Spiritual Change in Recovery

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Introduction

Alcoholism has often been referred to as a “spiritual disease,” especially within the context of Alcoholics Anonymous (AA). Consistent with this view, spiritual growth and development have been a central focus within the recovery process. AA, in this respect, offers a spiritual path to recovery from alcohol use disorders.

In this chapter, we focus broadly on spiritual change in recovery, particularly in relation to involvement in AA. We open with a discussion on defining spirituality and provide an operationalization of spirituality for present purposes. We next provide a conceptualization of alcoholism as a spiritual disease. This is followed by a review of topics pertaining to spirituality and AA. In this regard, we identify the core spiritual beliefs in AA, the AA practices thought to be relevant to spirituality, and the subjective experiences of spirituality in AA. We also discuss the important issue of spiritual awakenings. Following this, we survey the literature on changes in spirituality during the process of recovery from alcoholism.

Defining Spirituality

Few individuals would have difficulty in using the words “spiritual” and “spirituality” in their conversations or writings. Although there sometimes is a loss for words on how to define “spiritual” or “spirituality,” when people do apply the terms there is a consistent colloquial usage that equates spirituality with a variety of generally positive experiences, emotions, and states of mind.

One reason people have difficulty defining spirituality is that it is a complex phenomenon viewed as not sufficiently or adequately operationalized by any single continuum or by dichotomous classifications (Miller & Thoresen, 1999). Instead, spirituality is multidimensional. LaPierre (1994), for example, proposed six dimensions of spirituality: a search for meaning in life; an encounter with transcendence; a sense of community; a search for ultimate truth, or highest value; a respect and appreciation for the mystery of creation; and a personal transformation. Larson, Swyers, and McCullough (1998) proposed that definitions of spirituality need to include recognition of the sacred, the divine, and/or the transcendent. This appreciation for the multidimensional nature of spirituality has contributed to advances in our knowledge on this topic (for summaries, see Cook, 2004, Miller, 2003, and Larson et al., 1998).

Despite being defined in a variety of ways, spirituality (and also religious involvement) has been found to be positively related to health and negatively related to physical and mental disorders (Larson et al., 1998; Miller & Thoresen, 1999). In the case of substance use, spirituality and religiosity have been associated with lower levels of substance use in the general population (Gorsuch, 1995; Larson et al., 1998).

In an effort to develop a working definition of spirituality, Cook (2004) surveyed 265 published books and papers on spirituality and addiction. Cook’s summary indicated a range of uses of the term and a lack of clarity in its operationalization. However, he was able to specify 13 “conceptual components” of spirituality, at least as observed in the collection of works he evaluated. These domains reflected relatedness (i.e., interpersonal relationships), transcendence, humanity, a person’s inner core, force, or soul, meaning and purpose in life, authenticity and truth, values, non-materiality, non-religiousness (generally reflecting the opinion that spirituality is not the same as or mediated by any particular religious hierarchy or belief system), wholeness, self-knowledge, creativity, and consciousness.

In considering these results and indications, Cook developed a working definition of spirituality. It read as follows:

Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions. It may be experienced as relationship with that which is intimately “inner,” immanent and personal, within the self and others, and/or as relationship with that which is wholly “other,” transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth and values. (Cook, 2004, pp. 548–549)

Cook was clear in acknowledging the provisionality of the working definition and its limitations. Nevertheless, it is offered herein as a productive heuristic in our discussion of spirituality in the context of addictions generally and in the context of AA in particular.

Alcoholism as a Spiritual Disease

From its founding in June, 1935, in Akron, Ohio, AA has had a profound appreciation of a spiritual dimension in alcoholism and in recovery. This dimension is well represented in the two core texts of AA: Alcoholics Anonymous (also called the Big Book) (Alcoholics Anonymous, 1976), first published in 1939, and Twelve Steps and Twelve Traditions (Alcoholics Anonymous, 1981), first published in 1953.

AA most centrally provides a spiritual path to recovery. In the Big Book, it is asserted that “The great fact is just this, and nothing less: That we have had deep and affective spiritual experiences which have revolutionized our whole attitude toward life, toward our fellows and toward God’s universe” (AA, 1976, p. 25). Abstinence in and of itself is not viewed as recovery. Instead, abstinence alone is typically associated with what is called “white-knuckles sobriety” (Buxton, Smith, & Seymour, 1987), whereby the individual seeks (generally unsuccessfully) to avoid drinking through willpower alone. The stress associated with the use of this strategy typically overwhelms the individual, leading to a high probability of relapse.

