Southern Medical Journal:
Special Section: Spirituality/Medicine Interface Project
Alcohol Recovery and Spirituality: Strangers, Friends, or Partners?
Brown, Anthony E. MD, MPH; Whitney, Simon N. MD, JD; Schneider, Max A. MD; Vega, Charles P. MD
From the Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, the Departments of Psychiatry (Addiction Medicine) and Family Medicine, University of California Irvine College of Medicine, Orange, CA.
Reprint requests to Anthony E. Brown, MD, Baylor College of Medicine, Department of Family and Community Medicine, 3701 Kirby Drive, Suite 600, Houston, Texas 77098. Email: firstname.lastname@example.org
Abstract: Alcoholics Anonymous, with its steady but nonspecific promotion of belief in a higher power and its emphasis on the group process, long held a near-monopoly in the outpatient alcohol recovery field, but its hegemony has now been challenged by two very different perspectives. The first is a nonspiritual approach that emphasizes the individual’s capability to find a personal pathway to sobriety, exemplified by Rational Recovery. The second is a faith-based method, built on a religious understanding of alcoholism, of which Celebrate Recovery is a prominent example, based upon Christianity. Most communities offer a variety of approaches, so clinicians who are aware of these differences are in a good position to help patients make intelligent choices among the competing recovery philosophies.
* Awareness of outpatient self-help alcohol recovery program options can help clinicians identify the most suitable method for a particular patient, based on their preferences, regarding inclusion of spiritual beliefs in recovery.
* Alcoholics Anonymous achieves recovery through belief in a higher power that each individual may translate into his or her own belief system.
* Nonspiritual approaches emphasize the individual’s capability to find a personal pathway to sobriety, exemplified by Rational Recovery.
* Faith-based methods are built on a religious understanding of alcoholism and alcohol recovery, and Celebrate Recovery is a prominent example of one based on Christianity.
Alcoholics Anonymous (AA) is widely accepted as a model for alcohol treatment. However, the emphasis of the AA program on the importance of a higher power in recovery from alcoholism has led to controversy and a proliferation of programs with competing ideologies with regard to religion and spirituality. The philosophical spectrum of self-help programs now includes, in addition to AA, approaches that are nonspiritual, as well as others that are rooted in a specific religious tradition. Clinicians can help patients identify a treatment program that matches the patient’s preferences with regard to religion and spirituality as part of the recovery program.
Spirituality Versus Religiosity
Spirituality is a broader term than religiosity, as a person can be spiritual but not religious (Table 1). Religion is defined as an organized practice of a belief in a power greater than oneself.1,2 Religiosity is the extent to which an individual engages in the rituals of this commitment. Some people are spiritual but not religious; they may express their personal spiritual concept of a higher power through nature, music, art, or a quest for scientific truth, instead of through a specific religion.3,4
A Spiritual Approach
Spiritual alcohol recovery movements aim to provide relief from disease as a complement to traditional medicine, and attribute their success to transcendent sources.5,6 The most well-known spiritual approach to alcohol recovery is AA. Two former alcoholics, Bill W., a New York stockbroker, and Dr. Bob, a surgeon, established AA in 1935 in Akron, Ohio.7 Bill W. and AA published the Big Book in 1939 and the Twelve Steps and Twelve Traditions in 1952. AA has now grown to over 50,000 groups and 1,000,000 members.7
The philosophy of AA is belief in divine intervention and reliance on a higher power to maintain sobriety. AA is a spiritual program but not a religious one because its members define “God as they understand Him.”8,9 Members are encouraged to develop an individual relationship with their higher power.2 Since Twelve Step programs do not require participants to accept an exclusive definition of a deity, it is adaptable to different cultures and faiths.10 God and the higher power are open to individual interpretation regardless of religious background.11
During Twelve Step recovery, AA members build healthy relationships with others and with themselves through prayer, meditation, and group discussion (Table 2).12 Of note, seven of the steps refer to God, a higher power, or spirituality. Addiction is viewed as a negative form of spirituality where alcohol is the higher power. For many in recovery, the Twelve Step program fosters a new identity when they surrender to their higher power as a source of strength. Members admit wrongdoings and trust in their higher power to repair their character flaws. This approach encourages mutual dependence on the AA group and frequent meeting attendance to maintain sobriety through an awareness of the continued presence of alcohol abuse tendencies.8 A study of 100 alcoholics found that the practice of Step Eleven’s prayer and meditation had a positive correlation with increased purpose in life and length of sobriety.13 The continuance of the program aims to convert guilt over alcohol abuse into a desire to help other alcoholics.8
In recent years, two competing schools of thought have challenged the AA approach. The first, exemplified by Rational Recovery, argues that AAs spirituality, far from being a cornerstone of sobriety, should be excluded from the recovery program. The second, in contrast, moves beyond AAs generic spirituality to promote a recovery method that relies on a specific religious belief system.
