Cover Story

Seven of the 12 steps at the heart of Alcoholics Anonymous feature spirituality. For example, participants surrender their will to a higher power, use prayer and meditation to improve their relationship with him and seek spiritual awakening.

Over the years, researchers have confirmed an association between this kind of spirituality and positive outcomes in alcoholism and substance abuse treatment. Now psychologists and others are trying to figure out what's behind that association--research that's especially timely given the Bush administration's recent creation of a $600 million voucher program that could allow federal dollars to support faith-based treatment.

Exemplifying the new research interest is a series of exploratory grants given by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Fetzer Institute in 2000. Thanks to these grants and other initiatives, psychologists are finding that spirituality can play a role--sometimes more indirect than once thought--in preventing and treating alcoholism and substance abuse in vulnerable populations such as adolescents and minorities.

"A lot of the research in the past has just been correlative," says psychologist Thomas R. Gentry, PhD, a health science administrator at NIAAA, noting that confounding variables and self-selection biases have marred many studies. "To simply say the more often you go to a religious service, the less likely you are to be an alcoholic doesn't provide a whole lot of information a clinician can use. We're trying to figure out what part of the spiritual or religious experience is important."

Prevention...

Much of the new research focuses on how spirituality or religiosity could help prevent alcoholism and substance abuse in adolescents.

For example, Kathy Goggin, PhD, associate professor of psychology at the University of Missouri in Kansas City, says she was pushed into studying spirituality by the very adolescents she studies.

As part of an ongoing study of substance use and sexual risk behavior among urban African-American adolescents, conducted with her co-investigator Vanessa Malcarne, PhD, of San Diego State University, she asked her subjects whether she was asking the right questions.

"They kept saying, 'You're missing God,'" says Goggin, who received a NIAAA/Fetzer grant. "That scared us, since how to measure that has been a problem."

Goggin solved the problem by developing the Alcohol-Related God Locus of Control Scale, which measures whether adolescents believe God controls their drinking behavior. In a not-yet-published study, she used the scale to discover that the more adolescents believe that God plays a role in their lives, the less likely they are to drink.

Although the findings need to be replicated in other populations, Goggin says they have implications for prevention efforts.

"The one-size-fits-all approach to prevention has kept us from thinking about individual differences," she says. "For kids who believe God plays a role in their lives, it may be particularly helpful to incorporate that into prevention messages."

Research by psychologist Thomas Ashby Wills, PhD, a professor of epidemiology and population health at Albert Einstein College of Medicine in the Bronx, backs up the finding that spiritual or religious beliefs can be protective.

"With notable consistency, almost everyone who's ever studied religiosity has found it to be a protective factor for adolescents," says Wills, whose work is supported by NIAAA/Fetzer and also by the National Institute on Drug Abuse. "What's not well known is why it's a protective factor and how it works."

Wills thought that one traditional measure of religiosity--congregation membership--was too simple. "There are a lot of people who belong to a church, for instance, but don't go very often," he points out. Instead, Wills used a scale that determines how important religion is to people.

In a study published in Psychology of Addictive Behaviors (Vol. 17, No. 1) this year, he administered the scale to a multi-ethnic sample of 1,182 kids in metropolitan New York. In another study, he administered a similar measure to African-American adolescents in rural Iowa and Georgia.

What he found counters the conventional wisdom that adherence to doctrinal do's and don'ts explains religiosity's protective effect. He found that religiosity keeps kids from smoking, drinking and using marijuana by buffering the impact of life stresses. Religiosity was especially beneficial for kids facing stressful situations, such as illness or an unemployed parent. However, it's not just adolescents' religiosity that helps prevent drinking and drug use. Gene H. Brody, PhD, Distinguished Research Professor of Child and Family Development at the University of Georgia in Athens, has found that parental religiosity also plays a role.

In studies published in Developmental Psychology (Vol. 32, No. 4), Child Development (Vol. 69, No. 3) and the Journal of Marriage and the Family (Vol. 56, No. 4), Brody found that African-American parents in the rural South who were more involved in church were more likely to have harmonious marital relationships and better parenting skills. That, in turn, promoted kids' competence, self-regulation, psychological adjustment and school performance--all factors that keep kids from turning to alcohol and drugs.

"Imagine a series of steps," says Brody. "Religiosity works indirectly through family relationships to promote the factors that protect kids."

...and treatment

Other psychologists are focusing on spirituality's role in treating alcoholism and substance abuse, especially among minorities.

J. Scott Tonigan, PhD, research professor of psychology at the University of New Mexico in Albuquerque and another of the NIAAA/Fetzer grantees, rejects the common idea that spirituality and religiosity have a direct impact on treatment outcomes. Most of those studies that reach that conclusion are cross-sectional and thus suspect, he notes, and any effect they find is so small it's clinically irrelevant.

Like Brody, Tonigan has found that spirituality affects treatment outcomes indirectly. In a 10-year follow-up of 226 clients--a majority of whom became members of Alcoholics Anonymous--participating in a large NIAAA-funded trial called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), published in Alcoholism: Clinical and Experimental Research (Vol. 26, No. 5), Tonigan found that increases in spirituality predicted behaviors such as honesty and responsibility. Those behaviors, in turn, promoted abstinence from alcohol. "Spirituality is one of those variables that's really in the background," says Tonigan.

That's not to say that background effect isn't important. In another study published in the Journal of Studies on Alcohol (Vol. 59, No. 3), Tonigan found that spirituality allows Hispanics to derive just as much benefit from Alcoholics Anonymous as their white counterparts despite being less engaged in the program. According to Tonigan, this paradoxical finding is related to a deeper religious faith that makes Hispanics more comfortable with spiritually based programs.

And alcoholics and substance abusers themselves often feel spirituality plays a key role in recovery, say psychologists.

Many Alaska Natives, for example, believe that alienation from their spiritual heritage contributes to their community's high alcoholism rates and that reconnection to those roots helps them on their path to sobriety, says Kelly L. Hazel, PhD, an associate professor of psychology at Metropolitan State University in Minneapolis, Minn.

Although those beliefs haven't been confirmed by science, Hazel and former colleagues at the University of Alaska in Fairbanks have done research suggesting that spirituality can indeed play a role in prevention and treatment.

In one not-yet-published study, they interviewed more than 100 Alaska Natives who had been sober for at least five years, or who had never had drinking problems, with the hope of identifying protective factors. For many, spiritual reawakenings were the impetus for getting sober, and reconnecting with their spirituality--often a hybrid of native and Western traditions--helped them on their way.

"Leaders in the native sobriety movement had asked us, 'Why does the research always focus on the problems? Why doesn't it focus on the strengths?'" recalls Hazel. "Spirituality is clearly one of those strengths."

Rebecca A. Clay is a writer in Washington, D.C.