The Role of Connectedness in Relation to Spirituality and Religion in a Twelve-Step Model

The pervasive nature of substance abuse in the United States dictates that much of the research dollars and time is spent on clinical trials that measure anxiety reduction, medication management and the employing of behavioral models that stress gradual change. While these approaches use controls that can be studied and measured in the empirical sense, they often lack the important personal connections with the research participants. As these trials show less than hoped for efficacy, a new body of research is surfacing including spirituality, along with social supports as ways to aid recovery and reduce relapse. Many 12-step groups incorporate spirituality, as opposed to religion as a mainstay of an individual’s recovery effort. Spirituality is regularly mentioned across most twelve-step programs as an essential part of sustained and ongoing recovery. Practical definitions of spirituality have eluded researchers in part because they struggle to separate it from religion. While it may not be impossible to measure spirituality in an empirical sense, it may be possible to clarify what role spirituality plays in aiding sustained recovery and prevention of relapse into drug using behavior. We will suggest connectedness as an integral component in defining spirituality and demonstrate that in twelve-step recovery spirituality can be defined as gaining knowledge through connectedness to others.


Introduction
Those seeking recovery from alcohol and drugs are often encouraged to expand their spiritual life as a catalyst against relapse.Investigators have tried for decades to define spirituality in a way that can be agreed upon, yet most research papers define religion and spirituality in ways that completely cloud their separate meaning.Holleran-Steiker and Pape (2007) brought some clarity to the vast differences in these terms.Brown (2007) shed light on the need for accuracy in research and for a usable definition of spirituality exclusive of religion.Twelve-step groups embrace the view that their programs are spiritual and not religious-they are keenly aware of the disastrous outcomes of well-meaning proponents of abstinence that included religion to their own demise.Twelve-step members emphasize living by spiritual principles that encourage freedom from mood or mind altering substances.
Over several generations various methods to eradicate substance abuse have come and gone.United States history is wrought with examples at multiple attempts to reduce alcohol consumption.In fact the 18 th amendment to the constitution sought to eliminate the "manufacture, sale or transportation of intoxicating liquors."It could be reasonably argued that the purpose of this law was an attempt to control the epidemic nature of the alcohol related problems of that era.This act provided for the first large scale underground production of consumable alcohol.Private backyard distilleries popped up in many parts of the country and by 1933 the 18 th amendment prohibiting alcohol sales had been repealed.In the history of the United States this amendment has been the only one to have been reversed.In many parts of the country today, the same argument is being made for cannabis.Mexico in August 2009 legalized virtually all consumable drugs with the caveat that the amount within ones possession should be no more than would be considered for personal use.The inability of governments to control consumption is obvious.Stresses of daily living and the desire to escape ones present reality create unintentional addictions that even include prescribed medications.The research approaches have been effective to a small degree yet it seems that as inpatient treatment programs are eliminated more pressure is being placed on investigators to find a workable solutions addressing addiction.Heinz, Epstein, Kenzie and Preston (2007) concentrated on the efficacy of religion and or spirituality in positive outcomes in substance abuse treatment.They defined spirituality as: "a universal dimension of human experience arising in three ways, inner subjective awareness, relationships with others of a community and/or a relationship with something that is transcendent and beyond the self" (p.41).As one will see in this article, connectedness is presented as a theme that repeats itself continuously and becomes a repetitive thesis in describing spirituality.Efforts spanning several decades attempting to define spirituality are infinite, and include requests for researchers and academics to find a workable definition (Gallanter, Grodzicki 2005, Chen 2006, Bubnack 2007, Stewart, Koeske;Pringle 2007) that does not incorporate religion.
