Spirituality and the Treatment of the Dually Diagnosed within the Community This paper explores the use

of spirituality and its effects on the treatment of clients in a community setting with a dual diagnosis of both a substance use disorder and a major mental disorder. Spirituality, while essential in the holistic and effective treatment of clients with a dual diagnosis, remains a vague and elusive concept to the profession of nursing. As such, it has been difficult for the nursing community to fully implement spirituality into plans of care for clients. This is due to an ambiguity about the nature of spirituality related to a decontextualization of the meaning of spirituality within the profession of nursing. The effectiveness of the use of spirituality in treatment of those with dual diagnosis in the community setting is largely exhibited in the formation and implementation of specialized 12step group programs. In these programs, outcomes are arbitrated by several factors: belief in 12step principles, spirituality, and the instillation of hope (Magura, Knight, Vogel, Mahmood, Laudet & Rosenblum, 2003). Within the context of the 12-step program, spirituality is defined individually and is not considered a religious practice. However, the 12-step program relies heavily on the principle that the client is not capable within his or her own will to continue in remission and thus must give oneself over to a higher power (Davis & ONeill, 2005). This is the general commonality amongst the relativistic ideas of spirituality within all 12-step programs. It was found that spirituality supplied by the dually focused self help groups in the community, directly correlated with more frequent use of health promoting behaviors such as reflection, medication adherence, regular medical care, and regular self-care (Magura, Knight, Vogel, Mahmood, Laudet & Rosenblum, 2003). It was also noted that spirituality became an important tool for some in the recovery process within community treatment through the engagement of altruistic activities, specifically sponsorship of individuals related to 12-step programs (Brooks, Malfait, Brooke, Gallagher, & Penn, 2007; Cheney, Galanter, Dermatis, & Ross, 2009). Many participating in 12-step programs cited the program as a trigger to return to a spiritual belief system they had discarded when beginning to use drugs. Such a return was credited with providing support and helping maintain abstinence (Magura, et al, 2003). In additional studies, it was noticed that the integration of both biomedical and spiritual treatment yielded greater improvement in the outcomes of dually diagnosed clients than providing both services separately (Cheney, Galanter, Dermatis, & Ross, 2009; Galanter, 2006). It is important to note that traditional 12-step programs have been found to be inadequate in meeting the complex needs of dually diagnosed clients and there is a greater need for 12-step programs that specifically address the dual nature of these clients problems (Brooks, Malfait, Brooke, Gallagher, & Penn, 2007; Horsfall, Cleary, Hunt, &Walter, 2009). The desire for mentally ill clients to discuss spirituality and be treated with a spiritual aspect in their care is made evident in many of the studies mentioned. Additionally, completely holistic

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treatment, which incorporates spirituality, is indicated in the dually diagnosed for the treatment goal of dual recovery (Drake, 2007). Wilding, Muir-Cochrane, and May recommend that in clients with mental disorders, such as those dually diagnosed, health professionalsbe more open to clients spiritual experiences, even though the relationship between discussing spirituality and exacerbating spiritually based psychosis remains unresolved (151). Hammond offers four criteria suggested by Greenberg and Witzum for distinguishing between a spiritual experience and psychosis: psychosis is more intense than a religious experienceoften terrifying and preoccupying for the individualassociated with deterioration in the client caring for him or herself[and] often involves special messages from religious figures (35). While not conclusive or exhaustive, the four criteria may help in ruling out psychosis in the process of implementing spiritual care in conjunction with information on pre-episodic functioning, especially from religious leaders who were active in the clients life. In large part, recommendation of clinical implementation must start with self-discovery of ones spiritual orientation. It has been shown that those who are comfortable with their views on spirituality are often more comfortable discussing them with others (Hammond, 2003; Wilding, Muir-Cochrane, & May, 2006). From this point on, spiritual treatment is largely determinate on the definition of spirituality which one takes and, for the most part, the articles take an all inclusive, open-minded stance on spiritual incorporation into a plan of care. In taking such a definition, it is essential to ask open-ended questions of the patient in order to discover the clients views and perspectives on spirituality (Hammond, 2003). Such an approach brings out more than an assessment tool would and also allows the nurse to build a trusting therapeutic relationship with the client, a key component of bringing about positive outcomes in care (Brooks et al, 2007). Frank discussion of spirituality is stated by Wilding, Muir-Cochrane, and May as being essential to quality holistic care and in order to fully achieve discussion of spirituality the provider may need to briefly disclose their own view on spirituality. At this juncture in the relationship, it is posited by Hammond that further spiritual treatment can be implemented through basic psychosocial actions of acceptance, compassion, and agape love toward the client. Such actions can best be shown through providing a warm open and supportive atmospherevaluing [the] client (35) and furthered through adopting Rogers four core values to a counseling relationship: empathy, genuineness, respect, and unconditional regard (35). Hammond also proposes that love can also be demonstrated through referring clients to various agencies or persons in order to ensure the client food, housing, shelter, clothing and that their physical health is being attended (35). These measures are also correlated with reduced the risk of relapse in both substance use and psychological episodes (Brooks et al, 2007; Davis & ONeill, 2005; Drake, 2007; Magura, et al, 2003). Another psychosocial intervention proposed by Hammond to deal with spirituality include implementation of motivational interviewing if the client feels lost, alone, meaningless, or angry

