Addiction treatment programs commonly expect clients to work through at least the first few steps of Alcoholics Anonymous while in their care. After the first step of admitting your powerlessness over alcohol – and/or illicit drugs if they’re your problem – and unmanageability of your life, the second step of Alcoholics Anonymous is believing that a “Power” greater than yourself can restore you to sanity. Step 3 is making a decision to turn your will and your life over to the care of “God” as you understand “Him.” And although the only requirement for AA membership is a desire to stop drinking, AA members commonly expect fellow participants to work through its 12 steps (often with the help of a “sponsor”, someone with more AA experience), which are meant to be worked on sequentially and make regular reference to “God.” Yet a new review of the scientific literature in the prestigious journal Addiction reveals that having a higher power or even being “spiritual” are not essential to recovery from addiction – even in AA.
“Is Alcoholics Anonymous Religious, Spiritual, Neither?” is the title of this newly published literature review in the prestigious journal, Addiction. As an important aside, multiple federal courts have already determined that AA/NA programs are religious in nature and therefore, under the first amendment of the U.S. constitution, individuals cannot be mandated to attend unless offered a secular alternative. As for the question of whether AA is spiritual, the renowned author of the review, John Kelly, Ph.D., from Harvard Medical School and Director of the Recovery Research Institute at the Massachusetts General Hospital explains, “AA itself believes it is indeed spirituality that is the answer, stating explicitly that recovery is achieved through a ‘spiritual awakening’ from working through its 12-Step program.”
In fact, the focus of the review is not about whether AA is spiritual or religious. More accurately, as the subtitle of the article (“findings from 25 years of mechanisms of behavior change research”) indicates, it reviews the scientific literature on how AA helps the people whom it helps.
Some Background on AA Research
First, it’s important to understand that AA is a support program, often referred to as a “fellowship” by members or as a mutual help group by experts. But AA is not addiction treatment. However, AA philosophy and practices became a mainstay of addiction treatment decades ago when there was a dearth of research supporting its efficacy.
As Kelly explains, in the early 1990s, the Institute of Medicine and National Institutes of Health recognized AA’s widespread influence and, therefore, the need for serious scientific investigation into AA’s effectiveness and how it might help people change. This spurred funding for numerous studies on an approach called 12-step facilitation (TSF) in which professionals introduce people with substance (usually alcohol) use disorders to the philosophy and components of AA (for instance, the 12-steps, the concept of what a sponsor is, and the different types of meetings) and non coercively encourage meeting attendance. In such studies TSF tended to show as good or better outcomes when compared to other science-based approaches.
While TSF is not the same as going to AA on your own in the “real world,” Kelly also cites well-designed more naturalistic studies providing “consistent results pointing towards clinically meaningful benefit and cost-effectiveness resulting from AA participation.” In general, people who get involved in AA and stay involved tend to have better outcomes than those who don’t.
However, Scott Tonigan, PhD, a prolific AA researcher confirmed that, to his knowledge, the most recent statistics suggest that “…many people who start out in AA don’t stay with it over the long term. His most recent review of the scientific literature led him to conclude, “Overall, studies suggest that between 55 and 80 percent of problematic drinkers encouraged to attend AA while in treatment will stop attending AA within nine months.”
Dr. Kelly points out that the same point can be made about any kind of ongoing care for substance use disorders: people tend to drop out over time.
How Does AA Work When it Does Work?
The flurry of research since the early 1990s also included multiple studies on the mechanisms of behavior change through which AA confers benefits. The research suggests that AA has the ability to do the following:
- Help change social networks that support abstinence and recovery – for instance, increase friends who are supportive of recovery
- Boosting belief in personal ability to stay abstinent
- Increase recovery coping skills – for instance handle stressful situations or negative moods without turning to alcohol
- Help sustain recovery motivation over time
- Increase spirituality
None of this is to say that other mutual help groups such as SMART Recovery, Women for Sobriety, and LifeRing Secular Recovery do not have the ability to confer similar benefits. Far less research has been done on such AA alternatives, although a growing body of evidence is beginning to support the benefits of SMART Recovery.
