Written by Daniel Callahan, MSW
Recovery from addictions and alcoholism (see Appendix A) has long been a public health and social challenge for the medical, psychological, sociological, legal, and the religious “treatment” communities. Treatment need in the SAMSHA (2007) report is defined as having a substance use disorder or receiving treatment at a specialty facility (hospital inpatient, drug or alcohol rehabilitation, or mental health centers) within the past 12 months.
In 2007, 23.2 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (9.4 percent of persons aged 12 or older). Of these, 2.4 million (1.0 percent of persons aged 12 or older and 10.4 percent of those who needed treatment) received treatment at a specialty facility. Thus, 20.8 million persons (8.4 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a specialty substance abuse facility in the past year. Until the turn of the twentieth century a cure could not be found, often the alcoholic would be either institutionalized in a psychiatric facility (insane asylum) or jailed in a “drunk” tank (a jail cell) to sleep it off.
The Concept of Alcoholism
The concept of addiction and alcoholism as a disease has long been debated. Since the turn of the century the medical, sociological, and religious communities have adopted as a viable treatment protocol a spiritual approach utilizing the twelve-steps of AA as the recovery process. Callahan (2010).
Does spirituality play a substantial role in recovery or is spirituality a result of the recovery process? Fourteen scholarly articles and research studies were reviewed, evaluating the validity of spirituality in the recovery process utilizing two database providers, Infotrac and primarily EBSCO on the Argosy I-Library, independent knowledge of the subject studied, and personal experience of the writer. The literature review will describe the issues, the studies and the findings of the role of spirituality in the recovery from addictions process.
Alcoholism and Addiction
There appears to be a propensity to desire to differentiate between addiction, which includes substance abuse and chemical dependency, and alcoholism, which includes alcohol abuse and alcohol dependence (See Appendix A). Often this distinction seems to be made for sociological purposes. The idea of drinking alcohol is a socially acceptable, legal, recreational or religious ritual indulgence. The use of mind-altering drugs such as narcotics has severe legal, social and physical ramifications associated with their use. Although this writer will vacillate between the two terms it is simply the use of a citation of a scholarly article, research or theme of the point or thought this writer is developing. The DSM-IV-TR (2000) subsequently categorizes both alcohol and drugs under the title Substance-Related Disorders. There are two categories or classifications of Substance-Use Disorders, abuse and dependence.
Abuse is defined as repeated use of alcohol or other drugs leads to problems but does not include compulsive use or addiction, and stopping the drug does not lead to significant withdrawal symptoms the term substance abuse applies. (DSM-IV-TR 2000). Dependence is defined as when an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. (DSM-IV-TR 2000).
Based upon the research reviewed and received feedback from W7000 students and Professor Fuller. A case study of recovered individuals to explore the phenomenon of spiritually based recovery seems to have the most potential as a formidable approach to research for this student’s dissertation. Based upon the course feedback and the expected research approach the research question has been refined to include but not limited to “In the evaluation of reported positive outcomes of recovered individuals with at least ten continuous years of complete abstinence, what are the substantive factors for the recovery from alcoholism or addiction?”
There has been much debate over the past seventy plus years over the classification of alcoholism as a disease. The Founders of Alcoholics Anonymous (1938) cited Dr. William Silkworth, MD in the text for overcoming alcohol addiction presently known as “The Big Book”. Doctor Silkworth indicates there is a physical condition an allergy if you will a phenomenon of craving that is limited to this class of individual that never occurs in the average or temperate drinker.
Presently addiction is classified a disease and is listed in the Diagnostic and Statistical Manual of Mental Disorders. (DSM-IV-TR 2000). No matter the cause or classification of addiction there is a clear social and health challenge with the abuse of alcohol and other substances that requires a treatment protocol to overcome. The varying degrees of abuse whether the challenge is abuse or dependence recovery is considered a life long process. Often the medical or physical aspects must be addressed primarily. However sustained abstinence appears to requires a psychological shift.