The path to recovery espoused by AA does not suffer the above liability because it addresses physical, psychosocial, and especially spiritual aspects of recovery. The path to recovery is outlined in the Twelve Steps (see Table 1). Six of the steps include a direct reference to God or a higher power. Noteworthy is that Step 12 refers to a spiritual awakening that results from the working of the steps. We will have more to say about spiritual transformations later in this chapter.

Table 1. The Twelve Steps of Alcoholics Anonymous

Spirituality and AA

Distinguishing the Program and the Fellowship

Before discussing spirituality-related beliefs, practices, and subjective experiences in AA, it is important to note the fundamental distinction between the program of AA and the fellowship of AA. As highlighted by Tonigan, Toscova, and Connors (1999), the program of AA is comprised of the prescribed beliefs, values, and behaviors of AA. In essence, the program entails the working of the Twelve Steps, often involving the guidance of a sponsor.

The fellowship of AA, on the other hand, entails the practice and activities of AA. Helping others, building relationships among other members, and the sharing of joys and hardships, as examples, are aspects of what is described as the fellowship. In these respects, the fellowship of AA refers to the experiencing of AA. The guiding principles for fellowship are provided in the Twelve Traditions (see Table 2).

Table 2. The Twelve Traditions of Alcoholics Anonymous

Spiritual Beliefs in AA

There are five predominant spiritual beliefs in AA (Tonigan et al., 1999), each of which plays a core role in the recovery process. These central beliefs—higher power, personal relationship with a higher power, mysticism, renewal, and discord—will be discussed in turn.

The first spiritual belief, and the one most commonly associated with AA, is that of a higher power, introduced in Step 2. For many members of AA, this higher power is God. However, the AA literature is not dogmatic on this issue and is clear on the importance of the higher power being any transcendent being or source that can serve in this capacity. The key notion in adopting recognition of a higher power is that it is greater than and external to the individual.

It was with considerable foresight that the founders of AA allowed for a broad and encompassing definition of God and/or higher power. The following excerpt from the Big Book of AA (1976), in a chapter titled “We Agnostics,” captures this flexibility:

Much to our relief, we discovered we did not need to consider another’s conception of God. Our own conception, however inadequate, was sufficient to make the approach and to effect a contact with Him. As soon as we admitted the possible existence of a Creative Intelligence, a Spirit of the Universe underlying the totality of things, we began to be possessed of a new sense of power and direction, provided we took other simple steps. We found that God does not make too hard terms with those who seek Him. To us, the Realm of Spirit is broad, roomy, all inclusive; never exclusive or forbidding to those who earnestly seek. It is open, we believe, to all men.

When, therefore, we speak to you of God, we mean your own conception of God. This applies, too, to other spiritual expressions which you find in this book. Do not let any prejudice you may have against spiritual terms deter you from honestly asking yourself what they mean to you. At the start, this was all we needed to commence spiritual growth, to effect our first conscious relation with God as we understood Him. Afterward, we found ourselves accepting many things which then seemed entirely out of reach. That was growth, but if we wished to grow we had to begin somewhere. So we used our own conception, however limited it was. (AA, 1976, pp. 46–47)

The Big Book, in referencing the personal stories included in the volume, notes that “Every one of them has gained access to, and believes in, a Power greater than himself. This Power has in each case accomplished the miraculous, the humanly impossible” (p. 50). Importantly, all persons are viewed as fully capable of embracing this higher power. Indeed, this capability was viewed as likely innate, in that it is stated in the Big Book that “We finally saw that faith in some kind of God was a part of our make-up” (p. 55).

A second spiritual belief is that one must develop a personal relationship with one’s higher power. Developing and sustaining this personal relationship is a cornerstone for pursuit of the Twelve Steps. The process begins with Step 3. According to the Big Book, many AA members began the process by indicating the following to their respective higher power: “God, I offer myself to Thee—to build with me and to do with me as Thou wilt. Relieve me of the bondage of self, that I may better do Thy will. Take away my difficulties, that victory over them may bear witness to those I would help of Thy Power, Thy Love, and Thy Way of life. May I do Thy will always” (AA, 1976, p. 63). The initiation of this process is viewed within AA as a crucial “spiritual step” (p. 63).

