Signiﬁcance of Self-Transcendence for Rehabilitation and Relapse Prevention among Patients with Substance Use Disorder: A Qualitative Study

: A complex variety of restrictive and promoting factors are in play when people with substance use disorder face challenges concerning rehabilitation and relapse prevention. Self-transcendence sources are strongly associated with meaningfulness, and meaningfulness is found to be associated with less alcohol and drug use severity and relapse prevention. The aim of the present qualitative study was to investigate self-transcendence among patients with substance use disorders and to discuss its signiﬁcance for treatment and relapse prevention. An exploratory qualitative research design was employed, with individual interviews in a strategic sample of four patients with substance use disorder recruited from a religiously founded rehabilitation clinic in Southeast Norway. The transcribed material was analysed through systematic text condensation. A search for objects beyond immediate needs through self-transcendence was revealed, related to generativity and an unselﬁsh prosocial commitment to family and the surroundings, strengthening the participants’ self-efﬁcacy, conﬁdence, and safety. Spirituality and conﬁdence in a higher power or destiny generated order in life. The use of rituals contributed to tranquillity. Values gave new directions, and private confession helped to start over in life. For patients in rehabilitation aiming at relapse prevention, self-transcendence seems to be signiﬁcant as part of the recovery process. Possible implications for rehabilitation and relapse prevention are discussed.


