Spirituality, Twelve Steps, and substance use syndrome
The purpose of this paper is to review why spirituality and the Twelve Steps of AA have been significant in addressing treatment for Substance Overuse Syndrome. Though recognized as different diagnoses in the DSM IV, the terms substance dependence and substance abuse, along with the terms alcoholism and addiction, will be used interchangeably for the purpose of this paper, and will be referred to as Substance Overuse Syndrome. This paper will not approach the topic of the diversity in opinions of using spirituality for treatment of Substance Overuse Syndrome. As of 1990 over 88% of hospital based treatment programs used AA as a primary intervention (Ellis & Schonfeld, 1990). This paper will address why this path has worked for many. The author of this paper believes this is not the only path of treatment for recovery, however, for the sake of brevity, it will be the only topic of this paper.
Substance Overuse Syndrome
In order to prepare for treatment, it is important to search for the etiology of the disease or malady that one is going to treat. First, let’s look at some of the causes of Substance Overuse Syndrome. “Addiction is a state of compulsion, obsession, or preoccupation that enslaves a person’s will and desire….We succumb because the energy of our desire becomes attached, nailed to specific behaviors, objects, or people. Attachment, then, is the process that enslaves desire and creates the state of addiction” (May, 1988, p.14) The term behavior is often used in the definition of addiction because action is essential to addiction. Thinking is also a behavior, thus images, memories, fantasies, ideas, concepts, and certain feeling states can become objects of attachment.
Brown (1992), indicates that there is strong evidence that psychiatric symptoms manifested by a substantial percentage of substance abusers were not transient, but rather constituted symptoms of more chronic, severe, and often preexisting character pathology ranging from severely unhappy to fairly well adjusted individuals though often conflicted. The personality pattern of the substance abusing population is characterized by disregard for established social customs, lack of control and foresight, inability to maintain lasting personal commitments, and a need for unusual and varied experiences. Alcoholic men are four times more likely than non alcoholic men to present with antisocial personality disorder, while the figure for women is twelve times. “It would appear that descriptively oriented research generally supports the view that substance abusers…generally present a wide range of maladaptive personality profiles that fall along a continuum from a psychologically – distressed, severely neurotic, or ‘borderline’ personality subtype to a non – symptomatic, pronounced anti-social, or extremely narcissistic profile subtype, with perhaps a middle third major subtype being comprised of personalities presenting less pathological profiles, but whose symptoms represent various combinations or features of the other two” (Brown, 1992, p.5). He is making the point that there have been clinical observations demonstrating a strong relationship between substance abuse and the ‘disorders of the self’. Disorders of the self are referring to a constellation of pathological character traits or impairments having as a common denominator the presentation of a false, defensive self in an attempt to ward off intrapsychic conflict and avoid painful feelings. The psychodynamic theorists cite a vulnerability of the self as the basic or core problem with substance abusers. Brown (1992) states that Masterson believes the DSM-IV personality disorders can be conceptualized in four clinically relevant clusters: Borderline, Narcissistic, Antisocial, and Schizoid, and that development of these disorders can be traced to specific abnormalities in either, nature (genetic heritage of the individual), nurture (child rearing practices), fate (unavoidable traumatic experiences in life growing up), or a combination of these. Brown (1992) uses the Millon Clinical Multiaxial Inventory (MCMI), an instrument of 175 items used to measure disorders closely related to the DSM IV’s concepts of personality disorders, to support a strong relationship between substance abuse disorders and the ‘disorders of the self’. For substance abusers, relationships with the self, others, and God are unsatisfactory mainly because of attitudes of negative spirituality.
These theories by May, Brown, and Masterson are not contradictory to the principles taught in AA about alcoholism. In Alcoholics Anonymous (1976), Bill Wilson, one of the cofounders, states that alcohol was but a symptom of the problem. He goes on to say that the real problem lay rooted in the ‘self’, particularly in what Wilson called “defects of character”. Warfield and Goldstein (1996) define “character defects” as feelings, beliefs, and behaviors that lead the alcoholic to seek a sense of well being by abusing alcohol. They are frequently reflective of a pathological narcissism, in which the alcoholic behaves as though he or she were the center of the universe. “Self centeredness… is the root of our troubles. Driven by a hundred forms of fear, self-delusion, self seeking, and self pity…but we invariably find that at some point in the past we have made decisions based on self which later placed us in a position to be hurt….So our troubles, we think, are basically of our own making. They arise out of ourselves.” (Alcoholics Anonymous, 1976, p.62). AA’s basic tenet is that alcoholism is a disease of the self, a physical, mental, and spiritual malady.
