The 12-step model to the treatment of addiction is the most popular therapeutic model in the United States, and most adherents of the 12-step approach consider spiritual growth singular with recovery. This chapter offers a critical review and discussion of spirituality and religiousness as it has been investigated in the empirical literature on addiction. Curiously, although the 12-step model has been reported to produce outcomes relatively equivalent to more research-based therapies, for example, cognitive behavioral and motivational enhancement therapies, and actually a superior outcome when the treatment goal is total abstinence, the underlying stated mechanism of this approach, spirituality, has only begun to be systematically investigated using rigorous methodologies including randomized clinical trials. It is important to acknowledge that non–12-step spiritual and religious approaches also intended to mobilize and sustain addictive behavior change have proliferated in the United States, regardless of the presence or absence of empirical support. A cursory Internet search using “alcoholism” and “spirituality” as key words, for example, yielded 944,000 hits. It seems that the absence of empirical support for the efficacy of spirituality in reducing substance abuse has hardly impeded its application. Furthermore, referral to Alcoholics Anonymous during and after treatment is the norm in the United States, also regardless of the therapeutic orientation of the treatment provider. In this light, the practical issue is not if treatment-seeking alcoholics ought to be introduced to spiritual models of recovery. Rather, it is vital that researchers and clinicians have a working knowledge of spiritual approaches to addiction in order to better understand the psychological and social forces and resources facing prospective clients.
This chapter is organized into three sections. Historical reticence to investigate spirituality and religiosity by addiction researchers stems, in part, from the constructs poorly understood dimensions. The first section of this chapter therefore offers several working definitions of religiosity and spirituality. These definitions are intimately tied to distinct conceptual models pertaining to the role of spirituality in addiction. These models will be presented and discussed, and some attention will then be given to four psychometrically validated measures that are available to clinicians and researchers. The second section of the chapter advances the orientation that spirituality can be viewed as an outcome, a catalyst or intervention, a moderator, and as a mediational variable; in fact, the construct has been treated in each of these capacities in the empirical literature. A keen awareness of these distinctions is paramount to grasping the implications and avoiding the many pitfalls surrounding the study of alcoholism and spirituality. Third, this chapter focuses on what is currently known about Alcoholics Anonymous-related benefit, the largest and most studied of spiritual interventions. Here, special attention will be given to what is known about the importance of prescribed Alcoholics Anonymous spiritual practices in accounting for reduced drinking. The chapter will conclude with a brief summary.
Several caveats need to be voiced at the beginning of this chapter . First, the accelerating nature of empirical research in this area necessarily will result in a somewhat incomplete review. Studies now underway may offer findings that elaborate upon, clarify, or even contradict positions and interpretations offered in this chapter. Related, studies reviewed in this chapter were purposefully selected according to their scientific rigor, not because of the claims and interpretations made by study investigators. In essence, cross-sectional studies purporting to investigate causal temporal relationships were rarely selected for review. Third, it is important to stress the plasticity of spiritual and religious practices and beliefs. An individual rarely is “spiritual” in all situations with all people; nor does evidence indicate that the nature and expression of spirituality remains fixed over time. Although this plasticity is obvious and volumes have been written about it, there is a tendency nevertheless to reify spirituality as a trait construct. It is wise to remember that even prophets question, at one time or another, the depth and value of their spiritual and religious beliefs. It is also instructive to remember throughout this chapter that the measurement of this fluid and evolving construct occurred, in general, in research settings. The extent that this context influenced that measurement of spiritual beliefs and practices is unclear but certainly raises concern. Related, the very subjective nature of spiritual and religious beliefs and practices and experiences requires, at this juncture in time and technology, self-report. Legions of studies have investigated the unintended and undetected biases that arise in relation to self-report on subjective states. Beyond the scope of this chapter, we recommend that readers consult one of several excellent discussions on the reliability and validity of self-report in the areas of spirituality and religiosity.
Definitions of Religiosity and Spirituality
Now the whole earth had one language and a common speech…let us go down and confuse their language so they will not understand each other…That is why it was called Babel—because there the Lord confused the language of the whole world. Genesis 11
The struggle of defining spirituality and religiosity makes it clear how far we have come from a universally understood language. Researchers and practitioners posit opinions on how to define these constructs; the diversity in meanings clearly echoes the confusion, disagreement, and lack of productivity described in the book of Genesis. Zinnbauer and Pargament have aptly called these terms the “definitional tower of Babel.” As Zinnbauer and Pargament wrote regarding those in the field who study spirituality and religion, “[We] can agree on one thing: we have never agreed about anything” (p. 4). There is little disagreement that spirituality and religion are constructs deserving of research and clinical attention, but because an important first step in researching a construct is how to operationalize and measure the construct, we begin in a tumultuous place.
