding faith, testimonials regarding individual recovery, or simply group activities (such as recreational activities or even housecleaning). Also involved in the social cohesion process are activities that specifically provide mentoring or support to the individual. This could involve the presence of formal or informal mentors (or sponsors) such as program staff members modeling successful recovery, AA or other 12-step meetings to provide support and social reinforcement, or more general emphasis upon the group as a source of support for recovery. [For purposes of clarity, we should note that while the model proposed here is viewed as general, we are thinking primarily in terms of programs rooted in Christian tenets. Faith-based programs stemming from other religious traditions may be analyzable in terms of the proposed model, though our focus is upon Christian faith-based programs.] Social Learning Processes: A National Institutes of Health HIV Prevention consensus panel (Fishbein, 1997) representing the dominant theories of change–the Health Belief Model (HBM; Becker, 1974), the Theory of Reasoned Action (TRA; Fishbein and Azjen, 1975), and Social Learning Theory (SLT; Bandura, 1986)–identified three variables viewed as necessary and sufficient conditions for behavior change: (1) the strong intention to change the behavior (from the TRA); (2) the skills required for behavioral performance (from SLT); and,

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(3) an absence of environmental constraints or barriers (from HBM) (Fishbein, 1997). These variables are viewed as particularly relevant to the recovery process. Social learning and peer influence processes are regarded as crucial to skill building and the development of self-efficacy, which are essential to the individual’s ability to overcome environmental barriers (e.g., relapse cues). Applying these basic behavior change concepts to substance abuse recovery processes, would include peer modeling of desired behaviors, provision of information regarding peer norms, and abstinence values designed to produce a behavioral intention to change behaviors, as well as promoting changes in sense of self and core values. As the individual incorporates these cognitive changes and acquires behavior change skills and behavioral intention to change, peer influence processes become increasingly important in reinforcing behavioral changes (enhancing self-efficacy, self-esteem, reinforcement of skills) and providing social support) in the recovery process. Throughout the process, the program serves to eliminate barriers to behavior change through provision of food, shelter, caring for basic needs, and by offering a drug-free environment in which the individual can change. Spiritual Transformation Processes: Individuals engage in a search for meaning, and such quest for meaning is fundamental to the process of recovery (Albers, 1997). This process involves a radical (though not necessarily a sudden) change in the self, especially in terms of the identification of the self with the sacred (Zinnbauer & Pargament, 1998). From a stress-coping perspective (Ellison, 1993), human adaptation to environmental change involves appraisal and coping processes (Lazarus & Cohen, 1977). Pargament (1997) has emphasized the particular importance of spiritual appraisals and coping (e.g., “positive” perceptions of collaborative, supportive, forgiving relationships with God vs. “negative” perceptions of rigid, punishing, unforgiving relationships with God). These appraisals of self in relation to others and to God (or a higher power) are viewed as providing an important basis for inputing meaning to life experience. The shift from conceptions of a “punishing” to “forgiving” God are said to be important to recovery, as are changes in the direction of forgiveness of self (and increasing self-acceptance of self-worth) and others, as well as shifts from “negative” to “positive” religious coping strategies. Impact upon Treatment Readiness and Substance Abuse Behavior Change: Given these considerations, an intervention which enhances the individual’s sense of spirituality, meaning, forgiveness, and spiritual connectedness, thus motivating engagement in the faith-based sub-

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stance abuse intervention and into program activities (i.e., enhancing social integration), may further enhance social support and peer influence processes. Ultimately, these mediating spiritual mechanisms are posited to increase motivation to change, increase treatment readiness, and reduce substance abuse. Based on behavior change processes, social learning and peer influence are viewed as driving forces in the engagement and change process. Spiritual change (from “negative” to “positive” conceptions of God and corresponding coping styles; Pargament, 1997) would imply some change in the individual’s perception of his/her relationship to a Higher Power. At the same time, it would imply some change in the individual’s sense of self-worth, self-acceptance, and self-efficacy or mastery. Also involved would necessarily be some changes in perceived norms and values (of self and others) regarding substance abuse as the individual may internalize anti-substance abuse norms and develop a desire (intention) to change their patterns of substance use/ abuse. These changes suggest the importance of social processes and peer influence–both in terms of modeling anti-substance abuse behaviors as well as in providing social support and reinforcement for the adoption of new norms and behaviors (e.g., new cognitive or behavioral coping behaviors and/or abstinence or reduction of substance abuse). It must be emphasized that the proposed conceptual model seeks to help clarify the spiritual transformation process and should not be taken as a reductionistic attempt to explain away spiritual transformation in behaviorist terms. Rather, following from Rambo (1993), we emphasize that transformation involves a complex interaction of contextual and other factors contributing to the readiness to change. While social learning processes are important, more broadly, a faith-based program may provide an environment and a sense of community, forgiveness, acceptance and support (with role modeling of spiritual and drug-free norms, values, and behaviors) in which the process of spiritual transformation is nurtured. Having said that, it must be emphasized that programs will vary in structure and ideology and that such variation may be hypothesized to impact engagement, retention, and subsequent treatment outcomes. Empirical Support for Behavior Change Model Elements Faith-based programs can be viewed along a typology or continuum and may be highly variable in terms of religious affiliation and/or infusion of religious or spiritual content. To provide a sense of the general