It is likely that the nature of one’s relationship with a higher power will vary in terms of circumstances and where one is in working the Twelve Steps. Relevant to this point is research by Pargament et al. (1988) on styles of spiritual coping. They identified three styles that varied on the nature of the relationship with a transcendent power. The first was a collaborative style that emphasized the interchange between the individual and the higher power. The second was a deferring style in which the individual is passive and awaits answers to life problems from the higher power. The third was a self-directing style of coping in which there is an emphasis on taking personal responsibility for dealing with life problems and relying less on support from a transcendent power.

Tonigan et al. (1999) have discussed these different spiritual coping styles in the context of different stages of working the Twelve Steps. For example, Steps 1–3 often are described as “surrender steps,” during which the person admits his/her powerlessness over alcohol, derives hope in the ability of a higher power to restore health, and turns over one’s will and life to the care of the higher power. These steps have correspondence to the spiritual coping skills associated with Pargament et al.’s (1988) description of a deferring relationship with a higher power. In contrast, Steps 4–10 focus on self-examination, disclosure, and making amends to harmed persons, and Steps 11 and 12 highlight a deepened commitment to prayer and meditation and to service work (e.g., bringing the message to alcoholics in need). In these steps, listening and speaking with a higher power are highlighted, reflecting a collaborative relationship with one’s higher power. Pargament et al.’s (1988) third spiritual coping style, a self-directed coping strategy, is reflected broadly in steps and activities associated with accepting and pursuing personal responsibility.

A third AA spiritual belief is mysticism, often evidenced in miracles. Mysticism in AA reflects an appreciation of transcendental intervention that can and does occur. Importantly, transcendental intervention is not viewed as a random event. Instead, it is thought to reflect the unfolding of a larger purpose or reality, the plan of which may or may not become clear to the person. The foremost and overriding miracle within AA is the achievement of sobriety. Sobriety in this context is considerably more than quitting drinking. Instead, it reflects as well a profound spiritual transformation within the person, often taking years to fully emerge. This transformation is attributed to divine intervention.

A fourth spiritual belief in AA involves renewal. The notion here is that as steps are achieved (e.g., admitting powerlessness over alcohol, belief in a higher power, taking personal inventory), they are not left in the background. Instead, faith in a higher power, for example, needs to be begun anew and restored on a daily basis. As such, spirituality is experienced “in the moment,” on a day-to-day basis, and cannot be assumed or taken for granted. If it does dissipate, it can be restored through activities such as reaffirmations and renewals. Not attending to the process of daily renewals, according to the Big Book, places one at significant risk, as described in the following excerpt:

It is easy to let up on the spiritual program of action and rest on our laurels. We are headed for trouble if we do, for alcohol is a subtle foe. We are not cured of alcoholism. What we really have is a daily reprieve contingent on the maintenance of our spiritual condition. (AA, 1976, p. 85)

A final spiritual belief in AA concerns discord. Such distress is a sign that something is wrong with the person, independent of the cause (AA, 1981). The critical message to the individual is that he or she is in a state of incongruency with the plan of the higher power. Signs of discord often can be detected through regular, if not daily, personal inventories. It is important to note that discord is at least periodically experienced by most members of AA. In some cases it might entail, as an example, anger or resentment in the context of an interpersonal interaction. What becomes critical to the individual in terms of his or her recovery is a diligent working of the steps and reestablishing a syncronicity of the plan of the higher power.

The Practice of Spirituality in AA

The overall practice of AA entails the working of the Twelve Steps. Several of the activities associated with the working of the Twelve Steps have relevance to spirituality, and we discuss these activities in this section.

Among the foremost spiritual practices in AA are prayer and meditation. Step 11, for example, explicitly identifies prayer and meditation as a vehicle for improving conscious contact with one’s higher power. Steps 2, 3, and 5–7 all acknowledge and affirm the existence and power of a higher power and entail direct or indirect interaction with the higher power, which most frequently would be through prayer and meditation. In Step 5, an admission of one’s wrongs is made to the higher power, and in Step 7 the higher power is requested “to remove our shortcomings.”

