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The Science and Spirituality of Addiction . Assoc Professor Alan Gijsbers Addiction Medicine RMH President ISCAST Australia. Drug Dependence Comparing ICD-10 and DSM-IV Criteria. In common Withdrawal, tolerance and salience ICD-10

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The science and spirituality of addiction

The Science and Spirituality of Addiction

Assoc Professor Alan Gijsbers

Addiction Medicine RMH

President ISCAST Australia

Drug dependence comparing icd 10 and dsm iv criteria
Drug Dependence Comparing ICD-10 and DSM-IV Criteria

  • In common

    • Withdrawal, tolerance and salience

  • ICD-10

    • Rx withdrawal, compulsion, narrowing of repertoire, early relapse

  • DSM-IV

    • Lack of control 3 (greater use than intended, unsuccessful reductions, time on activity), use despite damage due to use

Science is more than phenomenology
Science is More Than Phenomenology

  • Accurate observation leads to hypothesis testing especially asking the question,

  • Why is it so?

  • This leads to some theories about mechanisms, which if tested and found to be robust, become the established explanation.

Mind altering drugs
Mind-altering Drugs

  • Pleasure Effect

    • Drugs of addiction enhance the limbic system (pleasure centre) of the brain.

    • “Artificial instant chemical pleasure”

  • Anaesthetic Effect

    • “...The need for chemical vacations from intolerable self-hood and repulsive environments will undoubtedly remain...”

      (A Huxley, 1953)

Neurobiological circuits in addiction
Neurobiological Circuits in Addiction

“Circuits that serve to color an experience with emotion and direct the individual’s response to rewarding stimuli, including food, sex and social interaction.”

Nestler EJ, Malenka RC. The addicted brain.

Scientific American. March 2004;290:78-85

Reward pathways
Reward Pathways


Excitatory Input

Enkephalin or


Inhibitory Neuron

k Opioid


Dopamine Receptors




Dopamine Neuron




m Opioid


GABA-A Receptors

GABA Inhibitory Feedback




(m, d?)




Ventral Tegmental Area


Nucleus Accumbens


Addiction more than just reward
Addiction – More Than Just Reward?

  • Not just the pursuit of pleasure

  • But a drive to use – cravings and compulsions

  • Add drive, control and memory to the basic reward mechanisms

Localization of Addiction PathwaysVolkow ND. Fowler JS. Wang GJ. The addicted human brain: insights from imaging studies. [Review] Journal of Clinical Investigation. 2003;111:1444-51,

  • Control – prefrontal cortex and the anterior cingulate gyrus

  • Drive - Orbito-frontal cortex

  • Reward – Nucleus accumbens and the ventral pallidum

  • Memory – Amygdala and hippocampus

Not all brains are the same
Not All Brains Are the Same

  • Varying responses to post-anaesthetic analgesia

  • Even those pain-killers that give pleasure do not necessarily lead to addiction

  • Not many patients in palliative care develop tolerance

  • Not all chronic pain patients develop tolerance

The full range of issues
The Full Range of Issues? Subjects

  • Emotional circuits

  • Evolved to enhance relationships and social survival

  • Emotional dysregulation and interpersonal ineffectiveness seem to be dominant issues in patients with addictions

  • Emotions may even be more important than cravings

I don t drink because i have cravings
I don’t drink because I have cravings... Subjects

“...I drink because I am angry, or I am pissed off...”

“...I drink because the pressure of work is too much....”

“...I drink because I want to get up my partner’s nose...”

“...I drink to drown the memory of my abuse...”

“...I drink to shut up the committee in my head...”

“....I drink to relax...”

“...I dunno, I just do.....”

Vaillant s positive emotions
Vaillant’s Positive Emotions Subjects

Faith, love, hope, joy, forgiveness, compassion, awe and mystical illumination are important limbic system drivers of human flourishing

Vaillant GE. Spiritual Evolution: how we are wired for faith, hope and love. Broadway books, New York. 2008.