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implications of the proposed framework to other substance abuse treatment modalities, we will now briefly discuss a number of established substance abuse interventions in order to highlight the presence of key behavior change elements outlined above. The relevance of this review can be viewed in a couple of ways. First, while our principal focus has been on faith-based programs, the factors posited by our model as driving the spiritual and behavior change process are more general. While the processes in faith-based programs may be common with processes involved in effective substance abuse treatment in general (i.e., empathy), it may be useful to show that the behavior change elements emphasized in the model are common in well-accepted substance abuse interventions. Second, given that our knowledge of what faith-based substance abuse programs actually do is limited, it may be useful to consider the compatibility of the different approaches reviewed below in terms of the general framework we have laid out. That is, while it is unlikely that extant faith-based programs incorporate accepted substance abuse treatment modalities, to the extent that a “best practice” treatment approach are compatible with a faith-based approach, the blending of approaches might be expected to yield more positive outcomes. AA and other 12-Step Models: The AA or 12-step model remains one of the most common substance abuse treatment modalities (Roman & Blum, 1999). As carefully analyzed by White (1998), the AA model is based upon explicit principles (12 steps) and involves not only spiritual principles (such as surrendering to a ‘higher power’) but also cognitive and behavioral rituals (going to meetings, getting a sponsor, working the steps, reading the “big book”) designed to help the individual keep sober. The steps reflect different components of the recovery process (White, 1998): Step 1 involves surrender and is said to open the individual up to experience beyond him/herself. Steps 2-3 involves a change in the individual’s relationship with a higher power–again, opening the individual up to something beyond the self. Steps 4-5, involving moral inventory and admission of wrongs, begin the process of individual identity transformation. Steps 6-7, involving willingness for God to remove defects and a request for God to change the individual, once again relate to the individual’s relationship to a higher power and reflect a shift away from the “self.” Steps 8-9, involving amends to others, represent action steps in changing the individual’s relationships with others. Steps 10-11, involving continued inventory and prayer/meditation, reflect rituals such as the “story,” slogans, laughter–all of which involve not only AA content, but also reflect AA as a social process. Finally, Step 12 involves service to

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others and reflects continuing changes in the individual’s relationship to others. What is clear in White’s (1998) analysis of the 12-steps is that, while the steps place heavy emphasis upon the “spiritual,” AA participation involves behavioral rituals and social process. In terms of our conceptual model of spiritual and substance abuse change during faith-based treatment, AA highlights several of the proposed fundamental processes. As a subculture, AA emphasizes, models, and reinforces pro-abstinence norms and mechanisms for coping with relapse cues. Role modeling takes the form of testimonials during meetings (“stories”) as well as “sponsorship,” in which more experienced group members mentor newer members. Social reinforcement takes the form of group congratulations and symbolic “chips” to commemorate achievement of different periods of sobriety. Social support is reflected in both formal and informal activities during meetings, in parking lots after meetings, and discussions over coffee. While methodologically rigorous studies of AA outcomes are rare, Project MATCH (1998) provides some of the strongest evidence that 12-step facilitation can yield abstinence outcomes as positive as other modalities. Indigenous Outreach Interventions with Out of Treatment Substance Abusers: The Indigenous Outreach model (Weibel et al., 1993) has been delivered to over 150,000 out-of-treatment injection drug users (IDUs) and has been extensively evaluated (Coyle, Needle, & Normand, 1998). In this model, indigenous recovering peer outreach workers provide street-level risk reduction interventions combined with off-street interventions involving risk-assessment, pre- and post-HIV test counseling, and a hierarchical HIV risk reduction message encouraging substance abuse treatment. Research indicates that this approach can produce behavioral changes on a number of HIV risk behavior dimensions (Coyle et al. & Normand, 1998) as well as increasing likelihood of entry into drug treatment (Needle, Coyle, Normand, Lambert, and Cesari, 1998). This model clearly incorporates a number of elements from our proposed model including role modeling and social influence (i.e., use of indigenous peers to model behaviors), skills training (i.e., demonstrations and behavioral rehearsal of condom and bleach use), enhancing behavioral capability or self-efficacy (use of peers to model efficacious behavior change and reinforce the individual’s sense of control over his/her drug use), and facilitation (i.e., provision of condoms, bleach, referral information, and vouchers to reduce barriers to use). Risk assessment serves to highlight the personal relevance of risk behaviors.