Definitions of religion, and particularly spirituality, have changed and evolved over the years. Once representing a single construct, these constructs are now distinct and some would say even incompatible. Spirituality is increasingly defined in contrast to religion rather than as interchangeable terms. The definitions are marked by explicit and implicit philosophical and theological underpinnings and thus remain vulnerable to claims that the definitions are either too broad or too narrow. Koenig described religion as an expression that is institutional, formal, outward, doctrinal, authoritarian, and inhibiting, and spirituality as an expression that is individual, subjective, emotional, inward, unsystematic, and freeing. Pargament reported that religion is moving “from a broadband construct—one that includes both the institutional and the individual, and the good and the bad—to a narrowband institutional construct that restricts and inhibits human potential” (p. 3). Apparent in the polarization of these two constructs is an underlying message that is an exaltation of spirituality and a condemnation of religion.
It is common for scholars to begin manuscripts with caveats of the difficulty in defining these terms, discuss the divergent definitions, and then provide an entirely new definition altogether. Other researchers approach the complexity by simply avoiding a definition, instead asking questions such as “do you consider yourself spiritual?” or “how important is religion in your life?” Although results from questions such as these contribute to our understanding of the perceived importance of religiosity and spirituality and other variables, this approach is limited in terms of not furthering our understanding of how these terms are uniquely understood and defined by participants.
It is evident that defining these constructs is difficult; however, research evidence supports the usefulness of this pursuit because of the clear connection between spirituality and religion and mental health. In a recent review of longitudinal studies, increased spirituality and religion seem to consistently promote a longer, happier life. For individuals with mental or physical health problems, spirituality and religion enhance pain management, improve surgical outcomes, protect against depression, provide coping resources, and reduce the risk of suicide. Although religion and spirituality are relevant to many problems dealt with by practitioners and there is a consistent link between spirituality/religiousness and physical and psychological well-being, in few areas of mental health are these issues as central as addictive behaviors.
The Relationship Between Religiosity/Spirituality and Addiction
In some sense, addiction represents the antithesis of spirituality. For example, one of the four noble truths of Buddhism is “Suffering is caused by attachment,” and a central focus for followers of this tradition is to relinquish craving and clinging to things. Yet the centrality of attachment is readily apparent in the diagnosis of substance use disorders—part of the criteria for a substance use diagnosis is that a great deal of time is spent in activities necessary to obtain the substance. May describes the spiritual nature of addiction as “a deep-seated form of idolatry. The objects of our addictions become our false gods. These are what we worship, what we attend to, where we give our time and energy.” Attachment to a substance is a futile attempt to impose direction in one’s life, a direction that displaces one’s prior values, meaning structures, and goals. Instead, individuals become concerned with purposeful action toward their next drink or their next high. In Tillich’s terminology, the substance becomes the individual’s ultimate concern.
Spirituality is also central to the most influential model of recovery in the United States. The recovery program of Alcoholics Anonymous views addiction as a fundamentally spiritual problem and has promoted spirituality and religion as a central factor to recovery since 1935. In the words of Bill W., the co-founder of Alcoholics Anonymous, individuals with substance abuse problems “have been not only mentally and physically ill, [they] have been spiritually sick” (p. 34). The program of recovery is therefore based upon a model of prescribed spiritual practices.
In addition to the spiritual program of Alcoholics Anonymous and other 12-step programs, the literature is also quite clear that religious involvement is predictive of lower current and future rates of problem drinking. For instance, more than 80% of the nearly 100 studies on alcohol and religion reviewed by Koenig et al. reported a negative association between religiosity and problems with alcohol. It seems that individuals who are more active in a religion and for whom faith occupies a central place in their lives are less likely to develop dependence on a drug. Similarly, individuals entering treatment for alcohol/drug problems tend to have very low religious involvement and are often quite alienated from organized religion.
Religiosity/Spirituality and Addiction Research: An Overview
In a review of the literature on spirituality and addiction, Cook examined 265 publications in order to identify the definition of spirituality by different authors. Cook found that only 12% of the papers explicitly defined the term “spirituality,” 32% offered a description of the concept of spirituality, 12% defined a related concept (such as “the spiritually healthy person”), and in 44% of the papers the term “spirituality” was left undefined. Breaking the conceptual content of the definitions into component parts, Cook classified the content of the various definitions into 13 conceptual components. Cook found that the four components that were encountered most frequently and were most central to the definition of spirituality were transcendence, relatedness, core/force/soul, and meaning/purpose. On the basis of these components, Cook proposed the following definition:
Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups, and traditions. It may be experienced as relationship with that which is intimately “inner,” immanent and personal, within the self and others, and/or as relationship with that which is wholly “other,” transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth and values (pp. 548–549).