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and afraid may help in cases of ambivalence. This intervention helps promote a feeling in the client that the health care provider believes they can change and thus the client is more likely to change because someone believes that they can (Drake, 2007; Hammond, 2003). This concept includes the general approval of those within the clients support group which includes family, friends, and additional health providers and has been seen to have a correlational effect on recovery and relapse prevention (Brooks et al, 2007; Drake, 2007; Davis & ONeill, 2005) Referral to a specialized 12-step group is indicated with dually diagnosed patients based on positive long-term outcomes and increased attention to spirituality within the group (Brooks et al, 2007; Drake, 2007; Horsfall, Cleary, Hunt, &Walter, 2009; Magura, et al, 2003). For future treatment of spiritual needs of dually diagnosed clients, advocating for integration of both biomedical and spiritual treatment is needed for it has been correlated with greater improvement in the outcomes of dually diagnosed clients than if both services were provided separately (Cheney, Galanter, Dermatis, & Ross, 2009; Galanter, 2006). While the usefulness of including spirituality in the treatment of dually diagnosed clients within the community is apparent, spirituality nonetheless remains a vague and elusive concept to the profession of nursing. This has been argued by Clarke to be due to the lack of critique in defining spirituality within the profession of nursing and as such has resulted in an approach that has been unwilling to seek out input from other professions, thus neglecting the best use of knowledge from other disciplines (1672). Clarke goes on to point out that the current view of whatever [gives] a persons life meaningrepresent[s] their spirituality becomes so unconditional and decontextualized in meaning that it can lead to viewing spiritual care as synonymous with psychosocial care as is evident in Hammonds suggestion that psychosocial treatment is concurrent with spiritual treatment. While psychosocial treatment may be an offshoot of spiritual consideration in the treatment of a client, it is certainly not synonymous with spiritual treatment even if it has the underlying cause of spiritual consideration. Furthermore, such a view must necessarily view all spirituality, including negative and antisocial beliefs, to be acceptable as spirituality and must be fostered and treated as such (Clarke, 2009). Wilding, Muir-Cochrane, and May state an additional problem as being that spirituality is poorly understood in relation to mental illness, especially related to potential psychosis exacerbation. Wilding, Muir-Cochrane and May additionally state that differentiating between mental illness and spiritual experiences continues to remain a problem in implementing spirituality into treatment, yet, as mentioned before, they recommend discussion of spirituality regardless. As can clearly be seen, most interventions suggested as best practice by the articles reviewed in this paper fall under the psychosocial area of practice in nursing. Clarke contends that this is a result of nursing defining spirituality in too large, too existential and too inclusive [of a definition] to be manageable in practice without being indistinguishable from psychosocial care (1672). Clarke suggests that the profession of nursing needs to revise its view of spirituality and

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contextualize it by looking outside the profession in order to help redefine its definition. Clarke offers the proposition that spirituality should be contextualized by the end it is directed to and by its motivation and also having to do with ultimate concernthe propensity to give more than pleasure and to point to the answering of fundamental questions of life[beliefs] grounded to your very being (1670). In the end, the definition of spirituality needs to be revised to better serve all clients in contact with the profession of nursing. The one-size-fits-all model that currently exists is inappropriate for providing patient specific and holistic care, especially in dually diagnosed clients in which spirituality can become a great asset in treatment (Clark, 2009; Wilding, Muir-Cochrane, & May, 2006)

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