Philosopher Michel Foucault has argued that the health sciences and the human sciences eclipsed religion in the 18th century, bringing about a revolution in the way we understand the deepest things about ourselves.
But this revolution has not yet been accomplished in the study of addiction. In contrast, research into the underlying causes and responses to addiction has, for over 200 years, consisted of a shifting hybrid between religion (or its non-dogmatic cousin known as spirituality), psychology, and clinical medicine.
In the middle of the eighteenth century, Christian theology provided the basis for understanding problematic alcohol use. For example, in 1754 Jonathan Edwards put forth such a theological perspective in Freedom of the Will:
When a drunkard has his liquor before him, and he has to choose whether to drink or no… If he wills to drink, then drinking is the proper object of the act of his Will; and drinking, on some account or other, now appears most agreeable to him, and suits him best.
The actions of “a drunkard” were the acts of a free, but depraved will according to this theological perspective. Over the subsequent fifty years, this perspective began to change. Benjamin Rush, the psychiatrist whose profile graces the seal of the American Psychiatric Association, did not have the concept of addiction in his own medical and psychiatric training when he first began to practice as a physician in the 1770s.
By 1812, however, Rush became one of the first to lay out the idea that problem drinking was an issue of medical concern when he described drunkenness as “a disease of the will.” In the half-century between Jonathan Edwards and Benjamin Rush, understandings about problem drinking shifted from the theological/moral to the medical. “Drunkenness” became “alcoholism,” a “drunkard” became an “alcoholic,” and “depravity” became “disease.”
A Genuine Conversion
The eclipse that Foucault chronicled in his cultural history of Western modernity seemed to be proceeding apace in this newly emerging field of addiction when Dr. Rush articulated a shift in rhetoric from depravity to disease. But it suddenly stalled as clinical medicine was unable to account for the perplexing existence of addiction, or to find effective clinical interventions to treat it.
For a time, psychology seemed to hold the promise of bridging the religious and the medical by articulating a theory for the etiology and treatment of addiction; but by the 1930s a figure no less prominent than Carl Jung had come to see that promise as fallacy and to state that hopelessness was the only result of relying on medical or psychiatric treatment to treat alcoholism. In his advice to one of his patients (advice now famous in the annals of Alcoholics Anonymous), Jung offered only one source for hope in dealing with addiction: “a spiritual or religious experience—in short, a genuine conversion.”
Bill Wilson, one of the founders of Alcoholics Anonymous (AA), credited Jung’s work as “beyond doubt the first foundation stone upon which our Society has since been built.” AA describes the central role of spiritual conversion in recovery from alcoholism, even as it relies on medical terms naming the condition as a disease. In America, then, for almost two hundred years, religion, medical science, and psychology have been involved in an intricate, shifting alliance in response to addiction.
We Admitted We Were Powerless
For the last half of the twentieth century, that alliance coalesced into a singular model of psychotherapeutic support, clinical diagnosis, and spiritual practice known as Alcoholics Anonymous (along with numerous other “fellowships” such as Narcotics Anonymous, Gamblers Anonymous, Sex Addicts Anonymous, Overeaters Anonymous—to name a few). However, that singular model is beginning to give way as psychology offers new theoretical models of behavioral change, medicine copes with the dismantling of publicly-funded addiction treatment programs that require primary care providers to address addiction directly, and religious scholarship raises radical critiques of the kind of religious tradition that was central to the founding of AA.
Various psychological theories of behavior change are finding that the foundational component to sobriety consists of an internal belief that one is capable of making and maintaining a change in behavior. In the late 1980s and early 1990s, clinical psychologists working in the field of addiction began to formulate models of behavior change that stood in sharp contrast to the first step of the Twelve Step model of Alcoholics Anonymous.
In AA, no recovery begins until one acknowledges her or his powerlessness: “We admitted we were powerless over alcohol—that our lives had become unmanageable.” But according to psychologists such as James Prochaska and Carlo DiClemente, recovery is not possible until a person begins to feel a sense of self-efficacy; that they have some capacity to make a healthier choice and to follow through on that belief with action.
Other clinicians have developed a widely-known behavioral model known as Motivational Interviewing that provides a number of therapeutic actions to help people move past their ambivalence and make a change in behavior. This model, which draws on the work of Prochaska and DiClemente, also argues that self-efficacy is integral to making a change toward healthier behavior. Another model of behavior change, known as Self Determination Theory, argues that lasting change is likely only if the motivation comes intrinsically. These new models, and others like them, differ fundamentally from a Twelve Step model in their assumption (an assumption that the models have tested with clinical research) that human beings begin the move toward sobriety not by admitting their powerlessness but by honestly acknowledging their power and capacity to make a realistic change.
