Revisiting spiritual guidance in treatment

Bill White has a response to the Bill Miller study on the effectiveness (or lack of effectiveness) of spiritual guidance in an addiction treatment setting. He warns against throwing the baby out with the bath water and offers a series of questions about spiritual guidance, recovery and treatment:

• How are the following defined and delineated:spirituality, spiritual awakening, spiritual orientation,spiritual practices, and SG? What is the relationship between spirituality, life meaning and purpose, andquality of life?
• Does the essence of spiritual experience get lost in efforts to artificially define and replicate it within a professional treatment intervention? Are the ingredients of spiritually oriented professional interventions the same as the ingredients that people in long-term recovery self-report as transformative?
• Will individuals entering or leaving treatment voluntarily participate in a spiritually based intervention? It is unclear in the two SG studies whether the low participation rates (means of 2.9 and 4.8 sessions attended of 12 sessions) were a function of the characteristics of study subjects, the design, and content of the intervention offered or were influenced by staff or organizational factors.
• Are there dose, duration, and timing effects of spiritually oriented interventions? Would different outcomes of the SG studies have been achieved if the dose (number of sessions attended) had been larger or if SG had been delivered as a program for treatment alumni with at least 1 year of sobriety? Are the effects of spirituality and SG different across the long-term stages of recovery?
• What is the role of choice in the spirituality experience and the SG process? Does the “having had a spiritual awakening” effect of AA's 12 Steps result from the individual ingredients of the steps, the cumulative effects of such ingredients, or the sequence in which these actions were taken? Are there greater effects from a focused exposure to a single spiritual philosophy/practice or, as with the SG studies, self-choosing exposure to multiple spiritual practices?
• Is there an ecology of spiritual experience? The milieu of the SG studies (addiction treatment institution) is markedly different than the milieu of 12 Step and alternative recovery support groups (community of shared experience). What effects do physical and cultural environment exert on spiritual experience?
• Does the relational context matter? There is considerable difference between the professional–client relationship with professionals not having prior experience working with addicted and recovering people (as in the SG studies) and relationships in recovery support groups that are characterized by moral equality, mutual vulnerability, mutual support, and long continuity of relationships.
• Are there potential iatrogenic effects of SG as suggested by the slowed improvement of depression and anxiety when compared to controls in the first SG study? Could mild iatrogenic effects occur in an early stage of an SG intervention that could be followed by substantial improvements (e.g., increased anxiety and depression while going through Steps 4 and 5 of Alcoholics Anonymous with significant improvements in emotional health following completion of these steps)?

I love the musing about the effect of this kind of service being delivered by alumni that have been out of treatment for a year. That opens up all sorts of interesting ideas, some having nothing to do with spiritual guidance. What about stage 2 recovery for those entering aftercare?