Journal of Substance Abuse Treatment 23 (2002) 319 – 326

Regular article
Patient attitudes concerning the inclusion of spirituality
into addiction treatment
Ruth M. Arnold, Ph.D.*, S. Kelly Avants, Ph.D.,
Arthur Margolin, Ph.D., David Marcotte, S.J., Ph.D.
Yale University School of Medicine, Department of Psychiatry, Division of Substance Abuse, New Haven, CT 06519, USA
Received 13 February 2002; received in revised form 12 June 2002; accepted 24 June 2002

Abstract

The purpose of this exploratory study was 3-fold: (a) to determine how ‘spirituality’ is defined by inner-city HIV-positive drug users;
(b) to determine perceived relationships between spirituality and abstinence, harm reduction, and health promotion; and (c) to assess interest
in a spirituality-based intervention. Opioid-dependent patients enrolled in an inner-city methadone maintenance program participated in the
study; 21 participated in focus groups and 47 completed a questionnaire. In the focus groups, two predominant themes emerged: spirituality
as a source of strength/protection of self, and spirituality as a source of altruism/protection of others. A large majority of the larger sample
expressed an interest in receiving spirituality-focused treatment, reporting that such an intervention would be helpful for reducing craving and
HIV risk behavior, following medical recommendations, and increasing hopefulness. African American women perceived spirituality as more
helpful in their recovery than did African American men. D 2002 Elsevier Science Inc. All rights reserved.

Keywords: Spirituality; Addiction; HIV; Methadone; Opiates

1. Introduction Members of AA view the 12 steps as providing guidance for

The incorporation of spirituality themes and foci within
health psychology research is an emerging field (Larson,
Swyers, & McCullough, 1998; Levin, 1996). Although
there is already a substantive literature examining various
dimensions of spirituality with respect to a wide range of
mental and physical disorders (Koenig, McCullough, &
Larson, 2001), there has been relatively little attention
among researchers on the incorporation of spirituality in
the treatment of the addictions (Miller, 1999) or in HIV risk-
behavior studies. This lack of attention represents a consid-
erable gap in our knowledge, given the prominence of such
spirituality-oriented lay programs as Alcoholics Anonymous
(AA) and Narcotics Anonymous (NA), whose 12-step
programs have at their foundation the concept of addiction
as a spiritual, as well as a medical and psychological,
disorder (Alcoholics Anonymous World Services, 1976).
* Corresponding author. CMHC/Substance Abuse Center, 34 Park
Street, New Haven, CT 06519 USA. Tel.: +1-203-781-4690; fax: +1-
203-974-7366.
E-mail address: ruth.arnold@yale.edu (R.M. Arnold).
a way of life, with spiritual processes such as a relationship
with God or a higher power and prayer at its core (Miller &
Kurtz, 1999). Although the specific aspects of religiosity
and spirituality that may influence recovery from addiction
are at present unclear, the extent to which AA and NA
members speak of a higher power as an important force for
change (Green, Fullilove, & Fullilove, 1998) suggests that
spirituality is an important dimension to consider when
studying recovery from addiction.
Research conducted to date supports the contention
that spirituality is a relevant factor to include in addiction
treatments (Avants, Warburton, & Margolin, 2001; Brizer,
1993; Gorsuch, 1994; Kendler, Gardner, & Prescott, 1997;
Mathew, Georgi, Wilson, & Mathew, 1996; Page & Andrews,
1996; Pardini, Plante, Sherman, & Stump, 2000). Pardini and
colleagues (2002) found in a study of 237 recovering
substance abusers that 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. In addition, in a study of over
2000 female-female twins, Kendler et al. (1997) reported that
current drinking and smoking as well as lifetime risk for

0740-5472/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved.
PII: S 0 7 4 0 - 5 4 7 2 ( 0 2 ) 0 0 2 8 2 - 9
320 R.M. Arnold et al. / Journal of Substance Abuse Treatment 23 (2002) 319–326
alcoholism and nicotine dependence were inversely asso-
ciated with personal devotion (such as frequency of pray-
ing and seeking spiritual comfort), fundamentalist
Christian beliefs, and religious affiliation conservatism.