Carroll (1991) cites in her research that one of the significant factors in the etiology of alcoholism is the vain attempt to satisfy deep religious needs by means of alcohol. She cites that of ten groups studied by Clinebell in 1963 and administered the Purpose in Life Test (PIL), alcoholics registered as the lowest in PIL. She believes this can be seen as the cause and effect of drinking.
Chapman (1996) discovered alcoholism to be described as a disease by Johnson with affective symptoms, and an emotionally based etiology. Chapman proceeds in his article to discuss how Vaillant argued that alcohol dependence exists on a continuum with a biopsychosocial explanation of this diagnosis.
The author of this paper is attempting to show the major roles that psychological and social disorders play in the development of Substance Overuse Syndrome. Chapman (1996), “addressing the physical and mental symptoms of alcoholism represent the logical, pragmatic, temporal approach to treatment. Though necessary, this approach is not sufficient to ensure a lasting recovery. It is by considering spiritual issues, issues related to connectedness, a sense of purpose in being, and relationship with others, …a platform is created that enables the person with alcoholism to reach recovery” (p42).
A Brief History
It was in the early 1930’s that spirituality was introduced into the treatment of alcoholism. One alcoholic, Ebby, was seeking help from the Oxford Group, which had an intense religious identity. Another gentlemen, by the name of Rowland, sought help from Dr. Carl Jung. It was Dr. Jung that told this gentlemen, he had seen people recover from the illness, as serious as he had it, only if they had a ‘deep religious experience’. These messages eventually came to Bill Wilson, a New York stockbroker, and co-founder of AA, who on numerous occasions had unsuccessfully attempted to stop drinking. History then tells the story of how Bill Wilson had such an intense spiritual experience when he was in the hospital for the last time. Wilson then embarked on the path Ebby talked to him about when he had previously visited Wilson at his home. This path led to a meeting with Dr. Bob Smith in Akron, Ohio around June 1935. It was from this point that Alcoholics Anonymous was founded and the Twelve Steps developed.
In a letter, dated January 30,1961 addressed to Bill Wilson, Jung wrote regarding Rowland, “His craving for alcohol was the equivalent, on a low level, of the spiritual thirst of our being for wholeness….The only right and legitimate way to such an experience is, that it happens to you in reality and it can only happen to you when you walk on a path which leads you to a higher understanding”. (Language of the Heart, 1988, p280). Jung went on to say, one can be led to that goal by grace, through personal and honest contact with others, or through higher education of the mind beyond the confines of mere rationalism.
In the forward of Alcoholics anonymous (1976), Dr. Silkworth wrote in the Dr.’s Opinion, “We doctors have realized for a long time that some form of moral psychology was of urgent importance to alcoholics” (p.xxv). This was the modern beginning of the use of spirituality in the treatment of alcoholism. Presently “attention to the spiritual aspects of the patient with substance abuse problems is mandated by the Joint Commission on Health Care Organizations for all substance abuse treatment facilities” (Peteet, 1993, p.263). Despite this fact mental health professionals are skeptical about the relevance of the spiritual approach to treatment effectiveness.
What is spirituality?
One would hope that after reading 25 to 30 articles, books, and journals regarding spirituality, that one could come up with a concrete, comprehensive, and understandable definition, a definition that would be empirically measurable and testable. However, this was not the case. One hundred writings may produce as many definitions of this term. It is the vagueness of this term, though, that may give it its strength. The vagueness allows the individual to apply his or her own meaning to the term, within the confines of certain common concepts. Presently, spirituality is being recognized as personal and subjective.
Historically, religion and spirituality were not distinguished from one another. It may be this close relationship in the two terms that hinders the definition of spirituality. Religion is a social institution in which people participate, whereas, spirituality is more of an individual searching for meaning. It has really been in the past twenty-five years that interest in spirituality has increased, and the term has shifted to include more elements.
“What is spirituality? To have the answer is to have misunderstood the question.” (Kurtz, 1992, p.15). Kurtz goes on to say that spirituality is an intangible and ineffable reality that we can’t define, but that defines us. In an attempt to define spirituality we see our own limitation, and not the limitation of spirituality. “Elusive in the sense that it cannot be ‘pinned down’, spirituality slips under and soars over efforts to capture it, to fence it in with words. Centuries of thought confirm that mere words can never induce the experience of spirituality.” (Kurtz, 1992 p.16). Yet, he goes on to say we all have spirituality, either a negative one that leads to isolation and self destruction, or one that is more positive and life giving. Negative spirituality is indicated in one who is insecure, defensive, and lacking in self-esteem.
