Religious and Spiritual Beliefs and Attitudes Towards Addiction and Addiction Treatment

Abstract
Introduction: Throughout history, ideas about addiction have been informed and influenced by religious belief and practice. Even continuing into the present, religion and spirituality are often thought to impact attitudes towards addiction and its treatment, particularly given the use of religion and spirituality in various well-known treatments such as Alcoholics Anonymous.
Although research has flourished with regards to the role that addiction and spirituality might play in vulnerability to addiction or the treatment of addiction, there has been comparatively less research examining how religion might impact attitudes toward addiction more broadly.
Method: The present work sought to examine the current state of empirical literature evaluating the relationships between religion and attitudes toward addiction and addiction treatment. In service of the above aim, a scoping review was conducted. Results: This summary of peer- reviewed, quantitative studies (n=36) found that higher religiosity is related to more belief in the disease model of addiction in providers, negative attitudes towards addiction, and a stronger support for spiritually based treatments. However, results varied based on the measures used and many relationships tested were not significant. There also appeared to be differences in the interaction between religion and spirituality and other variables, such as the respondent’s sex or whether the individual was a student or provider, in terms of attitudes. Conclusions: Further research is needed to fully understand the nuances in the relationship between these variables, including more clear operationalization and standardized measurement. Until such research is conducted, no cohesive conclusions can be drawn, and clinical implications remain unclear.
Keywords: religion and spirituality, addiction, addiction treatment, and attitudes.

In 2017, roughly 6% (19.7 million people) of Americans over the age of 12 met criteria for a substance use disorder in the previous 12 months (Substance Abuse and Mental Health Services Administration, 2018). Similar research with behavioural addictions1 suggests approximate population prevalence rates in the United States of 1-3% for Gambling Disorder (Welte, Barnes, Tidwell, Hoffman, & Wieczorek, 2015), 0.3-1% for Internet Gaming Disorder (Przybylski, Weinstein, & Murayama, 2017), and 3-6% for Compulsive Sexual Behaviour Disorder (Kuzma & Black, 2008). Each of these figures represent millions of individual people within the United States alone, and similarly high numbers found throughout the world suggest that addictions are a significant contributor to global disease burden (Degenhardt et al., 2018). Ultimately, recent estimates suggest that addiction in the United States bears an economic cost of over a trillion dollars a year in medical expenses, crime, lost productivity, and loss of life (Recovery Centers of America, 2016). Given the frequency of these disorders, their enduring presence in the public consciousness, and the costs associated with them, there is a persistent need for research into domains that may affect those suffering from addiction or provide relief and recovery for them. One such domain of interest is religion and spirituality (hereafter: religion/spirituality)2.

1 Behavioural addictions remain highly controversial within psychological and psychiatric research, with mental health research communities generally acknowledging that some behaviours can become dysregulated or compulsive but disagreeing whether or not such dysregulation represents true addiction or some other form of psychopathology (e.g., Griffiths, 2017; Kuss & Griffiths, 2015). Although such debates bear very strong implications for the conceptualization and treatment of out-of-control behaviour patterns, the present work does not seek to debate this particular issue. More specifically, for the present work we refer to behavioural addictions for the sake of parsimony, though we acknowledge that the status of such addictions is still subject to ongoing debate.
2 Religion or religiosity refers to a person following a set of beliefs and practices about their spiritual life prescribed by an institution (e.g., Christianity). Whereas spirituality refers to an internal belief or practice of an individual

