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The American Journal of Drug and Alcohol Abuse, 31:669–684, 2005 Copyright D Taylor & Francis Inc. ISSN: 0095-2990 print / 1097-9891 online DOI: 10.1081/ADA-200068459

Applying Behavior Change Models to Understand Spiritual Mechanisms Underlying Change in Substance Abuse Treatment James Alan Neff1 and Samuel A. MacMaster2 1

College of Health Sciences, Old Dominion University, Norfolk, Virginia, USA 2 University of Tennessee College of Social Work-Nashville, Nashville, Tennessee, USA

Abstract: Despite increasing attention directed to conceptual and methodological issues surrounding spirituality and despite the centrality of ‘‘spiritual transformation’’ in the recovery literature, there is little systematic evidence to support the role of spiritual change as a necessary condition for substance abuse behavior change. As an explicit conceptualization of mechanisms underlying behavior change is fundamental to effective interventions, this article: 1) briefly reviews relevant behavior change theories to identify key variables underlying change; 2) presents an integrative conceptual framework articulating linkages between program components, behavior change processes, spiritual change mechanisms and substance abuse outcomes; and 3) presents a discussion of how the mechanisms identified in our model can be seen in commonly used substance abuse interventions. Overall, we argue that spiritual transformation at an individual level takes place in a social context involving peer influence, role modeling, and social reinforcement. Keywords: Substance abuse treatment, spiritual change, behavior change models

Address correspondence to James Alan Neff, Professor and Associate Dean for Research, College of Health Sciences, Old Dominion University, Hampton Blvd., Norfolk, VA 23529, USA; Fax: (757) 683-4753; E-mail:

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J. A. Neff and S. A. MacMaster

INTRODUCTION Recently, there has been increasing attention directed to conceptual and methodological issues surrounding spirituality, religiosity, and their implications for health and well being (1). Unfortunately, systematic empirical research regarding the efficacy of interventions for alcohol or substance abuse that explicitly incorporate some spiritual or religious content is sparse. However, beyond the question of the efficacy of ‘‘spiritually oriented’’ interventions, ‘‘spirituality’’ and ‘‘spiritual change’’ in substance abuse treatment are critical issues, given that dominant intervention approaches endorsing 12-step philosophy typically emphasize ‘‘spiritual transformation’’ (2, 3) as fundamental to the recovery process. With all of the attention given to the process of spiritual transformation, we emphasize that an explicit conceptualization of mechanisms underlying behavior change is critical to understanding the effectiveness of substance abuse treatment in general, whether programs are spiritually oriented or not. Thus, a fundamental premise of this article is that spiritual mechanisms and spiritual change processes involved in substance abuse recovery require conceptual clarification. We argue that such processes may be usefully conceptualized in terms of well-established conceptual models of behavior change. This article seeks to: 1) briefly review relevant behavior change theories that highlight salient variables underlying change; 2) present a conceptual framework that articulates linkages between program elements, behavior change and spiritual change processes, and substance abuse treatment outcomes; and 3) briefly review commonly used substance abuse interventions to highlight the relevance of change mechanisms identified in our model. Our goal is to suggest that the seemingly ineffable concept of spiritual transformation in substance abuse treatment may be understood in terms of well-established behavior change processes. In particular, we emphasize that spiritual transformation, while involving transformation at an individual level, takes place in the context of a social process (4) involving peer influence, role modeling, and social reinforcement.

BACKGROUND Religion, Spirituality, and Substance Abuse Recent reviews (5, 6) suggest that: 1) religious or spiritual involvement may serve a protective function with regard to the development of substance abuse problems (7); 2) substance abuse treatment may result in some form of spiritual change (6); and 3) that spiritually based interventions may be effective for at least some individuals who are spiritually inclined (6, 7). However, while there is some consistent evidence to support these conclusions, religion and spiritual influences upon well being and substance

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abuse have received inadequate theoretical and empirical attention [(cf., Refs. (8, 9)]. In particular, little is known about theoretical mechanisms underlying spiritual change in substance abuse treatment (6, 7). We suggest that spiritual change or transformation in substance abuse treatment may be usefully examined in terms of the attribution of meaning, causation, and efficacy as they relate to behavior change. Along this line, Ellison (8) and Pargament (10) examine spirituality in terms of core socialpsychological processes of adaptation to life change and coping. Similarly, Miller (6) discusses spiritual change during treatment in terms of processes involved in effective substance abuse counseling. His work points to 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 (11). Thus, the literature suggests that an empathic ‘‘supportive’’ counseling style is associated with greater treatment engagement (12, 13) and other positive treatment outcomes (14, 15) than a ‘‘confrontative’’ style. This logic might lead to the hypothesis that treatment programs incorporating an empathic, accepting, supportive treatment approach might produce more positive outcomes. This article attempts to clarify the behavior change and spiritual change mechanisms underlying substance abuse treatment outcomes. Specifically, we apply behavior change theories such as the Health Belief Model, the Theory of Reasoned Action, and the Social Learning Theory to help explain behavior change during treatment. It is argued that an integrative model combining these conceptual elements can help to explain how spiritual change may mediate substance abuse behavior change outcomes.