This new research was spurred partly in response to cuts in funding during the Reagan era: medical providers began to see their clinical options for referral in alcoholism cases diminish, and they faced the daunting clinical work of addressing patients’ addictions as part of their clinical practice. The behavioral change theories provided some ways to medical providers to stage interventions with their patients. No longer did a patient have to “hit bottom” before a provider was able to talk with them about alcohol or drug use. These new theories provided a way to think about clinical responses to patients using drugs in chaotic ways, or ambivalent about stopping drinking. They also changed the metrics by which successful behavior change was measured. While all of the models support sobriety as a goal, they also, by and large, support any choice on the part of the patient toward less chaotic use as a step in the right direction. This shift to seeing behavior change on a spectrum rather than in black and white (adopting perspectives in terms of either addiction or abstinence) also created tension with a Twelve Step model.
The Suspect Theological Legacy of AA
Psychology and medicine, then, are both shifting in their theoretical understanding and clinical approach to addiction. Theologians and religious studies scholars are also raising critiques of the kind of religious practice that was so influential in the formation of Alcoholics Anonymous.
When Dr. Bob and Bill Wilson co-founded AA, they both claimed that the only kind of practice that provided them with any resolve against alcohol was participation in a religious and spiritual community. Initially, they found that community in the Oxford Group. This movement, which took its name from the English town where the movement was founded, was an evangelical Protestant organization that was wildly popular in the early decades of the 20th century. The religious practices of self-reflection and testimony that were so common to the Oxford Group were translated into a parachurch genre through which they could become part of an organization such as AA.
And yet, despite their early participation in the movement, both Dr. Bob and Bill Wilson eventually expressed misgivings and withdrew their membership before founding Alcoholics Anonymous. They were not the only ones to express concern. In 1936 Reinhold Niebuhr stridently criticized Frank Buchman, leader of the Oxford Group, for Buchman’s support of Hitler. Just this year, Jeff Sharlet (a research scholar in Religion and Culture at New York University, contributing editor for Harper’s and Rolling Stone, and RD regular) traced the connections between Buchman, the Oxford Group, and an influential evangelical political organization known as The Family; an organization Sharlet finds dangerous and tremendously powerful, the subject of his book entitled The Family: The Secret Fundamentalism at the Heart of American Power.
Alcoholics Anonymous has never been formally affiliated with the Oxford Group and it certainly has no present-day connection to the organization that Sharlet investigates. Nonetheless, the theological claims of the Oxford Group formed the basis for the spiritual practices of the Twelve Steps. Harvey Firestone, the multi-millionaire founder of Firestone Tires, hosted a meeting of the Oxford Group in 1933 in appreciation for the movement’s capacity to help his younger son, Bud, achieve sobriety. This meeting was a key event in the founding of Alcoholics Anonymous. The religious tradition of the Oxford Group was exceedingly amenable to the Firestones; claiming powerlessness over alcohol while retaining inordinate social and cultural power as business leaders is far different from coercing a confession of powerlessness out of a homeless man or woman who drinks a tallboy of beer, shoots up heroin or smokes crack, and has few options for comprehensive treatment programs to achieve sobriety.
What Would a New Approach Look Like?
The odd assortment of players in the history of AA, psychology, and religion—Bill W., Dr. Bob, the Firestone family, Carl Jung—may have been correct in their understanding that some kind of spiritual practice is necessary for some people to achieve sobriety. But surely that practice has a broader social-cultural context. Practical theologies that draw on liberation theologies (and there are many of these) could form a new foundation for thinking about the connections between alcohol use and spirituality; they could also create new spiritual practices that do not require a confession of powerlessness, particularly for those who have experienced pervasive social dynamics that conspire to deny them access to cultural and material power in their lives.
Men and women living in poverty, the preferential children of God in liberation theologies, bear the brunt of the dismantling of a comprehensive public substance abuse treatment system. In many circumstances, their only option to address active addiction is to confess their powerlessness before they can be part of a community of recovery. But surely there are other spiritual journeys they can embark upon.
What would a spirituality of recovery from chaotic alcohol or drug use look like if it were grounded in the theological claim that God has a preferential concern for the drug user? How would the kinds of practices that would arise out of this perspective provide new insights into the complex intersections between religion, spirituality, psychology, medicine, and addiction? We need to find out.