Meaning-Making , Religiousness and Spirituality in Religiously Founded Substance Misuse Services — A Qualitative Study of Staff and Patients ’ Experiences

The Norwegian health authorities buy one third of their addiction treatment from private institutions run by organizations and trusts. Several of these are founded on religious values. The aim of the study was to investigate such value-based treatment and the patients’ experiences of spirituality and religiousness as factors of meaning-making in rehabilitation. The study was performed in an explorative qualitative design. Data were collected through focus-group interviews among therapists and in-patients at a religiously founded substance misuse service institution. The analysis was carried out by content analysis through systematic text-condensation. Through different activities and a basic attitude founded on religious values, the selected institution and the therapists facilitated a treatment framework which included a spiritual dimension and religious activity. The patients appreciated their free choice regarding treatment approaches, which helped them to make meaning of life in various collective and individual settings. Rituals and sacred spaces gave peace of mind and confidence in a situation that up to now had been chaotic and difficult. Sermons and wording in rituals contributed to themes of reflection and OPEN ACCESS Religions 2015, 6 93 helped patients to revise attitudes and how other people were met. Private confessions functioned for several patients as turning point experiences influencing patients’ relations to themselves and their surroundings. Spirituality and religious activity contributed to meaning-making among patients with substance use disorder and had significance for their rehabilitation.


Introduction
Several institutions facilitating substance misuse services are founded on religious value factors like meaning-making, spirituality and religion.In various forms and degrees these factors are integrated into these institutions' therapy approaches [1].How institutions and their therapists arrange for such elements in therapy, their reasons for doing so, and patients experiences of these factors' importance in treatment are therefore of interest.
Substance misuse carries a large burden for the affected individual, and greatly impacts on several levels of society [2].The prevalence of drug use disorders in EU and Norway ranges between 0.3% and 0.9% [3].Lifetime prevalence of alcohol dependence/abuse is found to be 23% in a Norwegian sample [4].In the treatment of these disorders, the concept of meaning-making may represent a fruitful approach to understanding substance misuse services [5].For a person with addiction problems the intoxication can of itself represent meaning in life [6].On the other hand, his or her life in general might be experienced as meaningless with low well-being scores [7].The search for meaning in life is regarded as central in human experiences, and religion is assessed as a considerable provider of such a sense of significance by several contributors [8].
In Norway, the substance misuse services by the Pentecostal movement have assumed that Christian conversion, by changing object of significance from substance misuse to Christian faith [1], is a crucial starting point fundamental for successful treatment [9].Other substance misuse services based on religious values do not necessarily view inclusion of religious and spiritual factors as intervention.Rather it is an offer in general, in terms of, for instance, church services and pastoral counselling at the institution.Religiousness and spirituality have a purpose of its own, and possibly for that reason it may have significance for patients' rehabilitation [10].
Orientations towards an immaterial, supernatural power are considered as "religion" when it occurs as organized with institutional components of faith traditions [11]."Spirituality" addresses individuals' relationships with and search for the sacred.The sacred refers to God or higher powers, but also other aspects of life perceived as manifestations of the divine or features having divine-like qualities [12].Spirituality may involve self-transcendence in a quite broad sense as long as it is a search for existential goals beyond one's immediate needs.Throughout this paper, both "religion" and "spirituality" as terms will be used.These are overlapping constructs, and both therapist and patients refer to elements related to traditional organized religion as well as individual's private search for the sacred independent of organized settings.
Meaning is considered central in human experience [13].Humans face fundamental existential needs in life, like for instance self-regulation, control, comfort, identity, social acknowledgement, values and purpose.In meaning-making, people meet these needs adequately when they utilize the different sources of meaning [14].If fundamental relations or conditions in life are broken, sources of meaning are used to restore the balance between the individual's expectations of life and the reality as it is experienced here and now.Such reappraisal and usage of sources of meaning are essential when it comes to handling demanding life situations, such as living with substance use disorder.According to Schnell [14], sources of meaning can be categorized in different groups.To target objects beyond one's immediate needs is designated as self-transcendence."Vertical self-transcendence", consisting of religion and spirituality, is an orientation towards an immaterial supernatural power."Horizontal self-transcendence" targets other people, knowledge of self, nature, health, etc.With use of "self-actualisation", one's own capacities are developed and challenged."Order" is about relation to tested and durable values, traditions and practices.In "well-being and relatedness", individuals cultivate and enjoy what is good in life, both private and collectively.
Meaning-making can also be seen in the perspective of global meaning [13] where an overarching ideology or world-view can help individuals to see their lives in a larger context.Affiliation to, for instance, organized religion, with its overall understanding of existence, can serve as an important reference and may contribute to significant structures in life when experiencing demanding life situations.
Schnell's [14] concept of meaning-making takes a secular European context into account.To our knowledge, this perspective is not much used in investigations regarding meaning-making, religion and spirituality among patients with substance use disorder.
However, spirituality may be an important part of recovery from substance misuse [15].For instance, among different relapse prevention strategies, it has been found that engaging in prayer or relying on a "higher power" were of importance for patients in their attempts to stay clean at a Chicago rehabilitation centre [16].In a Canadian study, spirituality was one of the main themes when patients discussed what helped recovery, especially when spirituality was linked to nature, a supernatural power, the feeling of not being alone, and rituals [17].
Research regarding the significance of religion and spirituality as meaning-making in substance misuse services is needed for several reasons.Review of the international research literature shows limited knowledge [18], especially when studies of the 12-step program (Alcoholics Anonymous) and studies from America are excluded.Further, due to environmental, cultural, religious and health-related differences, findings from one context are not necessarily transferable to another [19].Thus, knowledge from specific environments is needed.In the Norwegian case, the health authorities bought one third of their addiction treatment from private institutions run by organizations and trusts in 2012 [20].Several of these are founded on religious values.Despite this considerable use of external services, little is known about the rationale behind such value-based treatment and patients' experiences in Norway.
Our aim was to investigate the significance and function of meaning-making, spirituality and religiousness in substance misuse services founded on religious values in a Norwegian context.Our research questions were: What is the treatment framework?What are the experiences of meaning-making, religiousness and spirituality in a treatment setting among the patients?