Introduction
The risk of relapse after treatment for substance use disorder is high. Numbers fluctuate, but it is noted that 40-75% of people receiving treatment have a relapse after a relatively short time of discharge (Andersson et al. 2019). Treatment of substance use disorder and avoiding relapse is complex, although it is acknowledged that the risk of relapse is linked to psychological factors. The extent of motivation for behavioural change seems to be of importance, as well as a therapeutic atmosphere (Hendershot et al. 2011).
Relapse prevention (RP) has, for many years, served as a valuable method of helping people with substance misuse problems (Hendershot et al. 2011;Marlatt and George 1984;Ross and Cook 2014). With a cognitive-behavioural approach, therapists have supervised patients with concrete and practical means, employing numerous intervention strategies (Ross and Cook 2014). When employing the RP model, both therapist and patient together address factors linked to what is defined as immediate determinants, such as high-risk situations, enhance the client's skills for coping with such situations, seek to improve the patient's self-efficacy, and thus restructure the client's comprehension of the relapse process. In this work, they also utilize global strategies where therapists and clients seek to find balance in the client's lifestyle, develop positive addictions, employ techniques to handle stimulus control and urge management, and develop relapse road maps, factors defined as covert antecedents.
Background factors such as family history, social support, personality, and drug sensitivity, together with cognitive factors such as drug-related outcome expectancies, global self-efficacy, and personal beliefs about abstinence or relapse, are the basis for identifying the factors that may determine who is vulnerable to relapse (Hendershot et al. 2011). Another group of factors is used to determine when relapse might occur, in addition to factors linked to cognitive and affective processes that may fluctuate across time and context, for instance, urges and cravings, mood, self-efficacy and motivation. In addition, momentary coping responses can determine the result of a high-risk situation.
There is much evidence concerning RP in randomized controlled trials (Bowen et al. 2014). However, potential shortcomings are stated, such as an emphasis on individual needs, values, and issues that may underlie problematic behaviour (Bowen et al. 2014). It is also pointed out that healthcare systems may be good at medical and technical issues in treatment but less skilled at seeing the patient as a person (DeMarinis 2013).
The question is whether emphasis on the concept of meaning-making could accommodate some of the mentioned shortcomings. Several parts of the RP model overlap with what is recognized as sources of meaning within the paradigm of meaning-making and the experience of meaningfulness (Schnell 2021). Meaningfulness is the basic trust that life is worth living, based on an (mostly unconscious) appraisal of life as coherent, significant, oriented, and belonging: Coherence is linked to life making sense, orientation is about having goals and aims in life, and significance emphasizes life's inherent values (Martela and Steger 2016). Many different sources of meaning are used for the processes of gaining meaningfulness in everyday life, global meaning, and when facing demanding life situations such as substance misuse. According to Schnell (2009), these sources can be organized into five dimensions with several sub-dimensions (see Table 1). Both RP and meaning-making are concrete and cognitive-and behaviour-oriented factors, including elements of global and individual factors. As with the background factors in RP, the sources of meaning include dimensions of relatedness and social interaction linked to comfort, community, care, attentiveness, etc., as well as self-actualization elements such as development, power, achievement, etc.
Particularly within the paradigm of meaning-making, self-transcendence as a source of meaning may be a factor that could expand RP strategies. Self-transcendence is a search for objects beyond immediate needs (Schnell 2021). It has been seen that a deeper sense of meaning is achieved through self-transcendence and prosocial collectivism compared to occupation with sources related to self-preoccupation and realization of personal potential (Van Tongeren et al. 2016;Reker and Wong 2012). Compared to RP, it may seem as though meaning making, to a larger extent, emphasizes the self-transcending aspect of social support and community, where responsibility for affairs beyond one's immediate concerns is taken (Schnell 2011). A good example of this may be generativity, which is an unselfish engagement with the surroundings and future generations.
Another difference may be seen, regarding what is designated as vertical self-transcendence. This search beyond immediate needs can be understood as religion when it occurs as organized and has institutional components of faith traditions (Sørensen et al. 2015). Vertical self-transcendence also contains a dimension of spirituality, addressing individuals' relationships with and search for the sacred, understood as God, higher powers, or features having divine-like qualities.
In general, meaningfulness is found to be positively associated with a higher quality of life and less depression and anxiety (Schnell 2009(Schnell , 2011Sørensen et al. 2019). The presence of meaning is associated with lower alcohol and drug use (Csabonyi and Phillips 2020) and contributes to a reduced risk of relapse (Roos et al. 2015). A meta-analysis showed that spiritual and religious interventions seem more efficacious for rehabilitation compared to interventions that do not include these factors (Hai et al. 2019). However, it is not necessarily a direct relationship between religious and spiritual factors and alcohol and drug use severity, because meaning in life seems to mediate their relationship with recovery (Lyons et al. 2010). A path analysis found that daily spiritual experiences directly influenced meaning in life, which in turn impacted alcohol and drug use severity (Gutierrez 2019). Bearing this in mind, it is also known that religion, spirituality, and generativity are among the sources of meaning with the strongest positive relation to meaningfulness (Schnell 2011;Sørensen et al. 2021).
The science of addiction recovery is focused on individuals' perceived needs and objectives as well as their subjective well-being (Best 2012;Laudet and White 2010;Vanderplasschen et al. 2013). From the recovery and addiction literature, it is known that recovery quite frequently involves employing different forms of spirituality or life philosophy, giving hope and meaning to life (Hipolito et al. 2011). Spirituality has been described by persons with addiction as giving a wider perspective in life and offering a feeling of dignity, with faith generating hope and consolation (Brekke et al. 2017). It has also been said that being in touch with something bigger, outside oneself, counteracts meaninglessness. Likewise, it has been stated that spiritual experiences offer tranquillity. As such, when meaning is found to mitigate alcohol and drug use severity, this connection is mediated by hope (Gutierrez 2019). Included in an RP strategy, religion and spirituality are utilized through different practices such as prayer, meditations, and Bible reading, as well as by participation in religious communities and rituals (Appiah et al. 2018). An experience of inner peace and calm may lead to a more ordered and predictable life, in addition to a sense of belonging in a community sharing experiences and struggles.
As a means of self-transcendence, objects beyond immediate needs can be sought through rituals. Rituals, in general, help to create meaning and order in life. Selftranscending and existential rituals are understood as activities signifying the meaning itself in life and death, helping to contain and maintain individuals' existence (DeMarinis 2013). Therefore, scarcity of access to rituals and self-ritualizing may cause mental distress, as well as problems with identity development and a sense of belonging (DeMarinis et al. 2008).
Knowledge regarding self-transcending factors in RP is scarce, especially outside the 12-step literature (Koenig et al. 2012). Even less is known regarding the significance that patients with substance use disorder assign to these factors. On this basis, the aim of the present qualitative study was to investigate self-transcendence among patients with substance use disorders and to discuss its significance for treatment and relapse prevention.

