Spirituality and recovery

Martin Nicolaus notices a not yet published study on the impact of spiritual guidance as part of treatment. There was no impact. In fact, the group with spiritual guidance by certified spiritual directors had worse outcomes on measures of depression and anxiety, though a group receiving spiritual guidance from their counselor did just as well as the other groups.

What's especially interesting about this study is that Bill Miller, the lead author, is very friendly to spirituality as an tool for facilitating change. He seems stumped but isn't questioning the study itself.

There is reason for confidence in the findings of this study. Outcome variables were carefully measured by independent interviewers, fidelity of interventions was good, and 82% of all possible follow-up interviews were completed. The studies were powered to detect a medium between-group effect size that would be sufficiently large to be of clinical interest ([Cohen, 1988] and Miller and Manuel (in press) Miller, W. R., and Manuel, J. K. (in press). How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review.Miller and Manuel (in press)). Null findings were replicated across two study designs, and the direction of differences was, in many cases, opposite to prediction. We thus found no evidence for a beneficial effect of this spiritual counseling approach during the acute phase of addiction treatment. Different and more intensive spiritual counseling might increase daily spiritual practices, spiritual experience, and meaning and thereby influence substance use outcomes. Given the magnitude of changes that occur in early recovery, however, we believe that a more promising approach is to focus on spiritual development after a period of stabilization in which other basic needs have been addressed. Within a long-term care perspective, spiritual direction may fit better in later recovery, with a goal of maintaining and broadening the initial gains of sobriety.

It would be interesting to see more research on spirituality and recovery. I'm inclined to believe that spirituality can be a useful therapeutic tool. If nothing else, for people when enter treatment with spiritual beliefs, it might be used to increase engagement and participation in treatment. It might also be used as a long term source of support for change. (We do value a holistic approach, right?)

Along the lines of a stage dependent model, as Miller suggests, Project SAFE reported that many of the African American women in the study initiated their recovery in 12 step groups and sustained their recovery in churches.

The study said nothing of the participants' predisposition to spirituality. That seems important to me.

Other questions that might be interesting include:

• What forms of spirituality are helpful or unhelpful? Some clearly emphasize a stronger internal locus of control while others emphasize an external locus of control.
  
• Can helpful elements of the helpful forms of spirituality be unbundled?
• What are the non-spiritual paths to those helpful elements?
• There is a persistent assumption that all clients will benefit from spirituality. Is this true? Are these some who might benefit, others who are unaffected and some whose treatment outcomes are harmed?
• Along the lines of Miller's thinking, to what degree are these responses stage dependent?
  

DF employees - let me know if you want a copy of the study.

Helping other alcoholics in alcoholics anonymous and drinking outcomes

This isn't a new article, but seemed worth sharing. Researchers demonstrate what mutual aid groups have known for decades. Helping other alcoholics helps the helper stay sober.

OBJECTIVE: Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. METHOD: Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. RESULTS: There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. CONCLUSIONS: These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober.

It would be interesting to look at two more things:

• If these finding hold up in other mutual aid groups. I suspect they would.
• We know that mutual aid group involvement is a better predictor of recovery than attendance. 12 step work is frequently identified as an indicator of involvement. It would be interesting to see if the benefits of helping are are different or more powerful than other forms of mutual aid group involvement.
  

Technorati tags: recovery, alcoholism, aa, mutual_aid, research, addiction

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More on radical recovery

I got some strong responses to Radical Recovery and thought you might want some more on the subject. Here are two more articles on the tension between 12 step recovery's focus on self-change and social activism.

• Radicalizing Recovery: Addiction, Spirituality, And Politics
• Needed: a radical recovery
  

Radical Recovery

For MLK day, here's an article by Bill White on "radical recovery." He describes a convergence of social activism and addiction recovery.

The article offers a model that goes well beyond the the interests of recovering people themselves and encourages advocacy in larger community contexts:

A radical recovery movement is now rising in America. That movement is flowing from the realization that addiction and its progeny of problems are visible everywhere, while recovery from addiction lies hidden. It is rising in the recognition that the stigma attached to AOD problems has increased in recent decades and has fueled the demedicalization and recriminalization of these problems. What started out as “zero tolerance” for drugs rapidly evolved into zero tolerance for people with AOD problems. It is in this regressive climate that a style of recovery is emerging that is radical in its scope (focus on environmental as well as personal transformation), radical in its inclusiveness (celebration of multiple pathways and styles of recovery), and radical in its synthesis of social responsibility and personal accountability. People in recovery are looking beyond their own addiction and recovery experiences to the broader social conditions within which AOD problems arise and are sustained. A radicalized vanguard of people in recovery is using personal transformation as a fulcrum for social change. They are living Gandhi’s challenge to become the change they wish to see in the world. Those who were once part of the problem are becoming part of the solution.