Design and Setting
The investigation was performed in an explorative qualitative design.The setting for the study was a private institution being part of and funded by the specialist healthcare service in South-East Norway.The institution provided a 12-month stay for all patients, independent of their individual progress of rehabilitation.An individual treatment approach were emphasized at the institution, where respect for the patient's participation and assessments were of importance.The institution employed professional therapists with various occupational backgrounds.

Sample
The sample consisted of both therapists and patients at the selected institution.The therapists were recruited through an enquiry from the investigators to the management of the institution who passed on an open invitation of participation to the employees.Among the 14 therapists willing to participate, specialist trained nurses, social workers, psychologists and a chaplain were present, allowing for maximum variation sampling [21].Several of the therapists had previously led the social work of local parishes.Except for these last therapists and the chaplain, no special competence regarding religion and spirituality was present among the staff.On the other hand, most of the therapists had been employed at the institution for many years.Consequently, a positive basic attitude towards religion and spirituality had been handed over between colleagues and integrated among several staff members through internal seminars and clinical practice at the institution.Both genders were present in the sample, and their age was between 40 and 65.
The patients were recruited by the investigators through information and open invitation at a daily morning meeting at the institution.Of the 26 patients, one third was excluded because at least a four months' stay at the clinic was required, due to distance from intoxication and adaption to the treatment programme.Finally, eight patients were willing to participate, four women and four men aged between 20 and 50.Misuse of alcohol, different drugs, pills and mixed misuse were present in the group.

