Developmental research on alcohol and spirituality: what we know and what we don't know.

For every viable government supported research area, there are three intertwined histories that evolve and interrelate to support the research scientists and to foster the field of study. There is the administrative history, the research history and the advocacy history. These histories are especially interesting and important for this field, alcohol and spirituality, which began with tenuous acceptance from alcohol biomedical researchers.

The research history of this field is in its developmental stage. The research supported through the Initiative discussed in this article will be cited as a milestone. By the year 2000, there was growing public interest in whether faith-based treatment and prevention programs were more effective than others in preventing alcohol-related disorders and maintaining abstinence. Research on specific faiths or on faith settings in addressing alcohol-related disorders was outside the scope of the Initiative and this article. The focus of the Initiative was to support research aimed at increasing our understanding of the potential results of faith-based programs and settings--an increase in spirituality. Certainly, the related advocacy history will be rich if research on spirituality provides useful information for the involvement of faith settings in recovery from alcoholism. This article will focus on the administrative history of the Initiative and will include judgments about what has been accomplished and recommendations for future research.

Administrative History

Developing a National Institutes of Health (NIH) supported research initiative on alcohol and spirituality was an ambitious undertaking in 1997. There had been a slow but growing interest nationally in the impact of religious and spiritual commitment and activities on health outcomes. A search of the NIH database of funded research grants revealed that the role and relationship of religion and spirituality in health was understudied. Two Initiatives were already in progress. Both were collaborations between an NIH Institute and the Fetzer Institute (http://www.fetzer.org/) in Kalamazoo, Michigan. The Fetzer Institute is a nonprofit foundation that supports scientific research and education exploring the relationship of the physical, mental, emotional, social, and spiritual dimensions of life. The first collaboration began in 1995 with the National Institute on Aging, and the second supported the development of an initiative on Spirituality and Rehabilitative Medicine. The Fetzer Institute supported a Request for Applications on "Spirituality and Religiousness in Aging and Health: Addressing Conceptual and Methodological Issues."

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The Fetzer Institute agreed that there was sufficient promise for alcohol and spirituality research and for developing a partnership with the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the NIH. The history of alcohol use and alcoholism is intertwined with spirituality and religion. Many religious traditions express strong beliefs about alcohol use, and some encourage specific practices with regard to the consumption of alcohol. In 1997, it was estimated that there were nearly 14 million Americans meeting the medical criteria for a diagnosis of alcohol abuse or alcoholism. These disorders cause enormous costs to society and more importantly, to families. Alcoholism is a disease associated with alcohol seeking and the increasing dominance of alcohol in a person's life, a dominance that essentially displaces other concerns and responsibilities. Why some people who drink get into trouble from alcohol use, while many others do not, has been a central question in alcohol research. It is clear that there are genetic influences on an individual's risk for alcoholism, but environmental influences are also key factors. Religiousness and spirituality are a part of the internal and external environment that should be considered when dealing with and treating people with alcohol problems.

In 1997, there were few pharmacotherapies with proven effectiveness for treatment of alcoholism, and the intervention of choice continued to be behavioral therapies; the most well known being participation in Alcoholics Anonymous (AA). Many intervention and treatment programs, like AA, insist that spirituality be at the core of any enduring recovery from alcohol dependence. A counter argument to the need for research on spirituality and alcoholism cites the fact that spirituality is not discussed or considered in addressing other chronic diseases such as diabetes and hypertension. The response to be considered is the unique ability of the chronic disease of alcohol dependence to separate the addicted individual from quality relationships with others. An alcohol dependent person often violates their own ethics and values, damaging their ability to rely on themselves. Providing guidance to the alcoholic in the healing of this aspect of the disorder through the 12 steps of AA is considered essential by some treatment programs.

Many books and publications have been written to expand on the 12 steps of AA. The essence of these appears to be the gradual healing of one's ability to form and maintain quality relationships with others and to recognize dependence on God or a force outside of oneself. It is this process that sparks the research interest in pursuing the relationship between spirituality and alcoholism that fosters change in the behavior in some alcohol dependent persons. A multisite trial funded by NIAAA found that a 12-step facilitation treatment was at least as effective, and on some measures of abstinence more effective, than two other behavioral treatment approaches, previously well supported by outcome research (Project MATCH Research Group, 1997, 1998).