Vaillant (2004) concluded that effective treatments for alcoholism should include four factors: external supervision, substitute dependency, new caring relationships, and increased spirituality. The twelve-step approach of Alcoholics Anonymous a mutual help program is noted as having central importance in the treatment and recovery from addiction. (Miller 2007). There are literally thousands of references, publications and hundreds of studies the largest group comprised studies of relationships between twelve-step attendance or involvement and various measures of spirituality. The majority of the studies demonstrate positive relationships. (Geppert 2006).
Although there is significant agreement in the positive aspects of the spiritual approach to addiction treatment and more specifically in the relationship to long term and prolonged recovery there are challenges, controversies and issues surrounding research methods, explaining the findings and the application of the findings in the treatment of addictions. (Jarusiewick 2000) points out that although there is a strong positive relationship between spirituality and addiction it is unclear whether spirituality helps the recovery process or is a result of recovery.
Galanter (2006) indicated that spirituality cannot be observed or measured. Most of the researchers utilize the self-improvement and mutual support groups such as AA and Narcotics Anonymous (NA) as the model studied. A few of the studies looked at the basis for the methodology of the twelve steps stemming from a Judeo-Christian foundation. Thus failing to explore the potential benefits of other spiritual perspectives such as Mormonism, Buddhism and Islam. Miller (2007) indicated that some religions eschew or prohibit the use of drugs and alcohol spiritus contra spiritum implies an incompatibility of alcohol and spirituality.
Of the fourteen articles reviewed eight of the studies indicated a positive role of spirituality in recovery, three discussed the positive role of spirituality specifically in treatment programs, one discussed AA’s efficacy in the recovery process, one offered a bibliographical index of the research and one article indicated that there is little systematic evidence to support the role of spiritual change as a necessary condition for substance abuse behavior change. (Neff 2005). Fifield (2005) addressed the roots of the twelve-step approach highlighting the role of the recovering individuals spiritual condition as the precursor to continued sobriety. The researcher holds that it has long been determined that spirituality is the key to recovery from addiction and the maintenance of that recovery.
The text of Alcoholics Anonymous termed “The Big Book” clearly identifies the role of spirituality, a spiritual experience, and the reliance on God as the path for recovery. The reliance of a power greater than oneself, a higher power and that Jesus Christ is the power greater than the individual and greater than addiction.
Spirituality vs Religion
Jarusiewicz (2000) clarified the difference between spirituality and religion in the recovery process. Indicating that religious involvement may play a significant role in easing the difficulty of the recovery process showing a positive association between church attendance and social supports. The researcher ultimately determined there is a positive impact on individuals that recovering individuals have greater levels of faith and spirituality than relapsing individuals. Okundaye (2001) discussed the importance of incorporating spirituality and the strengths perspective into social work practice. The article determines that social workers must increase their knowledge of the twelve-step approach and spirituality as an integral aspect of social work practice. The writers present the strengths based approach coupled with the twelve steps as a formidable practice in understanding addiction and recovery. Similarly from a social work perspective, McKinney (2005) suggests engendering spirituality in recovery as opposed to emphasizing biological and cognitive processes. The article is more of a how to for the Christian social workers as opposed to a research study per se. The paper outlines the two views of treatment and discusses the idea of engendering and incorporating the spiritual aspects of the mutual support model of AA.
The Road to Recovery
Similarly Laudet (2006) indicated the road to addiction recovery begins due to an abusers desire to attain a better quality of life. This study examines stress and quality of life as a function of recovery. Longer recovery was significantly associated with lower levels of stress and a higher quality of life. This study explores longer-term recovery as opposed to many of the studies that look at shorter periods of abstinence. The idea that having an increased hope for a brighter future or a better life will motivate individuals into beginning the recovery process.
Validated by the findings that longer-term sobriety results in less stress and higher quality of life standards. Glickman (2006) identified leadership roles within a Methadone Anonymous (MA) group as a key influencer in an individual’s recovery and spiritual transformation. Leadership roles in the helping process strengthened the spiritual and recovery process among this MA group. Although this is a small study group of only five individuals the data collection method was unique to the other articles this researcher located. Narratives of recovery were analyzed and increased spirituality emerged as a common positive thread.