Viewing Spiritual Change in Treatment from Dominant Behavior Change Models We have noted the relative absence of theoretical (or empirical) work regarding the nature of spiritual mechanisms underlying substance abuse behavior change. While there is some general agreement that some form of spiritual transformation takes place (3) involving a shift from negative, punishing to positive, forgiving views of spirituality and God (6), there has been little effort to formalize a model of the process. We acknowledge that substance abuse treatment programs may be diverse in the extent to which they emphasize religious or spiritual content. ‘‘Faith-based’’ treatment programs appear increasingly common (16) and Alcoholics Anonymous and other 12-step programs with their emphasis upon the individual’s relationship to a Higher Power (17) still represent a dominant treatment approach (18). At the same time, while 12-step programs predominate, treatment programs are diverse in the degree to which they may emphasize confrontational approaches (e.g., ‘‘therapeutic community’’ models) which, as was suggested


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Figure 1. Integrative conceptual model of spiritual mechanisms underlying substance abuse behavior change.

earlier, might impact the program’s ability to engage and retain clients in treatment. A framework for viewing substance abuse treatment and change in substance abuse behaviors during treatment is proposed which posits changes at several levels. This model is graphically summarized in Figure 1. Factors involved at different stages of the model are discussed below. Individual Attributes The model begins with what the individual brings to the program. Thus, we posit that individuals will differ at the outset in terms of spiritual background or history, current level of spirituality, and general treatment readiness. Substance abusers may be particularly likely to be disenfranchised from key societal institutions including the church. Further, as roughly 85% of drug users are out-of-treatment at any given time (19), levels of treatment readiness may be low. The typical individual may not be contemplating a change in their substance abuse.

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Program Elements As substance abusers are likely a disenfranchised group in a variety of respects, the question of how to engage and retain such individuals in the program and in the recovery process is critical. Following the earlier discussion, the presence of a program philosophy embodying empathy, acceptance, and forgiveness—particularly as an empathic, warm, accepting, and nurturing counseling style (described by Miller, Taylor, and West (12) as characteristic of effective substance abuse counselors)—may be posited to be critical to program success. Beyond acceptance, however, program elements providing structure and discipline would be crucial given the chaotic lifestyles that out-of-treatment substance abusers may well have been living. The presence of structured daily routines, individual or group chores, and rules prohibiting drug use or ‘‘street talk’’ would contribute to a sense of order. Further, following from discussions of the structure and function of religious groups by Durkheim (20) and Alpert (21), rituals and group activities promoting social cohesion also would be important. These might 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, promoting social cohesion and change would be activities that specifically provide mentoring or support to the individual. This could involve 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. As suggested earlier, programs may vary in the extent to which they incorporate such specific elements as well as in the extent to which they infuse religious and/or spiritual content (e.g., Bible or 12-step study). Social Learning Processes In emphasizing spirituality, meaning, social influence processes, and behavior change, the present conceptual model incorporates key determinants of behavior change identified by a consensus panel (22) representing the dominant theories of change: the Health Belief Model [HBM; Ref. (23)], the Theory of Reasoned Action [TRA; Ref. (24)], and Social Learning Theory [SLT; Ref. (25)]. Three variables are 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, 3) an absence of environmental constraints or barriers (from HBM) (22). While these behavior change models are general, these particular variables are viewed as especially relevant to substance abuse recovery. Social learning, peer influence, and social reinforcement are regarded as crucial to skill building and the development of self-efficacy, both essential