Design and Setting
The present study employed an exploratory qualitative research design using in-depth interviews. Thematic content analysis through systematic text condensation was employed (Malterud 2017). A strategic sample of patients with substance use disorder was recruited from a religiously founded institution for patients with substance use disorder in Southeast Norway.
The larger environment of the present study is the Norwegian context. Norway has a well-developed welfare system where everybody can receive treatment without cost. The majority of the population, 68%, belong to the Lutheran Church of Norway (Statistics Norway 2021). However, similarly to other Scandinavian countries, Norway is labelled by sociologists as one of the most secular countries in the world, with its inhabitants belonging to the church but not widely believing in its teachings (Repstad 2020). On the other hand, it is possible to observe a shift from affiliation to an organized religion to spirituality, understood as individuals' personal faith and approach to the sacred, independent of the opinions of others (Repstad 2020).
Throughout history, Christian organizations in Norway have run different institutions, hospitals, and rehabilitation clinics based on faith and social commitment. In the present study, data were collected from such a value-based and religiously founded institution. However, since the institution was financed by the specialist healthcare service in Southeast Norway, the patients did not necessarily apply to this institution because of its value-based foundation.

Sample
The sample was strategic and specific (Malterud et al. 2016). The participants were two men and two women between 40 and 65 years old. They did not have partners, but all of them had children. Most of the participants had education beyond upper secondary school. All of them had previously had good jobs, but none were employed at the time of the study. All participants were recovering from polysubstance use. The participants had almost finished a 12-month rehabilitation programme with an individual treatment approach. Due to regulations and routines at the clinic, it was known that the participants were abstinent from substances. The participants were recruited by the investigators through information and an open invitation at a daily morning meeting for the patients at the institution.

Data Collection
Data were collected through in-depth interviews, lasting for 60 to 90 min. The interviews emphasized the individuals' experiences about the significance of self-transcendence for rehabilitation and RP. In the interviews, the following themes were explored: The ways in which the participants valued self-transcendence and the search for objects beyond their immediate needs, if and how life philosophy and faith were important, the significance of rituals, and, eventually, whether and how the participants contributed to the restoration of broken relationships. The participants' values and links to global meaning systems were explored, death was thematized, and their relationships with others were investigated.

Analysis
The interviews were audiotaped and transcribed by the first author. Qualitative content analysis through systematic text condensation in a four-step model was employed for the investigation of the material (Malterud 2017): An overview of the data was established; meaning units were identified and sorted; the content of these codes was condensed; and the condensate was synthesized into descriptions and concepts in an analytical text. Due to the emphasis on self-transcendence, the approach was, to some extent, theory-driven and deductive. At the same time, within this broader frame, categorization of the material was made on the material's own premises with an inductive approach from below.

Ethics
Participation in the study was voluntary. The participants received oral and written information before signing the consent form and could withdraw from the investigation at any time. The Protection Officer at Oslo University Hospital approved the present study in accordance with the Norwegian Personal Data Act.

Results
Six themes of self-transcendence and their significance for rehabilitation and RP emerged from the material. Two themes were about generativity from the horizontal selftranscendence domain: (a) 'selfless engagement for family and children' and (b) 'selfless engagement for the community and helping others'. Theme (c), 'values', was to a large degree linked to religious institutional components of faith traditions. Theme (d), 'death and staying alive', had existential connotations within a frame of self-transcendence. Apparent vertical self-transcendence themes were (e) 'affiliation to religiosity and spirituality' and (f) 'rituals'.

Selfless Engagement for Family and Children
Despite demanding life situations and times without daily care and parental responsibility, the participants managed to keep in contact with their children in different ways. Relationships with the closest ones, and especially their children, had been and still were very important for the participants. At the same time, the participants realized this, they saw that their children had suffered in different ways from substance misuse, and they regretted it strongly. In different ways, the participants had undergone treatment for the sake of their children. The motivation for one of them was that his daughter had become mentally ill because of worries about him.
(...) if you ask if I have been her for my own sake? No. I have done it because it is other individuals, that is my daughter, my grandchild, who maybe wish, or I know they wish to see another daddy and grandfather than a plump laying in the gutter stones (...). Because, I don't want them to be left with a form of loss.
According to participants, their children were the ones who really gave them a reason to live. They also talked about their joy when their children succeeded in life, wanted to have contact with them, and had faith in them. However, to be trustworthy as parents, the participants realized they had to make a great effort and show them trust for a long time. It was important to them that their families were spared any worries.