In 1997, we knew that additional work was needed to better understand the role of religiousness and spirituality as protective and/or risk factors in the initiation of alcohol use and development of alcohol use disorders. Studies including measures of religious participation found a positive correlation between religiosity and abstinence from alcohol. Research confirms the impression that people who regularly attend religious services or describe themselves as highly religious, also report less drinking than others.

With an objective of understanding how spiritual growth or other characteristics of religiosity might be factors in preventing or delaying the initiation of alcohol consumption and abuse, this area of study was included in the Initiative.

While it was determined that there were alcohol research scientists who recognized the importance of studying spiritual growth and change during the treatment process, none had been successful in acquiring a research grant solely for this purpose. Furthermore, there needed to be agreement on what constituted a study of spirituality and how might this be related to studies of religiosity. Thus, the Initiative required a process to promote interaction and deliberation between interested scientists. Equally important was the need to solicit research grant applications using a mechanism of funding that would support developmental and exploratory study. There are several elements that are essential to any developmental research effort.

I. The development of a common understanding of terminology and the state of the science occurred in two meetings. Discussions on the scope and breadth of the Initiative were held with a working group that included NIAAA and Fetzer Institute leadership, alcohol research scientists, and religious leaders and theologians from a number of different perspectives. Out of this meeting came agreement that the viability of the Initiative depended on strict conformance to quality in the development and application of rigorous methodology.

In an earlier effort, the National Institute on Aging (NIA) and the Fetzer Institute developed a working document that identified different domains of religiousness and spirituality that may be relevant for studies involving health and health outcomes. Domains identified by NIA and the Fetzer working group include meaning, values, beliefs, forgiveness, private religious practices, coping, history, commitment, organizational religiousness, and daily spiritual experiences. The working group also concluded that domains to be used in studies for specific populations or disease processes need further refinement. This was the case for alcohol research, and these domains and others were considered by participating scientists. In addition to appropriate measures for spirituality, relevant alcohol use and demographic measures were required.

The NIAAA and the Fetzer Institute cosponsored a conference in 1999--"Studying Spirituality and Alcohol"--and jointly released a request for exploratory/developmental research grant applications in 2000. The request specified that $50,000 to 75,000 in direct costs would be awarded for two years. These grants were small in comparison to the average cost for a NIH study because their purpose was to support the gathering of preliminary data and testing of methods for subsequent larger and more comprehensive studies.

II. Development of a peer review community. The viability of a research field depends on the success of scientists to gain funding through a rigorous peer review process. The development of a peer review community with a shared understanding of the state of the science in the field and some enthusiasm for its potential usually accomplishes this task. In the case of this Initiative, there were 76 applications submitted, across diverse topics and requiring a broad base of review expertise. Careful consideration of each resulted in the identification of applications of the highest quality. With the funds available, a total of 15 exploratory/developmental research grants were awarded. Among the grantees were several authors of reports in this special edition of the Southern Medical Journal: Tonigan, Marlatt, Spicer, and Knight.

III. Development and maintenance of a research community. Grantees were required to include in their budgets funding for an annual meeting with staff from the Fetzer Institute and NIAAA to present their progress. The aims of these meetings included supporting an opportunity for researchers to comment constructively on the research methods and findings of others and increase future cooperation and collaboration among funded scientists.

IV. Increasing interest from the wider research community. Over the years, there has been an increase in interest in spirituality as a causal mechanism from the wider alcohol research community as a result of presentations, additional conferences, posters, and articles published by grantees. There has been an increase in the number of grant applications that include measures of spiritual growth and a widening of the scope to include the study of other aspects of human interactions on recovery. A mutual help research meeting was held at the national meeting of the Research Society on Alcoholism (2004) and interest has grown around the concept of helping as supportive of recovery.

