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April 2017

Year 15 of Tips & Topics; Spirituality & ASAM Criteria; Heart, patience and empathy


Several months ago, I started a conversation with Rev. Jack Abel, M.Div., MBA, Senior Director of Spiritual Care at Caron Treatment Centers. Caron, a leading not-for-profit addiction treatment center, is headquartered in Wernersville, Pennsylvania, and is not a religious organization. Jack leads a team of spiritual counselors, and adapts the historic model for Clinical Pastoral Education (CPE) common in hospitals and end-of-life care. He and his team are intentional about work in the practice gap of spirituality. They have refined a formal model of spiritual assessment and care as an integrated discipline of addiction treatment.
The ASAM Criteria editors have always believed in the importance of spirituality in addiction treatment. However we have not articulated well in  The ASAM Criteria how to integrate spirituality into multidimensional assessment and treatment. On page 54 of  The ASAM Criteria (2013) there is a section on spirituality: “ By assessing if and when spirituality has been meaningful for the individual in any or all of the assessment dimensions, strengths, skills, and resources can be identified to be incorporated into the service plan.”
Jack Abel agreed to lay out for  Tips &  Topics how he and his team at Caron Treatment Centers uses the structure of The ASAM Criteria assessment dimensions to integrate spirituality into the care at Caron. Spirituality is like comedian Rodney Dangerfield’s joke that he gets “no respect”. So here’s what Jack wrote. I reconfigured his content to fit with the style of  Tips &  Topics, but it is Jack’s work:
“The Chaplain Gets No Respect”:
Caron Treatment Centers uniquely integrates professional spiritual care
This month we take a close look at how one treatment provider is moving into this area in a way that draws heavily upon the ASAM Criteria.
Spirituality may or may not play a role in how we think about placement and ongoing care – but it can and should!
Many behavioral health facilities offer some access to persons who are trained in pastoral care, spirituality, or chaplaincy services. The provider may be a pastor, priest, rabbi, or shaman that comes in from the surrounding community. It might be someone on staff who brings mindfulness, grief counseling, visitation, or a “chapel” component to our care. There’s no uniform standard, and few formal models for how spiritual care is delivered, but it’s also something we see experimentation with, and a good bit of talk about.
Spirituality in Six Dimensions
The 2013 Third Edition of The ASAM Criteria notes, “ many have asked why there is not a Dimension 7 on spirituality.” The paragraphs on page 54 go on to suggest a few examples of how spirituality can be integrated across the six dimensions. At the same time, “ specific criteria have not been written incorporating the role of spirituality in placement or treatment decisions explicitly.”
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) also offers:
  • A new “Cultural Formulation Interview” (CFI) among several proposals for further research.
  • It is one of several assessment and monitoring tools “for which we determined that the scientific evidence is not yet available to support widespread clinical use” (p. 23f).
  • The introduction to the CFI chapter explains, “Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems” (p. 749).
So, spirituality, faith, religion, and culture: these are on the “radar” for ASAM and DSM-5, but also lacking clarity in terms of specific models and methods. Hence the title of our  tip, “the Chaplain gets no respect.”
How a spiritual care provider interfaces with the rest of the treatment team
A Respectable Chaplain’s Work Day
In some settings, the role of the chaplain may be quite ancillary or quite integrated. A small hospital without a formal program may allow clergy from outside to visit, with little or no documentation. On the other hand, a hospice program may include chaplains in treatment planning with patient and family involved.
What makes sense for addiction care at various levels?
Caron’s approach to the integration of spiritual care is on the more formalized end of this continuum.
  • Patients are assigned a spiritual counselor who is a member of their treatment team, and automatically scheduled for a formal spiritual interview, which typically occurs between the 3rd and 7th day of treatment (depending on availability and readiness, given the complexities of addiction withdrawal).
  • The assessment interview is captured in an extended narrative that becomes a part of the patient’s medical record, and is frequently referred to by other members of the treatment team.
  • Any action steps or interventions devised in the assessment are incorporated in relevant goal areas in their written treatment plan. Thus, the team and patient are engaged collaboratively in spiritual work as an integrated part of treatment goals.
The spiritual counselor then remains an engaged member of the patient’s treatment experience.
  • He or she provides lectures, small groups, specialty groups (e.g. grief and loss)
  • May collaborate in these components with other disciplines.
  • Patients with significant areas to explore that were identified in the initial assessment may benefit from an individual follow-up consultation if time and resources allow.
  • The spiritual counselor is a partner in the dialogue as the team provides ongoing treatment plan updates and works to author a plan for next level of care.
The Importance of Story
For each assessment, a variety of tools are woven into a foundational portrait of the recovery process as narrative and journey.
  • How can the individual and family move toward greater connectedness?
  • What are the barriers that impede this movement?