In discussing spirituality, certain terms are found regularly within the research literature.Connectedness to self, others and our environment appears (Dilorenzo, Johnson and Bussy 2001, Chen 2006, Holleran-Steiker 2007) in much of the literature that has been produced over the last decade.Researchers vary on their definitions of spirituality but are gradually embracing attempts at defining it (Chen 2006).Phrases such as inner strength, sense of awareness, inner core, unifying force, at one with one's environment, harmony with self, relatedness to others appeared in vast amounts of literature under review.(Bliss 2007) reported evidence that individuals who abuse alcohol may actually be seeking a spiritual experience, thus pointing to a possible association (Miller, Forcehimes, Campbell and Smith 2009) between alcohol use, alcoholism and spirituality.We propose that researchers look not toward abstinence as a marker for efficacy in substance abusing individuals but rather the presence or absence of connectedness as a variable of measurement.Holleran-Steiker (2007) in interviewing Patricia Pape at the ICAA Congress on Alcohol, Drugs and Other Dependencies in Venice Italy in November 2004 asked about spirituality, Pape suggested that the word spiritual has two major sources, "One is the Hebrew root, which is breath or wind" (p.118).Her comment points to breathe or one's breathing not a religious act, but rather automatic, without thought, rules, oaths or pledges.She continues, "This reference is to the spirit of God, which is not contained or limited, and gives life or breath to human beings" (p.118).A western point of view is influenced by the idea that if one believes in God they must be religious.She went on to note that the second root of the term for spiritual comes from the Greek word "psyche", which is also a major tenet of Jungian psychodynamic theory.In the Greek, according to Pape, the word spiritual gives reference to "the immortal soul, which for the Greeks means the true essence or the most real part of the human being" (p.118).If we follow Bubnack (2007) in his quest to define spirituality he utilizes the historical contexts, or roots of the word as a pathway to meaning.He noted that the word "spirit" was a referenced from the Latin word "spiritus" which in turn was derived from the word the Greek root "pneuma," which derived from the Hebrew word "rauch" (p.129).A scan of various dictionaries, encyclopedias and online search tools describe spirit or spirituality in terms such as energy, incorporeal, intangible, souls, wind, breeze; independent and opposed to matter.Miller, Forcehimes, Oleary and LaNoue (2008) sought to unearth the success of spirituality as an essential critical criterion in promoting successful treatment outcomes.Their ultimate conclusion was that in using a Spiritual Guidance (SG) intervention tool, there essentially "was no measurable difference between the (SG) and Treatment As Usual (TAU) protocols" (p.439).This may point to the immeasurable therapeutic value of the spiritual connectedness between members of twelve-step and other groups and a measurable disconnect often present in research trials.Additionally this finding may point not so much to the ineffective aspect of spirituality in treatment outcomes as to the unproductive nature of the (SG).Heinz et al. (2007) suggested that there has been little scientific research on the correlations between positive treatment outcomes and spirituality.This does not mean there is no connection, but rather not enough research exists to make a significant association.Heinz et al. (2007) did note that at the very least, spirituality contained or is concerned with interconnectedness within an individual that allows them to transcend some of their existential concerns.

Essential of Spirituality on Treat Outcomes
Critics of twelve-step programs believe, because of the unscientific approach utilized in helping alcoholics and addicts, that there must be a better way to improve treatment outcomes.Cognitive Behavioral Therapy, stiffer prison sentences and individual psychotherapy are certainly useful, but participants that attend twelve-step meetings believe there is benefit for anyone who has the desire to break their addiction.Therapy, prison and individual counseling all cost money, and in light of the fact that many insurance policies won't cover addiction counseling, the free nature and spiritual foundations of twelve-step recovery programs will continue to be recommended as a treatment option.On spirituality, Steifel and Servaty-Seib, (2009) noted that "involvement in AA/NA principles and its tenets would be positively related spirituality, which in turn would be negatively associated with painful grief reactions and positively associated with personal growth" (p.4)This statement suggests that their research revealed a correlation between the level of grief reactions and involvement with the spiritual aspects of twelve step groups.It should be re-emphasized that spirituality in self-help groups is strongly encouraged but not a mandatory precept for inclusion in their groups.Spirituality may appear less threatening in self help groups in part because each individual member decides what spirituality means to them.
