Abstract
The purpose of the present paper was to explore the concept and experience of God in relation to recovery from drug addiction from a scientific perspective. Examination of a diverse literature was undertaken, including five key threads: the universality of the experience of God; the induction of spiritual experiences of God through hallucinogenic drugs; the nature of drug addiction from an evolutionary neurobiological perspective; the 12 Step movement as the prototype for the place of God in recovery from drug addiction; and identified ingredients for successful recovery from addiction. The diverse threads of literature examined can be integrated around the concept of higher power as an important factor in recovery from drug addiction. Higher power can be manifested in individuals in diverse ways: religious, ethnic, spiritual including the use of entheogens, as well as cognitive behavioural development, but a common final pathway for all is the strengthening of executive functions (the brain's ‘higher power’). Practical implications for assisting people with drug addiction to achieve recovery through their own experience of God/development of higher power are outlined.
I will lift up mine eyes unto the hills: From whence cometh mine help. Psalm 121:1
The personality of God is the personality of man, freed from all the conditions and limitations of Nature Feuerbach 1874
I swear to drunk, I'm not God! Anonymous
The ability and tendency of human beings to go beyond what they can see and touch, and conceptualize an ideal imbued with spiritual meaning appears to be a universal human trait found in every human society throughout recorded time [1]. This universality is best explained scientifically by viewing religious propensity as a human trait that has emerged through the grindingly slow, stepwise process of natural selection, providing survival advantage as successive Homo species have evolved through to Homo sapiens [2, 3]. However, there is not yet an agreed primary mechanism by which this human propensity to create religions has been shaped by evolution and hardwired into our genes like an instinct [4]. Self-transcendence has been identified as a heritable personality trait that measures the individual's capacity to experience things beyond their own personal and interpersonal space; a state of ‘unitive consciousness’ [5] underlying an individual's religious inclination. However, the propensity toward religion may be a by-product of a more basic brain capability, which provided our species with survival advantage; for example an ‘intentional stance’ by which the human brain very efficiently perceives meaning in the various entities of the external world [6]. Expanded dopamine-rich ventral brain systems (present in other mammalian species) that mediate interactions with the most distant aspects of environmental space [7] may represent this brain capability underlying religiousness in humans.
Although there is a common religious thread throughout all human societies, there is considerable diversity in its expression across the different cultures of the world present and past. Religion in the West is dominated by the three main variants of Abrahamic God, found in Judaism, Christianity and Islam, respectively. In Eastern religious systems there is even greater diversity. For instance, Buddhism and Confucianism promote direct experience of a higher state of consciousness not necessarily associated with a transcendent God at all and the various movements and sects collectively known as Hinduism contain a bewildering array of religious belief and practice [1].
In the West, but curiously not so evident in the USA, Christianity is increasingly giving over to secularization, with the presence of technology, sceptical rationalist education systems and the provision of social welfare considered to be driving factors [8]. However, despite modernization and the powerful technologies associated with it, to the extent that human life on Earth is for the first time since the agricultural revolution beginning to be seriously considered at risk, the human inclination to experience things beyond the immediately perceivable and enthusiasm for religious beliefs and practices is enduring [9].
William James’ seminal work The varieties of religious experience documents a range of personal experiences involving God, including during altered states of consciousness [10]. For instance, he recounts a chloroform experience of the famous British writer J.A. Symonds: ‘After the choking and stifling had passed away, I seemed at first in a state of utter blankness; then came flashes of intense light, alternating with blackness, and with a keen vision of what was going on in the room around me, but no sensation of touch. I thought that I was near death; when, suddenly, my soul became aware of God, who was manifestly dealing with me, handling me, so to speak, in an intense personal present reality. I felt him streaming in like light upon me … I cannot describe the ecstasy I felt.’ This and many other stories and observations led James to a broad conclusion that certain types of experiences, whatever their ultimate validity, nevertheless have significant utility. “… we can experience union with something larger than ourselves and in that union find our greatest peace.” The relationship between taking drugs and finding God is not currently a normative experience in Western contemporary societies. However, the relationship between the two is well established in history and extends far into the origins of Homo sapiens.