One particular conundrum, evident in Cook’s definition and many other definitions of spirituality, is that scholars have begun to include aspects of mental health within the definition. If terms such as well-being and connectedness with others are considered part of the definition of spirituality, there is an inherent measurement problem when examining spirituality and religiousness in relation to positive mental health functioning. As Koenig stated, “Defining spirituality in this way assures that those who are ‘spiritual’ will be mentally healthy, and excludes those who are mentally ill from this desirable classification” (p. 351). In addition to this classification problem, there is also a concern in terms of measurement of treatment outcome. If a client shows improvement in mental health, we encounter the dilemma of whether this improvement is due to an increase in spirituality or religion or whether we are simply measuring improvement in quality of life.
Koenig’s concern is particularly relevant to how researchers understand addiction. Addiction involves a setting apart from oneself, others, and the world—a direct opposition to spirituality’s emphasis of oneness with all of humanity. There is therefore a clear confound as individuals with substance use problems begin to succeed in recovery—they begin to reconnect with humanity and realign their values and goals. The use of substances offers a way to “avoid being present to oneself” (p. 44). It is common for individuals with substance use problems to report that they feel disconnected from others, and as attachment to the substance increases there is a tendency to isolate from important relationships. In Alcoholics Anonymous, a common term is “terminal uniqueness,” describing a feeling of the alcoholic who feels an extreme uniqueness and alienation from his or her peers. Conversely, during recovery from substances, there is a tendency for individuals to attach to a Higher Power and reaffirm important relationships.
Readers interested in further exploring the definitions and distinctions of spirituality/religiousness are encouraged to access Geppert et al. These authors have compiled a priceless annotated bibliography of 1353 scholarly papers on spirituality/religiousness and addictions that are divided into 10 categories, ranging from the measurement of spirituality with attitudes about spirituality and substance use.
Conceptual Models of Spirituality and Religiousness in Addiction Research and Four Religiosity/Spirituality Measures
Although there are diverse definitions and applications of spirituality/religiousness topics in addiction research, two conceptual models serve as a framework for a majority of these endeavors. On one hand, the deficit model of spirituality/religiousness and addictions assumes that the process of deepening addiction involves the loss of spiritual/religious values, beliefs, and practices. Recovery, then, necessarily involves the acquisition or reestablishment of these values and beliefs. Here, the seeking of spiritual/religious values, practices, and beliefs fills an existential void created by years of substance abuse. Tacit to this model is the assumption that the quest or search for spiritual/religious meaning is innate. The second model, the coping model of spirituality/religiousness and addiction, makes few, if any, assumptions about the etiology of substance abuse and dependency. Instead, this model focuses on the potentially buffering properties of spiritual/religious practices and beliefs in avoiding relapse. Specifically, spiritual/religious practices and beliefs are interpreted to sever the linkage between aroused negative emotional states and subsequent substance use and abuse. In this regard, the coping model has explicit connections with two popular cognitive behavior–based strategies in the treatment of addiction: relapse prevention and cognitive behavioral therapy. Less obvious is the theoretical relationship between the coping and protective factor models in addiction research. One of the most consistent and enduring findings in spirituality/religiousness addiction research is the inverse relationship reported between spiritual/religious beliefs and practices and the development of substance abuse. Essentially, spiritual/religious practices are interpreted to buffer or attenuate processes that promote substance abuse. Processes within the coping model operate in a similar fashion, but with the key difference that spiritual/religious practices now buffer against the reestablishment of addictive behaviors.
Knowledge of these two spirituality/religiousness models offers at least two benefits. First, understanding these two models provides a conceptual framework to judge, classify, and select from the plethora of spirituality/religiousness measures available to addiction researchers and clinicians. Too often, authors of spirituality/religiousness measures do not explicitly identify the conceptual basis of their respective tool. As such, spirituality/religiousness measures are frequently misused, or they fail to provide a sensitive assessment of the process under investigation. Conceptual models offer clear predictions about causal relationships, and knowledge of the different predictions of these two models offers an important second benefit. Most striking, the deficit model ultimately predicts that the failure to enlarge upon spiritual/religious practices and beliefs will result, in the long run, in relapse to substances. Some of the most explicit examples of this model and its prediction on relapse can be found in the core Alcoholics Anonymous literature. The coping model of spirituality/religiousness and addictions does not lead to such a categorical prediction. Instead, failures to develop and apply spiritual/religious behaviors and beliefs may result in a continuum of adverse consequences given the absence of the presumed positive buffering effect, but alternative resources at multiple levels may offset the absence of spiritual/religious practices, for example, social networks supportive of abstinence. With this background, it is instructive to briefly review four spirituality/religiousness measures that have demonstrated psychometric properties and that are frequently encountered in the addiction literature.