What Has Been Accomplished

The exploratory/developmental research that was supported fell into three groupings: the role of religion and spirituality in prevention; the role of spirituality in the recovery process supported by AA; and spirituality and religiosity in recovery. Since the purpose of the small studies supported through this Initiative was to provide a foundation of publications to increase the competitiveness of applications for further studies, definitive findings were not anticipated. Nevertheless, progress was made in identifying some of the domains that appear to correlate with measures of recovery or decreases in alcohol use. Meta-analyses of data resulting from larger studies using similar domains and measures of alcohol involvement and spirituality are needed to confirm some initial results. Furthermore, as a result of these studies, more focused research questions have emerged.

As methods and techniques for quality studies of emotional intelligence, compassion, consciousness, as well as spirituality, emerge, there will be a greater understanding of the interrelatedness of many aspects of the recovering individual. There is the potential for collaborative multidisciplinary research that includes the approaches of affective neuroscience, neuroimaging, electrophysiological assessments and other physiologic and neurologic techniques to better understand mechanisms of behavior change and the change process over time.

Meanwhile, an expansion of research to pursue findings from current studies will be helpful for prevention and treatment providers.

Recommendations for Future Research

Studies to determine the role of religiousness/spirituality as a protective factor and/or vulnerability influence for alcohol abuse and alcoholism are still needed. Research on adolescents and young adults to examine changes in spirituality during the different stages of substance abuse: from initial use, to continued use, to dependence, and in prevention might be helpful in informing prevention approaches. Recent research has increased our understanding of alcoholism as a disease that most often begins during the second decade of life.

Research on elements of spirituality and the family members of alcohol dependent individuals might provide some effective intervention strategies.

A first priority should be in expanding studies of those domains of spiritual growth (eg, forgiveness) found to correlate with recovery to other behavioral change approaches. This category of studies provides numerous opportunities to pursue the role of each step of the 12 steps in changing the connectivity of the participants to others in and outside of the program. Also, of interest is the possibility that a study of the dynamics of the mutual help relationship would provide guidance to increase 12-step effectiveness. Studies of changes in measures of spirituality in those who recover from alcohol addiction without any formal treatment or intervention to determine what environmental support might have substituted for those factors that are components of the 12-step program might be informative.

While the Initiative discussed here focused on spirituality, the role of faith based institutions in supporting recovery should not be ignored. Studies of the role of religious institutional support (eg, African-American inner city churches) in the community matrix of care for alcoholism treatment would be of interest. There is a need to determine the components of specific religious denominations or churches known for their success in supporting the long term recovery process. Equally important would be research to determine the effectiveness of a curriculum on alcohol abuse and alcoholism for clergy and pastoral care ministers to empower congregations to support recovery.

Conclusion

The Initiative was successful in increasing enthusiasm for spirituality and alcohol as an area meriting rigorous research. A small research community was developed. An environment more favorable to the peer review of applications in this area of study has evolved within the alcohol research community and within the NIH. Research scientists participating in this Initiative are eligible reviewers for applications furthering the field. Elements, domains, and measures of spirituality were proposed and tested. The two year pilot research efforts resulted primarily in abstracts of findings and oral presentations at scientific meetings. With limited funding and only two years of support, it was challenging to conduct the research, analyze the results, publish data, and formulate applications for larger and more comprehensive studies. An Initiative with a longer period of support would have encouraged a stronger effort to expand on the findings. Nevertheless, researchers participating in the Initiative are completing studies and publishing peer reviewed papers, and they have been largely represented in this special section of the Southern Medical Journal. The potential remains high for studies addressing the role of spirituality or measures of spirituality to be included in research grant applications addressing broader topics.

Spiritual growth and development should not be ignored when considering the mental, physical, and emotional health of persons presenting with alcohol use disorders. Understanding how elements of spirituality correlate with behavioral change and healing from the distress and negative life events caused by alcohol will further the treatment field and provide additional approaches for intervention research.

Faye J. Calhoun, DPA, MS

From the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD.

Reprint requests to Faye J. Calhoun, DPA, MS, Consultant, 510 Holloway Street, Durham, NC 27701. Email: [e-mail]