Spirituality, Addiction and Recovery
Until recently, scientists have generally avoided the concept of spirituality in research and in clinical settings (Eliason, Amodia, & Cano, 2006). One explanation for this omission is that spirituality is often mistakenly conflated with religion – the latter being viewed as largely off-limits due to professional ethical considerations (Eliason et al., 2006). The rule of thumb has been that spiritual matters were best left to the realm of the clergy or mystics and kept outside of the boundaries of science.
Another factor which contributes significantly to the disconnect between science and spirituality is that the term is difficult to precisely define and therefore resists standardized measurement (Cook, 2004; Eliason et al., 2006). Many in Western science view with great skepticism that which is unobservable, and so spirituality has often been deemed to be non-existent (Eliason et al., 2006). Notwithstanding the disdain of science and medicine, a large majority of Americans describe themselves as “spiritual”, and many of them cite spirituality as vital to the maintenance of their personal health and well-being (Eliason et al., 2006; Galanter, 2008). The health sciences have begun to take notice of these claims. For example, the Joint Commission on the Accreditation of Healthcare Organizations now requires that psychiatric residents be trained in issues related to health and spirituality (Galanter, 2008). In addition, researchers in the social sciences have begun to seriously explore the concept of spirituality in an effort to understand how it influences various treatment outcomes; and to learn how positive outcomes mediated by spirituality may be maximized (Cook, 2004). Given that health experts now acknowledge the significant role that spirituality plays in recovery from a variety of illnesses, exploring whether the concept may be defined more precisely seems beneficial for research purposes.
The word spirit – which is derived from the Latin term spiritus – is believed to have first been used by a 17th century French mystic named Jeanne-Marie Bouvier de la Motte Buyon who, due to her esoteric views, attracted the ire of the Catholic Church (Cook, 2004). By the 20th century, use of the word had spread throughout the world though with widely varied meanings depending on cultural and other contextual factors (Cook, 2004). There are, however, theoretical and contextual parameters into which the concept of spirituality may be placed. Spirituality is generally accepted as a multi-dimensional construct involving cognitive, behavioral, affective, social, biological, ritualistic, and existential components (Eliason et al., 2006; Laudet, Morgan, & White, 2006). With respect to the various psychological dimensions, positive correlations exist between levels of spirituality and use of cognitive processes that have been linked to optimism, resilience to stress, lower anxiety, and improved coping skills (Laudet et al., 2006). Along these lines, spirituality has been described as a “three-dimensional cognitive-behavioral-process relationship with self, others, and a higher power” (Eliason et al., 2006, p. 128). Hanna (1992) points out that from a cognitive-behavioral-affective viewpoint, spirituality may be described as “know thyself”, “do good works”, and “love thy neighbor” (p. 167). Building on these relationships, Eliason et al. (2006) propose a cross-cultural bridging paradigm of spirituality that takes into account not only cognitive-behavioral elements, but also cultural contexts, developmental stages, and individual worldview. This four-quadrant model includes such factors as inner development, independent and dependent lines of spiritual development, socio-cultural influences (such as family, community, and culture), individual physical development, societal institutions, and dominant societal messages regarding spirituality (Eliason et al., 2006).