Story or “narrative” plays an important role in theology, philosophy, and social psychology. One of the central resources in Caron’s spiritual care training program focuses on the work of Arthur Frank, and his text, “The Wounded Storyteller”. It may not be obvious to persons who are unfamiliar with this material, but Frank looks masterfully at the types of stories people use to navigate through illness, and emphasizes the role of an “epic” story style in circumstances of serious illness and personal or family crisis.

As the continuum of care unfolds from initial inquiry through residential treatment to aftercare, a patient and their family members may tell the story of their journey in different ways.
  • It is not uncommon for people to adopt a “restorative” narrative, one that sees the treatment episode as brief and compartmentalized, a kind of ‘penalty box’ experience after which the ‘player’ returns to the ‘game’ of life.
  • At other points, the sense of having a coherent narrative may fall away, leaving a person in a “chaos” or un-utterable phase – a time when no story seems to make sense.
It is not surprising that 12-step recovery communities are largely story-based.
  • Ultimately, successful recovery is generally accompanied with a different kind of story, a story that often has classic features of epic narratives or “heroic” journey.
  • The traveler embarks upon a quest, entering the ‘sick world’ where a combination of helps and challenges shape movement towards a new, hoped-for outcome.
  • Connectedness, a fundamental aspect of spirituality, is central to every phase of the quest journey.
Saying yes, making alliances, facing trials, learning lessons: these are ways in which the spiritual counselor helps the patient and family tell the story of their experience, hopes, and challenges.


