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Article 95

Spirituality, Substance Use, and the Military

Heather C. Robertson

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Paper based on a program presented at the 2016 American Counseling Association and the Canadian Counseling and Psychotherapy Association Conference, April 1, 2016, Montreal, Canada.

Acknowledgements :The author would like to acknowledge Caitlin Winker and Nida Ahmed, St. John’s University Clinical Mental Health Counseling program graduates, for their contributions to the literature review for this manuscript and presentation.

The U.S. Department of Defense (2016) estimates that there are 1.3 million active duty military members and approximately 826,000 people serving in the National Guard and Reserve. While the total number of veterans is expected to decrease between 2010 and 2040, the percentages of veteran populations within that total, such as females, minorities, and Gulf War era veterans, are expected to rise (National Center for Veterans Analysis and Statistics, 2016). Military members and veterans total approximately 23 million citizens in the United States, or 7% of the overall U.S. population (National Center for Veterans Analysis and Statistics, 2016; U.S. Department of Defense [USDOD], 2016, U.S. Census Bureau, 2016). This statistic indicates that a small percentage of individuals in the United States have direct experience in the military.

The American Counseling Association Code of Ethics (ACA; 2014) explicitly states that professional counselors are to: provide developmental and culturally sensitive services (A.2.c.), respect multicultural and diversity considerations (B.1.a.), and only operate within their boundaries of professional competence (C.2.a.). Without direct experience in military communities or formal instruction in counseling military populations, counselors may struggle to understand military culture, communities, and challenges. As such, counselors may lack understanding of how the military culture may impact the client’s presenting problem and struggle to implement appropriate treatment options. Counselors have an ethical obligation to educate themselves on counseling approaches for diverse populations.

The ACA Code of Ethics (Section C) also states that counselors are expected to engage in counseling practices that are consistent with research. Thus, counselors have an obligation to be aware of effective treatment strategies for particular disorders. The Substance Abuse and Mental Health Services Administration (SAMHSA; 2014) reports that one in 15 military veterans has a substance use disorder. One strategy that is regularly utilized in substance use treatment is spirituality, including the client’s spiritual beliefs and spiritual practices as positive coping strategies (Berg, 2011; Ciarrocchi & Brelsford, 2009; Diaz et al., 2011; Galbraith & Conner, 2015; Giordano et al., 2015; Harris et al., 2011). Yet counselors may be unclear about how utilizing the client’s spiritual beliefs and practices that enhance spirituality can be an effective strategy for military veterans in substance use treatment.

A review of the counseling literature spanning from 2000 to 2015 was conducted utilizing the terms spirituality and substance use/abuse counseling; spirituality and military; military and substance use/abuse counseling; and military, spirituality, and substance use/abuse. This manuscript presents a summary of the findings, beginning with an overview of military culture and the extent of substance use among military members and veterans, and then summarizes literature addressing spirituality as a coping strategy for substance use disorder, military/combat issues, and the intersection of all three constructs (military, substance use, and spirituality). Finally, applications to counseling practice, as well as case examples, are included.

For simplicity, the term military veterans will be used interchangeably in this manuscript with active duty military, veterans, former military, military retirees, and National Guard and Reserve members, regardless of discharge status or benefit eligibility.

Military Culture

Military culture creates a unique community that may not be fully understood by the civilian population. One needs only to examine core values, creeds, and ethos of military organizations to understand the depth and dedication of military members’ service and sacrifice. Examples include the Army Values, the Soldier’s Creed, the Non- Commissioned Officers Creed, the Ranger Creed, the Marine Corps Motto and Values; portions of these are detailed below:

Seven Core Army Values (LDRSHIP)

Loyalty—Bear true faith and allegiance to the U.S. Constitution, the Army, your unit, and other Soldiers.

Duty—Fulfill your obligations.

Respect—Treat people as they should be treated.

Selfless Service—Put the welfare of the nation, the Army and your subordinates before your own.

Honor—Live up to Army values.

Integrity—Do what's right, legally and morally.

Personal Courage—Face fear, danger or adversity (physical or moral). (U. S. Army, n.d.-a, para. 1)

Soldier’s Creed

I am an American Soldier.