Recognizing the need for consensus for research purposes, Cook (2004) conducted a descriptive study of 256 books and papers on spirituality and addiction in an effort to identify common elements in usage of the term. According to the study, spirituality may be identified by its thirteen conceptual components which include: relatedness, meaning/purpose, transcendence, humanity, core/force/soul, self-knowledge (and self-actualization), authenticity/truth, values, non-materiality, (non)religiousness, wholeness, creativity, and consciousness (and awareness) (Cook, 2004). Of these components, relatedness appears most often in the literature, and it is an important recurring theme in a number of other studies which have explored the components of spirituality (Avants & Margolin, 2004; Chen, 2010; Cook, 2004; Green & Nguyen, 2012; Morjaria & Orford, 2002). Relatedness is frequently associated with principles such as interconnectedness, interdependence, service, trust, forgiveness, compassion, love, humility, tolerance, mercy, gratitude, and surrender (Cook, 2004). As the foundational principle of spirituality, relatedness influences the interpretation of many of the other conceptual components. For example, transcendence may be understood in terms of the relationship the individual has to the universe, to a Universal Spirit, or to some other god-concept; and self-knowledge as the relationship to oneself (Cook, 2004). Life meaning and purpose are also frequently mentioned in the literature in relation to spirituality which suggests that oft-asked existential questions such as “why am I here” and “what is the meaning of life” are essentially spiritual in nature (Cook, 2004). These considerations give rise to the following definition of spirituality which Cook (2004) proposes as a “working hypothesis”:
Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within 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)
Though Cook (2004) provides a well-conceived definition based on an exhaustive review of the literature, the issue remains as to whether spirituality can be measured apart from the concept of religiosity. As previously noted, because of the polarizing nature of religion, its conflation with spirituality has contributed to the reluctance of scientists to properly account for either of these important variables. Like spirituality, religion is a multi-dimensional construct that eludes definition (Cook, 2004; Kendler et al., 2003). Factor analysis reveals that its domains are often indistinguishable from those related to spirituality (Kendler et al., 2003). Five of the seven factors of religiosity measured by Kendler’s questionnaire overlap significantly with factors of spirituality (e.g. “I take time for periods of private prayer or meditation”; “I feel deep inner peace or harmony”; “I think about how my life is part of a larger spiritual force”; “I try to care for other people, even if I don’t really like them”; “I consider myself to be a very spiritual person”; “I feel grateful everyday”) (Kendler et al., 2003). When members of the general population are asked to define spirituality, approximately half of the survey respondents use conventional religious expressions (such as belief in God or Jesus, prayer, and church attendance), while the other half of survey respondents use less conventional expressions (such as those related to human spirit/soul, meditation, wholeness/oneness, inner/outer awareness) (Cook, 2004). Other studies which likewise acknowledge high correlation between spirituality and religion nonetheless report that when measurements of religiosity are controlled, spirituality is distinctly related to positive health outcomes (Eliason et al., 2006).
Generally, those who have sought to distinguish religion from spirituality have done so based on the perception that the former is typically tied to rigid dogma, organizational hierarchies, and sociopolitical institutions (Cook, 2004). Along these lines, Eliason et al. (2006) describe spirituality as an intrinsic variable, and religiosity as an extrinsic variable influenced primarily by external authority (religious leaders, documents, rituals). However, even if this were a valid distinction, it does little in terms of furthering differentiation. Even though religion may be molded by external forces, its very purpose may be to cultivate inner spirituality (Borras et al., 2010). Ultimately, it must be acknowledged that spirituality and religion are not necessarily mutually exclusive. It is certainly possible, however, to operationalize the terms in such a way to make them more or less similar to each other (Cook, 2004). Though there may be a need to fully differentiate spirituality from religion in future studies, for the purpose of this discussion, those factors of religiosity which bear no resemblance to the dimensions of spirituality are most relevant. These include the “God as judge” construct, religious creed and dogma, and items related to vengefulness (Kendler, 2003).
The Spiritual Bases of Addiction and Recovery
The relationship between spirituality and addiction recovery extends back to the founding of Alcoholics Anonymous (AA) by Bill Wilson and Dr. Bob Smith in 1935 (Morgan, 2002). Indeed AA’s basic text, published in 1939 and often referred to as the “Big Book” by its members, states that the addicted person has “not only been mentally and physically ill, but [has] been spiritually sick” (Alcoholics Anonymous, 2001, p. 64). From the very beginning, Wilson’s self-help recovery movement was influenced by a wide range of professionals who viewed addiction not only as a disease of the body and mind, but as a spiritual malady as well (Morgan, 2002). One of the pioneers of the early recovery movement was renowned Swiss psychotherapist and psychiatrist, Carl Jung, whose theories caught Wilson’s attention (Mullins, 2010).