For the substance abusing individual failure to adhere to their religious teachings can in some cases cause distress.In trying to embrace ones religion, the inability to take control of their lives may drive them, because of private shame or public guilt to delve more deeply into their using.Many chemical dependency counselors are aware of the private shame substance abusers feel and often relate that there is a component of disgrace that is often covered up by bravado.In many cases for the dependent individual their faith in God is tempered with guilt for their perceived sins of weakness.It is not that they do not have faith in God but rather in themselves.The hopelessness that accompanies these feelings often goes untreated by clergy.Twelve-step members are well acquainted with these feelings and often report that it contributed to their shame, thus increasing their using.If depression sets in, they are often counseled by the church leaders to confess their sins and repent.While admission of shortcomings is believed to have therapeutic value, by itself many alcoholics and addicts soon return to their past behavior.

Spirituality and Academia
Western academics and researchers are required as a part of their training to view spiritual beliefs in research as unscientific, with skepticism and even cynicism; they may very well being missing the most important aspects of spirituality.Moreover western thought toward spirituality might be handicapped by its superior, privileged, postmodern culture.If we consider that we may already understand spirituality but in trying to precisely define it, are actually tripping on the very information that will help us we may realize that we are looking in all the wrong places.Scientists for example will tell us that a neuron's ability to respond to stimuli determines whether or not it can be energized.As nerve impulses in neurons are activated by stimuli so spirituality may be motivated by connected experience.Scientists refer to the neural activity as "excitability," thus stimulating or changing the electrical charge inside the neuron such that chemicals can be transported to the target cell.If the neuron cannot respond to stimuli as the result of being inhibited by neurotransmitters, medication or chemical abuse then the "excitability" aspect is lost.Is it possible that spirituality is expressed in the same way?Belzen (2009) suggested that the field of psychology has no responsibility to define spirituality anymore than they would other domains.This view is understandable in light of the lack of substance abuse training in the field of psychology.Jung believed with astonishment that we use the word spirit to define desired religious experiences while also using the Latin form spiritus to describe a terrible toxin, alcohol.Thus evoking the linguistic irony of Jung's oft sighted spiritus contra spritum (Finlay 2000).To remove working psychotherapists input on research matters is akin to ignoring patients' concerns regarding misdiagnosis.
Further culture is often a non-factor in research trials in part because of the historical treatment of marginalized groups or the lack of outreach keeping them from participating at all.Many marginalized ethnic or sexually oriented individuals are skeptical of the motives of researchers who may be viewed as seeking a guinea-pig by entering these communities with specific intent, never to be heard again from until the next trial.This disconnect can also impact substance abusing and recovering individuals insomuch their built in propensity for resistance toward organizations than report to the mainstream.Gay, lesbian and transgendered individuals may resist entering trials because of what they view as a Euro-American male hetero-normative way of thinking.Those whose first language is not English may find difficulty in understanding standardized assessment tools that are often written by medical professionals that are culturally unaware.
Religious institutions also have a mixed success rate in dealing with marginalized groups.African American males for example have multigenerational connections to the church.While much progress is being made through outreach to non-heterosexual individuals, gay black men often feel ostracized and unaccepted within the congregation and often the communities.Adding to the unfair treatment, if gay black men happen to be substance abusers they very likely may be pushed further into their addiction and become even more leery of straight substance abuse counselors or licensed professional social workers.Yet within the twelve-step recovery model race, gender, creed and sexual orientation are non-factors toward inclusion within the recovery process.
Most twelve-step groups such as Narcotics Anonymous, Cocaine Anonymous, Al-Anon and Alcoholics Anonymous offer meetings not only to meet the needs of non-English speaking populations but also for those seeking recovery with others in their sexual orientation.
Investigators may need to reboot their entire grant proposal focus when seeking to define spirituality.Monies will certainly be withheld from further research if regurgitation of status quos doesn't change.Helminiak (2006) in effect called out researchers and academics to move out of the traditional methods of defining spirituality toward a better version than we currently use.Chamiec-Case (2008) reminds us that because of the large variation in attempts to define spirituality there does not exist a standard assessment tool for the use of clinicians.The reader may be under the impression that I am anti-religion and pro spirituality.The point that religion is and has been clearly defined is not a question for this paper.Religion is solidly a part of virtually every major cultural group on the planet.Spirituality on the other hand is at best regional.Trying to organize spirituality as humans have done with religion will truly make it them one in the same.Spirituality as a term does not eliminate good and bad, sinful or saintly.Likewise labeling individuals as spirituals does not guarantee benevolent motives.Warfield and Goldstein (1996) attempted to make clear that there can be negative types of spirituality.They proposed that in substance abusing individuals "negative spirituality underlies and sustains alcoholism" (p.1).