Other smaller scale studies have come to similar conclu-
sions (Brizer, 1993; Mathew et al., 1996). Religion and
spirituality, as potential resources for recovery, may also be
underutilized by clinicians who treat addicted individuals
(Goldfarb, Galanter, McDowell, Lifshutz, & Dermatis,
1997; Miller, 1998).
With respect to HIV risk-behavior research, Des Jarlais
et al. (1997) found that over one third of HIV-negative
injection drug users indicated that ‘‘prayer’’ or ‘‘God’s
help’’ was responsible for helping them avoid engaging in
behaviors that could lead to HIV infection. Our own work
(Avants et al., 2001) with inner-city HIV-positive injection
drug users has shown that strength of perceived religious
and spiritual support is an independent predictor of absti-
nence from illicit substances during methadone maintenance
treatment, controlling for the influence of pre-treatment
variables (addiction and psychiatric severity, CD4 count,
social support, and optimism), and during-treatment varia-
bles (methadone dose and attendance at counseling ses-
sions). We have also found a significant association between
HIV risk behavior and strength of spiritual and religious
faith and characteristics of drug users’ assumptive worlds.
Specifically, strong spiritual and religious faith, the percep-
tion that the world and the people in it are basically good,
and the perception of a meaningful world (i.e., the belief that
outcomes are just, are not randomly distributed, and can be
controlled by personal behavior) emerged as independent
predictors of high risk sexual behavior in a sample of
methadone-maintained drug users (Avants, Marcotte,
Arnold, & Margolin, in press).
Spirituality may be an especially salient dimension of
recovery for HIV-positive drug users (Biggar et al., 1999;
Demi, Moneyham, Sowell, & Cohen, 1997; Florence, Luet-
zen, & Alexius, 1994; Jenkins, 1995; Kaplan, Marks, Mert-
ens, & Terry, 1997; Tangenberg, 2001). These patients are
faced with the stress of a chronic, and potentially fatal,
disease as well as the daily challenges of becoming and
remaining abstinent (Carson, Soeken, Shanty, & Terry, 1990;
Jenkins, 1995; Tsevat et al., 1999; Woods & Ironson, 1999). It
has been suggested that religious faith may provide a buffer
against the depressive effects of stressful life events (Kendler
et al., 1997), and may also play a protective role in physical
and mental health (Benson & Dusek, 1999; Galanter, 1997;
Ellison, 1991).
Despite these encouraging findings, there are currently
few research-based interventions that incorporate spirituality
into addiction treatment. One reason for this may be the
inherent difficulty of defining ‘‘spirituality.’’ An associated
concern is that even if spirituality is operationally defined
for purposes of developing an intervention, it may not be
possible to address the diversity of beliefs and practices
of the patient population. Indeed, current interest in spiritu-
ality within the mental health community has resulted in
a plethora of articles, containing a number of different
definitions (Zinnbauer, Pargament, & Scott, 1999). It
is clear that spirituality is a complex, wide-ranging, multi-
dimensional concept (Larson et al., 1998), and there is
well-recognized difficulty in creating a definition that
encompasses all, or even many, of the apparently relevant
dimensions of this concept, that avoids possible contam-
ination with psychological or other existing constructs, and
that is applicable across manifold populations and disor-
ders (Gorsuch, 1994; Gorsuch & Miller, 1999; Koenig
et al., 2001; Larson et al., 1998).
Given both the complexity and diffuseness of the concept
of spirituality, prior to embarking on the development and
evaluation of a treatment intervention designed to incor-
porate patients’ spiritual and religious faith in the treatment
of addictive and HIV risk behaviors among HIV-positive
and HIV-negative injection drug users, we conducted a
study in order to gain a better understanding of the concept
of spirituality from the perspective of patients. The study
had three goals: (a) to explore how spirituality is defined by
inner-city HIV-positive drug users; (b) to explore perceived
relationships among spirituality and abstinence, harm reduc-
tion, and health promotion, and (c) to assess perceived
helpfulness of a spirituality-based intervention for various
aspects of recovery by sex, race, and HIV-serostatus.