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to the individual’s ability to make changes, maintain new behavior patterns, and overcome environmental barriers (e.g., relapse cues). More specifically, applying these basic behavior change concepts to substance abuse behavior change and recovery processes, key mechanisms involved in early stages of substance abuse behavior change (i.e., promoting problem recognition, treatment readiness, and engagement) would be 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. In later stages of the process, 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 would serve to eliminate barriers to behavior change, through provision of food, shelter, caring for basic needs, and generally provision of a drug-free environment in which the individual can change. Finally, these social processes promote individual self-efficacy required to avoid relapse. Spiritual Transformation Processes Focusing more specifically on spiritual change or transformation processes in the framework, we posit that the search for meaning is fundamental to the process of recovery (3). This process involves a radical (though nor necessarily a sudden) change in the self, especially in terms of the identification of the self with the sacred (26). Following a stress-coping perspective (8), human adaptation to environmental change involves appraisal and coping processes (27). In the case of substance abuse behavior change, 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) would be especially important [cf., Ref. (10)]. These appraisals of self in relation to others and to God (or a higher power) are viewed as providing an important basis for imputing meaning to life experience. Appraisals involving shifts from views of a ‘‘punishing’’ to ‘‘forgiving’’ God are said to be especially important in 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. Treatment readiness and substance abuse behavior change: Given these considerations, it is posited that an intervention which enhances a sense of spirituality, meaning, forgiveness, and spiritual connectedness, thus motivating further engagement into program activities (i.e., enhancing social integration), may enhance social support and peer influence processes. Such

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mediating spiritual mechanisms are posited to increase motivation to change, increase treatment readiness, and reduce substance abuse. To reiterate, based on our consideration of 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 (10) 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 necessarily would be some changes in perceived norms and values (of self and others) regarding substance abuse as the individual may internalize antisubstance 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 antisubstance 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). In sum, the proposed conceptual model emphasizes that transformation involves a complex interaction of contextual and other factors contributing to the readiness to change. While social learning processes are important, the larger point is that an effective substance abuse treatment 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. Different programs, however, may vary in structure and ideology in ways that may be hypothesized to impact engagement, retention, and subsequent treatment outcomes.

RELEVANCE OF THE PROPOSED MODEL TO CONVENTIONAL TREATMENT MODALITIES The proposed general framework suggests mechanisms whereby treatment programs may promote spiritual change and, subsequently, substance abuse behavior change—though programs may vary in structure as well as in terms of infusion of religious or spiritual content. To provide a sense of the more general implications of the proposed framework in terms of its applicability 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 model elements outlined above. Such a review is relevant to the extent that the factors posited by our model as driving the spiritual and behavior change process are general (social learning, peer influence, social reinforcement in an empathic accepting social context). As such, it may be useful to show how model elements are common in wellaccepted substance abuse interventions.


J. A. Neff and S. A. MacMaster

AA and Other 12-Step Models The AA or 12-step model remains one of the most common substance abuse treatment modalities (18). As carefully analyzed by White (17), the AA model is based on explicit principles (12 steps) that reflect different components of the recovery process. 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 others and reflects continuing changes in the individual’s relationship to others. What is clear in White’s (17) analysis of the 12 steps is that, while the steps place heavy emphasis upon the spiritual, AA participation 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. In terms of our conceptual model of spiritual and substance abuse change during faith-based treatment, AA highlights several of the fundamental processes proposed. 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 (28) 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 (29) has been delivered to over 150,000 outof-treatment injection drug users (IDUs) and has been evaluated extensively (19). In this model, indigeneous recovering peer outreach workers provide

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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 (30) as well as increasing likelihood of entry into drug treatment (19). This model clearly incorporates a number of elements from our proposed model including role modeling an 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 selfefficacy (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.

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 (31, 32). 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 (33) 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 on individual risk serves to highlight HBM dimensions of seriousness and susceptibility. From the standpoint of our conceptual model and emphasis on spiritual change, it is noted that the brief intervention/motivational interviewing approach does not explicitly involve dimensions of spirituality or faith. However, in his recent review of the field of motivational interviewing, Miller (11) 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. Based on this, one might expect faith-based motivational interventions emphasizing agape and acceptance to be effective in motivating treatment engagement and substance abuse behavior change with certain populations. 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


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maintain sobriety in the face of relapse cues (34, 35). The RPT model posits that relapse is an important and expected 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 (34). RPT emphasizes 5 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 (34). Several metaanalyses have shown RPT to be effective in reducing the frequency of relapse and the intensity of each individual lapse (36 – 38). 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 selfefficacy are core elements of RPT, consistent with social learning theory.