In recent years, there has been a notable increase in the study of religion and addiction (Benda & McGovern, 2006; e.g. Faigin, Pargament, & Abu-Raiya, 2014; Grubbs, Exline, Campbell, Twenge, & Pargament, 2017; Stauner, Exline, Kusina, & Pargament, 2019). Of note, this increase is in empirical attention, as various religious and spiritual (r/s) communities around the world have recognized for millennia that behaviours and substances may be potentially addictive and cause negative consequences (e.g., Sura Ma’idah 5:90-91). Throughout history, religious beliefs and attitudes have affected the way many people see the world and view others’ behaviours, particularly with regards to addiction. For example, the American temperance and prohibition movement is often viewed to have stemmed from religious, Protestant beliefs (Schmidt, 1995); and the most ardent believers in the potentially addictive nature of pornography or sexual behaviours tend to be the highly religious (e.g., Bradley, Grubbs, Uzdavines, Exline, & Pargament, 2016). However, between and within religions, there is variability surrounding which substances and behaviours should be avoided or followers should be wary of, with some faith traditions having codified, explicit instructions about what followers should do with those who are addicted (Royce, 1985).
Importantly, the effects of religion on addiction treatment are likely amplified in the United States, relative to many other affluent Western nations, as many of the largest substance abuse and behavioural addiction treatment and recovery programs are affiliated with religion either formally or informally. For example, the r/s influences in 12-step programs, such as AA and GA, are well-documented (e.g. Dossett, 2013; Witkiewitz, Mccallion, & Kirouac, 2016), and promotional materials for Celebrate Recovery (an evangelical Christian based 12-step addiction recovery program) boast a membership of 29,000 churches in the United States and a participant regarding the spiritual domain. In this way, an individual may be religious, spiritual, both or neither, and both terms refer to an individual’s thoughts and practices within the spiritual domain (Hill & Pargament, 2003).

reach of over 3.5 million people (www.celebraterecovery.com). Furthermore, research suggests that aspects of spirituality are useful and encouraged within addiction treatment (e.g. Heinz et al., 2010). Additionally, r/s traditions likely influence the addiction attitudes of more secular individuals. For example, a strong, overt r/s tradition’s presence in a society may impact political policies and, therefore, the views of more secular individuals who live there. As such, r/s beliefs and attitudes likely influence how individuals and societies view, and treat, those with addictions, regardless of the individual attitudes of the persons with addiction or the persons treating those with addictions. Based on the above factors then, there is a need to understand how r/s affects individuals’ views of addiction and how it should be treated. Based on this need, the purpose of the present work is to conduct a scoping review of current literature that examines how individual religious beliefs influence attitudes toward and beliefs about addiction, both in the United States and other countries.

There are references to addiction in five of the major world religions, as well as references to when substances or behaviours are encouraged or should be used with caution. There are, however, differences in views and strengths of attitudes surrounding what could become addictive or is helpful in r/s traditions. For example, some traditions suggest that behaviours and substances are acceptable if they are done in moderation and some even use substances or behaviours to access their Higher Power or create community and raise money. In some Native American spiritual traditions, some psychoactive substances may be used in some circumstances to experience a better connection to Earth, the self, or others, and thus bring understanding. (Oklevueha Native American Church Sacrament, n.d.). Similarly, Judeo-Christian traditions often use alcohol in rituals, such as the Jewish Passover festival and the celebration of the Eucharist in Catholic churches. In contrast, some Christian denominations disagree with the

use of alcohol during any sacraments and suggest that such practices may lead to a problematic relationship with alcohol and therefore instruct followers to refrain from drinking (e.g., United Methodist Church). Others still are silent on the matter and leave it to the follower’s conscience to decide whether to use alcohol (e.g., British Baptist Union).
Similar patterns as above are evident in behavioural addictions as well. For example, gambling is sometimes accepted as a form of raising money in Christian traditions, whereas it is not acceptable in others (Cohen & Schwartz, 2018). Similarly, religious groups often encourage specific forms of sexual behaviour. For example, in some Buddhist traditions, tantra is used as a way of having sex to attain enlightenment (Douglas & Slinger, 1979). Many other r/s traditions encourage individuals to have sex within the context of heterosexual marriage to encourage a healthier relationship, both between the people involved and with the Higher Power, as well as to avoid possibly harmful sexual behaviours (Pope John Paul II & Waldstein, 2006). Yet, many other forms of sexual behaviours (i.e., pornography use) are explicitly condemned, with the addictive potentials of such behaviours often being invoked as a reason for religious opposition to their use. Further complicating matters, many r/s traditions are silent on the majority of specific behaviours that may be considered addictive, such as video game play (Grubbs & Grant, 2020). In sum, though many belief systems across the globe often acknowledge addiction and, in many cases, have strong proscriptions around engaging in addictive behaviours or processes, there is little consistency across or within religious traditions regarding the pantheon of potentially addictive behaviours. As such, it is difficult to draw clear inferences regarding the effects of religious belief on perceptions of addiction and addiction treatment.

