versão impressa ISSN 0034-8910
Rev. Saúde Pública vol.42 no.2 São Paulo Abr. 2008
Zila van der Meer Sanchez; Solange Aparecida Nappo
Centro Brasileiro de Informações sobre Drogas Psicotrópicas. Departamento de Psicobiologia. Universidade Federal de São Paulo. São Paulo, SP, Brasil
To analyze the role of emerging religious interventions in the recovery from
METHODOLOGICAL PROCEDURES: An exploratory qualitative study carried out in the city of Sao Paulo, Southeastern Brazil, in 2004 and 2005. In-depth interviews were held with 85 former drug users who had turned to non-medical religious resources for the treatment of their drug addiction and who were free from drugs for at least six months. The religious groups included in the analysis were Catholics, Evangelicals and Spiritualists. The interviews contained questions relating to sociodemographic data, the religiosity of the interviewee, his or her history of drug consumption, medical treatment for drug addiction, religious treatment and prevention of drug consumption through religion.
ANALYSIS OF RESULTS: There were differences between the religious groups in the way that the drug addict was supported. The group that most used religion as an exclusive form of treatment was the Evangelicals, who rejected the intervention of a doctor andr any kind of pharmacological treatment. The Spiritualists most turned to therapeutic support for alcohol dependence, as well as conventional treatment, on account of their greater purchasing power. Catholics generally relied exclusively on religious therapy, but were less likely to reject the possibility of medical treatment. The importance given to prayer as an anxiolytic method was common in the three treatments. Confessions and pardons in the forms of (faith) conversions and penitence for Evangelicals and Catholics respectively served to help to rebuild people's lives and restore their self-esteem.
CONCLUSIONS: According to the interviewees, what helped them to maintain their abstinence from drugs was more than just religious faith. Other factors included the support, positive pressure and welcoming offered by the group, and the offer to rebuild their lives with the unconditional support of religious leaders.
Descriptors: Religion and Medicine. Substance-Related Disorders, prevention & control. Interpersonal Relations. Rehabilitation. Qualitative Research.
Quantitative epidemiological studies associate religiosity with reduced drug consumption and with better indicators for the recovery of patients who are receiving medical treatment for drug addiction.6,12,14
Religiosity serves to protect from drug consumption those people who regularly attend church,3 who abide by the teachings of their declared religion,12 believe in the importance of religion in their lives,14 or who have received formal religious education as children.6
A qualitative study in Brazil found that the most significant difference between adolescents from low-income families who were psychotropic drug users and those who were not, was their own and their family's religiosity. The researchers found that 81% of non-users practiced their declared religion of their own choice and interest, while the same applied to only 13% of drug users.21
Another study of university students in São Paulo found that those with a high family income and no (declared) religion were found to be at the greatest risk of consuming drugs.20 In addition, there was an absence of excessive drinkers among spiritualists and protestants who declared their religions.
The implication is that religiosity, independently of the religion that is practiced, helps in the recovery from drug addiction and reduces the indices of relapse among patients.7,18 Richard et al19 (2000) found that attendance at rituals and masses contributed to a reduction in the consumption of drugs such as cocaine, even when there was not necessarily any kind of formal treatment offered in these places.
Some authors suggest that religiosity can help in the process of drug rehabilitation in the following ways: increases in optimism, the perception of social support, resilience, decreases in levels of stress and anxiety.15 For Barret et al1 this mechanism has much more to do with social issues, including the re-socialization of the young individual through the re-establishment of a network of friends, and being in an environment in which drugs are not available.
Pardini et al16 point out that while there are few scientific studies that analyze the impact and role of religiosity in the treatment of drug addicts, many researchers theorize about the probable factors. Their conclusions are generally based on their beliefs and the indirect quantitative results of these studies. These authors therefore suggest qualitative studies that will allow the phenomenon in its various forms to be better understood.
There are indications, particularly coming from the media, of an emerging phenomenon in which Brazilian religious groups are involved in the recuperation of drug addicts within the religious "temple" itself, using only the faith of their followers as a means of treatment, and without recourse to any medication.
The aim of the present study was to analyze religious interventions in the recovery from drug addiction.
The Catholic, Evangelical (Protestant), and Spiritualist (Kardecist) religions were chosen on account of their impact and number of followers in Brazil, representing 95% of the population who declare some kind of religion (IBGE, 2000).13
A qualitative exploratory study using participant observation17,22 was carried out during 17 months in 2004 and 2005, in 21 religious institutions in the city of Sao Paulo in which rituals could be experienced. The people who participated in the in-depth interviews were those who had undergone a religious "treatment" for drug addiction and who had been abstinent for at least six months.