Solution Focused and Client-Centered therapists employ flexibility in their clinical approach.One factor is emphasis that the patients' views of themselves and the world.The short end of the pool is where most novice swimmers are trained and it could be that graduate level researchers may fail to notice what self-help simplicity has accomplished.Yet Saroglou, Buxant and Tilquin (2008) reported difficulty in determining positive connections as a direct result religion or spirituality (p.165) However with minimal effort on the part of researchers twelve-step members would support the opposite.Droves of twelve-step members would line up to report positive outcomes in their lives as the result of twelve-step spirituality.
It would be fully reasonable to suspect that substance abusing individuals experience personality disunity as a result of their using.This would not eliminate this person however from being spiritual.Additionally many exhibit these same traits before using alcohol or drugs at all.This further supports the hypothesis that spirituality is substantially able to stand on its own right.Religious teachings often encourage and support spirituality and sometimes refer to relief from problems through the power of the Holy Spirit.The Holy Spirit in Christian teaching was sent from Jesus of Nazareth and is available to those who believe.This broad description allows twelve step members to be open to any possibility that will strengthen their character and help them to remain clean.Some members renew their faith and return to practice the religion they had as youths.Twelve step-groups acknowledge that membership is limited to those who have a "desire" to be free of alcohol or drugs even if they still are using.Some members report that they attended twelve step-groups under the influence but were allowed to stay because of the tradition of tolerance.
Clinical investigators may find this openness hard to comprehend because of the restrictive nature of so many organizations.Family members often attend meetings who have no substance abuse issues, but are there to provide support for their friend or loved one who may have found freedom from addiction.Geppert, Bogenschutz and Miller (2007) reviewed several hundred papers on the subject of spirituality only a handful appeared to be focused enough to report on (p.393).We cannot forget that as far back as the 1950's, referencing the work of Carl Jung and others that Isabel Meyers and her mother Katherine Briggs created personality tests that are still being employed.Their Meyers-Briggs Type Indicator (MBTI) tests are used in too many disciplines to define.Possibly they found a baseline of normal personality and expanded from there.Is it possible that researchers are starting from the top down rather than from the top up due to funding concerns?Academics and researchers can be handicapped by their requirement of writing for the grade or the grant.The same status quo results will continue to bombard research journals and electronic media in a way that is not only repetitive but cumbersome as well.If we follow the trend of combining religion with spirituality in a simplistic way we take the risk of actually duplicating past harms.Weaver, Pargament, Flannelly and Oppenheimer ( 2006) noted how ambiguity and uncertainty regarding one's religious practices and lack of faith contributes to feelings of low self worth.Religion can measure success and failure by the admission of sin whereas spirituality is seen on a continuum.Spirituality allows for more than one person to be right at the same time whereas religion because of its hierarchal nature becomes for some, a constant reminder of their failures thus actually reinforcing dependence.

Spirituality Defined within One's Context
It is completely possible, and very likely that each generation defines spirituality in the context of their lives, experiences and cultures.For addicts and alcoholics, looking inward toward the mental, physical and spiritual aspects of their lives has been a hallmark for the twelve step model.Abstinence does not equal "recovery" in the twelve step philosophy, but rather employing the twelve steps on a daily basis is the primary feature toward spiritual healing and recovery.For scientists, researchers and scholars alike, the illusive success found in twelve-step groups is at best difficult to duplicate in a clinical trial or research lab.Since spirituality is subjective, any type of interpersonal spirituality measurement should be considered in the subjective sense, rather in the theoretical.The difficulty for many researchers is that clinical trials are often time limited and restricted to those who are either incarcerated or newly sober individuals who have recently left or are still in a residential or out-patient program.Jarusiewicz (2000) noted that spirituality in recovering individuals may not be fully realized for at least two years of recovery.