I am a warrior and a member of a team.

I serve the people of the United States and live the Army Values. I will always place the mission first.

I will never accept defeat. I will never quit.

I will never leave a fallen comrade.

I am disciplined, physically and mentally tough, trained and proficient in my warrior tasks and drills.

I always maintain my arms, my equipment and myself. I am an expert and I am a professional.

I stand ready to deploy, engage, and destroy the enemies of the United States of America in close combat.

I am a guardian of freedom and the American way of life. I am an American Soldier. (U. S. Army, n.d.-c, para. 1)

Non-Commissioned Officer’s Creed: Competence is my watchword. My two basic responsibilities will always be uppermost in my mind—accomplishment of my mission and the welfare of my Soldiers. (U. S. Army, n.d.-b, para. 2)

Ranger Creed: Never shall I fail my comrades. I will always keep myself mentally alert, physically strong and morally straight and I will shoulder more than my share of the task whatever it may be, one-hundred-percent and then some. (U. S. Army, n.d.-c, para. 3)

Marine Corps Motto: It guides Marines to remain faithful to the mission at hand, to each other, to the Corps and to country, no matter what. Becoming a Marine is a transformation that cannot be undone, and Semper Fidelis is a permanent reminder of that. Once made, a Marine will forever live by the ethics and values of the Corps. (U.S. Marine Corps, 2016, para. 1)

Marine Corps Values: Honor, Courage, Commitment, Ductus Exemplo (Lead by Example). (U. S. Marine Corps, n.d., para. 1)

These words become the values and character traits that are engrained in the military throughout their training and service. For many veterans, these values remain with them for life. The common themes throughout these words are strength, responsibility, honesty, and caring for others before one’s self. While admirable, these same characteristics may hinder them from seeking help or support for mental health, emotional, or other personal needs. Some military veterans struggling with substance use may feel ashamed, weak, or dishonest, which may hinder their willingness to seek help (Casey, 2011). According to Briggs and Reneson (2010), “the same military mindset that creates an effective soldier may be a significant barrier to seeking help” (p. 4). Beyond personal hesitation, military members may fear that their struggle with substances will impact their military career (Gibbs, Rae Olmstead, Brown, & Clinton-Sherrod, 2011). Thus, the culture of the military may unintentionally hinder the help-seeking behavior of some military veterans.

Substance Use Among Military Members and Veterans

News and media outlets have highlighted several areas of concern regarding veterans’ mental health and well-being. Recent reports of veterans’ suicides (U.S. Department of Veterans Affairs, 2016), homelessness, and substance use have illuminated the need for services and treatment. In addition to reporting that one in 15 veterans has a substance use disorder, SAMHSA (2014) also noted that only half of the veterans who require treatment for substance use disorders seek the treatment they need. SAMHSA estimates that 70% of homeless veterans also have a substance use disorder and that of those veterans in treatment for substance use, over 20% are homeless. The rise in suicides among veterans is alarming, with the Army suicide rate reaching an all-time high in 2012 (SAMHSA, 2014). The U.S. Department of Veterans Affairs (2016) estimates that in 2014, 20 military veterans per day died of suicide. Since research has demonstrated a connection between substance use and suicide (McGlothlin, 2008), the issue of substance use among veterans is a critical concern.

While the SAMSHA (2014) data primarily address substance use among veterans, several research studies have examined the depth of substance use among active military members. In a study of approximately 43,000 active duty soldiers at risk for alcohol abuse, Clinton-Sherrod, Barrick, and Gibbs (2011) found that nearly half (44%) were at risk for alcohol abuse, yet only 1–4% of those soldiers were referred for substance use treatment. Federman, Bray, and Kroutil (2000) found that service members who deployed were more likely to report heavy alcohol use when compared to those who did not deploy. In an effort to examine prescription opioid misuse, Golub and Bennett (2013) recruited 269 veterans to examine their substance use behavior prior to military enrollment, during military service, during their last deployment, and within the last 30 days. Alcohol, binge drinking, heavy drinking, marijuana, and powder cocaine were the most frequently cited substances throughout the veterans’ careers, with all types of alcohol use (e.g., regular, binge, heavy) increasing upon entering the military. While most other substance use decreased upon entering the military, the use of painkillers, heroin, and injected heroin increased from pre-military enrollment to the last 30 days of enrollment (Golub & Bennett, 2013). These findings demonstrate that substance use, including alcohol and illegal drugs, is active among military personnel and veterans. Counselors must be prepared to assist military members and veterans with substance use disorders and help clients identify strategies to cope with their substance use. One such strategy may be the use of spiritual beliefs and activities as a positive coping strategy during substance use recovery treatment.