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In terms of our focus upon faith-based programs, there is nothing explicitly spiritual in the indigeneous outreach worker approach itself, though the combination of indigenous outreach techniques with a faithbased approach emphasizing empathy, acceptance, and forgiveness might be hypothesized as an effective mechanism to engage out-oftreatment substance abusers into treatment. Indeed, “street evangelism” is a key component of faith-based treatment programs such as Victory Outreach (Garcia & Garcia, 1987), though such efforts are typically not informed by the indigenous outreach model. However, this might be a fruitful avenue to pursue for further research and practice. Brief Motivational Interventions for Alcohol and Substance Abusers: An extensive literature has developed documenting the effectiveness of brief interventions for alcohol abuse in primary care settings with regard to reducing alcohol use and alcohol-related problems (Bien, Miller, & Tonigan, 1993; Dunn, Deroo, & Rivara, 2001). Brief interventions involve a brief personal encounter during which a physician or other individual provides evidence of an individual’s problem drinking and provides information and encouragement to change their drinking behavior. Essentially, the motivational interviewing techniques (Miller & Rollnick, 2002) used involve use of social influence processes to provide information to facilitate changes in behavioral intention, knowledge of available options for change, perceived self-efficacy, and ultimately, changes in behavior. Emphasis upon individual risk serves to highlight HBM dimensions of seriousness and susceptibility. From the standpoint of our conceptual model and emphasis upon spiritual change, the brief intervention/motivational interviewing approach does not explicitly involve spirituality or faith. However, in his recent review of the field of motivational interviewing, Miller (2000) emphasizes the centrality of empathy, acceptance, and “agape” to the success of motivational interventions. Thus, he invokes a core religious concept–“Agape”–as being the driving element of motivational interventions. One might expect faith-based motivational interventions emphasizing religious or spiritual content to be effective in motivating substance abuse behavior change with certain populations. Again, such approaches may be quite useful with regard to treatment engagement and behavior change. Relapse Prevention Therapy: While most behavior change therapies focus on moving the individual into sobriety, Relapse Prevention Therapy (RPT) addresses the issue of how to maintain sobriety in the face of relapse cues (Marlatt & Gordon, 1985; Larimer, Palmer, & Marlatt, 1999). The RPT model posits that relapse is an important and expected

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element of the behavior change process and that through trial-and-error, new response patterns in high-risk situations are gradually acquired, corrected, and strengthened (Marlatt & Gordon, 1985). RPT emphasizes five components: assessing high-risk situations, learning effective coping skills, monitoring high risk situations, developing coping plans, and evaluating coping plans and skills. The goal of therapy is continued sobriety which promotes greater self-efficacy and confidence (Marlatt & Gordon, 1985). Several meta-analyses have shown RPT to be effective in reducing the frequency of relapse and the intensity of each individual lapse (Irvin, Bowers, Dunn, & Wang, 1999; Dimeff & Marlatt, 1998; Rawson, Obert, McCann, & Marinelli-Casey, 1993). Elements of a social learning theory approach are notable in several aspects of the RPT model. Role modeling and social reinforcement of adaptive responses are implicit elements of the therapeutic relationship (i.e., to increase the client’s understanding of relapse cues and his/her coping responses). Further, the acquisition of coping skills and enhancement of self-efficacy are core elements of RPT, consistent with social learning theory. Again, there does not appear to be any fundamental incompatibility between RPT and a faith-based approach. DISCUSSION This article provides an articulation of possible spiritual change mechanisms underlying behavioral change in substance abuse treatment, with a particular focus upon “faith-based” treatment. While the literature generally supports a positive relationship between spirituality and well-being and highlights the importance of spirituality to substance abuse treatment and recovery, this article is the first to provide a conceptualization of possible theoretical mechanisms underlying this commonly assumed view of spiritual change (often referred to as a “transformation”) during the course of treatment. Our approach has been to examine the process of spiritual change process in terms of established, empirically supported theories of behavior change. This paper has sought to clarify the nature of substance abuse behavior change in at least two important respects. First, our goal has been to demystify the process of “spiritual transformation.” Unlike much of the literature regarding spiritual transformation (cf. Albers, 1997) that appears to emphasize the other-worldly, mystical, nature of the transformation. While not meaning to minimize the importance or the profundity of the transformation experience in the individual’s life in terms of