Selfless Engagement for the Community and Helping Others
A community with a shared destiny of having problems with substance misuse was experienced among the fellow patients at the institution, according to the participants. It was noted among these veterans that they themselves positively contributed to the environment at the institution and the integration of newcomers. They also found benefit and enjoyment in attending meetings outside the institution where former patients were sharing experiences of how to stay away from relapse. It was important to experience shared community with those who managed to live meaningful lives without substance misuse after treatment. At the same time, these meetings also functioned as existential conversation groups, similar to the ones at the institution led by the chaplain, where needs, what has significance, and what gives meaning in life were articulated.
I attend in a group outside the institution. There I meet others who manage it and can listen to what they say. A social community with people who understand what I am going through, or . . . yes, it is a community almost like Anonymous Alcoholics or Narcotics Anonymous. (...) I can go there when I am discharged from the institution, once a month. And feel I am part of a community, then, with others who are just like me. Adult people.
And people who stayed here at the institution a long time ago, right. Maybe 20 years ago, and they still keep away from substances. Older people, then, 75-80 years old, sharing their stories.
Common for many participants was the desire to share their experiences with others who are in the same situation as they have been. The participants wished, among other things, to contribute to the prevention of substance misuse among young people, provide guidance on how to get out of situations of misuse, how to handle the public services when help is needed, and support people with mental health struggles. They wanted to implement practical assistance on these matters but also listen to the stories of others and just be there for someone and be a fellow human.
The only thing I know is that I know that I depend on that something or someone need me, in a way. Because, then I grow.
Some of the participants characterized such an effort as giving something back to the community. Earlier they had received help and now they wanted to help others. Such involvement was motivated by their own growth through participating. This attitude was exemplified by one participant who wished to engage in the shelter run by a Christian congregation where he himself was met, seen, given food, and encouraged to go to treatment. Although they had the experience of helping others, the participants also saw the disadvantages. When helping others earlier, they had set aside their own problems.

Values
The participants linked values to seeing life as a gift, with family and work as the most important ingredients in life. At this point, the participants were optimistic about considering starting over. They saw good possibilities in following society's rules, which meant they would find it easier compared to their former lives. The participants linked values to cleaning up their personal affairs and paying their debts; they also wanted to be independent, rather than a burden to others.
Even though they did not consider themselves Christians as such, most of them found appropriate rules to live by from Christian heritage. Values such as truth, loyalty, honesty, reliability, justice, generosity, and setting others higher than themselves were considered important by the participants. Values had become clearer in their new situation after treatment, where they saw the possibility of living the lives they really wanted to live. At this stage, some also had become more thankful, tolerant, and able to listen.
And I am thinking that if one avoids lying, if one is loyal, fair, and not just putting oneself firs, and think a bit over how I would feel if I did . . . , then I think you get far. (...) That is my values.

Death and Staying Alive
During substance misuse, seeing death and suicide as a possibility had given the patients a form of meaning. Death had more or less been considered a relief in contrast to a miserable life. It seemed that coincidences stopped the participants from fulfilling their intentions. In retrospect, one of them assessed her suicide attempt possibly more as a cry for help than a real attempt. Still, the participants had considered death as something meaningful in their demanding life situations.
The treatment process helped the participants to get to know themselves again. Consequently, they hoped and wanted to live for a while. The fact that it was important to their loved ones that they lived was an important motivation for holding onto life. At the same time, they did not fear death as such. In fact, some participants were curious about what would happen after death. Others had experienced close relatives dying in the last year. A sister-in-law had not wanted to die but she was not afraid; this situation was described as very sad but still an experience of confidence. All in all, the participants' former experiences had made them more confident in facing death.
(...) Things were so miserable. Then I realized and felt I was not any longer afraid to die. Life was so miserable, so it had not done me that much, really, I said at that time. I really felt it too. But it has changed. I have said at the stay here at the institution, that the only negative, more or less, is that I'm starting to get scared to die (laughing). I appreciate life again.