Considering the fact that newly recovering addicts and alcoholics are traditionally unstable, anxious and confused, utilizing them as research participants for gauging spirituality is severely suspect.Depending on the individual meeting of Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous or some other group, one might find members who have been successfully clean or sober in twelve-step recovery for several decades.It would not be unusual for these members to identify their spiritual transformation in terms of having recaptured their lives from destruction and identify themselves as productive members of society.This new outlook is in dramatic contrast compared with the inconceivable dejection many of these members report they faced in their substance abusing days.Furthermore the spiritual principles within these groups encourage members to attend meetings regularly in an effort to help each other stay clean.The connectedness these members experience is often the glue that holds them together.Unfortunately for researchers the twelve step tradition of non-affiliation with outside organizations greatly restricts access to these long-term members which makes accurate data collection difficult.It should be noted that members come to meetings on a voluntary basis, they do not take oaths, make promises, sign forms or questionnaires and for all members personal anonymity is highly valued.
Still the elusive nature for a workable definition of spirituality frustrates researchers in ways that are remarkable.It is possible that because of the historical connection between religion and spirituality that secular academic institutions and even mental health professionals keep the subject at arm's length.Grodzicki and Gallanter (2005) picked up on this problem, suggesting academics and patients alike may vacillate when approached about this topic.The subjective nature of spirituality makes it very difficult to evaluate because religion is often used to describe spirituality and vice versa.Brown, Salsman, Brechting and Carlson (2007) reported on the value on the value of spiritual beliefs as an effective measure against substance abuse, but also cited problems in locating research supporting spirituality absent of inclusions of religion.
In twelve-step recovery spirituality is defined in terms of spiritual awakenings and spiritual experiences (Alcoholics Anonymous 1939) and in each case, freedom from addiction and connectedness with a power greater than themselves includes being within a group with other recovering members.Therefore in seeing connectedness to those one meets at twelve-step meetings reinforces the idea of connectedness.Spiritual awakenings in twelve-step lore denote a ongoing systemic renewal rather than a dramatic onetime event."Recovery" in the twelve-step model comes slowly and over time; there is evidence that this type of occurrence is preferred over the sometimes quick and dramatic conversions some twelve-step members have reported.This may be in part because of the great number of relapses that occur in twelve-step culture and recovery treatment settings; requiring the addicted individual to re-enter treatment over and over.The spiritual aspect of twelve-step groups lies in the shared understanding that members have been spared from inconceivable personal hardship, defeat, destitution, misery, torment and devastation.They now commit themselves to thinking and conducting themselves along spiritual lines.The remarkable physical rehabilitative nature of recovery may often cause family members and clinicians to believe that these once helpless and desperate addicts are now somehow "normal."

Spiritual Experience
Probability models of success and failure are plotted on numerical histograms relying on confidence intervals to meet research funding requirements.Yet it appears that the connectedness that underscores twelve-step spirituality cannot yet be measured with the current hypothetical models.Additionally the term Spiritual Experience refers to the sudden and dramatic change in addicted individuals, causing major personality changes so dramatic they are often frightening.These experiences are often met with doubt, disbelief and skepticism by those close to the former abuser, and rightly so.Displays of zealous gratitude and a new appreciation for life would often be clinically diagnosed as Bi-Polar Disorder, ADHD or any of the several DSM-IV-TR categories or mood or personality disorder.Overall however, the AA views on these types of events are considered rare and the majority of their members report having gradual spiritual awakenings rather than sudden spiritual experiences.As one AA member put it, the dramatic sudden changes of spiritual experiences are usually reserved for the "sickest of the sick." Addicted individuals often suffer from emotional disturbances and substance abuse can be seen as compensatory for ego-state equilibrium.These fragile ego states are often reported by members who have relapsed over and over again; disappointing employers, family and friends.Large bodies of evidence exist that describe addiction as a relapsing disease.Lack of self-worth, anger, questions regarding the meaning of life, acts of hostility, denial, resentment and intense suffering often overwhelm newly recovering addicts, driving them once again underground.Chen (2006) suggested that although clinical investigators are not in full agreement in their views of what spirituality is, noted there are areas where they are in agreement.These areas include meaning in life, connectedness to self and others (p.307) and are in line with