“The self, others, and God provide the key elements within a definition of spirituality, and that other emerging themes, namely meaning, hope, relatedness/connectedness, beliefs/belief systems, and expressions of spirituality, can be articulated in the context of these key elements” (Dyson, Cobb, & Forman, 1997, p.1183). Dyson et al. (1997) identify the importance of spiritual well being as depending on a right relationship between self, others, and God. They continue that spirituality occurs in the context of communities, and that the state of the self is reliant upon the relationships with others. In a number of studies reviewed by Dyson et al. (1997) the following characteristics or needs of spirituality were found:
•Giving and receiving love and forgiveness from others is a spiritual need
•Also, having a common bond with others
•Affiliation and interdependence
•A person’s highest value in life can be his or her God, suggesting that spirituality is based on the person’s life principle
•Purpose and meaning in life are critical attributes to spirituality which includes a search for relationships that give a sense of worth and a reason for living.
Some common concepts of spirituality described by Zinnbauer et al. (1997) are; individual phenomena; identified with such things as personal transcendence, supraconscious sensitivity, and meaningfulness; ultimate purposes, higher entities, God, love, compassion, and purpose.
Pauly (1990) defines spirituality as a consciousness and a way of life. It may be understood as experiencing a sacredness of self, life, and the world. This acknowledgment of sacredness within then becomes the meaning and purpose for one’s life as a whole. A sense of connectedness is produced when one appreciates a sense of meaning and purpose, and the sacredness of oneself and all of life.
In Kus (1995), Father Leo Booth says “I define spirituality as the relationship between body, mind, and emotions that allows people to be positively and creatively connected to others and the world around them….Spiritual power is within us: it is manifested in our self esteem, in our ability to make choices, and take responsibility for our lives” (p.6). This relationship within the self of the body, mind, and emotions, shapes one’s ability to relate to others, and the spiritual power of the universe. Depression, addictions, compulsive behaviors, and low self-esteem are symptoms of a faulty relationship with the self, and of wounded spirituality. Spirituality cannot be measured. However, one can evaluate the degree of spiritual wounding based on the mental, emotional, and physical problems a patient presents (Kus, 1995).
Warfield and Goldstein (1996) state that of all the basic needs, belongingness is the most spiritual. Belongingness, “can be described as enjoyment of loving, accepting, and trusting relationships with one’s self, other people, the world in all aspects of life’s experiences, and the God of one’s understanding” (p.198).
Spirituality, though not necessarily definable in exactness, can be thought to have some basic characteristics. Those would be:
•Relatedness and connectedness with others and the world
•A sense of purpose in life
•A transendence of the self to some Higher Entity
•A loving and accepting relationship with the self.
The original founders of AA described the spiritual experience they were talking about as a personality change, a profound alteration in the alcoholic’s reaction to life (Alcoholics Anonymous, 1976). Fr. Booth believes spiritual empowerment puts people in charge of the changes in their lives. He believes “we are most spiritually healthy when we allow ourselves to be real, to be imperfect” (Kus, 1995 p.10).
In the previous discussions on Substance Overuse Syndrome and spirituality, some common points are found. If we plotted people with these points on a continuum, we would have persons who have Substance Overuse Syndrome on one end of the continuum, and Spiritual people on the other end, with a number of points in between. Common characteristics found in people with Substance Overuse Syndrome are ‘disorders of the self’, antisocial personality disorders, an emotionally based etiology (affective symptoms), a vulnerability of the self, and low self-esteem. Spirituality, on the other hand, encompasses the other end of the continuum, shown as a connectedness to self and others, an interdependence and interrelatedness with others, sacredness of self, self acceptance, acceptance of others, and self empowerment. The goal of treatment would be to move one’s patients along the continuum towards spiritual growth. O’Murchu (1994) states that if one can find a means of fostering spiritual growth, and increasing self esteem, then a natural process of inner healing can take place, and one can overcome this illness.