Recovery: The bridge to integration?

Bill White and Larry Davidson suggest that shifts toward recovery orientation models in mental health and addiction services could serve as a bridge toward integration:

“Recovery-oriented system transformation” is becoming an umbrella concept for integrating behavioral healthcare and creating systems of care that are culturally competent, trauma-informed, evidence-based, inclusive of families, based on strengths, and connected to communities (as indigenous sources of recovery support). Leading the call for such system transformation are new recovery advocacy movements in both the addictions and mental health fields. These movements, led by people in recovery, their families, and visionary professionals, are demanding that care be focused on the processes of long-term recovery and anchored within natural supports and local communities.

Theoretically, I don't disagree at all. My fear is that this process will not be a merger between equals, my experience (admittedly limited to southeastern Michigan) is of watching mental health systems devour addiction treatment systems. This fear is compounded by the fact that, at least in our region, mental health agencies are well-organized and well-connected governmental behemoths while addiction treatment programs are small, unstable and diffused.

Consider these historical reflections from some of Bill's other works:

The Segregation/Integration Pendulum
American history is replete with failed efforts to integrate the care of alcoholics and addicts into other helping systems. These failed experiments are followed by efforts to move such care into a categorically segregated system that, once achieved, is followed with renewed proposals for service integration. After fighting 40 years to be born as an autonomous field of service, addiction treatment is once again in the throes of service-integration mania. This cynical evolution in the organization of addiction treatment services seems to be part of two broader pendulum swings in the broader culture, between specialization and generalization and between centralization and decentralization. Once we have destroyed most of the categorically segregated addiction treatment institutions in America, a grassroots movement will likely arise again to recreate them. When the 21^st century once again gives birth to specialized addiction treatment, perhaps this “new” institution will be given a colorful name fitted to its form and function – perhaps something like inebriate asylum.

Diffusion and Diversion
Diffusion and diversion constitute two of the most pervasive threats in the history of addiction treatment institutions and mutual-aid societies. Diffusion is the dissipation of an organization’s core values and identity, most often as a result of rapid expansion and diversification. Diffusion creates a porous organization (or field) that is vulnerable to corruption and consumption by people and institutions in its operating environment. Diversion occurs when an organization follows what appears to be an opportunity, only to discover in retrospect that this venture propelled the organization away from its primary mission.

The current absorption of addiction treatment into the broader identity of behavioral health is an example of a diffusion process that might replicate two earlier periods – the absorption of inebriate asylums into insane asylums and the integration of alcoholism and drug-abuse counseling into community mental health centers in the 1960s. This diffusion-by-integration has generally led to two undesirable consequences: 1) the erosion of core addiction treatment technologies; and 2) the diversion of financial and human resources earmarked to support addiction treatment into other problem arenas.

A Panicked Field In Search of Its Soul and Its Future
In the face of such threats (managed care, facility closures, merger mania & integration into behavioral health systems), the field is experiencing a strange phenomenon. As the core of the addiction treatment field shrinks, the field is growing at the periphery. Where the total amount allocated to residential and inpatient treatment services is shrinking, the numbers of outpatient services is actually increasing, as is a growing number of new specialty programs that extend addiction treatment services into allied fields. The growth zone of the addiction treatment industry is not at the traditional core but in the delivery of addiction treatment services into the criminal justice system, the public health system (particularly AIDS related projects), the child welfare system, the mental health system, and the public-welfare system. If one looks at these trends as a whole, what is emerging in the 1990s is a treatment system less focused on the goal of long-term personal recovery than on social control of the addict. The goal of this evolving system is moving from a focus on the personal outcome of treatment to an assurance that the alcoholic and addict will not bother us and will cost us as little as possible.

The fate of the field will be determined by its ability to redefine its niche in an increasingly turbulent health-care and social-service ecosystem. That fate will also be dictated by more fundamental issues – the ability of the field to: 1) reconnect with the passion for service out of which it was born; 2) re-center itself clinically and ethically; 3) forge new service technologies in response to new knowledge and the changing characteristics of clients, families, and communities; and 4) the ability of the field to address the problem of leadership development and succession.