Affiliation to Religiosity and Spirituality
No participants asserted an affiliation to classic organized religion. However, several described faith in something outside themselves.
I believe in something, but I do not think it is God or Jesus, then . . . But I don't think anything is left to chance. I think it is a meaning to that we . . . I believe all people are born for a task. Someone get mor than others because they are able to handle it. Some people have much pain in life, right, and still, they stand upright and manage. Possibly, they are called dandelion children . . . yes. Many such things. And I believe we are given tasks. That we are here for a . . . that we have a mission, then. So, if that is to be a Christian, without calling oneself a Christian, then I guess I am, then.
Several of the participants were affiliated to selected parts of the Christian heritage, especially linked to ethical and moral issues, such as good deeds and an emphasis on good intentions. Some participants thought it was very important to do something good because such actions would, in turn, give back something good.
I believe that, sort of . . . I believe that . . . it is so very strong, the saying "do something good, or have a good thought behind what you do, then you get something good in return". It is . . . I have seen that it is very clear.
Even though they did not believe in God and Jesus, they had faith in the Bible's rules; for instance, "you should do unto others what you want them to do unto you". With experiences from the substance misuse environment and a rather demanding life among people with the same challenges, this rule appeared even more important to live by for the participants. Despite people doing bad things, an agnostic participant held onto the view that every person is born with the task of being good and doing good things and that there is something good in every person.
Experience of surviving a cold winter's night outdoors led one participant to believe in an ordered destiny, or at least that there was something governing life, and another did not believe in anything but himself. A third participant had her background in radical left-wing politics, with an atheistic intellectual approach to existential questions; however, after a long history of substance misuse and rehabilitation, she assessed herself as a seeker not too tied to deadlocked opinions as she was earlier. She had a wide definition of spirituality, and her experience of nature gave her joy. The thought of nature being created by somebody was new and she was still not certain about it. Nevertheless, she had become more grateful for being who she was and was more tolerant (e.g., towards religion) and able to listen.
Although the participants did not affiliate with Christianity or another religion, most of them did not have anything against being present at religious meetings. They chose to participate in the Lord's Prayer and benefitted from listening to the chaplain's sermon. An important factor of such settings was experiencing the community with the people there, both by being seen and receiving attention.

Rituals
Morning Prayer at the institution was shown to be an important place for the participants in terms of finding silence and casting uneasiness out of the body, in contrast to the stress and nervousness that characterized the participants when they arrived at the institution. The participants noted the relaxed atmosphere in the chapel and the frame around the morning prayers, with liturgy, candles, readings, the chaplain's sermon, hymns, music, prayers, and the blessing for the day were profound components. Another reason for participating was that ethics and values were highlighted. The setting of Morning Prayer induced good experiences and inner peace.
It's the atmosphere up in the devotional room up there, that . . . especially . . . I attended there mostly in the beginning of the stay. Because it is a special atmosphere up there. Of course. And, and it gave calm. Yes. Because, I remember when I came, I was very stressed and nervous. So, then I took to myself everything that could give some tranquillity. Yes.
Morning Prayer also covered the participants' need for community and the perception of closeness to others. The participants shared bad experiences or talked about their losses with others. After such stories, prayers were often said.
The participants reported different affiliations and strengths of connection to religion or to a higher power. Even so, this setting was characterized as a meeting with something bigger in the sense of self-transcendence, representing what participants considered spiritual. One participant said that what she encountered in these gatherings stood on its own two feet, yielding a form of energy she could not find elsewhere, except possibly in nature.
Rituals were also important in other settings. As opposed to practicing drinking rituals and the idea of drinking being something cosy with candles and soft music, one of the participants had developed her own ritual every morning. In contrast to previous drinking rituals, she lit a candle, read a value-based text and meditated over it; then she did yoga. This kind of activity gave the same experience as participation in Morning Prayer or visiting a church. She met something bigger outside herself, but she could not elaborate on precisely what this was.
Private confession as a ritual was practiced in the frame of pastoral care at the institution. As the distance from misuse became longer, the participants discovered serious life events linked to actions they had done that had damaged other peoples' lives. In conversations with the chaplain, the participants realized they needed forgiveness for their actions. A condition for receiving forgiveness was, according to the participants, to make it up with others, with oneself, and with God. The participants considered private confessions utilizing the church's ritual to be important in terms of laying burdens behind and proceeding further with their lives. For example, one participant had threatened a person with a gun and now struggled with heavy remorse. She knew she would not meet this person again and could not express her regret to him. In this situation, she assessed that private confession was the best option for cleansing her guilty conscience. However, according to the participants, this special act demanded a chaplain with absolute professional secrecy and a high level of integrity.
So, I think I need to talk to someone in peace and quiet and get it over with, then. Put it away. (...) I think that's okey to do here, as a part of what I have with me from the stay here. To get . . . He's (the chaplain) probably the only one I trust which can help me clean it out and get me a little whole again, then. (...) I have to feel a lot of confidence in someone I'll do such an act together with, then. It's not something you just do, just like you go and have a coffee. Not for me, at least.
The participants noted that private confession generated peace of mind and helped them to get rid of guilt through their own confession as well as by the absolution given by the chaplain.
For those participants who participated in and practiced different kinds of rituals, it was refreshing, generated peace of mind, and filled a void with something valuable. Unlike drinking rituals and substance misuse, with their besotting and devastating effects, rituals stimulated the mind, the feelings, and the senses, and also, according to the participants, gave them energy.