AA and the Twelve Steps
It is at this point that AA and its Twelve Steps can be used as an adjunct to treatment or personal counseling. The fellowship of AA is designed to instill in the alcoholic “the level of trust necessary to risk exposing their vulnerable selves to honest examination and correction of their dysfunctional behaviors and beliefs” (Warfield & Goldstein, 1996 p.196). This is done through the “suggested” Twelve Steps of recovery. The Steps represent the actions taken by the original members of AA to assure their own recovery from alcoholism. The Steps are found in chapter five of the Big Book (Alcoholics Anonymous, 1976) titled “How It Works”. This chapter starts by saying, “Rarely have we seen a person fail who has thoroughly followed our path” (p.58). Warfield and Goldstein (1996) summarize the steps as follows:
•Step 1. We admitted that we were powerless over alcohol, and that our lives had become unmanageable. The self-centeredness of a willful and irresponsible ego is recognized as the root cause of the destructive use of alcohol. Acceptance of powerlessness lays the groundwork for the transcendence of the faulty ego self. “This begins the process of breaking down the typical personality characteristic of obsessive control on the part of the alcoholic. If powerlessness is not internalized, a sense of spirituality cannot and will not exist” (Watkins, 1997, p.582).
•Step 2. Came to believe that a power greater than ourselves could restore us to sanity. The problems or ‘character defects’ that sustain alcoholism are a form of mental illness that is not conducive to self-treatment. It takes a power greater than the ego self. AA says God, as one understands God, is that power. However, until such time as the alcoholic accepts this, the group is an acceptable substitute. Alcoholics have used the phrase “Good Orderly Direction” as another understanding of God.
•Step 3. Made a decision to turn our wills and our lives over to God, as we understand Him. One makes the commitment to overcome their narrow ego self and grow spiritually by giving up his or her willfulness and surrendering to this power.
•Step 4. Made a searching and fearless moral inventory of ourselves. The alcoholic makes an account of his or her character defects and positive traits. There is an awareness of an acceptance from the fellowship despite one’s character defects. This is where the ego defenses begin to be surrendered.
•Step 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. The alcoholic now takes responsibility and acceptance for the past. This honesty helps to increase self-esteem.
•Steps 6 and 7. Were entirely ready to have God remove all those defects of character, and humbly asked Him to remove our shortcomings. This willingness to depend on God and the humility involved are evidence of the lessening of the influence of the ego.
•Steps 8 and 9. Made a list of all persons we had harmed and became willing to make amends to them all, and made direct amends to such people wherever possible, except when to do so would injure them or others. The process of making amends erodes egocentricity and constructs positive spiritual relationships with others. Spiritual growth is enhanced as one accepts responsibility for wrongs done to others.
•Step 10. Continued to take personal inventory, and when we were wrong promptly admitted it. Self-responsibility is taken for ones behavior and actions. Commitment to honesty in relationships helps the development in self-esteem.
•Step 11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for the knowledge of His will for us and the ‘power to carry that out. The ego is forsaken to the dependence of God’s will and grace.
•Step 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and practice these principles in all our affairs. “Ego transcendent spirituality is practiced in all relationships, and strengthened through helping other alcoholics.” (Warfield & Goldstein, 1996, p.201). The alcoholic does not stop here, but continues to rework the steps while new and more powerful patterns of beliefs and attitudes are established.
These Twelve Steps attempt to assist the individual in reconnecting to self and others, connecting to a Higher Entity in the universe, and restoring one’s purpose in life which is to carry this message.
Warfield and Goldstein (1996) summarize it so eloquently when they state, “As recovering alcoholics ‘work the steps’ of the AA program, guided by their sponsors in the supportive family environment, they begin to develop positive spirituality. This is reflected in the blossoming attitudes of unconditional love, acceptance, and trust in relationships with themselves, others, the world, life, and the God of their understanding. They come to believe that they are fundamentally okay even if their behaviors sometimes are not. They begin to love, accept, and trust themselves” (p.202). They continue that because of this, recovering alcoholics in AA learn to develop more satisfying relationships, in and out of AA. They learn to trust life and others as being fundamentally okay, and develop a trusting, accepting, and loving relationship with them.
Khantzian and Mack (1994) state there is increasing evidence that AA not only helps the members to succeed in arresting their uncontrolled drinking, but also in the positive transformation of their lives physically, emotionally, and spiritually. They go on to say that AA is based on group psychology that addresses, interrupts, and modifies core problems in self-regulation. AA benefits people in their feeling life by helping them access, experience, and express their emotions.