Religious Beliefs and Behaviors is a 13-item self-report measure with demonstrated psychometric properties. The tool yields two scales: Formal practices and God consciousness. Items in the God consciousness scale inquire about the frequency of prayer, meditation, and thoughts about God, whereas items in the Formal practices scale inquire about attendance at worship service and reading of scriptures or holy writings. Strengths of the Religious Beliefs and Behaviors measure include fast administration, availability of normative data based upon an alcohol treatment seeking sample ( N = 1637), and documented sensitivity to discriminate three groups of Alcoholics Anonymous–exposed adults over time in predictable directions, for example, gains in God consciousness and Formal practices increased at a faster rate over time among adults with more Alcoholics Anonymous exposure. The Religious Beliefs and Behaviors measure does, however, have limitations. Noted by Johnson and Robinson, one cannot determine from the Religious Beliefs and Behaviors measure if the behaviors of prayer and meditation occur independently of Formal practices, and findings are mixed about the ability of the Religious Beliefs and Behaviors scales to predict positive outcome. The Religious Beliefs and Behaviors measure is not copyrighted and can be used free of charge.
The Brief Multidimensional Measure of Religiousness/Spirituality, a 38-item self-report questionnaire, has 10 scales: Daily Spiritual practices (6 items), Values/Beliefs (2 items), Forgiveness (3 items), Private Religious practices (5 items), Religious and Spiritual Coping (7 items), Religious Support (4 items), Religious/Spiritual History (3 items), Organizational Religiousness (2 items), Religious Preference (1 item), and Overall Self-Ranking (2 items). The Brief Multidimensional Measure of Religiousness/Spirituality was a collaborative effort between the Fetzer Institute and the National Institutes of Health to construct a multifaceted measure of spirituality/religiousness that explicitly decoupled private and public spiritual/religious behaviors and practices. Widely recognized scholars developed spirituality/religiousness scales independently, often by reducing parent instruments into a brief scale. In addition to strong psychometric properties and partial normative data, the Brief Multidimensional Measure of Religiousness/Spirituality is especially useful because the manual provides the rationale, application, and psychometric citations for each scale. Based on a treatment-seeking adult sample ( N = 123), half of the scales showed significant increases over a 6-month period, and the Daily Experience scale was prognostic of reductions in heavy drinking even after controlling for a number of rival explanations (e.g., Alcoholics Anonymous involvement and gender).
The Spiritual Coping Questionnaire is a 22-item questionnaire that measures perceived relationship to God, with the basic premise that different kinds of God relationships imply different coping mechanisms. Three relationship-coping scales have been empirically validated with Alcoholics Anonymous–exposed persons and are labeled: Cooperative (α = 0.93), Deferring (α = 0.89), and Self-directing (α = 0.91) God relationships. Items pertaining to the cooperative God relationship stress mutual exchange between a deity and individual in making choices and decisions, while the deferring style is characterized by items that endorse the release of all responsibility for decisions to a deity. Finally, the self-directed style characterizes individuals who assume all responsibility for choices and who do not seek spiritual guidance. Spiritual Coping Questionnaire scales have been attractive to 12-step researchers because of the hypothesized developmental changes in spirituality that occur among Alcoholics Anonymous members as they work through the 12 steps. Specifically, steps 1–3 have been interpreted as reflecting a deferring relationship with a Higher Power, while later steps encourage a cooperative deity relationship, for example, steps 11 and 12. To date, temporal changes in coping styles have been documented among 12-step members, but the nature and pattern of these changes appear to be more complex than originally thought. In particular, longevity and participation in Alcoholics Anonymous appear to be related with shifting preferences in spiritual coping style, but actual step work was not.
Purpose in Life is a 20-item self-report questionnaire that uses a 7-point Likert scale (anchors: Never and Constantly). Used in a number of alcohol studies, the Purpose in Life measure is used to assess the extent that one experiences life meaning. Lower scores on the Purpose in Life reflect a relative lack of current life meaning. Little support has been found for this construct predicting later substance use among outpatient and aftercare adult alcoholics, and the item content measuring life meaning itself has been criticized. Specifically, the Purpose in Life along with other measures of life meaning is correlated with measures of well-being and, equally important, it is problematic to determine whether experienced life meaning is the result of spiritual/religious behaviors or practices or not.