what the Basic Text of Narcotics Anonymous calls "an end to loneliness and a sense of direction in our lives." (p.50)Much of the research misconnection with twelve-step spirituality can be found in their not understanding the culture.Many members were on the verge of death, had cheated many people who trusted them, were losing their entire life savings, their family, standing and friends.Twelve-step members in AA often refer to having drank themselves toward oblivion, were self absorbed and often needed to be cared for before coming into recovery.The personality changes necessary for sustained recovery often are excruciating for the first three years, many marriages fail and yet hope begins to emerge as the spiritual activities of their lives increase.These measurable changes toward being responsible, caring for oneself and helping others is stated as evidence to a spiritual awakening.Consider AA's Twelfth Step that encourages members who have had a spiritual awakening to try to help other alcoholics and use what they have learned in all areas of their lives.This new commitment to honesty, cooperation and humility catches those who know the former very off guard.Bliss (2007) noted factors that enhance twelve-step involvement and included attendance at twelve-step meetings, having a sponsor and having a spiritual experience.For the recovering person whose life was literally controlled by alcohol or drugs, spirituality in part can be defined as sustainable change; moving away from a previous state of functioning.Researchers might note the chances of abuse and ethical problems in conducting trials on unstable individuals; many Institutional Review Boards (IRB's) should be commended for being sensitive to this fact.In their recruitment of substance abusing individuals for research trials investigators screen each potential participant to ensure they are not seeking treatment.Also on days where infusions are part of the trial regimen a full staff of nurses and physicians are present to ensure "minimal risk" to the participant.
We may look harder at the medical field particularly nursing, where spiritual training of nurses and their assistants is an integral part of their training but is also offered in most states as part of the continuing education requirements.Grodzicki et al. (2005) pointed out that addiction counselors are already aware of the benefits of spirituality and noted that medical schools are seeking to fine tune their understanding.Concepts of spirituality may be impacted by a more capitalistic vision that views empirically based science as the best use of investment dollars where the results yield the most accurate outcomes.The scientific achievements of researchers can become severely impaired if intellectual hubris sets in.
The twelve step model places special importance on understanding of the fragility of the human experience, which may not make sense to a recent PhD staring at a scatter plot.In the twelve-step model, one chooses a God that they can understand, not one that they are told to comply with The twelve-step culture may be exactly what causes the addicted individual to thrive-that there is no cultural norm; one can be from any socio-economic, ethnic, religious or non-religious background.In these groups, as in the rest of society, culture is defined and updated by individuals within a group, and is influenced by the times in which they live.Cultural realities provide significant influence on belief systems and are defined in part by generational narratives.Spirituality, Spiritual Guidance and Spiritual Orientation in research are making small advances, but are far from what one might consider mainstream.Once a hypothesis can be tested and replicated over and over, with an expected outcome, it is generally accepted as fact.Spirituality however may be an exception to the standard hypothesis testing models as factors of individual preference and culture play a major part in its definition.Improvements in defining spirituality must include the culture and the times to which it is applicable.In trying to measure spirituality, the inclusion of cultures will better reflect the zeitgeist in which the most positive treatment outcomes are occurring.

Conclusion
Spirituality is found in the connectedness of twelve-step members.Because they are anonymous researchers might never understand the success of these groups.Twelve step members are often willing to speak with researchers but have a language not contained in graduate school textbooks.If we continue to speak to and from a Euro-American, heterosexual dominant culture paradigm we are guaranteed to have a non-workable definition of spirituality for a generation.The power of historical influence and economic power of religion may impair our ability to exclude it.We must not assume this subject will go away and must guard against allowing the use of allowing policymakers to allow spirituality to become a type of secular religion in disguise.
We are fortunate insomuch that the success of recovery from addiction in the United States is not only encouraged but accepted, there should be no shortage of grateful former addicts alcoholics and family members that would gladly share their views.But we can't as researchers show only temporary superficial interest resembling drive by research.We must develop and maintain standing relationships with those who will agree to speak with us.The medical field may help if we are not intimidated by science and they are not resistant to psychology.This paper was an attempt to suggest connectedness is a major ingredient in spirituality.