Developing Spirituality as a Coping Strategy

The concept of spirituality may be confused with other concepts such as religion, religious practice, or faith. Spirituality has been defined as “the continuous journey people take to find meaning in their lives” and “the process of searching for the sacred in one’s life” (Pargament & Sweeney, 2011, pp. 58–59). These definitions capture the personal essence of spirituality and the way it is individually defined by each person.

Two consistent findings from the literature are worth emphasizing. First, there appears to be an empirical relationship between spirituality and coping for clients exposed to trauma as well as other mental health disorders, such as substance use disorder, depression, and post-traumatic stress disorder (PTSD). Second, the effectiveness of spirituality as a coping mechanism is impacted by the client’s view of spirituality. For example, clients who viewed their spirituality/faith/religion as helpful, supportive, and loving were more likely to use their spirituality as a positive coping mechanism. Those who viewed their spirituality/faith/religion as punitive, harsh, or judgmental were less likely to use spirituality as a coping mechanism. These findings were consistent across the literature, regardless of military status or substance use (Berg, 2011; Ciarrocchi & Brelsford, 2009; Diaz et al., 2011; Galbraith & Conner, 2015; Giordano et al., 2015; Harris et al., 2011). Thus when examining the use of spirituality as a coping strategy, for either substance use or military-related trauma, it is important to remember that the client’s personal view of spirituality may impact its coping effectiveness.

Using Spirituality in Substance Use Treatment

Spirituality is a vital component of many 12-step groups, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). According to Juhnke, Watts, Guerra, and Hsieh (2009), emphasis on spirituality has been a central component of AA and other programs. Specifically, Juhnke et al. stated, “Clearly, when half of the 12-steps specifically address the recovering person’s interactions with God, one would minimally agree that spirituality is a critical theme within the 12-step community” (p. 17). Ciarrocchi and Brelsford’s (2009) research found that spirituality and religious practice serve as mood-enhancing agents when viewed positively by clients in substance abuse recovery; therefore, clients were less likely to use substances to enhance their mood. Examples of religious practice in their research included reading the Bible or “feeling God’s love for me” (Ciarrocchi & Brelsford, 2009, p. 27). Similarly, Diaz et al. (2011) examined individuals in substance abuse residential treatment facilities, including their participation in 12-step groups. The research found that over half of respondents reported high levels of depression and that there was a statistically significant inverse relationship between a respondent’s level of spirituality and level of depression.

Spiritual practices, in addition to spiritual beliefs, were also addressed in the literature. Juhnke et al. (2009) discussed the use of prayer with clients with substance use disorders who self-identify as having personal faith. Juhnke et al. began their discussion with an overview of AA’s emphasis on prayer, including the Serenity Prayer. The authors also discussed the value of prayer to help the client become self-sufficient, meaning that clients can pray independently for strength to overcome urges and cravings when not in the presence of a counselor. Juhnke and colleagues discussed the efficiency of prayer and the manner in which prayer can be quick, effective, and portable for the client.

Pruett, Nishimura, and Priest (2007) discussed the value of meditation in addiction recovery, emphasizing that recovery from addiction is often uncomfortable and frightening. The authors stated that meditation, which involves both the conscience and unconscious mind, provides clients with a tool to navigate this discomfort and fear. Much like prayer, the portability and utility of meditation is a benefit when addressing challenges of substance use recovery; however, unlike prayer, meditation requires training and practice on the part of the client (Pruett et al., 2007).

The portability and utility of spiritual practices, such as prayer and meditation, as well as the personal nature of each approach, may be appealing to military personnel who often relocate, work in remote locations, and may be faced with difficult or traumatic situations such as war, combat, and injury.