To address the first two goals, focus groups were con-
ducted with HIV-positive injection drug users. Focus groups
are a method of qualitative research that assesses participants’
attitudes and perceptions via researcher-initiated discussions
concerning target topics that may be recorded for subsequent
thematic study. The focus group methodology has been used
to examine a variety of topics in the addictions (Conners &
Franklin, 2000; Green et al., 1998; Nadeau, Truchon, &
Biron, 1997; Rhodes et al., 1999; Shoultz, Tanner, & Harri-
gan, 2000; VanderWaal et al., 2001) and was among several
qualitative approaches included in a technical review on
‘‘Qualitative Methods in Drug Abuse and HIV Research,’’
sponsored by the National Institute on Drug Abuse (Carlson,
Siegal, & Falck, 1995; Shedlin & Schreiber, 1995). Focus
groups are particularly useful for exploring participants’
attitudes towards issues and concepts in order to appropri-
ately incorporate them into systematic interventions (Krueger
& Casey, 2000). Our third goal was addressed by administer-
ing a brief questionnaire to a sample of HIV-positive and
HIV-negative drug users.
2. Materials and methods
2.1. Participants
2.1.1. Focus groups
Twenty-one HIV-positive participants, all enrolled in an
inner-city methadone maintenance program (MMP), com-
prised three focus groups (with 5, 7, and 9 participants).
 R.M. Arnold et al. / Journal of Substance Abuse Treatment 23 (2002) 319–326
Eighteen participants were male and three female. Eleven
participants were white, five were African American, and
five were Hispanic. Mean ( ± SD) age and education of the
participants was 44.2 ( ± 6.8) and 11.6 ( ± 1.7), respec-
tively. All but one of the participants was unemployed, and
all but one had current or past cocaine usage as well as
heroin usage. Three reported they attended AA or NA
meetings 3 –6 times in a typical week, 3 attended 1 –2 times
per week and 14 did not typically attend. Participants
identified themselves as Catholic (13), Protestant (7) and
Other (1). In a typical week, 1 person reported attending
religious services daily, 1 attended 3 –6 times, 9 attended
1 –2 times, and 9 did not attend (missing for 1 patient).
Participants were more likely to pray or mediate in a typical
week than attend services: 8 prayed or meditated daily, 3
prayed or meditated 3 – 6 times per week, 8 prayed or
meditated 1 – 2 times per week, and 2 did not typically pray
or meditate.
2.1.2. Questionnaire administration
Participants in the questionnaire phase of the study were
the 21 focus group participants and an additional 26
individuals (N = 47); all were methadone-maintained and
enrolled in the same inner-city MMP. Mean ( ± SD) age of
participants was 39.4 ( ± 8.22). Of the 47, 60% (28) were
male; 53% (25) were white, 28% (13) African American,
and 19% (9) Hispanic. Fifty-three percent (25/47) were
known HIV-seropositive. Mean years of education was
11.9 ( ± 2.1). Of the 47, 87% (41) were unemployed; 81%
(38) were injection drug users; 46 were cocaine users, and
had been using cocaine for 16.0 ( ± 7.8) years; all were
opioid-dependent, and had been using opiates for 15.9
( ± 9.45) years. Religious affiliation was as follows: of the
47, 21% (10) Protestant; 60% (28) Catholic; 2% (1) Jewish;
2% (1) Muslim; 9% (4) other; and 6% (3) none.
2.2. Procedures
2.2.1. Focus groups
Three focus groups were conducted. Participants were
members of established groups for HIV-positive injection
drug users that met regularly to discuss drug abstinence and
health care. The focus group sessions were conducted in late
September and early October 2001 during participants’
regularly scheduled group times. Prior to the focus group
discussion, participants were asked to complete a short
demographic, religious affiliation and practices form, as
well as a 5-item Perceived Helpfulness of Spirituality
(PHS) questionnaire. The five questions included in the
PHS were:
1. How helpful would it be to have a treatment that
addresses your spiritual or religious faith?
2. How much would a treatment that addresses your
spiritual or religious beliefs help you to reduce your
cravings for drugs?
321
3. How much would a treatment that addresses your
spiritual or religious beliefs increase your motivation
to reduce harm to yourself or others (for example, not
sharing needles and not having unsafe sex)?
4. How much would a treatment that addresses your
spiritual or religious beliefs increase your motivation
to follow medical recommendations (for example,
taking your medications exactly as prescribed)?
5. How much would a treatment that addresses your
spiritual or religious beliefs increase feelings
of hopefulness?