To select the sample, interviews were held with ten key informants, who helped the researchers to get closer to the target audience and helped in the preparation of the questionnaire.23 The key informants included: four evangelical representatives from the traditional Pentecostal and Neo-Pentecostal denominations, three leaders of Spiritualist groups who were responsible for the spiritual support in the Spiritualist centers, and three representatives from the traditional Catholic church.
The subjects were recruited using the "snow ball" 2 technique, that involves following up on a series of suggestions made by informants. Eight chains were followed up amongst Evangelists, seven amongst Spiritualists and five amongst Catholics.
The sample size (N=85) was large enough to guarantee the inclusion of all profiles to be studied, until the descriptions became redundant, and the point of theoretic saturation had been reached 22. Semi-structured interviews were held based around the questionnaire with some standard questions and others that were developed during the discussion.
The questionnaire was applied to the three groups and at the time of the interview, adjustments were made according to the particularities of each group. The instrument was developed around seven central topics divided into 46 questions: sociodemographic data, the religiosity of the interviewee, his or her history of drug consumption, medical treatment for drug addition, religious treatment, and prevention of drug consumption through religion. The socioeconomic class of the interviewee was evaluated using the Brazilian Criteria for Economic Classification.
The interviews lasted on average for 90 minutes, were anonymous and were recorded on the agreement of the interviewee, after he or she had read the terms of free and clear consent. Each interview was transcribed and identified using an alpha-numeric code made up of the initial of the interview's name, his or her age, sex (F or M) and a letter relating to the religious group: Catholic (C), Spiritualist (S) and Evangelical (E).
The research was approved by the Research Ethics Committee of the Federal University of Sao Paulo.
ANALYSIS OF RESULTS
A total of 69 men (81%) and 16 women (19%) were interviewed. There was a majority of men in all three groups, which reflects the fact that there are more male drug users in Brazil than female.4 The average age of Evangelicals was 35, and for Catholics and Spiritualists 36.3 and 48.1 respectively.
In terms of social class and education, the three groups involved in the interviews conformed with the profiles described by the Instituto Brasileiro de Geografia e Estatística (IBGE Brazilian Institute of Geography and Statistics) in the last demographic census.13 Evangelicals had the lowest income; the Catholics' income was average and similar to that of the Brazilian population on average, while the Spiritualists had the highest incomes. The unemployment rate was around 10% among Spiritualists and Catholics and 20% among Evangelicals. None of the Evangelicals had attended secondary education, while there were three times as many Spiritualists who had attended secondary education than there were Catholics (a total of three, compared with nine Spiritualists).
Religiosity during childhood and adolescence
While the majority of interviewees came from Catholic families, they did not declare their religion. There were no reports about the previous relevance of religion in people's lives, but all interviewees responded that they believed in God when they decided to seek help "from Him".
By applying the questions found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for diagnosing dependence, it was found that all interviewees had sought religious help when addicted to some kind of psychotropic drug. There were differences between the kinds of drugs and the religious groups that were sought out. All Evangelicals reported that they had used illicit drugs at least once in their lifetimes, even if just for experimenting, with the highest indices of addiction being associated with cocaine ane "crack" at the time of seeking religion. The diagnostic criterion that was most commonly cited was the persistent use of drugs, and legal problems resulting from trafficking or carrying drugs. The highest frequencies of alcohol dependency were found among Catholics and Spiritualists.
The people who benefited from religious "treatment" were not in an experimental phase of drug use. The majority reported negative symptoms from drug withdrawal and difficulties that they faced in overcoming the persistent urge to go back to consuming them. However, even without the use of medication, all managed to remain abstinent.
Most interviewees were addicted to cigarettes at the same time as being addicted to other drugs, but only six sought out religion to support them to end their tobacco addiction.
The average period of time of abstinence was five years in the three groups. This fact can be seen as an indicator of success, with almost all interviewees having been abstinent for at least two years. The longest periods of abstinence were found among Spiritualists and the shortest among Evangelicals, which may be due to the differences in ages between the two groups.
Seeking religious treatment
The interviewees reported experiencing existential and behavioral crises. The drugs no longer led to pleasure, but to anxiety that they believed that they had lost their life references.