Positive emotions
Positive Emotions Subjects

  • Are parasympathetic and soothing as opposed to the negative emotions which are sympathetic and arousing

  • Are long-term and reach out

  • Negative emotions are immediate and protective

  • Positive emotions create relational bonds which build community rather than the negative emotions which protect the immediate individual

Emotions Subjects

Humans thus seen are members of community rather than individuals and the emotions (especially the positive emotions) are designed to build community and the individual in that community

Thus Subjects

Emotions are not just to be avoided but essential to being human

Emotions predate verbal reasoning

Vaillant then makes much of the spirituality of the positive emotions in contrast to the barren rationalism of fundamentalism

Limbic is lyrical: Lexical is lame

Kandell s model
Kandell’s Model - Subjects

  • Neurology is a function of gene expression, but gene expression changes according to mental (learning) input.




Aversive Consequences

e.g. toxic effects reduced drug effect

organic damage psycho-social dysfunction

Distal Antecedents

e.g. peer groupsfamily interactionsparental drug use

Immediate Antecedents

e.g. licensing lawssocial pressuresavailabilitydemographic variables




Dispositionto usedrug

Drug Use

Neuro Adaptive State

Distal Antecedents

e.g. early learningdrug experiencegenetic endowmentdevelopmental events

Immediate Antecedents

e.g. mood stateswithdrawal statesexpectations

Withdrawal Symptoms



Reinforcing Consequences

e.g. mood enhancement psycho spcial facilitation avoidance of relief of withdrawl symptoms

Summary of the science
Summary of the Science Subjects

  • Addictive behaviours

  • Mind-altering drugs affecting the reward mechanism

  • Drive, reward, memory and control

  • Heterogeneity of the brain

  • Complexity of neuroscience

  • Emotions and relationships

  • Regarded by some as spirituality....

Spirituality Subjects

  • Left brain definition of right brain activity [limbic activity]?

  • Describe the indescribable?

  • Raises questions of the scientific evaluation of what’s going on!

Spirituality Subjects

“Spirituality simply means the direct experience of something special in life and living.”- S.Biddolph

Domains of spirituality cch cook addictions 2004 99 539 551

Relatedness Subjects













Domains of SpiritualityCCH Cook. Addictions. 2004;99:539-551

Spirituality as drive life
Spirituality as Drive/Life Subjects

  • Spirit = Breath = Life = Liveliness= Enthusiasm

  • Spirited person, spirited defence, spirited horse

  • Inspired

  • Expired

  • Dispirited

Eudaemonia Subjects

  • Eu = balance

  • Daemon = One's genius; a tutelary spirit or internal voice; as, the demon of Socrates. [Often written d[ae]mon.]drive

  • Eudaemonia = Balance of the drives = Aristotle’s ideals for which one strived

  • Addiction could then be described as dysdaemonia (!)

Spirituality Subjects

  • Meaning

  • Purpose

  • Relationships

Relationships Subjects

  • To self

    • Insight

    • Acceptance

  • To the environment

    • Which feeds and breathes us

    • Which touches us aesthetically

  • To other humans

    • Partner

    • Family

    • Friends

    • Community

    • Society

    • Enemy

  • To the Higher power

    • Imago dei

    • Strength [spirit] to live

Spirituality Subjects

  • Meaning Faith

  • Purpose Hope

  • Relationships Love

Faith Subjects

  • Asking what are the core understandings that shape a person’s attitudes to life.

  • Spiritual attitudes are sometimes shaped by a person’s faith in God, but there are other ways of expressing a person’s core beliefs and attitudes

  • Modern secular society however discourages the exploration of these dimensions (Taylor C, Ethics of Authenticity).

Hope Subjects

  • Frankl’s work, relationships and suffering.

  • Aristotle’s pursuit of the goods – eudaemonia Taylor’s Hypergoods – the core commitments which shape other commitments.

  • Without meaning and purpose life if hopeless, lacks momentum, and lacks drive.