Using Spirituality With Military Veterans

Military veterans may be exposed to combat and trauma throughout their service, particularly if they have been deployed to a combat region. The impact of spirituality on active-duty military and veterans with PTSD has been examined by several researchers. In a study of over 24,000 active duty military, Hourani et al. (2012) examined whether spirituality moderated the relationship between combat and three mental health conditions: depression, PTSD, and suicidality. They found that high spirituality only had a protective effect on depression and that spirituality had no impact on suicidality. Additionally, spirituality only had a moderating effect on PTSD for those with low- combat exposure, and that there was no impact for those with moderate or high combat exposure. Harris et al. (2011) found that a spiritual strength-building group intervention reduced PTSD symptoms among veterans in a Veterans Affairs (VA) treatment facility.

Several researchers have examined the impact of spirituality on military members’ mental health and ability to cope with traumatic events. Sterner and Jackson- Cherry (2015) studied spirituality, as well as religious beliefs and practices, among deployed military personnel. In their study, participants’ spiritual beliefs did not significantly impact their coping style; however, individuals who identified as Christian, as well as those who participated in regular religious/spiritual activities, reported higher coping scores than others. In a study of Vietnam veterans in recovery, Berg (2011) argued that PTSD and depression were “associated with profound spiritual factors” (p. 6). Berg examined spiritual injuries, such as guilt, anger, sadness, and despair, in relation to other mental health conditions. Berg discussed the significance of veterans’ guilt, and his study found a relationship between spiritual injuries and PTSD with depression. Berg argued for increased attention on treating the spiritual needs of those with PTSD.

The value of addressing spirituality with active-duty military members is gaining increased attention. The Spiritual Fitness component of the Army’s Comprehensive Soldier Fitness (CSF) program (Pargament & Sweeney, 2011) is one example. The Army CSF is a proactive, resiliency-building program, designed to prepare soldiers to maximize health and wellness in the context of combat and service. Spiritual fitness is defined as “the capacity to (a) identify what provides a sense of purpose and direction, (b) access resources that facilitate the realization of core self and strivings, especially in times of struggle, and (c) experience a sense of connectedness with diverse people in the world” (Pargament & Sweeney, 2011, p. 59). The authors explained that spirituality has been affiliated with strength and resilience, particularly for those who have experienced trauma. The Army has determined that training soldiers to develop spirituality may help to enhance coping strategies among soldiers. This program has developed into the Comprehensive Soldier and Family Fitness Training, encompassing five dimensions of strength: physical, emotional, social, spiritual, and family (U.S. Army, 2014). These five dimensions parallel the wellness model advocated for by Hayden, Jackson-Cherry, and Sterner (2014). Specifically, when discussing the wellness construct of resiliency, Hayden et al. advocated for exploring military client resources, which may also include spiritual or religious assets. When addressing cognitive wellness, the authors articulated how spiritual understanding may provide meaning and purpose when processing traumatic events.

These studies address the impact of spirituality among military veterans with PTSD, depression, suicidality and other mental health disorders. In addition, this research indicates that spirituality as a coping strategy, when combined with counseling models of wellness and resiliency, may be effective for military veterans with other mental health conditions, such as substance use disorders.

Spirituality and Substance Use Among Military Veterans

Research has demonstrated that deployed men and women have significantly higher rates of heavy alcohol use and alcohol dependence when compared to their non- deployed peers (Federman et al., 2000). Other studies have determined that longer military deployments result in more binge drinking episodes per month (Ramchand et al., 2011). Consistently, research has shown that the stigma and fear of repercussions for seeking substance use and mental health care are significant deterrents to military members and veterans getting the help they need (Clinton-Sherrod et al., 2011; Gibbs et al., 2011; McFarling, D'Angelo, Drain, Gibbs, & Rae Olmsted, 2011).

Interestingly, while there is ample literature on substance use and military members/veterans, and significant literature on spirituality and military members/ veterans, no literature could be located discussing the intersection of all three constructs. Morgan (2009) offered perhaps the closest insight to this intersection when discussing trauma, addiction, and spirituality. While not specific to military veterans, Morgan discussed the connection between trauma and addiction, self-medication after trauma, and the impact of spiritual beliefs and practices on offering hope to the wounded. Morgan pointed out that recovery from addiction and recovery from trauma both require a restoration of hope. Morgan recommended spiritual healing as a complement to addictions treatment for trauma survivors.