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their relationship to self, Higher Power, and others, our theoretical discussion has sought to show how the phenomenon may be understood in terms of social, cognitive, and behavioral processes. Though it remains possible that an individual can undergo a spontaneous change in their use of alcohol or other drugs in isolation (i.e., “self-change” in Prochaska, DiClemente, & Norcross’ (1992) terminology), that phenomenon is poorly understood (Miller & deBaca, 2001). Recently,Watson and Sher (1998) have sought to clarify the self-change process, noting a variety of factors which may influence the process and noting similarities in terms of processes of change in intentional behavior change (Prochaska, DiClemente, & Norcross, 1992). Their argument that selfchange has similarities to intentional change is compatible with the approach taken here. The fundamental behavior change processes that take place in substance abuse treatment may not be incompatible with what may take place in faith-based programs. Our focus has been upon faith-based programs as a setting in which role modeling and peer influence processes may be optimal for producing transformations in belief systems and behavior. The theoretical importance of the present efforts to specify “mechanisms” can be seen clearly in terms of Prochaska and DiClemente’s Stages of Change model (DiClemente, 2003). Since its development, the Stage of Change model has become the dominant conceptual model for both understanding and delivering substance abuse services, emphasizing the cyclical nature of behavior change as well as emphasizing the need to consider the individual’s stage of change in developing an appropriate intervention. While the Stage of Change model highlights the complexity of the behavior change process, it does not specifically detail the mechanisms that drive the change process, producing changes from stage to stage. Some implications of our discussion would be that empathy, forgiveness, and acceptance are important elements of engaging the individual in a change from “pre-contemplative” to “contemplative” stages. Similarly, role modeling processes would be important in providing norms and skills needed to move the individual to the “action” stage. Finally, social reinforcement and support provided by the communal setting would be critical to the “action” and “maintenance” stages. Such conceptualization is clearly an important first step in bridging the long-standing gap between substance abuse research and substance abuse services. The history of substance abuse treatment services has long been mired in a moral model of addiction and most services have included elements of spirituality both overtly and covertly even before the incep-

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James Alan Neff and Samuel A. MacMaster

tion of the field (i.e., religious conversion was long seen as the only intervention for problem drinkers). While AA and many clinicians have strong beliefs in the importance of spirituality, these have not necessarily been linked in the literature, theoretically or otherwise, to the body of growing evidence for empirically supported interventions. Our conceptual efforts therefore lend credence to the existence of the spiritual underpinnings of empirically supported interventions. Moving an understanding of spiritual mechanisms from an amorphous belief system to a more concrete explanation of the process further closes this gap by allowing researchers to move towards an element of substance abuse treatment that was once viewed as â&#x20AC;&#x153;unscientific.â&#x20AC;? Application of our integrative model may occur at both a research and practice level. First, our model may inform systematic empirical research on spiritual change during the course of faith-based substance abuse treatment, as well as providing a framework on which faith-based, and non-faith-based but spiritual, treatment programs can develop. Thus, for example, in addition to presenting our conceptual analysis of spiritual change mechanisms, we have also presented an overview of several substance abuse treatment approaches. The goal here has been to highlight elements of our model (i.e., behavior change mechanisms) that are common to these programs. Elements of social learning, peer influence, role modeling, and social reinforcement are common to many of such treatment modalities. And, empathy and acceptance also appear common to many approaches, suggesting possible connections with the literature on counselor styles and treatment effectiveness. While our principal objective in reviewing these approaches has been to show that the behavior change processes we discuss are not foreign to substance abuse treatment, the review also suggests that these approaches are not incompatible with a faith-based approach. That is, approaches such as motivational interviewing or indigenous outreach models could fit well within a framework emphasizing spiritual content. Of course, what takes place in faith-based programs is likely not informed by state-of-the-science approaches (e.g., street evangelism or outreach), but such programs might well benefit from the incorporation of some of these approaches. That is, brief motivational interventions based upon established models (Miller & Rollnick, 2002) which include a spiritual or religious overlay may be particularly effective in engaging certain populations. From a research perspective, important next steps might include utilizing focus group methodology with program participants and staff to identify both their conceptions of spirituality at an individual level (to