Discussion
In this study on self-transcendence among patients with substance use disorders, we found generativity to be especially prominent among the horizontal self-transcendence factors. The participants made great efforts to prevent relapse for the sake of the children and their children's well-being. At the same time, they wanted to give something back to the community by sharing their experiences and supporting those people striving. Further, values had become clearer through their process of rehabilitation, connecting to principles and rules to live by, often rooted in Christian heritage. This new insight made the participants want to clean up their personal affairs as well as pay their debts. In times of substance misuse, attention to death gave an experience of meaning, considered a relief from their miserable lives. However, after treatment, the participants found meaning in staying alive for the sake of themselves and their closest ones. The participants' linkage to vertical self-transcendence seems in line with spirituality, as their life view contained a personal and individual faith in an ordered destiny or a creative higher power outside themselves. However, elements of organized religion were also seen, with reference to common values from the Christian heritage and the use of the Church's rituals, filling a void with something valuable.
It appears that most of the participants in the present study through their 1-year stay at the rehabilitation clinic had gone through a shift, opening up to new perspectives. This was seen through several of the themes in our analysis. Values and what was considered significant in life, right and wrong, important and less important, had been concealed by heavy substance misuse. Abstaining from substances, and also the treatment process, had helped the participants to get to know themselves and thus helped them flourish. An awakening regarding what had gone wrong and what needed to be done was also seen.
Meaningfulness, as the basic trust that life is worth living (Schnell 2021), is, among other things, based on an appraisal of life as significant, emphasizing life's inherent values (Martela and Steger 2016). Consciousness regarding values and what they imply are of importance for the experience of deeper meaning and thus for counteracting relapse (Gutierrez 2019). Values mentioned by the participants encompassing global meaning, such as truth, loyalty, reliability, justice, generosity, and setting others higher than themselves, are said to generate deeper meaning compared to values related to the realization of self and personal comfort (Reker and Wong 2012).
Among the participants, it is possible to recognize a rather high level of self-reflection on these issues. It is likely that this can be seen on the basis of therapy and conversations with the chaplain, as well as conversations in existential conversation groups led by the chaplain. Such settings may help patients to articulate cognitive processes, their needs, and what has significance and gives them meaning (Frøkedal 2021). This ability to articulate positive urges and cravings, as well as strengths and wishes for their lives following their period of rehabilitation, may help them to avoid high-risk situations and relapse (Hendershot et al. 2011).
Generativity, including prosociality, is a strong predictor of the experience of meaningfulness (Van Tongeren et al. 2016;Schnell 2011;Sørensen et al. 2021). The unselfish engagement with their surroundings, family and children, as well as community affairs, was strong among the participants. The participants were motivated to stay away from relapse for the sake of their children. Correspondingly, a selfless interest in others' demanding life situations and in the collective might have strengthened the participants' self-efficacy, which is an important condition for RP (Hendershot et al. 2011;Ross and Cook 2014). Given that meaning is associated with lower alcohol and drug use (Csabonyi and Phillips 2020), contributing to a reduced risk of relapse (Roos et al. 2015), there are good reasons to support people with a risk of relapse in their selfless engagement with others. Knowing that collectivist approaches such as generativity and commitment to a larger social cause may generate a deeper sense of meaning compared to sources related to selfpreoccupation and the realization of personal potential makes this argument even stronger (Reker and Wong 2012). Thus, a prosocial community role may act as a mechanism that contributes to RP (Van Tongeren et al. 2016;Best 2016).
According to Yaloom (2002), facing the reality of death is an important incentive for seeing the value of life. Possibly more than others, patients with substance use disorder have seen death as a reality, as described by the participants in the present study and their wish to die at a certain point. Interestingly, despite having been very close to death, they did not fear death in their present situation and were curious about it. Conversations regarding existential questions in therapy for people at risk of suicide are considered essential by therapists (Søberg et al. 2018). At the same time, such conversations are also characterized as demanding due to, among other things, a scarcity of competence and awareness of these issues among therapists. It is likely that this situation may be coloured by the secularisation process seen in recent decades in Norway (Repstad 2020). At the same time, it is stated that despite such a situation, people are still in need of having their existential and spiritual needs met (DeMarinis 2013). A way to overcome this gap is through value-based institutions, their emphasis on a holistic approach and a fundamental attitude of openness towards the patients, together with professional considerations by therapists (Sørensen et al. 2015). Such an institution's emphasis on global and everyday life values in therapy is seen across the themes generated in the present study. The patients have adapted to a new situation, among other things, through consciousness about values, where the value of life itself and the will to stay alive seem the most profound.