Items were rated on a scale from 0 (not at all) to 4
(extremely). Written consent was obtained from participants,
who received US$10 vouchers for merchandise at a depart-
ment store as reimbursement for participating. The sessions
were led by the first author (RMA), who has been trained as a
focus group moderator and who had not had previous contact
with the participants. The regular counselor of the groups
did not attend. Sessions were tape recorded and transcribed.
2.2.2. Questionnaire administration
Twenty-six non-focus group participants completed the
PHS questionnaire in October 2001. These participants were
active in various research projects, and the PHS was
included in their assessments. Written consent was obtained
for the respective projects, as well as IRB approval to
include the PHS. Patients were paid US$25 in vouchers
for completing the PHS and the remaining assessments.
2.3. Data analysis
2.3.1. Focus groups
The participants in each focus group were asked several
questions about spirituality, including how they conceptual-
ized it, what role spirituality played in their recovery from
addiction, in what ways spirituality influenced the like-
lihood of engaging in health promoting behaviors, and
whether they were interested in having a spirituality-focused
component included in their substance abuse treatment.
Using standard focus group methodology, these questions
were examined across the three focus group sessions to
determine common themes (Krueger & Casey, 2000). Based
on the transcripts, quotes from the different sessions were
rearranged by question, allowing common threads across the
groups to become more evident.
Quotations are presented below to illustrate participants’
attitudes, grouped by common responses. Similar ideas were
expressed in at least two of the three focus groups, unless
otherwise indicated. If quotes about an issue were drawn
from only one group, at least two individuals must have
concurred on the topic to be included in the Results section.
2.3.2. PHS questionnaire
Individual items were entered into Multivariate Analysis
of Variance (MANOVA) and analyzed by sex, race, and
322 R.M. Arnold et al. / Journal of Substance Abuse Treatment 23 (2002) 319–326
HIV serostatus. Significant MANOVAs were followed by
univariate ANOVAs and, as appropriate, with simple effects
tests to examine significant interactions. In addition, in order
to provide an estimate of the representativeness of the focus
group participants to the larger sample, scores of the focus
group participants on the questionnaire were compared to
those who did not participate in a focus group.
3. Results
3.1. Focus groups
Participants in the focus groups seemed willing and eager
to talk about their understanding of spirituality, and its role in
their recovery. We were not sure how the topic would be
received, as spirituality/religion could be a highly personal
issue, or even a divisive issue for the groups, if interpretations
of spirituality or religious backgrounds clashed. However,
these concerns were fortunately unfounded: participants were
mutually respectful of each other’s views at all times.
Furthermore, they often told highly personal testimonials
concerning their religious/spiritual experiences and shared
ways in which spirituality/religiousness has influenced their
recovery, living with HIV, and engaging in risky behaviors.
Subsequent analysis of the focus group transcripts
revealed two themes concerning how focus group partic-
ipants usually conceived of, or expressed, spirituality in
their daily lives: as protector/helper to self, and as altruistic/
helpful to others. These conceptualizations were not mutu-
ally exclusive, and which one was prominent depended to
some extent on the issue being discussed. The following
section provides quotes from participants to illustrate the
expression of these themes in a number of relevant subjects.
3.2. Definitions of spirituality
When introducing the topic for the focus group, partic-
ipants were asked what first comes to mind when thinking of
the word ‘‘spirituality.’’ Not surprisingly, many initial
responses included organized religion, attending worship
services, and God or a higher power. Examples of God or
a higher power responses were: ‘‘Well, I’m a very religious
person. It means how a certain person feels about their own
spirituality, which means their relationship with God.’’
‘‘Spirituality to me is believing in a person that you really
care about the most. I use my daughter as my higher power.’’
After these initial responses, the comments about spir-
ituality shifted and tended to reveal a more internalized
conceptualization, usually suggesting a view of spirituality
as a protector or helper to self. Many referred to a subcon-
scious or inner voice that ‘‘talked’’ to them while chastising
or encouraging: ‘‘Even though I have made wrong choices, I
knew what the right choices were and I went against my
higher power inside of me telling me, ‘It’s wrong. It could
hurt you,’ or ‘You shouldn’t do it.’’’