Drugs and God
Hallucinogenic substances are common in nature and have been used by humans for tens of thousands of years. However, their use has been traditionally confined to religious ceremonies and rituals controlled by spiritual leaders for a range of purposes including healing, as well as bringing a special sense of occasion to important ceremonies associated with birth, coming of age, marriage, and death. Critical to these purposes was the facilitation of communication with deities and the spirit world. Hallucinogenic drugs used in this context have been termed ‘entheogens’ [11]. The rise of the Abrahamic religions (Judaism, Christianity and Islam) brought about a decline in these primitive religions and with them the use of entheogens, which were relegated to the status of being evil and of the Devil. However, emanating from the Christian tradition was the Enlightenment of the 17th and 18th centuries in which reason and rationality emerged as the key to objective understanding of the universe, thus sparking the development of modern empirical science. A landmark book on drugs, Phantastica, is a comprehensive documentation of psychoactive plants and was a driver behind the rediscovery of using various hallucinogenic drugs, including the two long-standing ‘God-finding drugs’, mescaline and psilocybin, as the 20th century progressed [12]. The subsequent discovery of lysergic acid diethylamide (LSD) brought about renewed interest in the West in therapeutic uses of hallucinogens, although now outside traditional religious guidelines and practices.
During the 1950s and 1960s LSD was used extensively in both Europe and the USA as a treatment for alcoholism, although a somewhat different approach was taken in the two regions [13]. A psycholytic (‘mind loosening’) approach was taken in Europe by the use of multiple, low-dose therapeutic sessions, whereas in the USA a psychedelic therapeutic experience was undertaken with the use of relatively high doses aimed at producing a life-changing mystical/religious experience for patients. Sustained improvement appeared to be associated with patients having such a transcendental experience.
By the late 1960s there had been only two controlled evaluations of LSD in the treatment of alcoholism [14, 15] and both were considered to have significant methodological problems [16]. Investigations with improved methodology subsequently found that LSD was not an effective treatment in itself in the treatment of alcoholism when medium–long-term outcome was measured [17]. However, a number of these studies reported significant benefit from LSD over various control conditions during the first 3 months following the experience [16, 18, 19].
Further research has been severely hampered by the classification of LSD as a Schedule 1 drug in the USA in 1965, a move that was soon replicated in all similar Western countries, including Australia and New Zealand. However, the use of psychedelics therapeutically may now be undergoing a revival [20]. A recent randomized controlled trial of psilocybin compared with the non-hallucinogenic stimulant methylphenidate, found that psilocybin produced a profound enduring spiritual experience in a group of normals, which was corroborated by significant others [21]. Even more pertinent here, is a randomized controlled trial of hallucinogenic doses of ketamine, which were found to be effective in inducing abstinence in a group of patients with heroin addiction in Russia [22].
Whereas, using drugs to treat a drug problem was serious questioned 30 years ago [17], the demonstration of naltrexone as an effective antidipsotropic in alcohol dependence in 1992 [23, 24], has heralded a new treatment era. Pharmacotherapy is fast becoming an established domain of intervention and a range of effective medications are emerging not only for alcohol dependence [25] but for the range of other drug addictions as well [26–30].
Before we now consider recovery from drug addiction, and the place of God (and drugs) in this process, it is useful to consider briefly what addiction is from the perspective of emerging neurobiological knowledge.
What is drug addiction?