Since interventions such as AA work through multiple mechanisms at the same time, sophisticated scientific methods have been used to try to determine the relative importance of the various ways in which AA benefits people and to determine whether different individuals benefit from AA in different ways. (In other words, which factors are most responsible for conferring the sobriety benefits of AA?) Three such studies used a large clinical sample of people to answer the following questions: to what degree does AA enhance recovery by boosting spirituality; by boosting individuals’ confidence in staying sober when exposed to high-risk drinking situations or when experiencing depression, anxiety, or anger; by reducing depression symptoms; and by helping people drop heavy drinkers from their social networks and adopt abstainers/low risk drinkers? These studies also examined whether AA’s effects in these areas depend upon other participant factors such as severity of addiction, gender, or age.
The findings are complicated. Overall, they suggest that AA helps different people in different ways. According to Kelly, “Another way of saying this is, “People use AA in different ways to help them with different recovery challenges that relate to their life-context and phase of recovery.” For instance, men tended to benefit much more from AA through its ability to help them cope with high-risk social drinking situations. This was also true for women but less so. For them, AA lowered risk of relapse to drinking by boosting their ability to cope with negative moods. As for young adults, they benefitted more by AA’s help with dropping heavy drinkers from their social lives. But somewhat contrarily, compared to older adults, young people (aged 18-29 years) were less likely to benefit from AA’s ability to help them befriend abstainers/low-risk drinkers – perhaps because there are so few young people in this age category who don’t drink and/or who go to AA?
On Having a Higher Power – or Being “Spiritual?”
Of particular note, when spirituality – AA’s chief purported mechanism of behavior change – is included in research analyses with other ways that AA can bring about change, it is “relatively small or non-significant,” according to the research findings. The only exception was among AA participants with more serious substance use disorders. Kelly states, “Specifically, we have found that spirituality is a mechanism, but only among those with more severe addiction histories.”
Kelly notes that it’s difficult to define and to measure what “spirituality” is, “despite the growth of those professing to be ‘spiritual but not religious.’” He makes an analogy of white light shining through a prism that unveils a spectrum of colors, stating, “shining spirituality through a prism uncovers its own multiple constituent parts – the positive emotions, such as gratitude, hope, forgiveness, ecstasy, bliss, compassion, awe and empathy.”
However one defines it, the finding that spirituality does not appear to be a big player for most people who benefit from AA should be good news for the many who are turned off by the “spiritual” side of AA – specifically the emphasis on having a higher power, which participants are told can be just about anything, including a door knob. But I know from personal experience that when AA members refer to their “higher power,” they commonly qualify it with “whom I choose to call God.”
A big issue is that the people who work at many 12-step-based treatment programs as well as many “true believers” in AA impose upon others the notion that you can’t recover without a higher power – despite the research findings described by Kelly. For instance, I interviewed a woman who was court-ordered to attend a 90-day 12-step treatment program. She did her best to follow the 12-step program in the context of her own unusual religion, but three days prior to graduating, the police arrived and took her to jail. The paperwork for her expulsion from the program indicated that she’d “failed to accept a higher power that coincides with their 12-step program.” Her social worker told me that officials in the department that licenses their state’s addiction programs agreed with him that the actions of this rehab were “absolutely inappropriate.” Fortunately, he intervened and was successful in placing her in treatment elsewhere.
Another young man with a serious alcohol use disorder told me about going to his first AA meeting – with great hesitation, in part, because he’s an atheist. The first speaker of the evening went on a long anti-Atheist rant. (Fortunately, several supportive, open-minded AA-seasoned friends accompanied the young atheist.) Although AA views itself as a spiritual rather than religious program, its materials also suggest that “the doubter” will “presently love God and call Him by name.” There are, indeed, conflicts in AA literature. (For a more enlightened, non-dogmatic perspective on AA and its stance on spirituality, see its 2014 publication, “Many Paths to Spirituality.” Unfortunately, many traditional treatment programs and AA members are not so enlightened.)
Tom Horvath, director of Practical Recovery and past president of SMART Recovery, sums up with, “As any practicing clinician knows, AA can be helpful. John Kelly’s review advances our knowledge about the diversity of ways AA actually works and points to the importance of not prescribing how clients should engage with AA. We need to let clients explore AA in their own way but also to tell them about other mutual help groups to explore as well. Unfortunately, it appears that rigidly prescribed approaches to AA and failure to inform clients about alternative approaches continue to be the norm.”
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