The Concept of God in Recovery
Sellman (2007) explored the concept of God in recovery from addiction by analyzing several studies of diverse literature including the universality of God, spiritual experiences of God through hallucinogens, the nature of drug addiction from an evolutionary neurobiological perspective, and the twelve-step movement as the prototype for God in the recovery process. The researchers discuss the idea of a universal trait, similar to many of the other researchers, which every human society has identified with a spiritual meaning of existence. These researchers explore Rational Recovery a takeoff of the AA model of mutual help based upon Rational Emotive Therapy that deemphasizes the role of the spiritual and focuses on the choice or power of the individual.
The model is not against the idea of God or spirituality rather the focus is on recovery first and then when recovery is achieved an individual can seek God and spiritual endeavors. Although there has been no significant research available comparing the two opposing models preliminary studies seem to show similar results. The researchers do indicate that spirituality may be prevalent in the experiences of recovery and not necessarily the result of the God of the Western culture.
Miller (2007) indicated that although research on spirituality and addiction is at an early stage, correlation evidence supports a positive relationship between religion, spirituality and recovery. One unique feature of this study indicates that mandated attendance at AA or other twelve-step programs is ineffective to say the least. There is also a correlation between attendance at AA during treatment and the probability of recovered individuals attending AA after inpatient treatment. Individuals that attend AA during the treatment phase of their recovery have a higher likelihood of attending after treatment ceases. Individuals that do not attend AA during treatment tend to not attend treatment upon completion of treatment.
Galanter (2006) evaluated spirituality utilizing several studies from physiology, psychology, and cross-cultural sources to determine if there is a relationship with substance abuse disorders. Galanter (2006) defined spirituality from a dictionary that is not cited as, “concerned with or affecting the soul,” “not tangible or material,” or “pertaining to God”. The researcher further stated that any given individual experiences spirituality subjectively.
The researcher indicates that due to relevant studies on religiosity and addiction there is more probability to better understand the construct of spirituality. The article first discusses “Understanding Spirituality” as being prominent in contemporary culture, citing a probability sampling of American adults that 95% believe in God or a universal spirit. The researcher contrasted the difference between religion and spirituality. Respondents that identified themselves as spiritual tended to identify God as loving and forgiving, while religious individuals defined God as more judgmental. The researcher pointed out the theme of Alcoholics Anonymous as a spiritual program for living free of dogma, theology or creed.
Spiritual Surrender and Interpersonal Surrender
In an extremely thorough review of empirical studies in the Christian church, Dyslin (2008) addressed the role of spiritual surrender and interpersonal surrender in the treatment of addictions. The researcher discussed the analogous pathway model of spiritually based addiction recovery programs. The research highlights the roots and emergence of the treatment in the Christian particularly Catholic tradition of confession and surrender. The researcher contrasts scriptural and religious teachings as the underpinning of the spiritual model of recovery. The study is more of an historic overview rather than a study of the approaches efficacy.
Heinz (2007) utilized an outcome study of individuals enrolled in an inner city outpatient treatment program to identify the effect of spirituality on recovery. The researchers indicate that there is little empirical evidence that there is a causal relationship between spirituality and recovery. The study did find a positive correlation between spiritual and religious experiences and substance abuse recovery. The use of the Index of Spiritual Experience (INSPIRIT), as a questionnaire measuring spirituality and religiosity had a positive relationship between negative urinalysis testing and higher religious and spiritual experiences.
The final study associated the increased positive outcomes of addiction treatment and recovery can be associated with applying behavioral change, spiritual transformation for an individual takes place in a social context involving peer influence, role modeling, and social reinforcement. The researchers clarify that other researchers have developed theories and studies on spiritual transformation as the precipitating factor in the recovery process rather than a result of the recovery process. The behavioral changes play a more significant role in the transformation process and not the other way around.
Identifying the fourteen articles for this literature review has enlightened this writer to the gaps in the research of the recovery process. The researchers cited agreed on the validity and positive relationship between addiction recovery, treatment and spirituality. This writer located and identified an abundance of scholarly articles on the subject. However, although the studies demonstrated a correlation between spirituality and recovery it is unclear whether recovery increases an individual’s sense of spirituality or a spiritual experience influences recovery.
