Marc Galanter, MD
CHAPTER OUTLINE
■ WHAT IS SPIRITUALITY?
■ UNDERSTANDING THE PHENOMENON
■ AA AS A SPIRITUAL RECOVERY MOVEMENT
■ SPIRITUALITY AS A PSYCHOLOGICAL CONSTRUCT
■ SPIRITUALITY AND RELIGIOUS EXPERIENCE
■ SPIRITUALLY GROUNDED RECOVERY IN AA
■ AA IN THE PROFESSIONAL CONTEXT
WHAT IS SPIRITUALITY?
Dictionaries define spirituality with phrases like “concerned with or affecting the soul,” “not tangible or material,” or “pertaining to God” (1). More broadly, it consists of the nonmaterial issues that give a person meaning and purpose in life; these can be found in a person’s religious orientation but can also be seen in their ethnic heritage, altruism, humanism, or naturalism. Spirituality infuses some alternative medical therapies that are not grounded in empirical science but have gained popularity because they address symptoms like anxiety or depression. Given the prominence of Alcoholics Anonymous and related 12-step groups, it can play an important role in the rehabilitation of substance-dependent people.
The issue of spirituality is prominent within contemporary culture, as evidenced in a probability sampling of American adults, among whom 95% of respondents reply positively when asked if they believe in “God or a universal spirit.” Responses to a follow-up question survey suggest that this belief affects the daily lives of the majority (51%) of those sampled, who indicated that they had talked to someone about God or some aspect of their faith or spirituality within the previous 24 hours (2).
UNDERSTANDING THE PHENOMENON
Spirituality can be classified among “latent constructs” like personality, culture, and cognition. These are not observed directly but inferred from observations of their component dimensions (3). Such constructs are typically multidimensional: understood from the vantage point of more than one discipline. As such, spirituality should be examined from perspectives as diverse as physiology, psychology, and cross-cultural studies. This approach is attempted in this article, but it will require expert interdisciplinary collaboration to pursue it to its fullest.
Some researchers have drawn distinctions between the two concepts. In one study, respondents identifying themselves as more spiritual saw God as more loving and forgiving, while those who assessed themselves as more religious saw Him as more judgmental (4). The fellowship of Alcoholics Anonymous is often described as “a spiritual program for living” (5), but one in which “there is no dogma, theology, or creed to be learned” (6). The presence of formal doctrine may be considered associated more with religion than with spirituality.
When considered from the perspective of its role in organized religion, the nature of spirituality in a given society is culture bound, even among Western postindustrial societies. In Sweden, where religious practice had once been an important aspect of the national culture, only 10% of the population indicates that religion is important to them, and less than 5% go to church each week (7). This stands in clear contrast to the United States, where these figures are many times higher (87% and 41%, respectively) (2).
AA AS A SPIRITUAL RECOVERY MOVEMENT
How does spirituality relate to recovery from addiction? There is a parallel between the way attitudes are transformed in intensely zealous groups and the way the denial of illness and the self-defeating behaviors of alcoholics and drug addicts may be reversed through induction into 12-step groups like AA.
Members of the lay public may conclude that certain health care issues are inadequately addressed by the medical community, particularly when doctors are not sufficiently attentive to the emotional burden that an illness produces. When mutually supportive groups of laymen coalesce to implement a response to this perceived deficit, they may form a spiritual recovery movement (8), one premised on achieving remission based on beliefs independent of evidence-based medicine. Such movements may ascribe their effectiveness to higher metaphysical or nonmaterial forces and claim to offer relief from illness.
AA can be considered as a highly successful example of a spiritual recovery movement, as such movements have three primary characteristics. They (a) claim to provide relief from disease, (b) operate outside the modalities of established empirical medicine, and (c) ascribe their effectiveness to higher metaphysical powers. The appeal of such movements in the contemporary period is due in part to the fact that physicians tend not to attend the spiritual or emotional concerns of their patients (9).
Clearly, the attitudes and behavioral norms that AA espouses are much more in conformity with the values of the larger culture than those of zealous religious sects. The expectation of avoiding drunkenness in AA, normative in our culture, illustrates this. People who are highly distressed over the consequences of their addiction are therefore candidates to respond to the strong ideologic orientation of AA toward recovery and are operantly reinforced by the relief produced by affiliation with the group’s ideology and behavioral norms, all related to abstinence and a spiritually grounded lifestyle. Significantly, AA generates distress in its members by pressing them to give up their addictive behaviors, but the distress associated with this conflict is relieved if they sustain affiliation and cleave to the group.
SPIRITUALITY AS A PSYCHOLOGICAL CONSTRUCT
Two empirically grounded perspectives have played a material role in framing how we conceptualize recovery. One derived from a model of psychopathology modeled on the work of Emil Kraeplin (10). He framed an approach that now characterizes the contemporary medical model for mental disorders, categorizing disease entities diagnosed on the basis of explicit and discrete symptoms. This approach is evident in the development of criteria for substance use disorders employed in recent editions of the symptom-based Diagnostic and Statistical Manual of Mental Disorders (11). From this perspective, a state of remission, colloquially called recovery in rehabilitation circles, can take place with the resolution of the specific symptoms listed as diagnostic criteria. A second perspective on recovery derives from behavioral psychology, whose model of stimulus–response sequences has led to the ordering of experience around discrete phenomena that can be observed by a researcher or clinician. From this perspective, recovery can also be defined in terms of observable, measurable responses to substance use, lending credence to recovery as a process defined in behavioral terms.