Others viewed their spirituality as an inner source of
strength or the sense of having found oneself, which also
served as a helper to self: ‘‘I think it is just a struggle you
as a person go through. Realizing the qualities you
have inside of you, and the strength you have inside of
you.’’ ‘‘Spirituality for me is when you are trying to find
yourself.’’ For a few participants in one group, to be
spiritual included helping others, the alternate theme that
emerged about spirituality.
3.3. Spirituality and recovery from addiction
Praying and belief in a higher power were most com-
monly cited as coping strategies in recovery from addiction.
As previously mentioned, 19 of the 21 participants prayed
or meditated at least once or twice a week, with 8 of those
praying on a daily-basis. Spirituality was conceived as a
protector/helper to self in these comments, as group mem-
bers asked for forgiveness or strength: ‘‘What I am saying is
that I don’t got the strength he [another participant] got. If
you bring dope in here I can’t say no. . ..I want to get high.
Therefore, I ask God, God Help me. Give me the strength so
that I can say no.’’
Many participants claimed that it was due to their belief
in God that they had achieved abstinence in the past or were
currently clean. This quote is typical of focus group mem-
bers who used spirituality as protector/helper to self: ‘‘I
incorporate the Lord in my life. Do what His will be, as best
I could. Sometimes I succeed. Sometimes I fail. But I never
give up. That is what works for me. It worked for me in the
past. When I indulged myself into the Lord, I was clean.
Because of that, spirituality, I was clean.’’ Another partici-
pant had this to say about maintaining her abstinence: ‘‘If
God did not help me, if God wasn’t there in my life, I don’t
think I’d be clean. I really don’t. . ..God gives me the
strength to be clean.’’
3.4. Spirituality and living with HIV
Many focus group members shared stories about near-
death experiences, either because of drug overdoses, having
full-blown AIDS, or suicide attempts, as well as about the
deaths of friends and loved ones to AIDS. For others, living
with HIV has resulted in a preoccupation with death. What
is interesting about these experiences, and what ties them
together, is that participants seem to have become more
spiritual because of them. Having ‘‘looked death in the
face’’ and survived has given many focus group members a
new lease on life. On learning he was HIV-positive, this
patient initially became depressed and suicidal, but then
made a choice to live to glorify God: ‘‘Everything was
wrong with me. And something told me inside myself, you
have a choice. You can either continue down the path of
destruction or you can ask God for forgiveness of what I
have done in the past and what I have done today and
continue on with my life.’’
 R.M. Arnold et al. / Journal of Substance Abuse Treatment 23 (2002) 319–326
Testing HIV-positive provided the impetus to enter
addiction treatment for a few. The following patient began
to value his life and friendships more after learning he was
HIV-positive: ‘‘For me AIDS, has taught me to value my
life. To worry about my health. . ..But when I became HIV,
after I went through what I went, I said, I got to grow up.
I wanted to change. I wanted to stop using drugs and doing
what I was doing. It’s like I was killing myself faster. . ..And
then when I accepted it, I started to value things. I started to
value friendship.’’
Others felt that the fact that they had come so close to
death, or that they themselves were still healthy despite
being HIV-positive, must mean that there was some reason
they were supposed to be alive, a reason that did not include
using drugs. ‘‘Why am I still this healthy? What is the
reason here? I think that played a part in the reason for me
trying to straighten out my life. You know? Quit being a
jerk. What the hell are you doing? They’ve given you a
freebie here. You’re supposed to be dead.’’ Another patient
stated: ‘‘I OD’ed [overdosed] twice. I mean literally died,
and He brought me back. . ..He brought me back for a
reason. And then I’m living with HIV. There’s got to be
something out there today that He wants me to do.’’
3.5. Spirituality and reducing HIV transmission
Few focus group participants spoke about spirituality
explicitly in connection with whether they did or did not
engage in risky sexual or drug-using practices that could
result in HIV transmission. In addition, none of the group
members admitted to having recently engaged in any sexual
or needle-sharing behaviors that would put others at risk.
The explanations they usually provided were altruistic.
Those who were married or had steady partners
claimed that they used condoms when engaging in sexual
intercourse. Love for their partners and a desire not to
transmit HIV were cited as the primary reasons for
engaging in safer sexual practices, both of which can be
conceived to be altruistic. Focus group participants not
involved in steady relationships were also altruistic; they
usually stated that they engaged in safe sex, or at a
minimum told their partners they were HIV-positive before
engaging in sexual activity. As one patient stated, ‘‘Me,
myself, personally, I have to let the person know [that I
am HIV-positive], and then whether we use a condom or
not, that’s just an adult decision.’’