Discussion

Research supporting the use of spirituality with military members and veterans with substance abuse issues, as well as research supporting the use of spirituality with military members and veterans who have experienced combat and trauma, lend evidence to the argument for using spirituality as a positive coping strategy. The following cases provide examples of how spirituality may help or hinder the recovery process. They are provided to demonstrate how clients come to treatment with their own spirituality definitions and experiences. Counselors are encouraged to review the cases while asking themselves critical questions surrounding the military veteran and their treatment, and determining if spirituality interventions should be explored as a coping strategy with these clients. Counselors need to assess additional factors, such as: Does the military veteran have a co-occurring disorder? Does the military veteran have a service-related medical condition or disability? Was the military veteran deployed to a combat region? Each of these questions provides information on how to best treat military veterans in substance abuse recovery treatment, as well as determining if using spirituality as a positive coping strategy would be an appropriate intervention during treatment.

Case Examples

Client A is a Navy veteran in his mid-50s with a diagnosis of cocaine use disorder. Client A has been clean for 18 months after completing his third treatment program and is currently on probation. Client A reports that his primary sources of strength are God, his family, and his church. Client A regularly attends spiritual services and often cites spiritual readings in group and individual sessions. Client A has brought spiritual readings to share with his individual counselor. Client A reports that he practices humility and gratitude daily and that he credits the Lord for bringing his family back to him after his addictive destruction. During his treatment planning meeting, Client A requested a social goal that included taking quiet time to pray. Client does not attend 12- step meetings, stating that he receives the support he needs from his church.

Client B is an Air Force veteran in his late 30s who did not receive an honorable discharge due to substance use, specifically hallucinogens. Client B does not consider himself religious, yet considers himself spiritual. Client B reports that now that he is clean and sober, he needs to keep his life in “balance.” Client reports that he practices his spirituality through his daily interactions with people and tries not to react negatively or with anger towards people or situations. Client reports that the universe tests him, and he needs to stay in balance to pass these tests. Client believes that getting outside in nature and laughing every day are part of his spiritual practices. Client B has been clean for over 2 years and participates in 12-step groups specifically for veterans.

Client C is a Marine Corps veteran, who is in his late 20s. Client C has a diagnosis of alcohol and heroin use disorder, has been clean for approximately 3 months, and is prescribed an opioid partial agonist medication. Client C is currently awaiting sentencing for a criminal conviction. Client C does not consider himself religious or spiritual and states that his parents were very religious and that he had religion “shoved down my throat” as a child. Client C reports that he was not able to watch mainstream movies or listen to music as a child due to his parents’ religious beliefs. Client C disengages from group discussion when other clients discuss spirituality and has outwardly complained about “all this spirituality talk” in group sessions.

Client D is a Reservist in her early 20s who tested positive for benzodiazepines (Xanax) during a drill weekend and was required to attend treatment. Client D has no prior substance use history or treatment experience. Client reports many conflicts with her immediate family and that her support system includes her wife and her wife’s son. Client reports that her faith is one of the most important things in her life. Client D reports growing up in the church and knowing that God loved her, even if she doesn’t go to church much anymore. Client D is embarrassed by the incident, reporting that she was under stress and made a bad decision and simply wants to fulfill the requirements of her unit. She does not attend 12-step groups.

These cases outline circumstances in which the client’s spiritual beliefs, formed anywhere from childhood to adulthood, may impact their treatment experience. These cases provide real world examples, edited for confidentiality and anonymity, of how the effectiveness of spirituality as a coping mechanism is impacted by the client’s view of spirituality (Berg, 2011; Ciarrocchi & Brelsford, 2009; Diaz et al., 2011; Galbraith & Conner, 2015; Giordano et al., 2015; Harris et al., 2011). Readers are encouraged to consider these cases, or similar cases, within the context of the implications for counselors that follow.