Research has shown that prayer and meditation are practiced often by members of AA. In their development of the Brown–Peterson Recovery Progress Inventory, Brown and Peterson (1991) surveyed self-help group members on how they “work the program.” The 58 survey participants (43% male) had a mean age of 35.5 years and 3.13 years of sobriety. All reported belief in a higher power. In terms of prayer, 57% engaged in prayer upon rising, 74% before retiring, and 35% during the day. In terms of meditation, 45% practiced meditation, relaxation, or quiet time daily and 48% read from one or more meditation books.

It is anticipated that prayer and meditation will result in divine intervention for the individual. Often this divine intervention is viewed as a miracle, the ultimate miracle being sobriety. In Step 2, divine intervention is anticipated to restore health and sanity, and in Step 7, such intervention is sought to remove shortcomings.

A second spiritual practice in AA involves the identification of past and present wrongdoings and making a personal disclosure about such misdeeds “to God, to ourselves, and to another human being” (Steps 4, 5, and 10), along with the willingness and commitment to make amends for these (and any future) wrongdoings and misdeeds (Steps 8–10). As described by Tonigan et al. (1999), the activities associated with these steps should engender positive and mutually beneficial social relationships, based now on honesty, respect, trust, and the ability to acknowledge past misdeeds. Not surprisingly, these are the same qualities that ultimately characterize a personal relationship with one’s higher power.

The development of personal relationships is another important spiritual practice in AA. Such relationships could involve a number of components, including the expressing of feelings, talking honestly, admitting when one is wrong, treating others as one would like to be treated, forgiving others as quickly as possible, and listening to others even when not agreeing with them (Brown & Peterson, 1991). The “sharing of experiences” among AA members may be a particularly important aspect of those relationships, given research by Kingree (1997) that such sharing was significantly and positively related to commitment to AA.

A final spirituality-related practice in AA is service. As a starting point, the working of the Twelve Steps, and especially the working of relevant steps on a daily basis (traditionally Steps 1–3 and 10–12), sets the stage for two particular service contributions. The first contribution is to the unity and common welfare of the organization. According to Tradition 1 of AA, any member’s personal recovery is dependent on the unity within AA. When working the steps and pursuing and/or maintaining one’s personal recovery, the AA member is servicing the common welfare of the organization. A second contribution is the service provided to others by carrying the AA message “to the alcoholic who still suffers” (AA, 1981, p. 150). Taken together, as the AA member “conforms to the principles of recovery” and pledges “obedience to spiritual principles” (AA, 1981, both quotes p. 130), he or she is providing service to the organization and to others in need.

Subjective Experiences of Spirituality in AA

As noted earlier in this chapter, spirituality at minimum is complex and multidimensional. Not surprisingly, experiences of spirituality within AA similarly are complex and varied. Nevertheless, there are several subjective experiences of spirituality in AA that are experienced by many members, and we will present them in turn. These subjective experiences of spirituality are humility, serenity, gratitude, hope, and forgiveness.

Humility is a profoundly important concept in AA, above and beyond its relevance to the working of Step 7. According to the text of Twelve Steps and Twelve Traditions (AA, 1981), “the attainment of greater humility is the foundation principle of each of AA’s Twelve Steps. For without some degree of humility, no alcoholic can stay sober at all…. Without it, they cannot live to much useful purpose, or, in adversity, be able to summon the faith that can meet any emergency” (p. 70).

Among AA members, humility “amounts to a clear recognition of what and who we really are, followed by a sincere attempt to become what we could be. Therefore, our first practical move toward humility must consist of recognizing our deficiencies” (AA, 1981, p. 58). Among one’s greatest deficiencies as an alcoholic, according to the Big Book, is selfishness/self-centeredness. “So our troubles, we think, are basically of our own making. They arise out of ourselves, and the alcoholic is an extreme example of self-will run riot, though he usually doesn’t think so” (AA, 1976, p. 62).

Achieving humility in large part begins with a recognition of an all-knowing and powerful higher power. This recognition occurs in the process of working Steps 1 and 3, which highlight the powerlessness of the individual to overcome alcohol and the desirability of turning one’s life over to the care of a higher power. Humility is also developed in Steps 5–7, whereby the individual admits the nature of his/her misdeeds (following “a searching and fearless moral inventory”) and humbly requests that the higher power remove one’s deficits in character and other shortcomings. Relatedly, the practice of Step 10, reflecting an ongoing personal inventory and admitting any wrongs identified, represents an effort to maintain and reinforce humility.