With regard to needle sharing and the use of potentially
contaminated needles, most participants claimed that easy
access to clean needles in their community (e.g., the ability
to purchase needles at a pharmacy and to obtain needles
from needle exchange vans) has made needles a ‘‘non-
issue’’ in terms of spreading HIV. Altruistic reasons cited
for not letting others use their needles, at least unclean
needles, included concern about the possibility of transmit-
ting HIV to others, and that it was simply ‘the right thing to
do.’ One participant expressed it this way: ‘‘I think about
323
doing harm to people and what not, because I am a strong
believer in that, the way I put it, what goes around comes
around. You reap what you sow. I figure if I put someone
else at risk or harm someone else, it’s coming back my way
one day.’’
There were a few who explicitly cited their spiritual faith
as the impetus for not sharing needles and other parapher-
nalia. ‘‘When I was ignorant, let’s say, when I didn’t know
about this HIV needle thing, I shared needles like everybody
else. I didn’t have a higher power or spirituality to guide me
to not do it. But, now it’s like another life. It’s like I am
living in another century. I don’t do the things I did before,
because of my spirituality.’’
Perhaps for the reasons they mention, mostly altruistic,
focus group participants did not engage in risky sexual or
drug-using behaviors. However, it should be noted that
participants also met regularly in the context of their
methadone maintenance treatment. Given that they would
continue to interact with each other and with other metha-
done maintained patients, it is unlikely that they would be
forthcoming with examples that indicated they had put
others at risk.
3.6. Spirituality and adherence to medical recommendations
Many focus group participants were prescribed com-
plex medical regimens for the treatment of HIV, whereas
others indicated that their HIV health care provider did not
feel HIV medications were yet necessary. Most of those
taking medications did not attribute medication adherence
to their spiritual faith. A few, however, did express thanks
to God for the medications that allowed them to maintain
their health; their comments contributed to the theme of
spirituality as protector/helper to self. ‘‘I was on death’s
door, supposedly, and I thank God every day that the
scientists were able to come up with the combination of
medications that they did.’’ In addition, as noted previ-
ously, many focus group members are grateful that they
are still alive, despite being infected with HIV and having
watched friends die with AIDS. This sense of gratitude
seemed to have inspired them to work hard to remain
abstinent from illicit drugs, which, in turn, serves to
maintain their health.
3.7. Patient interest in integrating spirituality into addiction
treatment
Overall, focus group members reported interest in having
a spiritual/religious component to their addiction treatment.
This was evident throughout the course of the discussion, as
well as from the PHS questions, discussed in the next
section with the full sample. When asked if they felt a need
for an intervention that would specifically integrate spiritu-
ality into their addiction treatment, most patients were
supportive. ‘‘Oh, absolutely. I think I need it more than
anything.’’ ‘‘Like once a week is good for me.’’
324 R.M. Arnold et al. / Journal of Substance Abuse Treatment 23 (2002) 319–326
3.8. Questionnaire: Perceived helpfulness of integrating
spirituality into addiction treatment
Of the 47 methadone-maintained patients who completed
the PHS questionnaire (Inter-item reliability alpha = .91),
the majority reported that an intervention that integrated
their spiritual and religious faith into addiction treatment
would be helpful in their recovery. Median scores for
the first four questions were 3.0 (‘a lot’), and for perceiv-
ed effect on increasing hopefulness the score was 4
(‘extremely’). There were no main effects for sex, race, or
HIV serostatus. However, there was a significant multi-
variate Sex by Race interaction; F(5, 38) = 2.56, p = .04.
Subsequent univariate ANOVAs were significant for 3 of
the 5 items ( p < .05; df = 2,41; F = 4.33, 5.06, 5.26,
respectively). Examination of simple effects tests revealed
that African American females had higher mean scores than
did African American males on perceived helpfulness of
integrating spirituality into addiction treatment: females =
3.50 ( ± 0.55); males = 1.71 ( ± 1.50); t(11) = 2.75, p = .019;
for HIV harm reduction: females = 3.00 ( ± 1.55); males =
1.29 ( ± 1.25); t(11) = 2.21, p = .049; and for increasing
hopefulness: females = 3.67 (± 0.52); males = 1.86 (± 1.68);
t(11) = 2.53, p = .028. There were no significant sex
differences for white or Hispanic patients. Focus group
participants did not differ from non-focus group participants
on any item of perceived helpfulness of spirituality.