Empirical Religiosity/Spirituality Questions in Addiction Research
There are four types of research questions that can be asked about spirituality using prospective longitudinal studies. Heuristically, these questions are, (1) what direct effect does spirituality, or changes in spirituality, have on drinking? (intervention question); (2) what changes in spirituality occur as a result of trying to mobilize and sustain addictive behavior change? (dependent measure question); (3) How may spiritual/religious practices and beliefs attenuate or enhance receptivity to treatment, aftercare, or Alcoholics Anonymous (moderation question) and, most complex (4) how may spirituality, or changes in spirituality, statistically explain the direct relationship between a cause (e.g., prayer) and a desired effect (e.g., abstinence)? (mediation question). This latter question, first formally described by Baron and Kenny, comprises four subquestions that focus on the temporal and causal relationships between, at a minimum, three measured variables. Fig. 62.1 highlights, with a hypothetical example pertaining to spirituality and addiction, both the ideal temporal relationship between measures and the nature of questions that must be affirmed to declare that a measure, here spirituality, explains or accounts for an observed and desired effect. For the interested reader, a detailed collection of papers specific to mediation and alcoholism can be found in Huebner and Tonigan.
Spirituality as an Intervention and Outcome
Investigations of spirituality/religiousness have used both cross-sectional and prospective longitudinal designs to address these empirical questions, with cross-sectional investigators frequently making the case that study findings offer insight into casual relationships. Although one-shot studies do offer some important perspectives on the correlational structure of domains of interest, a number of factors limit their value in understanding causality, not the least of which is the self-selected (and often) biased samples upon which study findings are based. As an example, Poage et al. conducted a cross-sectional study of 53 Alcoholics Anonymous–exposed adults. From this volunteer convenience sample, the investigators asked if length of sobriety, spirituality, and general life contentment were associated. Consistent with predictions, Alcoholics Anonymous members with more years of sobriety reported significantly higher spirituality than Alcoholics Anonymous members with fewer years of sobriety, and spirituality and contentment were significantly and positively associated. Of interest, years of sobriety and contentment were not associated. Pointed out by the authors, however, causal linkages between these three constructs remain unclear, at best. Did spiritual growth predict the sustaining of sobriety (or vice versa)? Alternatively, years sober and age were positively related ( r = 54) in this sample. Did the enhanced spirituality of Alcoholics Anonymous members with more sobriety, then, simply reflect the well-documented phenomenon that as we age we become more open to religious and spiritual explanations for the human experience? Although studies such as this certainly have value and should be conducted, they are generally avoided in this review because of the number of rival explanations for study findings.
With the exception of studies specifically focused on Alcoholics Anonymous (reviewed in Section III), there have been surprisingly few longitudinal studies that have investigated how, if at all, spirituality/religiousness-based interventions influence subsequent substance use. For clarity, the studies reviewed in this section are arranged according to the intensity of the spiritual/religious intervention, beginning with the studies that involved minimal or modest intervention efforts. Walker and colleagues, for example, sought to determine whether intercessory prayer impacted the drinking of 40 treatment-seeking alcoholics. Consenting participants were randomized into treatment as usual, which consisted of individual and group counseling in an outpatient setting, and the other half of the sample was assigned to the intercessory prayer condition. Here, in addition to treatment as usual, volunteers prayed for the well-being and abstinence of individuals in the intercessory prayer group. No mean differences on the key measure of drinking were observed between the two groups at the 3- and 6-month follow-ups. Findings suggested that prayer by the substance abuser did predict subsequent reductions in drinking in both groups, but this finding did not consider that prayer is a prescribed Alcoholics Anonymous–related behavior and, as such, this benefit may have reflected the social benefit of Alcoholics Anonymous as much as that of prayer. Counter to investigator predictions, alcoholics who reported that family members or close friends were praying for their welfare and treatment success tended to drink more frequently at follow-up relative to those alcoholics who did not report such prayer efforts by loved ones.