A more thorough definition of spirituality that is inclusive of all spiritual dogmas, traditions and values is necessary to identify whether all forms of spirituality produces identical positive outcomes. The Judeo-Christian perspective, or some form or variance of traditional religious doctrinal belief is associated with the concept of spirituality. Some of the studies indicated that increased human values, higher standards of living and other emotional feelings or beliefs of increased joy are indicators of spirituality, yet the concept of God and religion garnered more attention.
As a practicing individual in addiction recovery, a student of the process, a professional in the addiction recovery, forensic and mental health fields, and an Ordained Minister this writer can identify researcher interpretations, biases, and inconsistencies in the research and vice versa this researchers personal and professional history may bias the interpretations as well. The idea Sellman (2007) portrayed in the comparison between Rational Recovery (RR) and the AA mutual help models on the surface appears to be correct. The researcher identified an RR point of contention with the AA program suggesting that a spiritual experience can or should be developed prior to recovery is incorrect.
The development of a spiritual experience is enhanced as an individual recovers typically simultaneously with an increased awareness of spirituality and possibly religious commitment. The AA foundation stems from a combination of religious doctrine, psychological, psychiatric, and medical methodology. The founders and developers of the AA twelve step approach transcribed their results, retraced their steps in hind sight and ensured that all individuals would be included in their society regardless of any external affiliations, race, creed, sex, political views etc. This is not an attempt to justify or offer a slanted opinion of the AA process it is simply uncovering a significant challenge in the literature.
Another significant deficit in the literature is the lack of identification of the severity of the addicted individuals studied. Are the individual’s problem drinkers, alcohol dependent, alcohol abusers or substance abusers, etc? Are their significant differences in the outcomes of the varying degrees of abuse? Are the outcomes more favorable for one addiction over another? Are they similar or do they vary for cocaine addiction verse heroin dependence? Is the dual diagnosis of a mental health condition a significant factor in the recovery process? What are the potential hazards of religious orientation with a schizophrenic or psychotic individual?
It is extremely apparent to this writer that there is a significant amount of work yet to come in the development of a formidable literature review for this students dissertation. The articles, research studies and materials uncovered thus far fall short of the intended goal and research question. What is the role of the spiritual process in the recovery from addiction?
The fourteen articles reviewed are a minimal starting point for the dissertation process. Simply locating studies that are in agreement with this writer’s belief is not consistent with an unbiased research study. The research has uncovered several studies that are in congruence with the hypothesis that spiritual transformation plays a positive role in the recovery from alcoholism and addiction. Gaps have been identified in the research, findings, premises, review, and methodologies presented. The benefit of spirituality is presented in all of the literature reviewed. Increased recovery rates are attributed to AA, spirituality and religious commitment. Individuals that report prolonged abstinence from drugs and alcohol are more likely to have an increase of spiritual well being. Individuals reporting chronic relapse or have dirty urine’s report no spiritual or religious affiliation or experience.
It is clear by the data that spirituality plays a significant role in the recovery process. Whether spirituality is a result of recovery or the positive correlation or causal factor cannot be determined by the research to date. Additional research studies must be evaluated to formulate a stronger hypothesis of the relationship of recovery and spirituality.
* Alcoholism; a chronic disorder characterized by dependence on alcohol, repeated excessive use of alcoholic beverages, the development of withdrawal symptoms on reducing or ceasing intake, morbidity that may include cirrhosis of the liver, and decreased ability to function socially and vocationally.
* Addiction; the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.
* Alcohol Abuse, when repeated use of alcohol leads to problems but does not include compulsive use or addiction, and stopping the drug does not lead to significant withdrawal symptoms the term substance abuse applies.
* Alcohol Dependence, when an individual persists in use of alcohol despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.
* Substance Abuse, when repeated use of illicit drugs leads to problems but does not include compulsive use or addiction, and stopping the drug does not lead to significant withdrawal symptoms the term substance abuse applies.
* Chemical Dependency: when an individual persists in use of illicit drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.
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Vaillant G.E. (2004). Alcoholics Anonymous: Cult or cure? Australian and New Zealand Journal of Psychiatry, 39, 431-436.
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