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The 12 steps: building the evidence base: the latest research initiatives seek insight into how spirituality affects recovery.

Practicing the 12 Steps of Alcoholics Anonymous (AA) has a profound and positive impact on abstinence from substances and on life functioning. These benefits occur whether the Steps are worked as part of mutual-help group attendance or are facilitated within the context of professionally delivered treatment (e.g., Minnesota Model/12-Step facilitation). (1), (2), (3) In recent years, scientists have been studying the mechanisms by which the 12-Step philosophy exerts its effects. Studies have shown that the approach works by increasing social networks in support of abstinence and by increasing an individual's self-efficacy, or confidence in maintaining sobriety. (4), (5), (6), (7) These factors, in turn, lead to improved health and substance use outcomes.


There is another angle from which to examine the impact of the 12 Steps, however, and that angle is spirituality. It is a long-recognized paradox in human experience that when a situation is most bleak, the best opportunity for a spiritual awakening might arise. Bill W. and Dr. Bob, AA's founders, recognized early on that drug and alcohol addiction often bring a person to openness to spiritual experience. As a result, spirituality is a core component of AA's 12-Step philosophy. Spiritual principles include recognition of, willingness to trust, and commitment to maintain "conscious contact" with a power greater than oneself. (8)


Spirituality is a difficult concept to study scientifically. Ask 10 people how they define spirituality and you will receive 10 different answers. To some, spirituality implies a connection with the metaphysical, whether that is a traditional concept of God or a nontraditional concept of a higher power. To others, spirituality is intertwined with religion and formal, organized practices such as church attendance and group prayer. Despite differences in conceptualization, and challenges with measurement, scientists have begun to examine spirituality's role in recovery from alcohol and drug dependence.

Research findings to date

Among treatment seekers, lower levels of spiritual well-being have been observed among those with higher alcohol use severity (9), suggesting that an inverse relationship exists. Furthermore, spirituality levels have been shown to increase during the course of treatment for alcohol and drug dependence.

A study by Sterling and colleagues, for example, compared 36 individuals who relapsed to alcohol use in the 30 days prior to a three-month follow-up with 36 matched controls who maintained abstinence. (10) All participants exhibited significant increases in spirituality scores over time as measured on five different instruments from intake to discharge. Gains in daily spiritual experiences, religious and spiritual coping, spiritual beliefs, gratitude, tolerance and humility were maintained at three-month follow-up. Among those who relapsed, however, spiritual experience index scores dropped significantly by the time of the follow-up.

Spirituality levels and spiritual practices are also related to improved outcomes. Practicing Step 11 (prayer and meditation) and higher spirituality levels among AA members are known to correlate positively with life satisfaction and outcomes. (11), (12) In addition, a sense of purpose, gratitude, forgiveness--all aspects of spirituality--and belief in a higher power predicted the number of steps worked and the quality of recovery (degree of inner peace, degree of personal growth and ratings of relationships) among participants in addition treatment. (13) A study by Robinson and colleagues also found a positive relationship among daily spiritual experiences, a sense of meaning and purpose in life, and the subsequent absence of heavy drinking at six months post-treatment. (14)

The degree to which spiritual principles pervade a treatment center's philosophy may have an important impact on spiritual change. Recent studies examined the impact of spiritual guidance as an add-on to behavioral counseling. (15) Using both randomized and cohort designs, the studies found no differences between participants who received spiritual guidance sessions and those who received treatment as usual. However, spiritual guidance was not provided in a program in which spiritual principles permeated the treatment program philosophy. Furthermore, the level of spiritual guidance provided was low, with participants averaging three to five sessions overall. Also, staff members who delivered the intervention either had no experience working with substance-dependent patients or had little to no experience in providing spiritual guidance.

Taking research to the next level

Recovering AA and related mutual-help group members, treatment staff and other professionals have long observed the transformative spiritual process associated with the 12-Step philosophy. And, as described above, initial studies have documented the important role of spirituality in recovery, giving it much-needed scientific attention. However, research is needed to understand the specific mechanisms by which spiritual change occurs and directly influences outcomes.

The Big Book of AA outlines a testable, theoretical explanation of spiritual change that drives ongoing recovery and health. As described in the chapter "How It Works," self-centeredness and selfishness form the root of an alcoholic's troubles while resentment is "... the number one offender--from it stems all forms of spiritual disease." (16) The chapter provides an almost linear model of transformative change that takes a suffering individual from a place of negativity and desperation to one of recovery and improved health.

Because spirituality is a core component of the 12-Step philosophy and the Hazelden model of care, Hazelden's Butler Center for Research has launched an extensive study to examine this process of spiritual change. Labeled "Spiritual Transformation and Recovery," the research project seeks to understand better the mechanisms of spiritual change and its impact on outcome among those treated for alcohol and drug dependence.

Only by understanding changes in self-centetedness, selfishness, resentment and the development of a desire or longing for closeness with a higher power, and their direct relationship with recovery, will we understand how best to facilitate this process among those who struggle.

We are testing a path analytical model to address the following questions:

* What is the extent and nature of changes in resentment, self-centeredness, selfishness and aspects of spirituality over the course of treatment with a 12-Step based approach?

* Which aspects, if any, change? When? And for whom? Can we identify who will struggle most at the outset?

* Do changes in these constructs follow the theoretical path outlined by Bill W. and Dr. Bob many years ago? Can we use changes in self-centeredness, selfishness, resentment and spiritual development to predict post-treatment alcohol and drug use rates, quality of life, and 12-Step program involvement?

We hope the results of this study will give treatment providers a better understanding of the process of spiritual change and its influence on outcome. We hope to better identify the characteristics of patients who will struggle so that we can target specific treatment efforts earlier in the process. Ultimately, findings from this project could lay the groundwork for future controlled or even randomized clinical trials.

Finally, a greater understanding of the nature and impact of spirituality in recovery could influence how spirituality is incorporated into a variety of programs with diverse theoretical approaches.

Testing the underlying theory described in the Big Book of AA will allow us to examine the spiritual components of the 12-Step philosophy that are most important in influencing change. By conducting research projects such as these, scientists can demonstrate the profound role of spiritual change in promoting recovery. We need to give spirituality the scientific validation it deserves.

Valerie Slaymaker, PhD, is Chief Academic Officer and Provost of Hazelden's Graduate School of Addiction Studies. She also serves as the Executive Director of Hazelden's Butler Center for Research. Her areas of interest include addiction treatment research, academic program evaluation and implementation of evidence-based practices in clinical and educational programming. Her e-mail address is Photo of Slaymaker by Tad Saddoris.


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(14.) Robinson EA, Cranford JA, Webb JR, et al. Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample. J Stud Alcohol Drugs 2007 Mar;68:282-90.

(15.) Miller WR, Forcehimes A, O'Leary M, et al. Spiritual direction in addiction treatment: two clinical trials. J Subst Abuse Treat 2008 Dec;35:434-42.

(16.) Alcoholics Anonymous World Services, Inc. Alcoholics Anonymous. New York City: 1976.

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Author:Slaymaker, Valerie
Publication:Addiction Professional
Article Type:Report
Geographic Code:1USA
Date:May 1, 2009
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