Spirituality and religion are said to be fundamental for addiction recovery and RP, as well as taking culture and context into account (DeMarinis 2013; Dosett and Metcalf-White 2019). The participants' vertical self-transcendence in the present study was, to a large degree, related to spirituality. When describing what they believed in, it went in the direction of something outside themselves, a higher power, or a destiny, rather than to God. Their personal, individual approach was based on several traditions in addition to personal reflections and opinions. However, the participants were also affiliated with selected parts of organized religion, in this case, the Christian heritage. This was seen particularly with regard to ethical and moral issues and also rituals. Most likely, this may be an expression of the Norwegian culture and how spirituality is shaped among individuals in this secular context when searching for objects beyond their immediate needs in a vertical sense (Repstad 2020). Experiences of getting help from a higher power in demanding situations, and a certainty that something outside themselves governed and created order in life, contributed to confidence and safety. Patients in a long-term recovery process, similar to the present participants, may undergo what is called a spiritual makeover, developing a durable spiritual identity (McClure 2019). A value-based institution accommodating holistic treatment, such as in the present study, may contribute to such durable 'post-Christian spirituality', eschewing both religion and secularism and helping patients to endure their spirituality. The relevance of an emphasis on spirituality is shown through several studies demonstrating a protective effect of spirituality on relapse rates (Sliedrecht et al. 2019).
In the present study, the implications of affiliation to spirituality and religiosity are seen especially when vertically searching for objects beyond immediate needs through rituals. Identity development, a sense of belonging, and the experience of meaning and order in life are gained through the activity of rituals (DeMarinis 2013;DeMarinis et al. 2008). Rituals at the institution contrasted the life of the participants, from their former stressful and uneasy situations to the relaxed atmosphere of peace and calm in the chapel when attending Morning Prayer. An important feature was the experience of community with others in the ritual setting. It is well known that social interaction is an important predictor of better mental health, as well as for RP (George et al. 2002). However, it is likely that religious and spiritual environments and communities contribute even further to resistance against relapse (Koenig et al. 2012).
RP demands behavioural change (Hendershot et al. 2011). An example of such change is seen in the case where a patient previously had practiced drinking rituals with candles and soft music but now every morning she practices the ritual of reading a value-based text, meditation, and yoga. This stood out as a deliberate choice of using the same method but with new content that included spiritual elements experienced from rituals at the institution. Among people with drinking problems, drinking rituals are quite common and are often meant to provide special energy for problem solving (DeMarinis et al. 2008).
Interestingly, the new spiritual ritual of the participant produced a form of energy that she could not find elsewhere, except at Morning Prayer, in church, or in nature. It seems as though this new ritual contributes to a larger dimension, something to hold on to for preventing relapse, even though it could be difficult to articulate what this 'bigger outside oneself' was.
Private confession is not very prominent in the Norwegian Lutheran context, as opposed to Roman Catholic contexts in other parts of Europe. However, the practice of private confession in the frame of a church ritual appeared rather common in the present material. This could be seen in the setting of the value-based rehabilitation programme at the institution and the patients' awakenings concerning their mistakes. Not least, the availability of an ordained chaplain should be mentioned. Receiving forgiveness is a precondition for leaving mistakes behind and starting over to go further in life and is found to function as a spiritual mechanism in recovery from substance use disorders (Lyons et al. 2010). Performed in the frame of an organized religious ritual, the function as a spiritual mechanism may be stronger due to commitment to oneself, to the chaplain administering the ritual, and towards God or the higher power expected by the participants to be part of this special ceremony.