Implications for Counselors

Assessing Spiritual Beliefs of Military Veteran Clients

As the case examples demonstrate, clients come to counseling with varying degrees of spiritual beliefs and practices. It is important to understand a client’s beliefs, or lack thereof, and how these beliefs were developed. An assessment of military veterans’ spiritual beliefs is an essential first step before the counselor decides to implement any spiritually-based counseling intervention or strategy. This assessment is best accomplished early in the counseling relationship or as a component of the formal intake process. The topic of spirituality can be infused into a discussion or assessment of client strengths and support systems. It is important that counselors broaden their own definitions of spirituality and allow the client to lead the counselor in a description of their spiritual or religious beliefs. Juhnke et al. (2009) have provided questions for counselors to utilize when assessing for spiritual beliefs or practices. Most importantly, the counselor seeks to assess how these beliefs may impact the client’s treatment and recovery.

Assessing Impact of Military Culture

This awareness and assessment of spirituality also extends to the client’s military culture and the impact that this military culture may play in their help-seeking and recovery process. There are formal assessment measures for military veteran clients in substance use services. For example, the New York State (NYS) Office of Mental Health (OMH) and Office of Alcoholism and Substance Abuse Services (OASAS) publish a combined Military Assessment that evaluates military experience and also screens for traumatic brain injury, trauma, sexual trauma, social struggles, community supports/ resiliency, as well as the impact on family, couples, and children (NYS OMH OASAS, 2016). Beyond formal measures, counselors can use skills such as focusing, reflecting meaning, and interpretation (Ivey, Ivey, & Zalaquett, 2014) during sessions with clients to help explore the significance of their military experience in their lives. Some questions that might draw out these beliefs include: What inspired you to join the military? What does being a veteran mean to you? How has your service impacted you? How has your separation from the military impacted you? How has it impacted your family? These questions may help the military veteran to explore the significance of their military culture and its impact, if any, on their substance use disorder.

Including Spirituality in Substance Use Treatment With Military Veterans

Developing spirituality as a coping mechanism should be considered for inclusion in counseling with military veterans. Counselors can help military clients make connections between their current struggles with addiction and their spiritual beliefs. Many spiritual clients in addiction recovery connect with and are comforted by 12-step group concepts, particularly the Serenity Prayer and references to a higher power (Diaz et al., 2011; Juhnke et al., 2009). Counselors may wish to consider prayer or meditation as a positive coping strategy to manage urges and cravings for substances (Juhnke et al., 2009; Pruett et al., 2007). Occasionally, clients may request to pray in session with counselors. Counselors may wish to encourage client-led prayer to ensure that the counselor’s perception of prayer and spirituality is not being imposed on the client. In my practice, veteran clients have brought their spiritual beliefs and practices to counseling sessions. In one situation, a military veteran client brought spiritual readings to our individual session. The readings were based on a spiritual sermon he attended in which he felt the words of the pastor spoke directly to him and his addiction. The spiritual message focused on “coming home” and the client regularly expressed gratitude for his wife and children taking him back “home” after his time away from the family, both during his addiction and during his military service. In another circumstance, a military veteran client sang a spiritual song in group sessions to demonstrate how he copes with emotional struggles. The client discussed how he had learned these songs in childhood, when his family was active in the church. The client viewed those memories positively and saw his struggles with addiction as being contrary to his spiritual beliefs. This client shared with the group how these “old church songs” brought him peace, when he was feeling discouraged.

I have also explored with military clients the option to keep a prayer journal or a gratitude journal that they may elect to share during session. Another military veteran client, who at one time had considered becoming a monk after his military service, shared that he had filled “dozens of notebooks” with prayer journals throughout his time in service and exploring the monastery. In these circumstances, the client’s spirituality was an active component of their treatment. Other interventions that inspire mindfulness (Pruett et al., 2007) and may be a part of a client’s spiritual practices include labyrinth walks, using mandalas, and yoga.

Counselors have a responsibility to tailor client treatment to the client’s level of readiness and motivation, which includes not emphasizing spiritual constructs and coping strategies if they do not resonate with the client. Harris et al. (2011) also emphasized that “not all trauma survivors are open to spiritual interventions” (p. 434). Dr. Ben Nordstrom, Medical Director of Phoenix House services, states that some clients may object to participation in 12-step meetings, some based on philosophical beliefs or opposition to religious beliefs (Phoenix House Training, 2016).