Both perspectives are well suited to the study of psychopathology and have lent the addiction field approaches to studying addiction as a disorder, one that is compatible with research approaches employing experimental controls that are used in the physical and biologic sciences. Both have therefore had heuristic value in promoting a research field that has yielded many advances in addiction treatment. There is a third perspective, however, that is defined on the basis of addicts’ reports of their own subjective experience. These experiences are not directly observable by the clinician, but are available only as reported through the prism of the person’s own introspection and reflection. This model is more difficult to subject to measurement, but instruments are being developed that can be applied for its study, as will be discussed below. This approach is inherent in the spiritually oriented psychology of Carl Jung (12), who had a direct influence on Bill W.’s framing of the Alcoholics Anonymous ethos (13). William James (14), often described as the father of American psychology, also discussed mental phenomena in terms of subjectively experienced mystical or spiritual experience. (In fact, he wrote that “the drunken consciousness is one bit of the mystic consciousness [p. 378].”) The need for spiritual redemption was vital in the writings of Viktor Frankl, who wrote “Man’s Search for Meaning” (15), and has recently been espoused with regard to psychotherapy by William Miller (16).
This third perspective is related to the model of spiritually grounded recovery we discuss here, insofar as it emphasizes the achievement of meaningful or positive experiences, rather than a focus on observable, dysfunctional behaviors. Research on this third approach would typically rely on self-report scales, such as those which can be facilitated by development of instruments like the Life Engagement Test (17), the General Well-Being Schedule (18), or our own Spiritual Self-Rating Scale (19). We consider its role in AA, models for how it takes place, and ways it can be measured. In this respect, recovery can be understood as a process whereby an abstinent addicted person is moving toward a positive adaptation in life. This movement can take place with varying degrees of success, depending on the person’s own innate capacities and the circumstances in which they find themselves.
SPIRITUALITY AND RELIGIOUS EXPERIENCE
The relative role of spiritual experience in the 12-step recovery process has been investigated from a variety of perspectives, generally in relation to patients’ experience in AA. Kelly et al. (20) reviewed studies that applied mediational tests to ascertain how AA achieves beneficial outcomes and found little support for a role of AA’s specific spiritual mechanisms. In fact, with regard to religiosity, Tonigan et al. (21) found that, although atheists were less likely to attend AA meetings, those who did join derived equal benefit as did spiritually focused individuals. On the other hand, in one study on persons recovering from cocaine dependence (22), respondents attributed their positive outcomes to religion and spirituality. Additionally, Zemore (23) followed up a large sample of substance abusers 1 year after inpatient treatment and found that increases in spirituality contributed to the increment in total abstinence associated with 12-step involvement.
Our own experience, as well, is compatible with these findings, as we have found in multiple settings (24–26) that spirituality is integral to recovery in 12-step groups. This was particularly evident among long-term members.
SPIRITUALLY GROUNDED RECOVERY IN AA
The AA “program of recovery” is mentioned in numerous places in the Big Book, Alcoholics Anonymous (27), and is associated there with terms such as “spiritual experience” and “spiritual awakening” and with working AA’s Twelve Steps. Four of the steps include the word God, which is qualified “as we understood Him.” Some clarity is lent to this latter phrase in the Big Book where it is pointed out that, “with few exceptions, our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves” (p. 569–570). Flexibility on the issue of theistic belief is also made clear in one chapter that addresses any alcoholic person “who feels he is an atheist or agnostic,” encouraging their membership as well. The text points out for these members that even “We Agnostics … had to face the fact that we must find a spiritual basis for life” (p. 44) in order to achieve recovery, implying therein the fellowship’s distinction between spirituality and theistic religion.
This issue of theistic connotation, however, is as yet resolved relative to the judicial system, where the application of AA is sometimes constrained because of potential church/state conflicts. It is open to question, however, whether the theistic connotations of AA can be modified without vitiating the program’s effectiveness. In this relation, it should be noted that in a 5-year follow-up of recovering cocaine-dependent patients, the strength derived from religion and spirituality significantly distinguished between those who had a highly favorable outcome from those who did not (22). Additionally, attendance at religious services distinguished significantly between criminal justice clients referred for substance abuse treatment who had a positive outcome and those who did not (28).
Spirituality among long-term members is likely instrumental in sustaining the integrity of the fellowship itself. The prominence of spiritually committed long-term members at meetings and their availability to serve in the sponsorship role create readily available models for earnestly held sobriety. They serve as role models for believing commitment to the 12-step spiritual ethos to help newcomers achieve stabilization in membership. Nonetheless, some people attending NA meetings may find it hard to identify with the spiritual orientation of long-term members.