Jung’s psychological approach was heavily influenced by his understanding of spirituality which he based on a theory of unconscious archetypes collected throughout human history (Galanter, 2006). In a “Short History of AA”, Mullins (2010) describes an occasion in 1931 when Jung met a man named Rowland H. who presented with serious health complications due to alcoholism (pp. 152-153). Though Rowland H. initially improved after treatment, he later returned to Jung for help after experiencing another demoralizing relapse. Jung explained to Rowland H. that though his chances at lasting recovery were poor, he had seen some cases where alcoholics had undergone a “vital spiritual experience . . . in the nature of huge emotional displacements and rearrangements” resulting in complete and lasting recovery (Alcoholics Anonymous, 2001, p. 27). Prior to his death, Jung wrote a letter to Wilson in January 1961 in which he compared Rowland H.’s craving for alcohol to “a low level . . . spiritual thirst of our being for wholeness expressed in medieval language: the union with God” (AA Grapevine, 1963, p. 6). In the same letter, Jung noted that “spiritus” may be used in Latin to denote both “the highest religious experience [and] the most depraving poison” – an irony he expressed by the phrase “spiritus contra spiritum” (AA Grapevine, 1963, p. 6).
American psychologist and philosopher, Williams James, also figures prominently in the early recovery movement. His book The Varieties of Religious Experience, which Wilson had read, is a classic treatise on religion and spirituality, viewed by many as a philosophical masterpiece (Hanna, 1992). Therein, James derided what he refers to as “medical materialism” and argued that science falls short in explaining the important link between spiritual experiences and personality change (Galanter, 2006; Hanna, 1992). For James, spiritual experiences are of two types: the “slow” experience occurs gradually, over time, and involves a merging of higher and lower drives; while the more profound “sudden” experience occurs abruptly though less commonly (Sandoz, 2005). James believed that spiritual experiences generally arise from a sequence of three events: first, a personal calamity or series of calamities which the individual cannot seem to solve; second, surrender and admission of personal defeat; and third, a plea for divine assistance (Sandoz, 2005). Many of the spiritual experiences described in the first printing of the AA Big Book are of the “sudden” type (Alcoholics Anonymous, 2001). This left the impression that recovery could only be had where there occurred spectacular emotional upheavals, an overwhelming sense of God-consciousness, followed by sudden personality changes (Alcoholics Anonymous, 2001). Indeed, Wilson himself described his own conversion as a white-light, profound spiritual experience (Velten, 1996). Later printings of the Big Book sought to correct this impression and instead endorsed the gradual, or slow model of “spiritual awakening” which James’ further described as being of the “educational variety” (Alcoholics Anonymous, 2001, p. 567).
Both Jung and James believed that alcoholics are in search of a spiritual experience which they find, albeit temporarily, in the bottle (Galanter, 2006). This seeking is an expression of the desire to escape some sort of intra-psychic pain and to fill the internal void – it is a “misguided desire for the spiritual realm” (Galanter, 2006; Okundaye, Smith, & Lawrence-Webb, 2001, Sandoz, 2005, p. 57). But the relief is short-lived as the heavy use of these substances results in serious disruption of the spiritual dimensions of life leading instead to alienation, and intense feelings of loneliness, emptiness, and separateness (Okundaye et al., 2001). Ironically, the spiritual bankruptcy created by addiction ultimately fuels it, in what becomes a vicious downward spiral marked by repeated failed attempts to escape from the mounting pain of reality (Okundaye et al., 2001). The addicted person lacks a sense of meaning and purpose in life (other than finding and using more drugs) which in turn creates an existential vacuum the frustration from which likewise exacerbates the addictive process (Chen, 2006). As previously noted, meaning and purpose is an important factor in the construct of spirituality and may be defined as “coherence and purpose in one’s existence, the pursuit and attainment of worthwhile goals” (Recker & Wong, 1988 as cited by Chen, 2006). Lack of meaning and purpose in life often leads not only to substance abuse but to a variety of other negative health outcomes including a poor sense of well-being, neuroticism, and suicidal ideation (Chen, 2006). Galanter (2007) proposes that the diagnostic criteria for substance dependence (or “addiction”) be revised to include assessment of spiritual dimensions including loss of sense of purpose; feelings of inadequate social support; continued substance use in spite of moral qualms; and loss of the ability to resist temptations to use substances.