Extending this line of research, Miller et al. tested the efficacy of a trained and monitored spiritual guide on later substance use. Here, the spiritual intervention intentionally went beyond Judeo-Christian beliefs and practices and included such Eastern practices as meditation. In the first of two companion studies, the investigators recruited 60 inpatients from a 30-day program to receive treatment as usual or treatment as usual plus 12 sessions with a spiritual guide. The spiritual intervention consisted of 13 modules that included such topics as prayer and meditation, gratitude, guidance, acceptance, fasting, service to others, and worship. Although both intervention groups reported large pre-post gains in abstinence, no between-group differences in substance use were observed between the treatment as usual and treatment as usual + spiritual guide groups at follow-up. Also, contrary to prediction, the group receiving spiritual guidance did not report higher scores on three a priori selected measures of spiritual functioning: daily spiritual experiences (Brief Multidimensional Measure of Religiousness/Spirituality), meaning in life (Purpose in Life questionnaire), and private religious practices (Religious Beliefs and Behaviors). Not addressed in this study was whether the emphasis on 12-step attendance in treatment as usual adversely affected the discriminability of the two interventions.
A second study at the same facility was done to increase exposure to the spiritual guide intervention. Here, facility counselors delivered the spiritual guide intervention and it was embedded into the treatment as usual program. In a cohort design, 40 participants received treatment as usual and the following 40 received a spiritual guide in addition to the treatment as usual. In general, findings paralleled the earlier study: no group differences in substance use at 3- and 6-month follow-ups were found, although both groups reported significant reductions across a variety of illicit drug use measures. Unlike the first study, modest between-group differences in daily spiritual experiences were found favoring the spiritual guide group at 4- and 6-month follow-ups, but this differential change in spirituality did not statistically mediate or explain increased abstinence for the spiritual guide group.
Bowen and colleagues have provided tentative support for the effectiveness of Vipassana meditation in reducing substance use among incarcerated adults. Although replication via a randomized clinical trial design is highly desirable, this work represents some of the more rigorous study of the effects of spirituality that is not Judeo-Christian in origin. Specifically, they reported that an intensive 10-day Vipassana meditation program housed in a minimum-security prison resulted in significantly lower substance use and alcohol-related consequences relative to self-selected control inmates. In addition, at 3-month follow-up the inmates who participated in the Vipassana meditation also reported significantly higher optimism scores and lower levels of psychiatric problems relative to controls. The Vipassana meditation protocol consisted of long hours of silence, teaching of Buddhist principles including the Four Noble Truths, and instruction in meditation.
Spiritually Based 12-Step Therapy
Twelve-step treatment is the final spiritual intervention to be addressed in this section. Placement of this intervention in this section, separate from our review on Alcoholics Anonymous, reflects the important, albeit frequently forgotten, distinction between formal 12-step treatment and community-based 12-step programs. (See Ferri et al. for an example of how confusing the two can lead to erroneous conclusions.) To be sure, both 12-step entities introduce and facilitate progress through the 12 steps of Alcoholics Anonymous and strongly encourage long-term Alcoholics Anonymous meeting attendance. In this regard, both 12-step entities can be regarded as sharing a common spiritual focus—for example, 11 of the 12 steps make reference to God or a Higher Power, and spiritual concepts such as acceptance, surrender, meditation, and belief in a Higher Power are the central content of the steps.
It is the practice of the prescribed 12-step behaviors that most clearly distinguishes community-based Alcoholics Anonymous and formal treatment, and these differences in practice fundamentally influence both the interpretation and impact of working the 12 steps. Some of the more obvious examples of how the two 12-step entities differ include: Community-based Alcoholics Anonymous encourages sponsorship to aid an Alcoholics Anonymous neonate through the 12 steps while formal 12-step treatment offers no analog to this important sponsor-sponsee relationship. Continuing Alcoholics Anonymous meetings are led by a nonprofessional member of the group and cross talk in meetings is strongly discouraged. Just the opposite conditions are found in group-based therapy in formal 12-step treatment, with further distinctions made by the use of evidence-based treatment manuals. And, finally, confrontation to accept the label of alcoholic frequently occurs in 12-step treatment (i.e., denial is a concept developed within the treatment context in response to this practice), while in community-based Alcoholics Anonymous the individuals elects if, when, and how self-labeling of “alcoholic” is appropriate. Beyond the scope of this discussion, it is also important to note that 12-step treatment shares several features incorporated within cognitive behavioral therapy.
With this background, the focus of this section is to review those studies that investigated the independent effect(s) of the spiritual emphasis in formal 12-step treatment. To begin, several studies have investigated the plasticity of “Alcoholics Anonymous–specific” cognitions that are foundational to spirituality as it is expressed in 12-step programs. Morgenstern and Bates, for example, reported that cognitive shifts promoted by 12-step therapists at residential and intensive outpatient treatment centers did predict later improvement, for example, commitment to abstinence, but others did not, for example, negative expectancies. Of interest, the authors also reported that severity of cognitive impairment did not influence or moderate the extent of desired cognitive shifts, yet more impaired individuals did not appear to benefit from such cognitive shifts to the extent of those who were less impaired. Likewise, using a composite measure of 12-step disease model beliefs, Finney et al. found modest increases among 970 veterans assigned to 12-step treatment in Alcoholics Anonymous–related cognitions during therapy, but such changes did not explain later abstinence rates. Finney also reported that 12-step therapy led to a significant pre-post gain in the percentage of individuals endorsing an alcoholic identity (7% gain).