In the clinical context, recovery is based on a person’s behavioral and physiologic status, which can be assessed by recourse to criteria employed in the DSM. Some of these criteria are also embodied in the addiction severity index (29), which is employed widely in research to evaluate recovery. These items can be assessed relatively easily, as they are premised on observable behavior or delineated by symptomatology described by patient, family member, or clinician.
A spiritually grounded definition of recovery, however, can be useful as well. Such a concept relates to the importance of nondemographic subject factors, originally proposed as “quality of life” issues (30)—among which spirituality can be considered. In this context, a series of suitable criteria for “diagnosing” addiction (a more apt a term than “substance dependence”) could be developed. They could then be used to assess the spiritual aspect of recovery associated with the 12-step experience. Resolution of these issues could be considered as important to the spiritual aspect of recovery from addiction. A series of criteria could include items such as
■ Loss of sense of purpose due to excessive substance use
■ A feeling of inadequate social support because of one’s addiction
■ Continued use of a substance while experiencing moral qualms over its consumption
■ Loss of the will to resist temptation when the substance is available
Another aspect of the DSM format can be considered as well. The manual stipulates “course specifiers” of remission such as “on agonist therapy” and “in a controlled environment.” These are included because they are explanatory to the clinician. To them could be added, “fully engaged in a program of Twelve-Step recovery,” which would be equally explanatory to many clinicians.
But are spiritually grounded criteria measurable? In recent years, methodologies have been developed and validated that could be used to assess outcome based on such subjectively experienced criteria. They employ a systematic approach to measurement and can be used to describe spiritually related states:
A. Affective state:
(i) A sense of well-being, measured by the General Well-Being Schedule (18) (which we employed) or the Subjective Happiness Scale (31)
(ii) Contentment with one’s life circumstances, measured by the Satisfaction with Life Scale (32)
(iii) Positive affect, assessed with the Positive and Negative Affect Schedule (33), dealing with both variables as separate dimensions, rather than bipolar ends of the same scale
(iv) Feelings of support, employing a scale for Perceived Social Support (34)
B. Existential variables: meaningfulness in one’s life, assessed by the Purpose in Life Test (35)
C. Flow (the experience associated with engaging one’s highest strengths and talents to meet achievable challenges), as measured by Experience Sampling (36) or the Flow Scale (37)
D. Spirituality: the Spirituality Self-Rating Scale, which we developed and applied to both substance-abusing and non–substance-abusing populations (19), as well as other such scales. By means of our own scale, we were able to distinguish different populations of substance abusers’ level of spiritual orientation from the nonsubstance populations.
E. Personality assessment: the Classification of Strengths (38), a series of characteristics based on categories of moral excellence drawn from observations across different cultures
F. AA involvement: measures of the degree of affiliation and commitment to the AA fellowship (39)
A methodology for defining recovery based on measurements like these may not have the same appeal to biomedically oriented clinicians as does the conventional symptom-based approach, as these measurements are based on self-report of the person’s subjective state. Furthermore, the enthusiasm of newfound recovery may yield a Hawthorne effect. The biomedical format currently applied in diagnosis derives from the school of Kraeplin and subsequent investigators like those who developed the Feighner criteria (40) in the 1970s and then in the ensuing DSM system. Spiritual variables, however, have a lineage as well, from William James, Carl Jung, and Bill W.
AA IN THE PROFESSIONAL CONTEXT
The spiritually oriented 12-step approach has been integrated into professional treatment in some settings where it serves as the overriding philosophy of an entire program or, in others, where it is one aspect of a multimodal eclectic approach. The Minnesota Model for treatment, typically located in an isolated institutional setting, is characterized by an intensive inpatient stay during which a primary goal of treatment is to acculturate patients to acceptance of the philosophy of AA and to continue with AA attendance after discharge (41). Although a variety of exercises are included during the stay, this approach has been criticized as dogmatic because of its sole reliance on the 12-step approach. The outcome of this model, however, has been shown to yield positive results in a survey of patients discharged from one such setting (Hazelden, in Center City, MN) (42), but randomization of patients treated in Minnesota Model facilities with those treated by means of an alternative approach is needed.
A more eclectic option is illustrated in the integration of 12-step groups into a general psychiatric facility for the treatment of patients dually diagnosed for major mental illness and substance abuse. The importance of spirituality in such a highly compromised population was evidenced in our studies (19) in which such patients ranked spiritual issues like belief in God and inner peace higher than tangible benefits like social service support and outpatient treatment. One inherent advantage of this format is that it benefits from the introduction of an inspirational approach to patients who, as Goffman has pointed out (43), have become “degraded” by stigmatization due to their psychiatric disorders.
In summary, spirituality is a matter of personal meaning that is widely accepted. It is also central to the recovery process from addiction for many AA members. The fellowship of AA, in fact, can be considered a movement developed in relation to people’s spiritual needs. Although spirituality is subjectively experienced, it can be assessed systematically in given individuals by employing currently available empirical techniques. By such means, an important aspect of addiction recovery can be defined and studied.
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