It is well established that spirituality operates as a protective factor against addiction, and therefore it must be acknowledged that it can likewise serve as a mediating factor in recovery (Laudet et al., 2006). The renewed interest in the relationship between addiction, recovery and spirituality has arisen as a result of the shift in focus from addressing individual deficiencies to enhancing individual recovery capital (Morgan, 2002). Experts now widely agree that addiction is a chronic, relapsing condition that requires long-term intervention as opposed to short-term episodes in treatment (McClellan et al., 2000). Treatment that is holistic and integrative must take into account the interconnected and dialectic nature of humans focusing not only on biopsychosocial factors, but on spiritual dimensions as well (Leung, Chan, Ng, & Lee, 2009; Morgan, 2002). In both active addiction and in recovery, the individual is in search of spiritual wholeness; though in active addiction, the individual has gone astray down a path of self-destruction (Laudet et al., 2006). In recovery, however, healthy adaptations are utilized instead as a means to move towards spiritual healing (Galanter, 2007). During early recovery as the transition is made into a spiritual way of life and as their worldview undergoes drastic revision, many individuals will experience grief-type symptoms for the loss of the addict identity (Streifel & Servaty-Seib, 2009). A major component of this grieving process involves a cognitive shift from the addict self-schema to the spiritual self-schema (Avants, Beitel, & Margolin, 2005). This shift, which is the hallmark of recovery, may best be understood in terms that are both humanistic and spiritual. For example, Abraham Maslow’s (Maslow, 1964) description of “peak experiences” and AA’s description of “spiritual experiences” are both subjectively felt by the individual and each is indicative of the human potential for self-actualization (as cited by Galanter, 2007).
The Spiritual Dimensions of Alcoholics Anonymous
Alcoholics Anonymous is the most frequently used and the most widely available treatment program in the United States (Buddie, 2004; Eliason et al., 2006). Because of the potential for long-term engagement, AA may be more accurately described as a form of aftercare rather than treatment (Magura, 2003). Well over fifty percent of those who receive treatment for addiction will attend a 12-step meeting, and it is estimated that more than 5 million people attended such meetings over a 2-year period (Cashwell, Clarke, & Graves, 2009). Over 2 million people identify as members of AA, and printings of its “Big Book” have exceeded 25 million copies (Galanter, 2007; Galanter, 2008). There are no membership dues or fees to become a member of AA though individuals may elect to make voluntary contributions to the organization (Alcoholics Anonymous, 2002). According to its stated traditions, the only requirement for membership to the AA program is “the desire to stop drinking” (Alcoholics Anonymous, 2001, p. 562). The 12-steps and traditions of AA have been adapted to meet the needs of those seeking recovery from other addictions including drugs other than alcohol, food, gambling, and sex (Warren, 2012).
Alcoholics Anonymous is often described as a “spiritual program for living” (Galanter et al., 2007, p. 257). In AA, the process of recovery centers on a philosophical shift as a core component of change (Velten, 1996). Dr. William Silkworth, who is featured in The Doctor’s Opinion in the AA Big Book, believed that the addicted person must experience an “entire psychic change” without which there is “very little hope” of recovery (Alcoholics Anonymous, 2001, p. xxix). This psychic change is closely related to the spiritual experience or spiritual awakening that comes about as a result of working the 12-steps and adhering to the AA program of recovery (Galanter, 2007). Those who report having experienced a “spiritual awakening” are more than three times as likely to remain abstinent in long-term follow-up notwithstanding antecedent religiosity (Galanter, 2008).
Though abstinence from drugs and alcohol is a condition precedent to recovery, in the 12-step model, abstinence alone will not necessarily lead to the peace and serenity brought about through spiritual awakening (Greene & Nguyen, 2012). In fact, persons who remain abstinent without adherence to the AA program of recovery are often referred to as “dry drunks” by AA members because they have failed to enlarge their spiritual lives and continue to suffer mentally and emotionally though without the use of substances (Mullins, 2010). As opposed to just being “dry”, AA leads to spiritual maturity through acceptance, humility, and the experience of serenity (Zenmore & Kaskutas, 2004). The AA program of recovery has many components including working steps, attending meetings, sharing at meetings, having a sponsor, reading recovery literature, having a home group, service work, and regular contact with others in recovery (Laudet et al., 2006). Though many of the elements of the AA program have been shown to correlate to positive outcomes, whether an individual has worked the 12-steps is the best indicator of lasting recovery (Chen, 2006). From a theoretical perspective, the 12-steps lead to changes in cognition (which includes beliefs and attitude) and behavior which in turn lead to reduction in symptoms of addiction (Morgenstern, Bux, LaBouvie, Blanchard, & Morgan, 2002). Taking into account spiritual dimensions, the first eleven steps may be viewed as practical exercises in which the individual engages universal spiritual principles culminating in the “spiritual awakening” promised in the 12th step (Buxton, 1987).