Another core experience of spirituality in AA is serenity. The term serenity has been used in the broader psychological literature to reflect peace of mind or inner peace, often in the presence of difficult times. Writing specifically in the context of addictions, Bailey (1990) defined serenity as “feelings of tranquility, gratitude, contentment, affection for others, and a deep inner peace” (p. 1). Bailey (1990) highlighted serenity as “the cure for all addictions” (p. 1).

The importance of serenity in AA is reflected in part by its adoption of the Serenity Prayer, which is shown in Table 3. The Serenity Prayer was popularized in the United States by Reinhold Niebuhr, a twentieth-century theologian, and it has been used within AA since the 1940s. Although the term serenity is not formally defined in the AA literature, the text of the prayer includes coverage of a variety of AA elements and themes (Connors, Toscova, & Tonigan, 1999). These include acceptance, letting go of control over certain elements of life, developing trust in and surrendering to God’s will, discerning when to take appropriate action, accepting life on life’s terms, having a present-day orientation, and experiencing joy.

Table 3. The Serenity Prayer

Gratitude is a third subjective experience of spirituality in AA. From a religious–spiritual perspective, gratitude typically represents an awareness or recognition of God’s grace. Grace in this context can take the form of a gift or the provision of strength to address a difficult or pressing task. Sobriety is viewed by many AA members as a gift of divine intervention by a higher power, for which the AA member expresses gratitude on a regular if not daily basis. This gratitude is expressed in the continual working of the Twelve Steps and the daily living of a sober life and all that it represents.

A fourth subjective experience of spirituality is hope. Hope has a long-standing status as central and vital to healing and recovery. Yahne and Miller (1999) have outlined the ways in which hope may operate in service of recovery. For example, they note that hope for many individuals is will or willpower, as in the will to overcome and/or recover. According to Yahne and Miller (1999), other forms in which hope can contribute to healing and recovery are as a “wish” for a particular outcome and as a “horizon,” such that individuals look “down the road,” beyond their current difficulties.

There is another manner in which hope facilitates healing and recovery, and it has particular relevance to spirituality in AA. This aspect of hope is what Snyder (1994) has labeled wayfulness. It pertains in part to where people place or invest their hope, and in the context of AA hope is placed fully and unconditionally in one’s higher power. It is not possible to overemphasize this dimension of hope in AA and the manner in which it operates to engender the belief that a higher power can restore health and sanity and that one could turn over one’s will and life to the care of this higher power.

A last spiritual experience for many in AA is forgiveness. As discussed by Sanderson and Linehan (1999), “the spiritual practice of forgiveness…points a way out of destructive retribution and offers practical guidelines for effective reconnection with oneself and others” (p. 208). Forgiveness can be applicable in two senses—forgiveness of others and forgiveness of self. In the context of others, forgiveness permits a letting go of anger and the expression of understanding or compassion. Forgiveness of self is for many just as, if not more, relevant. The working of Step 5, in which there is the admission “to God, to ourselves, and to another human being the exact nature of our wrongs,” is the means through which AA members understand that they can be forgiven. According to the text of Twelve Steps and Twelve Traditions (AA, 1981), “Our moral inventory had persuaded us that all-round forgiveness was desirable, but it was only when we resolutely tackled Step Five that we inwardly knew we’d be able to receive forgiveness and give it, too” (p. 58, italics in original). Webb, Robinson, Brower, and Zucker (2006) have postulated, based on data gathered from patients in treatment and at follow-up, that forgiveness of self may be particularly difficult to achieve.

Spiritual Awakening

The Twelfth Step of AA reflects the expectation that the working and practicing of all of the steps will result in a spiritual awakening. After having had this awakening, however defined, AA members attempt to carry the AA message to other alcoholics and they more broadly apply the twelve-step principles throughout their lives. It is acknowledged that members’ definitions of a spiritual awakening may vary considerably from person to person. Nevertheless, there are important common threads. According to the Twelve Steps and Twelve Traditions (1981),

When a man or a woman has a spiritual awakening, the most important meaning of it is that he has now become able to do, feel, and believe that which he could not do before on his unaided strength and resources alone. He has been granted a gift which amounts to a new state of consciousness and being. He has been set on a path which tells him he is really going somewhere, that life is not a dead end, not something to be endured or mastered. In a very real sense he has been transformed, because he has laid hold of a source of strength which, in one way or another, he had hitherto denied himself. He finds himself in possession of a degree of honesty, tolerance, unselfishness, peace of mind, and love of which he had thought himself quite incapable. What he has received is a free gift, and yet usually, at least in some small part, he has made himself ready to receive it. (pp. 106–107)