This realization of the crisis was not immediate, sometimes taking up to two years, at which point they joined the religious group for various different reasons, depending on the group. Amongst Spiritualists and Catholics, the group with the highest rates of alcohol and drug dependency, this crisis was marked by a loss of control over their own lives, including looking after their children, working, washing and other activities. These people described emotional shocks that resulted from their alcohol consumption, such as this account of an alcoholic coma:
"My son found me collapsed on the floor, totally drunk. The following day he cried a lot and asked me, 'Dad, don't die, you died yesterday, don't die again! Tell me you're going to stop drinking, like Mum asked you.' I realized that I didn't have a choice, that I had to change." (L35MC)
According to the accounts of the Evangelicals, their realization of a crisis was related to legal problems linked to dealers and the police; they were more afraid of being shot than of any of the physical consequences of drug use.
The majority of respondents reported that information about the powers of the Evangelical church passed on through the television or by relatives and friends played a fundamental role in their decision to seek help from this source. Proof of the church's "effectiveness" in curing illnesses, including chemical dependence, could be related to the interviewees' faith in the power of the church.
"I knew that I had to find God. I was hearing things about the Evangelicals everywhere and thought to myself, if God really did cure the blind and lepers, why can He not cure drug addiction as well, why can't He help me get myself off the streets and away from this misery?" (C31ME)
Previous experiences of conventional treatment
Most Catholic and Evangelical interviewees had never undergone any conventional treatment for drug addiction, and reported that their first choice was to seek help in religion, since it was free and accessible. The small number of people who said that they had sought medical help emphasized the difficulties they encountered in trying to access public services in that area and the delays involved in arranging consultations and possible therapies, as the following account shows:
"They leave you waiting for a lifetime. You are a drug user, and if they make you come back a month later, it is already too late and you are even more deeply involved than before. That's why I didn't even start [medical treatment]." (N26ME)
Among Spiritualists, the group itself advises that medical treatment should be sought in parallel to spiritual "treatment". When the individual was not able to cover the cost of individual treatment, he or she joined a self-help group such as Alcoholics Anonymous (AA). Unlike with other groups, financial considerations were not cited as a reason for not seeking treatment. Spiritualists believed that it was essential to have medical treatment alongside "spiritual treatment" to ensure the effective recovery from any kind of pathology; however they also considered the approach and treatment offered by health professionals to be cold and distant, as the following account attests:
"Medical treatment is fundamental. But you are made to feel worthless. Doctors act as if they are superior and are dealing with Joe Bloggs. Then you go to a [Spiritualist] center or to AA and people treat you as an equal, they don't look down on you or look at you with disgust. This makes all the difference." (R50MS)
Common elements of religious treatment
The forms of "treatment" that are common among the groups include: prayer, reflection about life after death and faith as a way of promoting a good quality of life. The objective of the "treatment" is total abstinence; none of the groups accepted damage limitation as a measure of success. The issues of awareness about life after death and the meaning of faith are treated in weekly religious gatherings, which have a different name according to the religion (Mass, worship, "Gospel"). These meetings include regular moral and informative guidance, meaning that the principal teachings of Jesus Christ come to form the moral foundation for the follower.
The principal consensus shared by the religions is the need for regular prayer, particularly at times when the individual is overcome by an uncontrollable urge to use drugs. The three religions encouraged this practice as a way of avoiding relapses and advised that their followers at the very least pray when they wake up, asking for protection during the day and again before they go to sleep, giving thanks for the protection that they have received. In all cases, the prayer or worshipping is a form of direct contact with God, a form of dialogue between father and child. In terms of the treatment for addiction, prayer is considered to be a substitute for pharmacological therapy and plays an anxiolytic role in the same way that medication does:
"I dreamed at night that I was taking drugs and woke up dripping with sweat with my heart racing. So I would go down on my knees and pray. It was like that for a month. " (V37ME)
Prayer not only serves to calm the drug user, by placing the worshipper in a meditative and mind altering state,5 but it also helps the follower to develop faith by sharing the responsibility for the "treatment" with God. In this way it eases the burden of a solitary battle and allows for God's protective intervention against the "bad spirits" or the "devil".
Faith also helps to improve one's quality of life. By adopting religious references, the follower puts his or her faith in the protection of God and chooses to respect the norms and values that the religion dictates, thus improving his or her quality of life. This behavior can lead quite naturally to one's distancing from drugs and a lack of interest in them, driven either by fear or just by the realization of the moral decay that is associated with drug abuse. Facing up to difficulties from a spiritual perspective that is supported by faith can lead to one's natural distancing from any kind of attitude that is contrary to the morals preached by the religion. In addition, the fact of being able to count on God's limitless support can create a sense of constant protection, comfort and well being.