Data Collection
Data were collected through focus-group interviews, two sessions among therapists (seven plus seven informants) and one among patients (eight informants).Each session lasted for one hour and 30 minutes.The therapists' interviews were conducted in November 2013, the patients' interview in February 2014.Due to the focus-groups being a discussion-forum, only a handful of themes were selected.Based on an interview guide the therapists discussed treatment at the clinic in general, the function of meaning, meaning-making, spirituality and religiousness in treatment, their contribution as therapists, and the significance of the institution being founded on religious values.The patients discussed where they found meaning in life, what was important in treatment in general, the religious basis of the institution, in which way meaning-making, spirituality and religiousness could be significant in treatment, and the pastoral care at the institution.

Analysis
The availability of informants was higher among the therapists than among the patients.Therefore, two sessions were held among the therapists and analyzed as a whole.The patient session was analyzed separately.The analysis was carried out by qualitative content analysis through systematic text-condensation based on Giorgi's phenomenological analysis in a four-step model [22].First, an overview of data was established, next meaning units were identified and sorted, further the content of these codes was condensed, and finally the condensate was synthesized into descriptions and concepts.

Ethics
Participation in this study was voluntary.Before participating, informants received information and signed an informed consent form.The study was approved by the Protection Officer at Oslo University Hospital in accordance with the Norwegian Personal Data Act.

Results
The intentions behind treatment, as well as experiences of treatment at the selected institution, were important as a whole when describing possible functions of meaning-making, spirituality and religion.From the content analysis, eight themes, two among the therapists and six among the patients, turned out to be central (see Table 1).
The presentation of the findings in the following is thus twofold.In Sections 3.1 and 3.2, the most prominent themes among the therapists are shown, with regard to values and arrangements at the institution.In Sections 3.3-3.8,we will present the patients' experiences of treatment, and the most prominent meaning-making, spirituality, and religious factors within it.
Table 1.Central themes arising from the content analysis among therapist and patients.

The therapists The patients The institution's values
Meaning in life The institution's arrangements To be met at the institution Violation of rules Choice of approaches in treatment Spiritual and religious activities The chaplain

The Therapists' vs. The Institution's Values
A long history of being an institution founded on religious values together with the staff members' professional considerations and practices set a treatment framework where emphasis on the spiritual dimension was essential.At the same time, the therapists stressed that patients' participation in explicit religious activity related to rituals and spiritual guidance by the chaplain was voluntary, due to demands from the funding authorities.The descriptions of the patients' perceptions and experiences presented later must be seen in this light.The common goal among the therapists was to help the patients to rediscover their own dignity.The basic attitude of the therapists was coloured by the fact that the majority of them had worked there for many years.The values of the institution had been handed over to new therapists and been incorporated among them.Such values were expressed through the therapists' fundamental attitude of openness towards the patients and included in their assessments of the patients' needs, for example in conjunction with rule violation."If a patient has committed undesirable actions, the institution should actually react to it and in worst case discharge the patient.However, it is my assertion that the perspective of forgiveness and a new opportunity, anchored in the Christian view of values, is emphasized when assessing patients' violation of rules at this institution."(Therapist # 6) For the therapists, spirituality was first and foremost how they met and saw the patient in various ways and settings, based on a holistic view of human life.Spirituality as the fourth dimension in care was seen by the therapists as important for, and included in, the three other dimensions, the physical, the mental, and the social dimension.It was emphasized by a therapist that the practice and the awareness of spirituality in treatment was a reason for her to work at this very institution.
The therapists held a broad understanding of spirituality and defined it as for individuals (i.e., the patients) to go beyond themselves and at the same time identify the core of themselves.Spirituality among the therapists was closely linked to values of different kinds, expressed in therapy as well as through everyday life situations at the institution.Care and benevolence were important factors in how they met patients.
"Especially in the first weeks here, our patients bear quite a burden of shame, feelings of guilt, remorse, and such heavy stuff.At the same time it is important for them to receive hope, faith and forgiveness.And here at the institution it is an arena where they can get some help and support in that direction.Almost regardless of belief and faith I see that these factors makes them well."(Therapist # 5) The therapists aimed to be as unprejudiced as possible in meeting the patients on the patients' terms.Warmth and respect towards patients should as well be part of the institution's fundamental values manifested through the therapists.However, despite such ideals, the therapists could have relatively tough internal discussions concerning how to handle specific situations regarding patients' actions and how to confront them with, for instance, undesirable behaviour.