In addition to being discussed in Alcoholics Anonymous (1976) and Twelve Steps and Twelve Traditions (1981), the nature of the spiritual awakening receives attention in an appendix to the Big Book. Much of the text of the appendix clarifies that while some individuals may experience spiritual awakenings that are “sudden and spectacular upheavals” (AA, 1976, p. 569), many do not. Indeed, most spiritual awakenings occur more gradually. It is noted that most such awakenings are similar to what William James called the “educational variety,” in that spiritual changes develop gradually over an often extended period of time. These clarifications were provided by the organization to counter any impression that spiritual awakenings should be or needed to be “sudden and spectacular.”

The importance of spiritual awakenings to the process of recovery in AA has been discussed in some detail by Forcehimes (2004), who highlighted spiritual awakening as “the true mechanism of change in AA” (p. 504). Forcehimes postulated a three-step process toward a spiritual transformation. The first step involves hitting bottom, when the individual faces the reality that he or she has lost all control over drinking. Hitting bottom is followed by a phase of contrition, which in turn is followed by surrender, reflecting in many ways what occurs in the working of Steps 1–3. Forcehimes identified several outcomes of spiritual transformations: a release from burden, the loss of a desire to drink, the provision of service to others, and inner peace.

Changes in Spirituality over the Course of Recovery

The past several decades have witnessed laments that there has been so little research on the role of spirituality in alcoholism, alcoholism treatment, and recovery (e.g., Galanter, 1999; Miller, 1990). However, this state of affairs is gradually changing, and progressively more research on spirituality and addictions is appearing in the scientific literature. We have benefited from this growing body of literature in developing this section on changes in spirituality over the course of treatment and/or involvement in AA.

Before surveying some of this literature, we should note that a review of the research on the relationship of AA participation (whether alone or in conjunction with formal treatment) to recovery is beyond the scope of this chapter. Nevertheless, it is worth stating, as a background context, that AA participation during or after treatment is positively associated with better recovery outcomes, including higher odds of abstinence (e.g., Tonigan, Connors, & Miller, 2003; Tonigan & Toscova, 1998). When AA involvement (as opposed to AA attendance) is the focus, this relationship is particularly strong (Horstmann & Tonigan, 2000; Montgomery, Miller, & Tonigan, 1995). Research also has shown that individuals who attend AA during or after professional treatment are more likely to describe improvements in drinking than those who do not (Emrick, Tonigan, Montgomery, & Little, 1993; Moos & Moos, 2005). A comparable indication emerges from a study by Humphreys, Moos, and Cohen (1997) using a general community sample of alcoholics. It was found that those who attended AA during the first year of follow-up showed greater improvement than those who did not. Furthermore, the number of AA meetings attended in the first 3 years was a significant predictor of improved status at an 8-year follow-up. Similar findings have been reported in a 16-year follow-up study of treated and untreated alcohol abusers (Moos & Moos, 2006).

These findings, considered in the context of a broader literature concerning AA-related outcomes, suggest strongly that AA involvement is associated with improvements in substance use outcomes. However, the nature of these changes and the mechanisms by which they are manifested have received much less attention. The relationship between AA involvement and specific changes in the domain of spirituality, along with the causal role spirituality may play, is only slowly being articulated.

AA Activities in Relation to Spirituality and Outcome

We noted earlier that greater involvement in AA is associated with superior outcomes. This raises the question of which AA activities account for such improvements. This issue was pursued in reviews by Emrick et al. (1993) and Tonigan and Toscova (1998). In the latter review, the relationship between 12 AA-related activities (reaches out for help, has an AA sponsor, works Step 1, leads a meeting, does twelve-step work, tells a story at a meeting, sponsors an AA member, works Steps 6–12, works Step 2, works Step 3, takes–retakes Step 4, and takes–retakes Step 5) and abstinence. Ten of the 12 activities (all except takes–retakes Step 4 and takes–retakes Step 5) were positively related to abstinence, indicating that many of the activities described in the Twelve Steps and in the AA core literature contribute to abstinence. The activities with the strongest relationship to abstinence were reaches out for help, has an AA sponsor, and works Step 1. Interestingly, working Steps 2 and 3, maintaining belief in a higher power and turning one’s life over to the higher power, were much less strongly related to abstinence. Related to this, Morgenstern, Labouvie, McCrady, Kahler, & Frey (1997) found that increased AA involvement predicted better outcomes among substance abusing patients and that these effects of AA affiliation were mediated by a set of common change factors (maintenance of self-efficacy, maintenance of motivation, and increased active coping efforts) (see also Bogenschutz, Tonigan, & Miller, 2006, and Connors, Tonigan, & Miller, 2001). More recently, Tonigan, Miller, and Connors (2000) found that increased engagement in AA-related practices and beliefs predicted significantly more abstinence and less intense drinking when drinking occurred. Finally, in another study related to step work, Carroll (1993) found that spirituality (operationalized as the extent of practice of Steps 11 and 12) was positively associated with length of sobriety and with perceived life purpose.