The descriptions earlier in this paper of Substance Overuse Syndrome indicate “disorders of the self” as a primary characteristic. This is presented as a false, defensive self with intrapsychic conflict and avoidance of painful feelings. Brown (1992) characterizes the personality pattern of the abuser as having a disregard for established social customs, lack of control and foresight, and having difficulty in maintaining lasting personal relationships. In contrast, a spiritually sound personality is characterized by personal subjectivity, relatedness and connectedness with others and the world, a sense of purpose in life, a transcendence of the self to some Higher Entity, and a loving and accepting relationship with the self.
Warfield and Goldstein (1996) observe that alcoholism is essentially cognitive (AA members refer to it as ‘stinking thinking’), behavioral (habitual and dysfunctional actions), and spiritual (relationship centered) in nature. Therefore, achievement of wellness must focus on all three elements. Most treatment centers address the cognitive and behavioral components, and pay little attention to the spiritual one. Alcoholics Anonymous incorporates all three components in its program of recovery. It provides the alcoholic with both a fellowship and program of rehabilitation. The steps are designed to confront a diseased ego and promote its transcendence through creation and maintenance of positive spirituality. It promotes loving, accepting, and trusting relationships with self and others, and ultimately the God of one’s understanding.
A treatment facility or counselor that truly encompasses spiritual growth in one’s treatment plan, would include the following:
•The concept of self would be “we” oriented rather than “I” oriented.
•The life goals would be harmony with nature, rather than achievement, accomplishment, and acquisition.
•Humility and acceptance would play a role in recovery.
•Behaviors that show coexistence and sharing would be exemplified rather than control and dominance.
•Intervention would be to address the disharmony
•Understanding recovery would mean acceptance and serenity.
•Harmony and a sense of belonging would indicate recovery (Chapman, 1996).
AA World Services, Inc. (1976). Alcoholics Anonymous: The story of how many thousands of men and women have recovered from alcoholism. (3rd. ed.). New York: Author.
Booth, L. (1995). A new understanding of spirituality. In R. L. Kus (Ed.). Spirituality and Chemical Dependency, (pp. 5-17), Binghamtom, N.Y.: Haworth Press.
Brown, H. P. (1992). Substance abuse and the disorders of the self: examining the relationship. Alcoholism Treatment Quarterly, 9(2), 1-27.
Carroll, S. (1993). Spirituality and purpose in life in alcoholism recovery. Journal of Studies on Alcohol, 54(3), 297-301.
Chapman, R. J. (1996). Spirituality in the treatment of alcoholism: a worldview approach. Counseling and Values, 44(1), 39-50.
Dyson, J., Cobb, M., & Forman, D. (1997). The meaning of spirituality: a literature review. Journal of Advanced Nursing, 26(6), 1183-1188.
Ellis, A., & Schonfeld, E. (1990). Divine intervention and the treatment of chemical dependency. Journal of Substance Abuse, 2(4), 459-468.
Khantzian, E. J., & Mack, J. E. (1994). How AA works and why it’s important for clinicians to understand. Journal of substance Abuse Treatment, 11(2), 77-92.
Kurtz, E., & Ketcham, K. (1992). The spirituality of imperfection. New York, N.Y.: Bantam Books.
May, G.G. (1988). Addiction and grace. New York, N.Y.: Harper-Collins.
O’Murchu, D. (1994). Spirituality, recovery, and transcendental meditation. Alcoholism Treatment Quarterly, 11(1-2), 169-184.
Pauly, L. E. (1990). Depression and spirituality: toward a holistic formulation of depression. Unpublished doctoral dissertation, Marquette University.
Peteet, J. R. (1993). A closer look at the role of a spiritual approach in addictions treatment. Journal of Substance Abuse Treatment, 10(3), 263-267.
The Language of the Heart. (1988). Grand Central Station, N. Y.: The AA Grapevine, Inc.
Warfield, R. D., & Goldstein, M. B. (1996). The key to recovery from alcoholism. Counseling and Values, 40(3), 196-205.
Watkins, E. (1997). Essay on spirituality. Journal of Substance Abuse Treatment, 14(6), 581-583.
Zinnbauer, B. J., Pargament, K. I., Cole, B., Rye, M. S., Butter, E. M., Belavich, T. G., Hipp, K. M., Scott, A. B., & Kadar, J. L. (1997). Religion and spirituality: unfuzzying the fuzzy. Journal for the Scientific Study of Religion, 36(4), 549-564.