The Therapists' vs. The Institution's Arrangements
It was important for the therapists to facilitate spirituality and religiousness as part of different approaches of therapy; nevertheless, as with other therapeutic activities at the institution, it was the patients' choice what to make use of.For instance, it was up to the patients whether religious and/or spiritual questions should be part of the conversational therapy or not, following a mapping of their spiritual history on entering their stay.
At the institution, several artefacts, such as pictures with religious motives, proverbs, crosses and other Christian symbols were visible expressions of the institution's religious foundation.However, several of the therapists regarded the chapel and the rituals taking place there, like the morning prayers, the weekly service with Holy Communion and celebration of the church festivals as even more important.A therapist said she sometimes encouraged patients to take part saying that the morning prayers may be a good way of starting the day.Rituals and symbolism were assessed by the therapists as important to facilitate even though participation for patients was voluntary."I will light a candle in that window (pointing at the chapel) every morning to convey to those in the square outside who maybe never participate in the chapel that there is something spiritual here, something about taking humans seriously, something about love.So, it is something we … I will show symbolism, then."(Therapist # 3) The chaplain functioned outside the therapist team when working with rituals and pastoral counselling.At the same time, he was an integrated part of the institution's total effort of treatment.The chaplain also arranged for conversation groups discussing existential questions, world view, and relevant themes at the institution such as "from shame to dignity", "from guilt to emancipation", and "in the landscape of grief".

The Patients' Experiences-Meaning in Life
When discussing meaning in life here and now, staying clean from drugs was the first and most conspicuous theme for the patients.They wanted to find solutions to their problems of misuse.As a basis for this project, several patients saw the need for long-term perspectives with something to reach out for in life, to have goals and dreams, and to have something meaningful to do in everyday life."You can invest in your own future by doing good things", as a patient put it.Contact with nature helped clear thinking and making sensible choices.Support from and to relatives, friends and fellow patients gave meaning in life.
A superstructure in the effort of the patients' rehabilitation was to restore the different kinds of broken relationships that had arisen through many years as misusers.The patients found meaning in working with this complicated landscape of shame and guilt "What gives me meaning in life is to be clean, and if you get in contact especially with the family, and try to get in contact with former friends, maybe, (…)." (Patient # 1)

The Patients' Experiences-To Be Met at the Institution
Life as an addict had been demanding on several levels.The patients' identity in earlier life had been linked to what they did, connected to misuse, and not to who they were as individuals.They were lonely, isolated and frightened.Often they carried mental health problems like neuroses, anxiety and avoidant personality disorder.Such experiences stood in considerable contrast to how many of the patients experienced their arrival and stay at the institution."I was really scared before I came.(…) When I arrived here, I met a therapist with a big heart expressing warmth and goodness.I felt confident together with her from the very beginning."(Patient # 7) Those with positive experiences felt they were met and seen with an open mind.In these patients' view, the therapists and other workers at the institution expressed confidence through personal human qualities like care and love.Other patients did not have the same overall positive impression.These patients were quite selective regarding which therapist worked well for them or not regarding how they were met.

The Patients Experiences vs. Violation of Rules
Patients compared the institution's treatment with other institutions they had been to.A pronounced difference was, for instance, how this institution handled rule violation regarding remaining substance-free during the stay.At other institutions they would be exposed in front of others and had to tell in public what they had done.In contrast, here they would be protected and withdrawn from the other patients until the situation had been stabilized and the patients were ready to move on in the treatment.
"If you crack you have to sit on a chair and everybody is sitting in a ring around you, and then you have to proclaim your sins.Here you will be protected and withdrawn."(Patient # 4) The patients felt more confident with the last approach.They experienced that they were better taken care of with a withdrawal under such circumstances, and they thought it would have better effect on their rehabilitation in a long-term perspective compared to a confrontational mode.