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get at dimensions of spirituality that may change in the treatment process) as well as identifying key dimensions of faith-based programs that serve to engage and retain individuals in treatment. Further, concept mapping methods (Trochim, 1993) could be used in conjunction with focus group methods to inform the development of culturally grounded measures for use in evaluating spiritual change empirically as well as in developing a typology of faith-based programs. Indeed, a limitation of the present analysis is that we have discussed general processes that “may” take place in faith-based substance abuse treatment. In reality, faith-based programs are varied, and we really do not know what takes place in the programs. Empirical research, both qualitative and quantitative, is needed to give a clearer picture of what faith-based programs look like and what they do. What we have attempted to do is to develop a general conceptual model of the change process. The next step is to examine programs to see the extent to which they incorporate dimensions of structure, acceptance, forgiveness, empathy, etc., and to see the implications of such variation for program functioning and outcomes. At a practice level, providing a framework that incorporates both empirically supported elements and a spiritual mechanism may be invaluable in organizing and delivering services. A next step might be to explore the conceptual linkages between Stages of Change (Prochaska et al., 1992), for example, and models of spiritual change or development (cf. Fowler, 1994). Specifically, whereas the Stage of Change model emphasizes the need to target the individual’s stage of change in terms of readiness for substance abuse behavior change, an integrative approach might suggest the need to target both the individual’s stage of change and their level of spiritual development. Optimal intervention strategies may need to target both. Such a notion is implicit, if not explicit, in statements by Miller (1997) that spiritual interventions may be effective for those that are “spiritually inclined.” CONCLUSION Inclusion of a spiritual mechanism within substance abuse or any other practice area should not be new to social work. The ecological perspective and “person in environment” model of social work practice provide for the inclusion of the element of personal spirituality, and therefore spiritual change/growth, in viewing any individual presenting for services. The importance of this model from a social work perspec-

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tive is not the inclusion of spirituality, but the linkage between spirituality and the behavior change mechanisms in the various interventions outlined in this article. As noted above, the next step is to empirically examine the utility of the conceptual framework articulated here with regard to faith-based programs and ultimately to examine variation in faith-based program structure and ideology in relation to substance abuse treatment outcomes. REFERENCES Albers, R.H. (1997). Transformation: The key to recovery. Journal of Ministry in Addiction and Recovery 4: 23-36. Alcoholics Anonymous. (2nd ed.). New York: Alcoholics Anonymous World Services Inc., 1995. Allport, G.W. (1958). The Nature of Prejudice. New York: Anchor Books. Alpert, H. (1961). Emile Durkheim and His Sociology. Russell and Russell, Inc: New York. Armstrong, T. (1996). Exploring spirituality: The development of the Armstrong measure of spirituality, pp. 105-115. In Jones, R.L. (Ed.), Handbook of Tests and Measurements for Black Populations. Vol. 2. Cobb and Henry: Hampton, VA. Bandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall. Becker M. (1974). The health belief model and personal health behavior. Health Education Monographs 2: 324-473. Bien, T.H., Miller, W.R., and Tonigan, J.S. (1993). Brief interventions for alcohol problems: A review. Addiction 88: 315-336. Castelli, J., and McCarthy, J. (1997). Religion-Sponsored Social Service Providers: The Not-So-Independent Sector. Aspen Institute Nonprofit Sector Research Fund. Unpublished. Centers for Disease Control and Prevention. (1999). HIV/AIDS Surveillance Report. Atlanta, GA. Chatters, L., and Taylor, R. (1994). Religious involvement among older AfricanAmericans, pp. 196-230. In Levin, J. (Ed.). Religion in aging and health: Theoretical foundations and methodological frontiers. Thousand Oaks, CA: Sage Publications. Chatters, L.M., Levin, J.S., and Taylor, R.J. (1992). Antecedents and dimensions of religious involvement among older black adults. Journal of Gerontology 47(6): S269S278. Coyle, S, Needle, R., and Normand, J. (1998). Outreach-based HIV prevention for injecting drug users: A review of published outcome data. Public Health Reports 113: 19-30. DiClemente, C.C. (2003). Addiction and Change: How Addictions Develop and Addicted People Recover. New York: Guilford Press. Dimeff, L.A., and Marlatt, G.A. (1998). Preventing relapse and maintaining change in addictive behaviors. Clinical Psychology-Science & Practice. 5(4): 513-525.

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RECEIVED: 04/07/02 REVISED: 09/05/03 ACCEPTED: 12/09/03