Equally significant, however, is the social support that AA offers its members through meetings, sponsorship, and service work (Chen, 2006). In order to recover, the individual must come to understand that the required support will come from sources beyond the self (Flynn, Joe, Broome, Simpson, & Brown, 2003). Recovery does not occur in the same state of isolation from which it is often born, and therefore connecting with others is essential to effecting lasting change (Warren, 2012). Chen (2006) defines social support as “an interpersonal transaction that involves emotional concern, instrumental aid, information, and appraisal” (p. 307). Laudet et al. (2006) cite studies which demonstrate that social support contributes to numerous mental and physical health benefits including: acting as a buffer to stress during difficult times; improved satisfaction in life; increased health, happiness, and longevity; decreased substance use; significant increases in subjective well-being among substance users with co-occurring disorders; acquisition of effective coping skills leading to greater self-efficacy; and peer support for abstinence. Studies have consistently shown that high levels of social support are predictive of abstinence (Chen, 2006). Conversely, low levels of social support are predictive of relapse (Laudet et al., 2006).
In addition, the social support provided through membership in AA may best be described in spiritual terms. Kurtz (1982) notes that inherent in participation in AA is the acknowledgement of connectedness to others. Such acknowledgement necessarily involves transcending the self and embracing relationships with others who are likewise limited (Kurtz, 1982). The sense of belonging and connecting essentially helps the recovering individual to overcome the isolation and alienation of addiction through meaningful engagement with others thereby fulfilling the spiritual relatedness need (Cook, 2004; Laudet et al., 2006). Even atheists and agnostics who attend AA are more likely to remain abstinent than those who do not; a finding which suggests that spiritual growth has less to do with the religious beliefs and more to do with the affiliative aspects of the AA program (Tonigan, Miller, & Schermer, 2002). It should also be noted that the spiritual dimensions of social support extend to helping others which is a core component of the AA program and has been identified as an additional protective factor in recovery (Galanter, et al., 2008; Zenmore & Kaskutas, 2004).
Ultimately, the testimony of those who have achieved lasting recovery provides the most convincing evidence. Across cultures and social identities, those who were once addicted frequently emphasize spirituality as an important element in their own recoveries (Eliason, 2006, Flynn et al., 2003). Numerous studies have confirmed the effectiveness of AA’s spiritual approach. Twelve-Step Facilitation (TSF) has been shown to be as effective as Cognitive-Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET); and it is more effective than other modalities for those with alcohol dependence, cocaine dependence, severe histories of poly-substance abuse, and poor social support networks (Borras et al. 2010; Buddie, 2004; Galanter, 2007; Morgenstern, et al., 2002). Only AA and the other 12-step fellowships provide the recovering person an opportunity to affiliate with a volunteer organization on an extended basis at no charge (Galanter, 2007). This is an important consideration when weighing the need for long-term intervention against the current managed care environment driven by the desire to reduce costs and limit the length of professional treatment engagement (Galanter, 2007).
The evidence clearly demonstrates that the AA program improves not only substance use outcomes, but social functioning as well (Galanter, 2008). Involvement in 12-step fellowships leads to fewer symptoms of despair, anger, resentment, and anxiety (Streifel & Servaty-Seib, 2009). Galanter (2007) has observed that AA operates as a form of positive psychology that can “buoy the mood of many of its members by promoting a sense of spiritual renewal” (p. 268). However, as will be discussed in upcoming series installments, the spiritual dimensions of the AA program can operate as a barrier to recovery for some individuals; though the spiritual awakening promised by the AA program is likely accessible to everyone just as William James suggested – by experiencing it. Indeed, “faith without works is dead” (Alcoholics Anonymous, 2001, p. 76).
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LINKS TO OTHER SERIES INSTALLMENTS:
Part II: Narcissism, Addiction & Spirituality
Part III: Religious Dilemmas & Spiritual Solutions
(Parts I, II and III of this series were originally written in the Spring Semester of 2013 by the Site Administrator in partial fulfillment of the requirements for the Bachelor of Integrated Studies Degree at Murray State University)