There are several theoretical models that influence how the scientific and medical communities view addiction and addiction treatment. These most commonly include:1) the Medical/Disease model, which suggests that the substance or behaviour effects the brain’s structure or functioning (e.g., Volkow & Morales, 2015) directing practitioners towards pharmacology treatments (e.g., Grant, Odlaug, & Schreiber, 2014; Jorenby et al., 2002); 2) the Moral/Ethical model, which focuses on whether an action is morally “good” or “bad,” and views addiction as a sin or the behaviour/substance as an evil, leading to various treatment suggestions, which in the more religiously based versions tends to be based on religious teachings (e.g., Celebrate Recovery; Iran Human Rights Documentation Center, 2012; The United Methodist Church, 2016); and 3) the Biopsychosocial model, which emphasizes the role of social and psychological factors as well as brain functioning (e.g., Blaszczynski & Nower, 2002) supporting the use of therapy alongside pharmacology (e.g. Carroll et al., 2003) and the importance of social connections, such as AA (Tracy & Wallace, 2016). Not surprisingly, it seems that religion might influence which of these models any given individual places credence in.
R/s views often influence notions of how to treat addiction or those thought to be acting in a way that could become addictive. Oftentimes this mirrors the r/s tradition’s beliefs and attitudes towards the behaviour or substance itself. That is, oftentimes a religious group’s teachings about substance use informs how that group approaches the treatment of individuals addicted to such a substance. For a particularly extreme example, Articles 136 and 264 of Iran’s Penal Code suggest, by invoking Islamic Sharia law, that a person convicted of drinking three times must receive the death penalty (Iran Human Rights Documentation Center, 2012). In a more general example, AA (which is deeply religious in many regards, e.g., Dossett, 2013; Witkiewitz et al., 2016) notes that it works towards abstinence only for the sake of restoring a healthy relationship with the Higher Power (Alcoholics Anonymous World Services Inc, 2018). Moreover, as noted above, r/s traditions administer and manage many treatment facilities and recovery programs (e.g. AA; Timberline Knolls, 2019). These programs often offer a range of resources, from support groups to medication-assisted recovery programs. Additionally, some r/s traditions are moving towards an acceptance of harm reduction and maintenance practices. For example, some mosques are now being used as centres for medication-assisted recovery, including methadone maintenance (Rashid et al., 2014).
R/s traditions often manage behavioural addiction treatment centres and programs. For example, Lutheran Social Services manages one of the largest gambling counselling networks in North Dakota (www.gamblernd.com) and Pure Life Ministries works with individuals to reduce sex addiction symptoms (www.purelifemisitries.org). Similarly, in an extreme example, Kyle Long (the alleged shooter in several Atlanta area spas in March of 2021) spent substantial time in an evangelical, inpatient sex addiction treatment program in the greater Atlanta area (Berman, Shammas, Armus, & Fisher, 2021). Importantly, however, the behaviour that is the focus of an addiction may strongly influence the type of treatments viewed as acceptable by the religious group involved in treatment. The United Methodist Church’s Social Principles states that “As an act of faith and concern, Christians should abstain from gambling and should strive to minister to those victimized by the practice.” Therefore, even though they teach against gambling at any point, they also recognize the difficulty of addiction and encourage their followers to help gamblers to attain abstinence. Conversely, in the case of sexual addiction, it is more likely that r/s traditions would support moderate use, within a church sanctioned relationship, given that the behaviour is more socially accepted and seen as central to human nature (e.g. Pope John Paul II & Waldstein, 2006).