The Nuts and Bolts of Spiritual Assessment
One of Caron’s innovations involves elucidating spiritual needs in parallel with the ASAM Criteria dimensional framework. This enhances collaboration with interdisciplinary partners in the treatment process, and supports the involvement of patients and families in understanding this model of the recovery journey. This SKILLS segment explores in some detail:
  • What spiritual assessment and interventions may consist of
  • Some of the models most useful for designing them
  • How differing personal and cultural backgrounds are taken into account.
Spiritual Assessments
1. In general, the spiritual counselor’s assessment presents findings about the patient’s suffering and its impact on their connection to self, others, the natural world, and to universality, faith, or transcendence as they may conceive it. Pastoral, theological, and clinical frameworks can, and should, be referenced to provide context and support for the assessment.
2. These frameworks are a foundation of clinical chaplain training. Different spiritual care clinicians will bring different preferences and experience. Typical models through which a patient is viewed include stage-based models of human development, grief and loss, or trauma.
3. Another aspect of assessment is the patient’s cultural or personal history – how does their tradition or exposure to none or many influence their negotiation of the recovery journey? Twelve-step recovery concepts and models are often in view as well, for example addressing self-reliance through sponsorship and “higher power” relationships, addressing resentments with an inventory and reconciliation process, or coping with distress through prayer and meditation.
Theological and pastoral care training prepares the spiritual care practitioner for this task. A rich pastoral care education includes various stage-based models like:
  • Phil Rich’s formulation of grieving
  • Judith Herman’s stages for trauma recovery
  • James Fowler’s identification of five “stages of faith”
  • Paul Pruyser’s work on ministerial diagnosis. 
In addition, the team at Caron is trained:
  • To be mindful of learning styles and cultural and religious frameworks which inform the expectations and struggles of each person and family.
  • Howard Gardner’s theory of multiple intelligences and the DSM’s CFI are key resources.
  • Each spiritual care clinician has their own identity, formation, and belonging. They are accountable for understanding how this informs their experience of the spiritual care encounter, attending to projection, transference, and counter-transference as these occur.
As is the case with other target areas:
  • Identified spiritual care concerns may be mild, moderate, or severe.
  • In certain instances, strengths are identified rather than areas of need or focus.
  • While not equating to formal diagnoses of other disciplines, spiritual care findings often correlate with medical and psychological diagnoses identified by other practitioners – and should. 
Formulate spiritual care assessments using the ASAM Criteria dimensions, and increase compatibility and integration with other practitioners in the multidisciplinary care team.
Treatment assignments, designed collaboratively with the patient, become part of the written care plan. Spirituality is also a focus area in their family program, and throughout the treatment continuum: in preparation dialogues and in next steps after residential care.
Examples in Six Dimensions
In reporting findings to the treatment team, the spiritual counselor writes to one or more of the six ASAM Criteria dimensions.
Dimension 1, Acute Intoxication and/or Withdrawal Potential
Exploring an individual’s past and current experiences of substance use and withdrawal.” The discipline of spiritual care attends to tremors, eye contact, and ability to focus, and even emotional elements of withdrawal like homesickness. Some patients will invite comment in this area; others merit no observation on Dimension 1. Consider a patient in early withdrawal, whose emotions are characterized by fear and loneliness, perhaps having “burned bridges” and sought treatment multiple times previously. This Dimension 1 lamentation, with aspects of fear and loneliness, constitutes an aspect of their spiritual assessment or “diagnosis.”
Dimension 2, Biomedical Conditions and Complications
Exploring an individual’s health history and current physical condition.” Spiritual care attends to the chart and patient’s presentation, and explores how biomedical conditions contribute to the patient’s self-understanding and negotiation of the challenges of existence. A patient with chronic migraines sees their unrelenting pain not only as a medical affliction, but as a cause for despair. Other examples of particularly significant Dimension 2 presentations might include HIV positive status, an amputation, or a history of cancer.
Dimension 3, Emotional, Behavioral, or Cognitive Conditions and Complications
Exploring an individual’s thoughts, emotions, and mental health issues.” What is the patient’s suffering? How does their suffering affect their connection to self, others, the natural world, and to the transcendent – the “God of their understanding?” Dimension 3 is often the most significant area of findings for spiritual assessment. Shame is a frequent challenge for those with use disorders in Dimension 3, and religion, culture, or spiritual outlook often layer this with a narrative of brokenness that seeks forgiveness or redemption. Grief, trauma, and life meaning or purpose are also central to this Dimension. Multiple keywords may apply, for example faith and trust, grief, or woundedness and healing (trauma). It is helpful not only to identify areas of focus but to provide insight into severity and staging.
Dimension 4, Readiness to Change
Exploring an individual’s readiness and interest in changing.” The discipline of spiritual care explores change in varied terms including fear, developmental processes, ritual theory, religious or spiritual conversion, and 12 step recovery. Appropriate findings here are based on the data described in an interview summary and might include observation of patient’s difficulty with surrender in part or whole, fear in relation to specific issues like care planning, or an inability to conceive of a new paradigm.
Dimension 5, Relapse, Continued Use, or Continued Problem Potential
Exploring an individual’s unique relationship with relapse or continued use or problems.” The spiritual counselor helps identify obstacles and risk factors for the achievement or maintenance of a sustained recovery. Apathy and self-reliance are frequent concerns. The patient’s cultural or religious context may contribute positively or as caution. This dimension may simply highlight findings in other areas, which present the greatest concern, but simple redundancy should be avoided.
Dimension 6, Recovery/Living Environment
Exploring an individual’s recovery or living situation, and the surrounding people, places, and things.” The discipline of spiritual care may be especially interested in the network of relationships or meaningful attachments and their status. Distrust, alienation, and resentment are frequent keywords. Examples would be marital discord, strained parent-child relations, hostility or risk in friendship and work settings, and the loss or reduction of any sense of “home” and “belonging.”
Spiritual Treatment in Action
1.  Documented Action Steps. Beyond spiritual “diagnosis,” a compelling area of spiritual interest involves action steps toward identified treatment goals – what are often called clinical “interventions.” At Caron, the initial assessment includes a “disposition” which summarizes any assigned interventions, recommendations, and collaborative engagement of the multidisciplinary team. This might include suggestions for specific approaches to prayer or meditation, reading or writing assignments, art projects, attendance at Chapel or other services, etc.
In the same way interventions can become “boiler plate” in other disciplines, there are core spiritual care practices that frequently are proposed. These often include:
  • Breathing and other mindfulness practices
  • Specific readings from classic recovery texts
  • Observance of customary faith practices (e.g. Sabbath)
  • Grief processing is often aided by the writing of therapeutic letters
  • Resentments in recovery are often processed through AA’s “fourth step” columnar exercises.
The items mentioned above are supported as “evidence-based” in the classic sense.
There is also historic evidence provided by the witness of faith traditions, recovery communities, and the archetypal role of the priest/minister/shaman in our diverse human heritage. Prayer, meditation, ritual, calendar, study, mentorship, and more structured spiritual roles and rites of passage are all tools that can contribute meaning, hope, help, and transformation in the journey of recovery.
2.  Contextualization. The spiritual care professional can aid in grounding identified treatment goals within the context of a client or family’s cultural, religious, and personal thought-world.
  • While mindfulness exercises in the generic sense appeal to many, others may be interested in the meditation practices of their family of origin faith experience.
  • A learning style limitation or preference may suggest music or collage as better methods over reading or letter-writing.
3.  Collaborative Care. It is important to recognize that significant interventions should be brought to the attention of the primary counselor, and often also the psychologist and unit coordinator – possibly through case consultation beyond documentation in the chart.
  • Any follow-up intention or scheduling should be noted.
  • The spiritual counselor is a regular attendee at treatment team meetings, so that progress towards the fulfillment of action plans and larger objectives can be assessed and the treatment plan updated on an ongoing basis.
  • The treatment plan is then a ‘living’ document, rather than a snapshot, which may quickly lose relevance.
Respecting the Spiritual in Your Context
Caron’s deployment of a spiritual care team as an integrated component of residential addiction treatment makes a comprehensive program like this possible. Satisfaction surveys indicate spiritual care content adds significant value to the patient’s perceptions of treatment. Caron’s outcome measures consider an individual’s overall health and wellness, which includes spirituality.
1. Depending on your level of care and other factors, there may or may not be possibilities for full-time spiritual care providers as a component of treatment.
2. The factors raised here, though, and the associated skills for spiritual assessment and treatment planning, are ones that may be beneficial.
3. Consider who may be functioning in this kind of role in an informal or supplemental way. Often there are specific providers who incorporate spiritual aspects in their mental health or medical evaluation and treatment.
4. There may even be administrative and support staff who are providing a spiritual care component not easily recognized. It may have no “footprint” in the medical record.
In whatever way spiritual issues are addressed in your setting, the next time someone mentions “that guy” or “that woman” who “does the spiritual stuff,” don’t disregard the role they may be able to play in assisting your clients to wellness and flourishing. Respect them. The thought may be a great one after all!
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association, 2013.
Fowler, James. Stages of Faith: The Psychology of Human Development and the Quest for Meaning. 2nd ed. New York, NY: HarperCollins, 1995.
Frank, Arthur. The Wounded Storyteller: Body, Illness, and Ethics. 2nd ed. Chicago, IL: University of Chicago Press, 2013.
Gardner, Howard. Frames of Mind: The Theory of Multiple Intelligences. 2nd ed. New York, NY: Basic Books, 2011.
Herman, Judith. Trauma and Recovery: The Aftermath of Violence-from Domestic Abuse to Political Terror. 1R ed. New York, NY: Basic Books, 2015).
Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies®, 2013.
Pruyser, Paul. The Minister as Diagnostician: Personal Problems in Pastoral Perspective. Philadelphia, PA: Westminster Press, 1976.
Rich, Phil. The Healing Journey through Grief: Your Journal for Reflection and Recovery. New York, JY: John Wiley & Sons, 1999.