Project MATCH was one of the largest and most rigorous prospective studies of the efficacy of 12-step therapy to mobilize spiritual/religious practices and beliefs. At 12-month follow-up, no group differences were found in measures of drinking intensity and frequency of abstinent days between 12-step, cognitive behavioral, and motivational enhancement therapies, although 12-step therapy did have a significantly higher rate of total abstinence relative to cognitive behavioral therapy and motivational enhancement therapy at 12 months. Tonigan and Miller sought to identify those aspects in the 12-step facilitation that accounted for the relative parity in increased days of abstinence and reductions in drinking intensity. No support was found for 12-step therapist emphasis upon total abstinence as an explanation for the relatively good outcomes in the 12-step condition, although these therapists did endorse the goal of abstinence more than cognitive behavioral therapy and motivational enhancement therapists did. Likewise, intended cognitive shifts in perceived powerlessness and loss of control over alcohol did occur within the 12-step treatment, but these shifts did not explain drinking outcomes at 12 months. Finally, a primary objective for the 12-step facilitation counselor was the encouragement of client spiritual development. As intended, at the end of 12 weeks of therapy, 12-step facilitation clients reported significantly higher God consciousness scores relative to cognitive behavioral therapy and motivational enhancement therapy clients. Virtually no relationship, however, was found between increased God consciousness at the end of treatment and proximal abstinence 6 months after treatment, days to first drink and heavy drinking day, or 1-year total abstinence. Thus although 12-step facilitation therapists were effective in evoking increased God awareness, this increase appeared to be unrelated to subsequent increases in abstinence.
Robinson and colleagues have recently reported positive findings between increased spirituality and abstinence among 12-step–treated adults ( N = 123), and some of the unique features of this study warrant special attention. As background, they recruited 154 adults with alcohol use disorders who were presenting for 12-step outpatient treatment and, following consenting procedures, administered a baseline assessment that included an array of spirituality/religiousness measures along with semi-structured interviews for measuring alcohol consumption. Eighty percent of the sample was contacted and interviewed 6 months after recruitment and the assessment battery was readministered. In this naturalistic study, significant pre-post gains were reported on 5 of 10 spirituality/religiousness measures, nearly all of which were different than those measures described earlier in this section: Purpose in Life ( d = 0.26), Positive religious coping ( d = 0.14), Forgiveness ( d = 0.24), Daily spiritual experiences ( d = 0.19), and Spiritual/religious practices ( d = 33). By isolating the effects of spiritual gains in predicting the presence or absence of heavy drinking at 6 months by first controlling for gender, baseline heavy drinking, and pre-post changes in Alcoholics Anonymous involvement, they found that two spirituality/religiousness measures sustained their prognostic value in predicting abstinence, gains in purpose in life, and daily spiritual experiences. This set of findings represents one of the rare examples of mediated spirituality/religiousness effects as defined by the criteria of Baron and Kenny. It is not known why gains in spirituality/religiousness measures explained reductions in heavy drinking in the Robinson et al. sample but not in previous investigations. Methodologically, earlier investigations used continuously scaled measures of drinking, whereas the Robinson et al. group employed a dichotomous measure of relapse to heavy drinking over the 6-month period (yes/no). Furthermore, the Robinson et al. team used spirituality/religiousness change scores despite voiced concerns that such techniques are prone to regression artifacts. Nevertheless, all investigations approached the topic of study with (1) standard recruitment and design choices, (2) psychometrically sound measures, and (3) achieved good follow-up rates.
In general, then, the weight of evidence suggests that cognitive shifts congruent with Alcoholics Anonymous ideology can be successfully mobilized in 12-step therapy. Demonstrations of such shifts have included beliefs in the disease model, endorsement of the alcoholic identity, commitment to abstinence, and a belief in a Higher Power. Applying a Scotch verdict, the relative importance of these shifts is mixed, at best, in accounting for the generally good outcomes associated with 12-step therapy. The question is not decided, however. Work by Robinson et al. offers the possibility that previous studies have employed measures that were insensitive to the processes of interest.