It is equally important to understand how clients came to form these beliefs, what significant events in their lives may have contributed to them, and how these beliefs impact them now, if at all. Client beliefs may have originated from non-exposure, misinformation, or a negative experience with spirituality. For example, clients may have a misconception that 12-step groups require that they believe in God. Counselors have an opportunity to educate clients on 12-step concepts, the interpretive nature of one’s higher power, and other areas in which a client may require psychoeducation. In these circumstances, it is important that counselors have provided psychoeducation and non- spiritual or secular options if available. A client who has a negative perception of spirituality, as indicated above, will likely not utilize spirituality as a positive coping mechanism (Berg, 2011; Ciarrocchi & Brelsford, 2009; Diaz et al., 2011; Galbraith & Conner, 2015; Giordano et al., 2015; Harris et al., 2011). Thus, requiring a client to use a spiritual construct as a component of their recovery might actually do harm to the client and could be considered in breach of the ACA Code of Ethics (2014), A4. Avoiding Harm and Imposing Values.

Limitations and Future Research

Limitations

The literature reviewed in this manuscript is not exhaustive and it is possible that some elements may have been omitted due to human error. Two areas that did not receive attention in the manuscript, yet are relevant to the topic, are pastoral counseling and moral repair/spiritual injury. The field of pastoral counseling is broad and vibrant, extending beyond the scope of this manuscript. The concept of moral injury and/or spiritual repair is also beyond the scope of this manuscript. Berg (2011) began to address this concept, explaining that Vietnam veterans, like other veterans, must deal with issues such as mortality, grief, despair, survivor guilt, betrayal, and awareness of their role in the midst of death, combat, and trauma. Berg discussed the existential nature of these issues, their spiritual value, and the damage that unresolved issues can impose on sobriety and recovery. Like pastoral counseling, the concept of moral injury, while related to spirituality, substance use, and military, is beyond the scope of this manuscript.

It is also important to note that spirituality may not always be effective in substance use treatment. Spiritual by-pass, the concept of avoiding the necessary work of recovery due to spiritual beliefs, may hinder one’s recovery process (Cashwell et al., 2009). Furthermore, studies of college students have found that spirituality and religion were protective factors for some, but not all, substance use behaviors (Galbraith & Conner, 2015; Giordano et al., 2015).

Future Research

There is a dearth of research examining the collective constructs of spirituality, substance use, and the military. Further research is needed to examine the impact of spirituality specifically on military members and veterans in recovery from substance use. It is worth examining how spirituality impacts the recovery of military members and veterans when compared to civilians in recovery. Longitudinal studies that examine the development of spirituality for military personnel over time, including pre-service, active duty, and post-service, in relation to substance use behavior, would also be beneficial. Research providing for collaboration with pastoral counselors, as well as traditional mental health and physical health providers, would allow for more holistic treatment of the military veteran in recovery. Finally, since many of the large scale studies pertaining to military members and substance use, or military members and spirituality, are conducted through the U.S. Department of Defense or the Veterans Administration, research is needed that captures the “marginalized” veterans, including those that are homeless, ineligible for VA benefits, or in other ways disconnected from the military community.

Conclusion

There is a reasonable argument that utilizing spirituality may be used as a positive coping strategy for military veterans in recovery who view spirituality as helpful and supportive. Empirical research has identified spirituality as a positive coping mechanism for military veterans who have experienced trauma. In addition, research has also identified spirituality as an effective coping mechanism for individuals in substance use recovery. While there is sparse literature discussing the combined concepts of spirituality, substance use, and military members/veterans, there appears to be a sound rationale for spiritual interventions in counseling military members/veterans in recovery, as long as the military member/veteran views their spiritual beliefs as helpful. Counselors may wish to discuss spiritual interventions, such as 12-step concepts, prayer and meditation, spiritual readings or music, and prayer/gratitude journaling, as techniques to support recovery. Counselors also have a responsibility to ensure that they do not impose their spiritual values onto clients and that they accept clients’ spiritual beliefs, or non-beliefs, with an accepting and nonjudgmental attitude. There is an opportunity to further research on the intersection of spirituality, substance use, and military members and veterans.