The Patients' Experiences vs. Choice of Approaches in Treatment
Compared to detailed treatment programmes with rigid methodologies elsewhere, the patients found it more positive to have choices.Here, they could take responsibility for their own rehabilitation process.Quite different approaches and activities were available at the institution and the patients used those they experienced worked for them.Activities such as psychological treatment, conversation with other patients, pastoral counselling, group sessions, physical activity, hiking in the mountains, craft activities, creating things, going on trips, morning prayers and religious services helped them to face their challenges from different angles.
"You could say about this institution that it is rehabilitation for advanced patients.In a way you have to take the case in your own hands.At the same time you have good helpers around."(Patient # 4)

The Patients' Experiences vs. Spiritual and Religious Activities
Even though patients participated in organized religious settings like morning prayers and services, faith seemed to appear at an individual level where patients needed to make their private decisions on what should be the content, and what faith meant to them personally.Still, the spiritual and religious activities facilitated by the institution had important functions for treatment experiences.According to some of the patients, the morning prayers and the weekly service led by the chaplain served as important places for processing different themes, helping several of the patients to relate to others and to reflect on demanding issues important for their state of rehabilitation.For one of the patients, this was especially exemplified through sermons, where she found help for how to ask for forgiveness.
Other patients experienced the rituals and the chapel as invigorating, giving peace of mind and confidence in contrast to life with addiction problems."We need some peace and tranquillity, right.There has been so much negativity, action and impulses and anxiety and things like that earlier.So, to get some peace of mind is cool, right."(Patient # 4) However, it was important for the patients to stress that they had not come to the institution for religious salvation, but to become clean.

The Patients' Experiences vs. The Chaplain
The chaplain appeared as a kind of "holy person" with a certain role.He was described by the patients to be a symbol, a carrier and mediator of something bigger.This function was experienced in social settings and talks as well as in his formal role as chaplain administering services, morning prayers and pastoral counselling.His special, compassionate and respectful manner invited to conversations regarding existential questions in a wider sense.
"He has an authority here at the institution, but actually he can…, he can go so deep that he places me as a patient… One time he asked me 'NN, in our next appointment, would you come here and teach me about forgiveness?How did you learn to forgive yourself?'And I just; wow (surprised and a bit frightened)!'Are you asking me about that?'And it was so good.He is so non-judgemental.He is so… There is no harm in that man.And I think that it is a big deal for us staying here and for us sitting here.The confidence he oozes out daily." (Patient # 5) The patients underlined that the chaplain's contribution was different to that of the therapists.He had a wider perspective.It was not his task to be restrictive.His independent role was important for the patients, with special emphasis on him administering a strict degree of professional secrecy.According to several of the patients, the chaplain would not share with others, e.g., therapists, what was said during pastoral counselling.Neither would the content of the conversation be analyzed, as it would be by the psychologist or another therapist.This facilitated open conversation where patients could raise subjects they possibly would not share in therapy.Consequently, in the patients' view, the chaplain contributed to treatment despite not being a therapist.
This was especially true when it came to confession.When introducing his work to newcomers, the chaplain gave information regarding the possibility for confession with respect to patients' possible needs of settlement and deliverance.Confession including absolution given by the chaplain represented a significant instrument in conversations and pastoral counselling.Even more important was its functioning as a symbol and ritual, and the power within it contributing to patients' processes of rehabilitation and leaving things behind."The chaplain is the spokesman of Jesus.If you struggle with such a heavy burden that you need a confession, this is a reassurance, if you have enough balls to dare it."(Patient # 5) Confession as a tool in rehabilitation was also desired by agnostics: "So, the chaplain has a moral professional secrecy.That is important because I, for my part, have some things in my life that I have to come to terms with.And my plan is to use the chaplain for that purpose.But I am not ready yet.But I perceive that he is the only one, absolutely the only one I want to talk to about these things, then.And that is good to know." (Patient # 3)