Religiosity/Spirituality as a Moderator in 12-Step Therapy
Propst reported that the effectiveness of cognitive behavioral therapy for depression was significantly enhanced for religiously oriented individuals when spiritual matters were discussed within therapy sessions. Here, a person’s spirituality/religiousness orientation moderated the effectiveness of an evidence-based approach. In the treatment of alcoholism and addictions, the moderator role of spirituality has not yielded as straightforward findings. At face value, for example, it would seem that spiritually focused treatments, for example, 12-step program, would be received more favorably and be more effective for like-minded people.
Two investigators have examined this issue within the context of a randomized clinical trial. Connors et al. essentially made this prediction when they argued that self-reported religiosity of an alcoholic would moderate the effectiveness of 12-step outpatient and aftercare therapy. The composite measure of spirituality/religiousness included responses to questions about the practice and frequency of prayer, meditation, and formal practice of religious attendance and reading of Holy Scripture. They predicted that alcoholics higher in endorsement of spirituality/religiousness would be more comfortable with the spiritual aspects of the 12-step therapy. Enhanced comfort with the 12-step model would become manifest in higher treatment retention, stronger therapeutic bond, and greater satisfaction with treatment, each of which is a positive and significant predictor of increased abstinence after treatment. On the basis of drinking outcome, no support for this matching hypothesis was found. Likewise, no support was found that comfortability with spiritual/religious beliefs and practices led to higher 12-step treatment retention, satisfaction, or therapeutic bond relative to individuals lower in spiritual/religious values.
Within the same study, Tonigan and colleagues applied a more general and inclusive definition of spirituality in predicting a differential response to 12-step therapy. In particular, they computed a difference score that represented current perceived meaning in life after subtracting the seeking of life meaning. Unlike the comfortability hypothesis, they reasoned that alcoholics high in meaning seeking (but perhaps not very high on spirituality/religiousness) would find the spiritual focus of the 12-step therapy more engaging and, hence, more effective. Consistent with the work by Connors et al., no support was found for a differential response to 12-step therapy based on the general measure of clients’ meaning seeking when judged by percentage abstinent days or drinking intensity for the 12 months after treatment.
Several naturalistic studies have approached the question of whether client spiritual/religious beliefs and practices moderated treatment effectiveness. Oumilettee et al., for example, made a similar prediction as Connors et al., with the key distinction that sampled alcoholics were veterans, and participants were not randomized to treatments. Here, substance abuse treatment programs were classified according to their dominant therapeutic orientation, that is, cognitive behavioral, 12-step, and milieu therapy, and matching of client characteristics and provider types was self-selective. Using similar spirituality/religiousness measures as Connors et al. (e.g., Religious Beliefs and Behaviors) they, too, reported that 12-step treatment response was unrelated to baseline spirituality/religiousness status. Finally, Kaskutas et al. investigated the role and influence of spiritual/religious practices and beliefs on long-term sobriety and Alcoholics Anonymous involvement among 587 men and women presenting for treatment at private and public facilities in California. Although the sampled treatment centers represented a broad spectrum of services and therapeutic orientations, nearly all encouraged 12-step attendance and included 12-step induction strategies as part of their services. At 3-year follow-up, no association was found between length of continuous sobriety and spirituality/religiousness endorsement at baseline.
Finally, Kelly et al. conducted a unique single-group longitudinal 3-year study of substance-abusing adults who presented for intensive outpatient treatment ( N = 227). Here, individuals were assessed at intake and at 1-, 2-, and 3-year follow-ups. In addition to concluding that mutual-help participation contributed to positive outcomes during the follow-up phase of the study, Kelly et al. tested several prospective hypotheses about the role and influence of religious/spiritual variables in recovery.
In sum, findings from both randomized clinical trials and naturalistic studies appear to have arrived at the same conclusion, namely that spiritual/religious practices and beliefs are relatively inert in the context of being offered a spiritually based 12-step program. Contrary to predictions, then, endorsement of spiritual/religious practices and beliefs does not seem to provide an advantage to a substance abuser when they are assigned to 12-step therapy. Conversely, substance abusers who report less interest in spiritual/religious practices and beliefs do not appear to be placed at a disadvantage when assigned to 12-step therapy. It should be stressed that almost all of the studies reviewed in this section relied on self-reported spirituality/religiousness status, generally a single item asking whether one was religious, spiritual, agnostic, or an atheist. Well known, single-item responses lack reliability, and it is not clear whether more comprehensive spirituality/religiousness measures collected at the onset of 12-step treatment may offer a different picture than the one presented here. At this time, however, the limited evidence suggests that spiritual/religious beliefs and practices are relatively unimportant when determining whether or not to assign substance abusers to spiritually based 12-step therapy.