Another AA-related activity is helping behaviors, which have been systematically pursued in research by Kaskutas, Zemore, and their colleagues (e.g., Zemore, 2007; Zemore & Kaskutas, 2004). In this work it has been shown that greater helping in AA is associated with higher levels of spirituality (Zemore & Kaskutas, 2004). Relatedly, Pagano, Friend, Tonigan, and Stout (2004) have shown that individuals who engaged in helping behaviors in AA (operationalized as sponsorship or completing Step 12) were less likely to relapse in the year following alcoholism treatment, relative to those who had neither of these helping behaviors. These findings emerged independent of the number of AA meetings attended.

Taken together, it appears that many AA-related behaviors, several of which can be viewed as spiritual in nature, are related to varying degrees to recovery. Activities one might view as spiritual processes were not among the strongest predictors of abstinence, although it may be that spiritual activities may operate in important ways as a mediator, setting the stage for one’s continuation and subsequent maintenance of important AA behaviors (Tonigan & Toscova, 1998). This issue will be discussed later in this chapter.

Changes in Spirituality in Recovery

There have been indications in the past that spirituality-related dimensions change over the course of recovery. Brown and Peterson (1990), for example, surveyed AA members on factors associated with their recovery. They found a marked shift in “core values,” a shift that was described as a significant point in participants’ personal recovery. Brown and Peterson noted that AA members in recovery in particular highlighted the value of “inner harmony.” In a more recent project, Tonigan, Miller, and Connors (2001) found that meaning and purpose in life increased over the course of treatment, consistent with previous research (e.g., Waisberg & Porter, 1994). These indications are consistent, of course, with the Twelve Steps and their outlining of a plan for spiritual development and growth.

More recent research has begun to assess changes in spirituality in recovery along a broader array of dimensions. Research by Robinson, Cranford, Webb, and Brower (2007) is an excellent example. They assessed individuals as they entered outpatient alcohol treatment and again 6 months later, evaluating a range of behaviors, beliefs, and experiences associated with spirituality and religiosity. There were significant increases along half of the ten aspects of spirituality/religiosity assessed, and specifically for spiritual/religious practices, daily spiritual experiences, forgiveness, positive religious coping, and purpose in life. Significant decreases in alcohol use also were observed. Follow-up analyses revealed that the odds for “no heavy drinking at 6 months” were associated with increases in daily spiritual experiences and purpose in life. This finding was observed even after statistically controlling for involvement in AA and for gender.

Another recent study explored comparable dimensions of spirituality over the course of residential treatment and a 6-month posttreatment follow-up (Connors, Walitzer, & Giegel, 2003). In addition, a particular focus was placed on AA participation over these periods of time. Several noteworthy findings were reported. First, the patients reported significant increases (from pretreatment-to-treatment discharge) on the majority of the 13 dimensions of spirituality assessed (e.g., hope, forgiveness of others and self, existential and religious well-being, serenity, purpose in life). Second, engagement in AA practices during treatment was significantly related to pretreatment-to-treatment discharge change scores on several measures of spirituality (i.e., hope, forgiveness of others, religious practices, and serenity). Third, pretreatment-to-treatment discharge change scores on several measures of spirituality (i.e., forgiveness of others, religious practices, purpose in life, serenity, existential well-being) were significantly correlated with percent days abstinent during the 6-month follow-up period. Fourth, AA attendance during the first 3 months following treatment discharge was significantly related to 6-month scores on a variety of dimensions of spirituality (e.g., forgiveness of others, serenity, existential and religious well-being, purpose in life). Taken together, these findings indicate that patients in residential treatment report significant increases along a range of dimensions related to spirituality; that AA practices during treatment are associated with increases along a range of dimensions related to spirituality; that increases along certain dimensions of spirituality (forgiveness of others, religious practices, life purpose, serenity, and existential well-being) are related to abstinence at 6-month follow-up; and that AA attendance immediately (first 3 months) following treatment is associated with month 6 reports on measures of spirituality.