In spite of differences in content and intensity, faith is developed in the religious groups, where the religious leaders present arguments about its potential to heal, to promote well being and to save. In this way, the form that the faith takes is influenced by the religion's content. For Evangelicals, it is common for groups to set aside time for the witnessing of faith, whereby someone who has received a gift from God, as a result of their faith, tells their story.
Irrespective of the religion, faith is considered to be a key element in the individual's spiritual or religious life, and this explains why these meetings are of fundamental importance.
"The treatment is to have faith. What they show there that is different is that this leads to results. You see that God is powerful. I prayed and said: wow! It really does work!" (S49MC)
The realization of the existence of the spirit and the immortality of the soul help the individual to have a broader vision of the future. It is a consensus among the religions that the abuse of drugs is harmful to both the present and to the future, and transcends death. The possibility that criminal behavior may also damage one's spiritual growth is also emphasized. For Catholics and Evangelicals, a drug user who has not been redeemed will spend eternity in "Hell", paying for this sin against God. In Spiritualism, a drug user is said to acquire a negative karma that inhibits his or her spiritual development and needs to be shed in future incarnations, either through suffering or through practicing charity. These religions believe that the use of drugs is damaging, both for one's present and future, thus emphasizing the user's responsibility. In addition the religions believe that lower spirits, evil forces, demons and personal spirits (a term used to describe the negative influence of entities that are invisible to the living) can influence a drug user to return to his habit.
The religious meeting in which followers of the institution congregate is known as Worship in Evangelism, Mass in Catholicism ane "Gospel" in Spiritualism. In spite of these different names and dynamics, the objective of such meetings is to disseminate religious knowledge. In this way, it offers an opportunity for drug addicts to come into contact with the information required including the moral basis of the religion and the path to salvation, based on the Old and New Testaments or, in the case of Spiritualism, on the writings of its founder, Allan Kardec.
The Neo-Pentecostal Evangelical gospels and Mass with the Charismatic Renovation Catholicism are similar, their central elements being contact between members and worship. Worshippers are invited to call out encouragement to their "neighbors" in the church and to pray for help for other people.
"I worshipped every day at the meeeings (...) It was there that I found freedom (...) God slowly began to bless us and I no longer wanted to carry on with my old life." (A36ME)
In Spiritualism, the meetings of worshippers are led by a speaker who presents on a theme, leads prayers of thanks, makes a request and/or leads worship and a call for God's intervention, called a "vibration". The whole process is carried out in silence, with no chanting, sacraments or liturgies.
The religious groups keep mutual-help groups, based on the 12-steps structure of AA ou Narcotics Anonymous, as part of the "treatment".
"Wow! The meeting is the best thing that happened to me ( ) There you can completely open yourself up, share everything and its just like doing therapy, but for free. People listen to you and give you advice and you leave feeling light. Walking on clouds." (N19FC)
Religious "treatment" among Evangelicals
The interviewees who had undergone formal evangelical "treatment" (linked to the church) for drug dependence attended the meetings and took part in the general activities of the church, thus feeling compelled to stop using drugs. For them, it is faith that heals people; they believe that God saves (and therefore cures) His children who have faith and that this faith is demonstrated through regular attendance at church, as the following account shows:
"They say: don't stop going to church, because it might be that your case does not involve immediate liberation, but gradual redemption and that if you leave the church now, it will be too late and you will have lost your chance. So you have to keep attending with faith and God will save you." (N26ME)
The responsibility for resolving your problems lies with God, since faith is sufficient to free you of all your past guilt and sins.
Evangelicals offer three specific resources for the treatment of drug dependency: the meeting of the cells a group of around 12 church-goers who meet weekly to study the bible and give any kind of emotional support to its members; casting out of the devil performed by Neo-Pentecostal groups, in their healing and freeing groups; and bible readings, which are considered to be a way of receiving the blessing of God.
Religious "treatment" among Catholics
Unlike the Evangelicals, most Catholic interviewees receive "treatment" that follows the AA model, using Catholic principles and without any medical treatment.
The interviewees reported that God gave them the strength to stop using drugs, but their success depended on the individual strength, without any kind of mystical component. The success of the treatment" was attributed to something "concrete", such as support to people or groups, as the following person testifies:
"On the day that I arrived I was very well received. A welcoming that scored top marks. I am sure that if that lady had not treated me as if I were the most important person in the world, I would not have gone back and would not have become part of the group." (E29FC)
The Catholics alone offer two particular therapies: confession and the Eucharist. Confession is considered to be a form of spiritual therapy. When the priest offers forgiveness through the Eucharist, makes the sign of the cross and tells the person that he is forgiven of sin, the individual has the feeling of having shed his past as a sinner and becoming a servant of Jesus, and this improves his self-esteem. The confession allows the drug user to rid himself of blame for his past mistakes thus opening up the possibility of a new future, starting from scratch. Interviewees believed that in the Communion, they were receiving part of Jesus and that this would protect them from the desire to use drugs.