Discussion
In summary, we found that the therapists were influenced by the institution's set of values and their own faith histories.Despite differences, they shared a common commitment to integrate the spiritual dimension into treatment and everyday life at the institution in various ways.The patients stressed that they had not come to the selected institution seeking religious salvation, but to become clean.Still, several patients had positive experiences regarding the therapists' obligingness, care and love based on the spiritual foundation discussed.Activities related to spirituality and religiousness were among several patients regarded as important together with other factors contributing to treatment.Rituals and sacred spaces could give peace of mind and confidence in a situation that up to now had been chaotic and difficult.The importance of the chaplain's role was accentuated with regard to pastoral presence in social and conversational settings, and his administration of morning prayers, services, pastoral counselling and private confession.In total, it seems as if several factors contributed to meaning-making for the patients.
It was important for the patients to have the possibility of making their own choices regarding which of the activities offered at the institution they should utilize in their rehabilitation, concurrent with recent trends within addiction treatment [23].On the other hand, confrontational methods are demanded by patients in other studies [17].From a psycho-dynamic point of view, it could be questioned why the therapists at the institution want to present themselves to the patients as unprejudiced, or why they seek to protect and withdraw patients in cases of rule violation instead of confronting them with other patients present.However, several of the patients in the present study had negative experiences of confrontational therapies from other institutions.They found the current individual rehabilitation programme worked for them, with reference to emphasis on future expectations and social support in the therapy.In this respect, several of the patients had chosen the current institution, perceiving the fact that different therapies match with different patients.This is, however, not evidence of the quality or the effectiveness of the institution.
The patients related to religiousness and spirituality in a cognitive manner.Sermons with references to the Bible and the wording in the rituals contributed to themes of reflection regarding their own personal life histories helping them to revise attitudes and how they met other people.Equally important, however, were the non-verbal experiences.Religious spaces, artefacts, religious symbols and rituals such as morning prayers and service, perceived through the body and the senses, seemed to have importance as a resource, which also has been found in other studies [24].Such non-cognitive experiences contributed to peace of mind and confidence in contrast to a chaotic life of substance misuse.As self-transcendence, patients in both cognitive and non-cognitive settings reached out for objects beyond their immediate needs.Despite different degrees of relating to a supernatural power, this connection to religion and spirituality had significance for patients and functioned as sources of meaning in general and more specifically in their rehabilitation processes.Situated in a vertical self-transcendence paradigm [14], this kind of meaning-making may enhance the probability of living a meaningful life compared to other sources of meaning [25].Further, the factors discussed are seen by others as important for relapse prevention [16].Consequently, religious and spiritual factors can be seen here as sources of meaning contributing to the patients' current desire to stay clean, which was most prominent when the patients discussed meaning in life in their present situations.
Morning prayers and services with Holy Communion were based on old texts and hymns and were expressions of long-standing traditions and ideology which may contribute to a global meaning system and set life into a frame of reference [13].It contributes to meaning in life when adjustments in life can be made through rituals [14,25].Consequently, moral issues are also part of individuals' appraisals in this matter, as emphasized by patients in this study.They saw the importance of doing good things which in turn generated good consequences for the patients and their surroundings.In the patient conversations, it came through that such moral considerations were based on ideologies like humanity, and to some extent also on religious values, with reference to global meaning systems [13].
A prominent finding in the material was the quite extensive use of private confession as an important way of putting negative life events and misdeeds behind them.Private confession within the frame of pastoral counselling by the chaplain and his strict vow to secrecy contributed to turning point experiences for the patients.The patients' articulation of their transgressions and the chaplain's proclamation of the forgiveness of sins could be important elements here.Also, the setting as a ritual and the actions associated with it, such as the chaplain's hand laid on the head of the patient, may have contributed to the patients' experience of this ritual being crucial and cleansing in their rehabilitation processes.An interesting parallel is First Nations women's positive experience of re-purification ceremonies for rehabilitation purposes [17].The fact that agnostics also wanted to take part in private confession may show the importance of rituals in substance misuse services in general.As is the case for rites of passage in general, such ad hoc rituals in a therapeutic setting can mark a distinct transformation from one status to another, generating a sense of order, community and transition [26].This may help patients to change object of significance in their lives [1].Additionally, knowing that private confession is virtually absent in pastoral care in the setting of the majority church in Norway may be an expression of this ritual's pronounced significance and function within substance misuse services.People with addiction problems may to a larger degree than others find confession significant as a source of meaning due to their former lives bearing traces of guilt and shame, and the need to rebuild broken relationships.
To cultivate relationships is an important issue within meaning-making [14,25].However, according to the patients, life as a substance misuser had in many cases led to broken relationships.On the other hand, it was underlined that restoring these broken relationships gave meaning in life.Important issues within this process are forgiveness of others, to be forgiven and, not least, forgiveness of the self.In addition to making meaning, forgiveness of the self has been shown to be a predictor of favourable outcomes regarding future substance misuse [27].As a source of meaning, such processes are closely connected with well-being where joy, love and comfort experienced in relation to family, friends and other relations are essential goals [14,25].These factors were underlined as important by the patients when they described the long, demanding, but also positive process of restoring their relationships with their closest ones.