A Nonspiritual Approach
Critics of the spirituality embedded in AA and similar programs argue that this encourages an individual to become dependent on something outside of themselves to remain sober and that this external dependence creates a state of hopelessness.14 Some addiction medicine specialists are skeptical of the therapeutic value of spirituality and associate it with traditional organized religion, something that they believe should be kept separate from recovery programs.10,11,15 A variety of organizations such as Rational Recovery, Self Management and Recovery Training (SMART Recovery), Secular Organization for Sobriety, Women for Sobriety, and Moderation Management promote a nonspiritual approach to self-help recovery.14,16–20
Although a paucity of evidence is available to evaluate their efficacy, the few studies on Rational Recovery (RR) allow it to be a good example of this type of approach. In 1988, Jack Trimpey published The Small Book and established Rational Recovery (RR) based on Rational Emotive Therapy by Albert Ellis.16,21 RR expresses concern that addicted individuals are not able to connect with a higher power other than their addiction and does not support redefining the patients’ spirituality during the recovery process.22 Rather than attributing a lack of control or spiritual deficit to alcoholism, RR promotes the innate capability of the individual to devise a rational personal pathway to sobriety.16 The program does not utilize a specific multistage guideline, but rather, emphasizes an internet-based individualized sobriety program without groups.22 When an employer or a court requires structured alcohol recovery, RR argues that the individual should be able to choose the approach he or she finds most promising.2,16 A study examining the beliefs of 429 RR members showed that 75% attended an AA meeting previously, indicating that patients may experiment with more than one self-help treatment modality. Not surprisingly, RR members were less likely to emphasize the role of religion in their personal life than other Americans. In this sample of RR members, 53% believed in “God or a Universal Spirit” and 13% felt that religion was “very important” to them. A Gallup Poll of the general American public about the same time showed that 94% believed in “God or a Universal Spirit” and 55% felt that religion was “very important” to them.16 Patients who are less spiritual in general may therefore be more likely to be comfortable in a nonspiritual recovery program.
A Religious Approach
In contrast with the nonspiritual approach rejecting AAs emphasis on a higher power, other recovery movements promote a strong connection within a specific religious perspective. The faith-based approach is supported by studies of the role of spirituality in addiction. Since the majority of adult alcohol use begins before age 21, it is relevant that spiritual involvement is associated with a lower incidence of substance use in adolescents.23 In addition, a study of 100 male twins found that high levels of spirituality were negatively associated with alcohol abuse.24 Prior spiritual experiences can have significant influence on recovery. Seventy-five percent of AA members report a prior religious affiliation and about half claim to have strong spiritual beliefs. Sixteen percent of participants report reading the Bible and 24% pray regularly.25,26 Positive prior religious experiences allow those in recovery to frame their higher power according to the tenets of their faith.8 Many members say their spirituality increased through their participation in a Twelve Step program.25,27 Those who accept the spiritual paradigm have more frequent AA attendance, associated with lower relapse rates.28 Those that are best described as spiritual without a designated religion should be comfortable in AA. However, a significant number of people with a religious background will desire to pursue recovery within the beliefs of their religion and may prefer an explicitly faith-based approach.
For the religious individual, the best means to determine if supportive resources are available within their current belief system is through their local church, temple, synagogue, gurdwara, mosque, or other place of religious worship. For those of a Christian background, a variety of websites provide information on recovery programs such as Celebrate Recovery, Alcoholics Victorious, Alcoholics Recovery, and Overcomers Outreach.29 The growing Celebrate Recovery program exemplifies the faith-based approach. It was developed in 1990 through Saddleback Church in California by Pastor Rick Warren, author of The Purpose Driven Life, in response to AAs “vagueness about the nature of God.”30 This self-help group utilizes “8 Recovery Principles” (Table 3), using the Bible to define a Christian concept of the higher power. Celebrate Recovery incorporates weekly meetings, group self-help discussion, and individual sponsors. The group leaders are not counselors and do not provide professional clinical advice. The program emphasizes personal responsibility and religious commitment and has spread to over 800 churches from a variety of Christian denominations in several countries.30
Clinicians can now recommend one of three distinctly different types of alcohol recovery programs — nonspiritual, spiritual but not religious, and religious. AA groups are widely available, Celebrate Recovery groups are spreading rapidly, and Rational Recovery is open to anyone with access to the internet at home or in a library. The debate over the proper role of spirituality and religion in alcohol recovery seems likely to continue indefinitely, but for a specific patient who needs guidance in choosing a recovery program, a short discussion of his or her spiritual beliefs and attitudes should make it clear which program is most suitable. AAs spiritual approach can accommodate a variety of personal beliefs within its members. Rational Recovery is representative of a philosophy that can probably better meet the needs of those patients who wish to keep their personal beliefs outside of the structured recovery process or who consider themselves nonspiritual. Finally, Celebrate Recovery is an example of a recovery program geared for patients who identify the Christian religion as a significant part of their personal belief structure and wish to join a group that will build on that foundation. All three of these recovery programs have had success in promoting sobriety and each is appropriate for some patients.
All individuals involved in preparation of the manuscript are listed as authors.
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