Strengths and Limitations
The present study was, to a large extent, based on research literature from rehabilitation contexts, and less strictly related to RP, due to little research on self-transcendence and RP. An obvious methodological limitation of the present study could be the number of participants. On the other hand, the sample was strategic and specified, the study aim was supported by established theory, and the participants delivered deep and broad descriptions of the matters of the study. Thus, it may be argued that the sample held sufficient information power (Malterud et al. 2016). The participants' views on the relevance of self-transcendence for RP were found implicitly in the interviews. The findings, therefore, had to be discussed against theory and previous empirical research to further understand its possible implications. Such considerations may support the study's transferability.
The study was performed in a secular Norwegian context. The findings must be seen from that perspective. It should also be taken into consideration that the participants' perspectives of spirituality are essentially based on a Christian Lutheran heritage.

Conclusions
Previous research shows that self-transcendence, including global values, generativity, religiosity, and spirituality, is strongly associated with meaningfulness and that meaning is associated with RP and less alcohol and drug use severity. In particular, self-transcending sources of meaning and values related to global meaning seem to be profound. The present study explored how patients with substance use disorder were affiliated with the mentioned self-transcending factors and what this may have implied for them.
After abstinence and rehabilitation, a high level of self-reflection regarding values, right and wrong, important and less important, and what was significant and meaningful in life was seen among the participants, giving direction in life. Strong motivators for preventing relapse after rehabilitation were the participants' children and an unselfish prosocial commitment to the surroundings, both of which strengthened the participants' self-efficacy, confidence, and safety. Attention to death helped the participants see the value of life. Vertical self-transcendence appeared through spirituality and confidence in a higher power or destiny, generating order in life. This search for objects beyond immediate needs was especially seen using rituals, contributing to tranquillity. Behavioural change was observed from a drinking ritual, for example, to a spiritual ritual, producing a unique form of energy. Private confession in the frame of a religious church ritual helped the participants to leave their mistakes behind and start over to go further in life.
A complex variety of restrictive and promoting factors are in play when people with substance use disorder face challenges concerning relapse after rehabilitation. The present study shows how self-transcending factors may have significance for patients with a substance disorder. The dimension of self-transcendence, with its different factors, may contribute to flexibility in a somewhat wider sense than spirituality and religion alone when investigating the search for objects beyond immediate needs and its potential as resources for rehabilitation and relapse prevention for patients with substance use disorder. Further research should follow the participants over time, for longitudinal investigations of how they face high-risk situations, urges and cravings, etc., through self-transcendence and how relapse is avoided through these mechanisms.
Author Contributions: T.S. substantially contributed to the study design of the work, to acquisition and analysis of the data and to drafting and critical revisions of the text. L.L. substantially contributed to the study design of the work and to critical revisions of the manuscript text. Both T.S. and L.L. gave their final approval of the manuscript text as well as their agreement to be accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.
Funding: This work received funding from the Innlandet Hospital Trust, Brummunddal, Norway (Grant no. 150267). Open Access funding was provided from VID Specialized University, Oslo, Norway.

Institutional Review Board Statement:
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Protection Officer at Oslo University Hospital in accordance with the Norwegian Personal Data Act.

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The dataset generated and analysed during the current study is not publicly available due to privacy restrictions.

Conflicts of Interest:
The authors declare no conflict of interest.