Limitations and Implications
A limitation of the present study may be that the interviews with the patients were performed in a therapeutic setting.How the informants will view these questions after their stay is difficult to predict.The sample of patients could be positively selected.On the other hand, after exclusion the patient sample consisted of about half of the potential participants at the institution.A focus-group interview approach may be criticized for a harmonizing presentation of the topic in question.However, the conversation climate among the participants gave room for disagreements.A focus-group interview approach was utilized because group dynamics were needed to generate knowledge on the present topic.It is also a limitation that this study collected data from one institution only.Consequently, it may be difficult to generalize the present findings to other Norwegian programs.Additionally, generalization of qualitative studies is difficult in general.
Despite obvious limitations concerning generalization, possible clinical implications and incentives for development of clinical practices can be seen on the grounds of the present study.Nevertheless, further research on the topic in comparable contexts is demanded.Religion and spirituality have value on their own.Additionally, this study may show that religious rituals, services, and symbolism through art and architecture etc. had significance for peace of mind and comfort and thus made meaning in life among those affiliated to these factors.Facilitation of such practices within institutions may be a first step towards an integration of religious and spiritual factors in clinical settings.
We have also seen in the material that religious wordings in sermons, rituals and hymns, and pastoral counselling together with private confession have led to reflections over former, present and future life and contributed to meaning-making in this respect.Meaning-making has generated new platforms for how patients can live their lives, how patients relate to broken relationships from the past and how they can relate to their family and friends in the future.To some extent, such aspects are taken care of today, but not all institutions have their own chaplains.An even more integrated strategy would be to include religious and spiritual factors in the therapeutic setting, if the patients find it relevant.However, therapists in general are in lack of competence regarding religion and spirituality.On the other hand, the most important part for the therapist is to have an open attitude towards the patients' possible religiousness and spirituality as resources in therapy.Patients with substance use disorder often suffer from broken relationships, guilt and shame.In this perspective, religious and spiritual factors in meaning-making may for this patient group, possibly more than for others, be a relevant perspective in the clinical setting.

Conclusions
Through different activities and a basic attitude founded on religious values, the selected institution and its therapists facilitated a treatment framework which included a spiritual dimension and religious activity.The patients appreciated their free choice regarding treatment approaches, which helped them to make meaning of life in various collective and individual settings.Rituals, especially private confession, could function as turning point experiences influencing their relation to themselves and their surroundings.