A final dimension of spirituality, if not the overarching dimension according to the AA core literature, is spiritual awakening. Of course, whether and to what degree one may have experienced a spiritual awakening is highly subjective. In a study on this issue, Tonigan (2007) reported that one in five individuals (20%) who participate in AA and who engage in step work report having a spiritual awakening. In another report, Piedmont (2004) found that experiences of spiritual transcendence among substance abusers in treatment increased from the beginning of treatment to an 8-week follow-up assessment. Furthermore, Kaskutas, Turk, Bond, and Weisner (2003) found that patients who reported the experiencing of a spiritual awakening as a result of the AA participation were almost four times more likely to be abstinent at a 3-year follow-up relative to patients who did not experience a spiritual awakening. However, Tonigan (2007) highlights an important caution in the interpretation of spiritual awakenings. In this regard, he notes that most individuals already report a belief in God before initiating AA participation, raising the question of whether individuals might be experiencing multiple “re-awakenings” over time.

An important issue that warrants attention is the interplay of changes in spirituality and changes in drinking during recovery. Not clearly specified to date is whether changes in spirituality precede changes in drinking, if changes in drinking precede changes in spirituality, or if they operate in concert with each other. The data reviewed above would suggest that changes in spirituality are related to changes in drinking, although perhaps only modestly. However, they do not establish the precise causal relationships between spirituality, AA involvement, and recovery. It is anticipated that continuing research in this arena will provide better insights into these relationships. For example, Zemore (2007) recently conducted a mediational analysis specifically testing the hypothesis that spiritual change helps to explain the effects of self-help group involvement on recovery outcomes. The study included individuals receiving treatment for chemical dependency. Results showed that, as expected, increases in self-help group involvement from baseline to follow-up predicted higher odds of total abstinence at the 1-year follow-up and that this relationship was partially explained by increases in measures of spirituality. Thus, emerging evidence seems to be supporting a causal role for spiritual change in the efficacy of self-help groups.

Another important issue warranting mention is consideration of outcomes beyond drinking behavior. It will be of interest to determine how changes in spirituality are related to other domains of life functioning, including psychological and physical health, marital and family relationships, friendships, and vocational pursuits.

A final issue concerns direct versus indirect effects of spirituality. Most research has focused on potential direct effects of spirituality on achieving and maintaining abstinence. As noted by Tonigan (2007) and also earlier in this chapter, this relationship appears to be modest, at least based on the research available to date. In discussing this matter, Tonigan (2007) highlighted the possibility that spirituality and/or spiritual practices facilitate or produce behaviors that in turn account for achieved abstinence. In such a scenario, spirituality would be serving as an indirect effect. As an example, Tonigan (2003) studied the indirect effects of spirituality in AA-related activities over time. He found that AA practices assessed 3 years after treatment were positively associated with spirituality, which predicted sustained AA practices assessed 10 years after treatment, which in turn were predictive of abstinence at that point in time. This finding suggests the benefit of spirituality as reflected in its contribution to the maintenance of AA practices over time.

Conclusions

Spiritual growth and development are a central focus of AA. Indeed, AA has been described as providing a spiritual path to recovery. This chapter has described a variety of topics pertaining to spirituality and AA, including core spiritual beliefs, AA practices relevant to spirituality, and subjective experiences of spirituality in AA. A growing body of literature has been addressing the interplay of changes in spirituality, changes in drinking, and AA involvement. Research to date indicates a positive relationship between AA-related activities and abstinence and that dimensions of spirituality (e.g., inner harmony, life meaning) change over the course of recovery. Increases on these and other dimensions of spirituality appear to coincide with abstinence and/or decreases in drinking. Further research in this area will be advancing our understanding of the interplay of changes in spirituality and changes in drinking over time, whether changes in spirituality are related to improvements in other areas of life functioning, and the direct versus indirect effects of spirituality on achieving and maintaining sobriety.