Therapeutic Communities Therapeutic Communities (TCs) represent a drug-free residential treatment model dating back to the 1960s. The approach, often characterized as ‘‘community as method,’’ utilizes strict norms and peer influence process to change negative patterns of thinking and behavior through individual and group therapy, group sessions with peers, community-based learning, confrontation, games, and role-playing (39). Research has supported the efficacy of this method (40) and DATOS data have shown TCs to lower levels of cocaine, heroin, and alcohol use; criminal behavior; unemployment; and indicators of depression for individuals who complete treatment (41). While TCs have traditionally involved longer lengths of stay (18 – 24 months), briefer TC models have more recently been examined (42). As in our proposed model, TCs utilize peer influence, mediated through a variety of group processes, to generate a sense of community and to help individuals learn and assimilate social norms and develop more effective social skills (42). However, in contrast to the model proposed here, a key component of the TC model has traditionally been a confrontational ‘‘verbalattack therapy’’ approach. While the approach is clearly confrontative, residents are asked to view confrontation as a way to help them ‘‘see their problems’’ rather than as a personal assault (43). The benefits of confrontation recently have been questioned, though the need to consider other contextual factors surrounding the role and implications of confrontation have been emphasized (44). TCs, thus, appear to involve social learning principles as proposed in the model presented here and combine a structured environment, discipline, and

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group processes, though in different ways than our model proposes. Of interest is that, where our model proposes acceptance and forgiveness as key to engagement and retention, a TC confrontational approach would appear to run counter to those principles. While TCs have been shown to produce positive outcomes, studies have also noted high drop-out rates (42). One might posit that the TC model might be most successful in prison-based or other court-mandated settings where engagement and retention are less subject to individual choice. Clearly, the TC model offers a thoughtprovoking counterpoint to the model proposed here.

DISCUSSION AND CONCLUSIONS This article describes possible spiritual change mechanisms underlying behavioral change in substance abuse treatment. While the conceptual literature generally supports the importance of spirituality in substance abuse treatment and recovery, this article is the first to provide a conceptualization of possible theoretical mechanisms—based on established behavior change mechanisms—underlying this commonly assumed view of spiritual change (often referred to as a ‘‘transformation’’) during the course of treatment. This article 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. Thus, much of the literature regarding spiritual transformation [cf. Ref. (3)] appears to emphasize the otherworldly, 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 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, and Norcross’ (45) terminology), that phenomenon is poorly understood (46). Recently, Watson and Sher (47) have noted similarities between self-change and processes of change taking place in intentional behavior change (45). Their argument that self-change has similarities to intentional change is compatible with the approach taken here. We have argued that fundamental behavior change processes take place in substance abuse treatment and that treatment programs provide as a setting in which role modeling and peer influence processes produce transformations in belief systems and behavior. Programs may vary in structure and orientation, thus influencing potential outcomes, although underlying processes are similar. The theoretical importance of the present efforts to specify mechanisms can be seen clearly in terms of Prochaska, DiClemente’s and Nacross’ (45) Stages of Change model. That is, since its development, the Stage of Change


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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 vis-a`-vis change would be that empathy, forgiveness, and acceptance may be important elements of engaging the individual in a change from ‘‘precontemplative’’ 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. Conceptual clarity is an important first step in bridging the long-standing gap between 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 inception 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 the discussion of spiritual mechanisms from vague beliefs to a more concrete explanation of the process in terms of change mechanisms further closes this gap, allowing researchers to approach a component of substance abuse treatment once viewed as ‘‘unscientific.’’ In terms of implications of the present conceptual analysis, our proposed framework incorporating both empirically supported behavior change elements and spiritual change may be helpful in informing service delivery. A next step might be to explore the conceptual linkages between Stages of Change (45), for example, and models of spiritual change or development [cf. Ref. (48)]. Specifically, whereas the transtheoretical 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 (6) that spiritual interventions may be effective for those that are spiritually inclined. In sum, while our focus has been conceptual, we hope that the article has methodological implications. Our objective has been to conceptualize the phenomenon of spiritual change in terms that can ultimately be operationally defined and measured. We would argue that while accepted research designs

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exist for examining treatment outcomes, the consideration of spiritual change requires a further level of complexity—not simply the addition of a measure of ‘‘spirituality’’ at baseline or follow-up. Rather, we have proposed an integrative conceptual model, incorporating factors at differing levels that may influence the process. Not only have we incorporated individual-level variables (such as spiritual background and readiness to change), but also program-level variables such as program philosophy and structure. Research designs should further allow consideration of spiritual change, assessed multidimensionally, over time to assess whether such change represents a necessary condition for substance abuse behavior change. Thus, our focus has been on the possible mediating role of spirituality and spiritual change. Again, as noted above, the next step is to empirically examine the utility of the conceptual framework articulated here with regard to examining program outcomes and ultimately to examine variation in individual- and programlevel variables in relation to substance abuse treatment outcomes.


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Profile for Emily Sandberg Gold

Applying behavior change models to understand spiritual mechanisms underlying change in substance ab  

Applying behavior change models to understand spiritual mechanisms underlying change in substance ab