Religious "treatment" among Spiritualists
An evaluation of the Spiritualist "treatment" is compromised by the fact that the interviewees from this group also received medical treatment for the same purpose.
The principal forms of Spiritualist therapy involve different steps to re-find one's energy balance and freeing oneself of "under-evolved spirits" through a method known as dispossession. Spiritualists focus on the emotional state of the drug addict, seeking to improve his self-esteem and helping him to face up to difficulties, using the morality of the Gospel.
Although all the interviewees in this group had been involved in these processes, they did not give them much importance in the interviews.
Spiritualists believe that their religion offers them the opportunity to change their way of thinking and acting and, for this reason, they carry out good acts, such as charity, which in turn encourages "protective spirits" to help them.
"What most helped me in this process [recovery from alcohol addiction] was my voluntary work in the day care. You feel useful, you help out, and above all, you receive a lot of spiritual help for this. At the beginning I was going once a week, but then began going three times a week. If I could, I'd go every day. It gives me life." (L51FS)
Welcoming and cohesion of the group
The principal factor that ties the interviewees to religion is the welcoming that they received within the group. When they first join the group, they are at such a low point both physically and morally that they already feel excluded from society. But then they are treated with respect and dignity within the religious group and it is at this moment that they reacquire an identity in this new group and are not asked of anything in return, no demands or conditions.
Physical contact that is free of prejudice impacts on and values drug addicts. There is consensus among them that they value this kind of treatment, since they are put at the same level as those who welcome them to the group and sometimes they even hear stories about people like them who have made mistakes and were redeemed.
In the Evangelical group, priests and lay people help to raise the newcomer's self esteem by emphasizing that person's qualities and using arguments that focus on God's plan in that person's life. For someone who has been socially excluded, with no idea of how he or she is going to reintegrate, there is much solace in the thought that they are so important that God has a plan especially for them. And it is from this that stems their interest in remaining part of the group.
Professed traditional Catholics (those that are not part of the charismatic renovation) and Spiritualists are less welcoming than the Evangelicals or Charismatics. However, there is always someone who is responsible for monitoring or guiding the new member. By treating the newcomer with affection and respect, they also show how they value that person and help to improve their self-esteem. Catholics propose a less radical form of therapy, pointing to future problems in the after-life resulting from drug use and to the protection that can be found from harm in this life, if they do their part or, in other words, of they force themselves to distance themselves from drugs and from difficult positions.
Dermatis et al8 noted that the cohesion in these treatment communities and the friendships that arise from these group are important in drug addicts' recovery and they begin to form part of a new micro-society, in which they feel valued.
In addition, Galanter10 suggests that the welcoming offered by the religious groups is an incentive for the new member to remain part of the group,9 since it represents a first step in identifying with the group and subsequently helps them to accept spirituality as a form of therapy.10 This social support was recognized as one of the mechanisms that explains the benefit that religion can have on health, beyond faith or the mystical characteristics of these groups,11 creating an environment of unconditional support for the newcomer.15
Religion not only encourages abstinence from drug use, but also offers social resources for rebuilding one's life: a new network of friends, a way of spending one's free time doing voluntary work, individual "psychological" attention, value placed in the individual's potentials, cohesion within the group, unconditional support from religious leaders without judgment and, particularly amongst Evangelicals, the establishment of a "new family".
An important component in the success of these "treatments" is found in the welcoming offered to those who come in search of help, and the way that this welcoming is transmitted, helping them to recover their self-esteem and to rejoin society through new activities and new social bonds. This structure is founded in religious faith, which promotes ties to the group by offering religious and philosophical answers to questions about life.
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Zila van der Meer Sanchez
R. Botucatu, 862
Ed. Ciências Biomédicas, 1º andar
04023-062 São Paulo, SP, Brasil
ZM Sanchez was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq; doctorate scholarship).
Research supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP; Proc. N. 04/01177-2).
Article based on the doctorate thesis by ZM Sanchez, presented to the Post-graduation Program in Psychiobiology of the Escola Paulista de Medicina of Universidade Federal de São Paulo, in 2006.