  • Addiction is about the pursuit of immediate pleasure irrespective of the long-term consequences.

Love Subjects

  • Self

  • Others

  • Natural environment

  • A higher power

  • Supernatural forces

  • One of the dimensions of addiction is alienation and recovery focuses on reconnection

What about
What About? Subjects

  • Truth...(embodied and personified)?

  • Justice and righteousness?

  • Failure and forgiveness?

Spirituality Subjects

  • Drive to life and liveliness

  • Meaning purpose and relationships

  • Truth, justice and mercy

Spirituality and religion wr miller

Aspect of the Individual Subjects

Difficult to delimit – transcendent

Can be stifled by religious rituals and practices

Socially organised structure

By definition boundaried - beliefs, practices, governance and rituals

Spirituality and Religion (WR Miller)

Spiritus contra spiritum
Spiritus Contra Spiritum Subjects

  • “You see, "alcohol" in Latin is "spiritus" and you use the same word for the highest religious experience as well as for the most depraving poison. The helpful formula therefore is: spiritus contra spiritum.”

    CG Jung Letter to Bill W

Flesh vs spirit
Flesh vs Spirit Subjects

  • Dominant ethic in Pauline writings (Rom 6-8, Gal 5:1-23).

  • Spirit – human spirit or Divine spirit indwelling humans?

  • Divine power to put to death the deeds of the flesh and to live a new life of freedom and love.

  • Fruits of the spirit contrasted with the deeds of the flesh.

Aa spirituality
AA Spirituality Subjects

  • Based on the Buchman’s Oxford Group Movement (Moral Rearmament) of the 1930’s

  • Buchman came into deeper experience of God at a Keswick Convention in about 1909

  • No doubt initially Christian based

  • Current tension between a generic spirituality on the one hand and the Christian Right on the other

Aa spirituality 12 steps

Powerless Subjects

Power available

Surrender to that Power

Moral inventory

Admit wrongs

Ready to remove defects

Ask Him to remove shortcomings

List persons harmed

Make amends

Continue inventory

Prayer to improve conscious contact

Spread message of spiritual awakening

AA Spirituality – 12 Steps

Spirituality and our patients
Spirituality and Our Patients Subjects

  • The spirituality gap

  • Respect for the patient’s integrity

  • Aware of need and hence the ability to meet it

  • Start them on a journey looking at meaning, purpose, power, relationships

  • Compassionate care expresses our spirituality

D a spiritual change
D&A Spiritual Change Subjects

  • From salience to perspective

  • Bondage to freedom

  • Powerlessness to power

  • Indiscipline to discipline

  • Self-centredness to other-centredness

D a spiritual change1
D&A Spiritual Change Subjects

  • Fear to trust

  • Sinfulness to goodness

  • Disorder to order

  • Despair to hope

  • Grace: an unconditional acceptance yet a maintenance of standards

From my practice
From My Practice Subjects

“You know after your session [on spirituality] I realised I was totally dispirited...I have no spirit...can you help?”

That afternoon
That Afternoon Subjects

  • Found a book in a secular bookshop Secrets of a Bullet Proof Spirit.

Conclusion Subjects

  • Science and spirituality interact in the field of addiction and a comprehensive program of recovery calls for a radical re-ordering according to a patient’s core values and hyper-goods. It also calls for relational repair. Spiritual input is thus crucial as people work through their pain and reach out for radical healing.

Harm minimization vs abstinence
Harm Minimization Subjectsvs Abstinence

  • Abstinence from mind-altering drugs is the bottom line in addiction therapy

  • Harm minimization recognises the reality of ongoing drug use and seeks to reduce the degree of harm causes by use eg

    • Substitution pharmacotherapy

    • Needle and syringe exchange programs

    • Injecting rooms

    • Supply of clean opioids in a supervised situation

  • Abstinence is the best form of harm minimisation but carries greater risk of significant harm

Dole nyswander s original trial

NEJM 1969;280:1372-1375