I read an article on April 24 by Julie Pace, Associated Press White House Correspondent. I was intrigued by her report that President Trump “acknowledged that being Commander-in-Chief brings with it a “human responsibility” he didn’t much bother with in business, requiring him to think through the consequences his decisions have on people and not simply the financial implications for his company’s bottom line.”
Here, everything, pretty much everything you do in government involves heart, whereas in business most things don’t involve heart,” he said. “In fact, in business you’re actually better off without it.” (I added italics)
Yes, President Trump is so right …..”everything…..involves heart”.
  • “Heart” is what the staff on the United Airlines flight forgot about (or lacked) when Dr. David Dao didn’t want to give up his seat on the plane, concerned about getting back home to see his patients the next day. If you missed the video of his being dragged up the plane aisle:  United Airlines and Dr. Dao
It took United Airlines too long to get President Trump’s message that “everything involves heart”. United CEO Oscar Munoz eventually said the airline won’t allow law enforcement officers to haul seated paying passengers off its flights again “unless it is a matter of safety and security.”
(Don’t get me wrong. There are always two sides to the story and I fly United whenever I can.  But if United’s culture was ‘person-centered’, there would have been an easy fix to the problem.  For example- ask if anyone else, less concerned about their seat, would give up their seat for $1,000, $2,000 or whatever it took.  Even $10,000 would have saved United millions in lost image, revenue and stock price.)


  • “Heart” is what the flight attendant on American Airlines forgot about when he grabbed the stroller from the distraught and crying mother carrying 15-month-old twins.
“What we see on this video does not reflect our values or how we care for our customers,” the airline said in a statement. “The actions of our team member captured here do not appear to  reflect patience or empathy, two values necessary for customer care. In short, we are disappointed by these actions.” (I added italics)
Heart, patience and empathy.
You would think addiction and mental health professionals would be the first people to know about heart, patience and empathy. However it hasn’t been too far back in behavioral health treatment history that we were more focused on rule breaking, behavior control and sticking to our policies. We did this:
  • Discharged people for having a flare-up of addiction and drank alcohol or used other drugs.
  • Heavily confronted clients with profane language, punishments and re-traumatizing practices to strip a person of their defenses.
  • Blacklisted clients – barring them from treatment for months, after three poor outcomes in the program.
  • Used physical restraints and leather straps to tie down psychiatric patients to their beds.
Heart, patience and empathy.
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