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The 12 Steps: Building the evidence base

May 1, 2009
by Valerie Slaymaker, PhD
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The latest research initiatives seek insight into how spirituality affects recovery

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

Valerie Slaymaker, PhD


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

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

Research findings to date

Among treatment seekers, lower levels of spiritual well-being have been observed among those with higher alcohol use severity9, suggesting that an inverse relationship exists. Furthermore, spirituality levels have been shown to increase during the course of treatment for alcohol and drug dependence.

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

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

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

Taking research to the next level

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

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