4. Discussion
We conducted an exploratory study aimed at assessing
a number of issues germane to offering a spirituality-based
treatment to methadone-maintained drug users enrolled
in an inner-city MMP. During focus groups with HIV-
positive drug users, participants were quite willing to
discuss their own interpretations of spirituality and to share
their spiritual/religious experiences. Despite the variability
in how spirituality was conceptualized by participants, two
primary themes emerged during the course of the focus
groups: (a) spirituality as a source of personal strength/
protector of self; and (b) spirituality as altruism/protector of
others. Spirituality as protector of self was most evident
when focus group members discussed their recovery from
addiction, having to face their own mortality due to HIV,
and available medical treatments, whereas spirituality as
protector of others was most evident when participants
talked about HIV harm reduction behavior (e.g., not
sharing drug paraphernalia and not engaging in unsafe
sexual practices).
The inner-city drug-users participating in the current
study expressed an interest in being provided with an
intervention that addresses spirituality. However, it was
clear from the focus group discussions that any intervention
that attempted to address the spiritual needs of drug users
would need to be flexible enough to allow for several
interpretations of spirituality, including a conceptualization
of spirituality that does not include belief in a ‘‘higher
power.’’ This is not to suggest that spirituality should be
conceived as either theistic or non-theistic. Rather, individ-
uals should be able to define it for themselves. As Miller
(1998: p. 980) states, spirituality is understood to be
operative at the level of the individual, and its definition
‘‘must be one that does not rely upon particular religious
contexts, that is accessible and observable regardless of
one’s personal beliefs, and that can thereby be used to
characterize all people’’.
Findings from the questionnaire administration among
the larger sample indicated that participants thought that
addressing spirituality in addiction treatment would be
helpful in their recovery, for reducing craving, for reducing
HIV risk behavior, for following medical recommendations,
and particularly for increasing hopefulness. The vast major-
ity expressed an interest in receiving a spirituality-focused
intervention. There were no significant differences in per-
ceived helpfulness of spirituality in recovery by HIV-seros-
tatus. However, there was a Sex by Race interaction, with
African American women perceiving spirituality as more
helpful than did African American men, a finding that is
generally consistent with the literature (Kaplan et al., 1997).
This latter finding suggests that researchers should be
sensitive to possible gender, sex and cultural differences
in how spirituality is perceived.
This study has several limitations that should be taken
into consideration in the interpretation of findings. The
focus groups were small and the participants were not
randomly selected, and, therefore, the data may not be
generalizable to larger populations. Furthermore, the par-
ticipants knew one another and met regularly, suggesting
that they might have been influenced more than usual to
make socially appropriate responses. The data from the
questionnaire are similarly based on a small sample, and
should be interpreted conservatively. Lastly, it is possible
that participants’ past or current attendance at AA or NA
meetings may have influenced them to respond in an
‘‘AA-appropriate’’ fashion.
Our finding that the incorporation of themes involving
spiritual and religious faith into addiction treatment was
welcomed by the drug users in our sample will come as no
surprise to many substance abuse counselors, and certainly
not to advocates of AA and NA self-help groups. Neither
is the study of spirituality new to the field of psychology.
On the subject of the spiritual self, William James (1890/
1950) wrote over a century ago, ‘‘And the spiritual self is
so supremely precious that, rather than lose it, a man
ought to be willing to give up friends, good fame,
property, and life itself’’ (p.315). James, as with many
contemporary clinical psychologists and theorists (e.g.,
Miller, 1998), also viewed spirituality as a dimension of
human experience that warranted scientific investigation.
We hope that findings such as ours, although preliminary,
will encourage clinicians and researchers to develop spir-
 R.M. Arnold et al. / Journal of Substance Abuse Treatment 23 (2002) 319–326
ituality-focused interventions that can be subjected to
empirical evaluation.
Acknowledgments
Supported by grants K21-DA00277, R01-DA10851,
P50-DA09241, and P01-MH/DA-56826, National Institute
on Drug Abuse.
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