One of the defining features of a drug addiction is the manner in which behaviour appears to become increasingly driven by forces outside of the person's conscious control. Specifically, as a person continues to use drugs regularly, their ability to choose whether or not they take drugs becomes increasingly difficult as drug-seeking behaviour becomes increasingly compulsive [31]. Continued use of a substance by a person, despite their knowing of the significant physical or psychological problems being caused by this behaviour, is the phenomenological expression of this underlying compulsion, described as one of the seven criteria for diagnosing drug dependence [32]. In a relatively short space of time of several decades, there has been a paradigm shift of thinking about what drug addiction is, from considering it as a personality failing or breakdown in a person's ability to exercise normal conscious control over their behaviour in relation to taking a psychoactive drug, to addiction being viewed as a neurobiological brain disease involving unconscious learning. Vaillant describes this conceptual shift as a move away from considering ‘addiction as a more or less conscious use of an active drug in order to provide either emotional solace or exquisite self indulgence. … [to] a whole constellation of conditioned, unconscious behaviours’ [33].
This paradigm shift has been brought about by a surge in knowledge of the brain as it relates to behaviour, especially through the advent of functional neuroimaging technologies. The neural pathways that mediate addiction are being confirmed as involving circuits between evolutionary old structures of the brain, particularly the nucleus accumbens and the amydala in the limbic system, and the more recently evolved neocortex, particularly anterior cingulate, orbital prefrontal and dorsolateral prefrontal cortex [34]. The hints that drug addiction involved a process of hijacking primitive survival mechanisms [35] underlying the well-known clinical observation that ‘addicts appear to be using drugs as if their lives depend on it’, has been strengthened by research into learning and memory. Neural mechanisms related to learning and memory are beginning to explain how subconscious pathological learning and overvalued memory related to reward (from drugs) drive compulsive addictive behaviour [36].
Breaking this compulsive behavioural pattern is one of the great challenges of recovery from drug addiction. No wonder some believe that only a force as big as God is sufficient for recovery to occur.
God and Recovery
Various Christian denominations have been centrally involved in providing assistance to people with addiction. Religious conversion is a central drive but generally overlaid with a strong social work ethos. In New Zealand this involvement by the churches can be seen in the Anglican City Missions’ night shelter and social detoxification services, Catholic underpinning of the Vincentian Recovery Centres, and outreach work by fundamentalist groups such as Assemblies of God and the Destiny Church. However, the biggest and most enduring contribution by the Christian religion to addiction treatment work has been by the Salvation Army initiated by William Booth's mission to London's underclass, beginning in 1852 [37]. The Salvation Army now runs social services including alcohol and drug services in 111 countries in the world [37]. In both Australia and New Zealand, the Salvation Army's comprehensive set of addiction services are an intrinsic part of addiction treatment services as a whole.
However, the place of God in recovery from drug addiction (including alcoholism) is most popularly linked with Alcoholics Anonymous (AA) and in particular the ‘Road to Damascus’ conversion experience of one of its founders, Bill Wilson, which transformed his life and following which he is said to have never taken another drink of alcohol [38]. Bill Wilson subsequently met Dr Bob Smith, also a member of the Oxford Group and together they founded AA, which has become the most important self-help movement in the international addiction arena to this day. What were the circumstances of Bill Wilson's spiritual experience? Several months preceding it, during a third hospital admission, he was pronounced to be a hopeless case of alcoholism and his wife was informed that he was likely to require committal. On 14 December 1934, while in a state of depression undertaking a fourth hospital detoxification, he is said to have cried out “if there be a God, will he show himself”, following which Bill experienced what later he and others referred to as his “white flash” or “hot flash” experience. The next day he is said to have received a copy of William James’ book The varieties of religious experience [10] and was deeply inspired by it, revealing to him three key points for recovery: (i) calamity or complete defeat in some vital area of life; (ii) admission of defeat; and (iii) appeal to a higher power for help. These were the beginnings of the 12 steps later to be written by the Board of Alcoholics Anonymous in December 1938 [39].
The first three steps describe the basis of the key spiritual experience at the heart of AA philosophy; a psychological shift from relying on oneself, now acknowledged as inadequate in the face of the addiction problem at hand, to gaining strength from an idealized higher power, God. Accepting that one is ‘not-God’ [40] and therefore without ultimate control over alcohol is viewed as the prelude to a spiritual awakening and ‘finding God’ (see Anonymous at outset). These first three steps have been referred to as the basis for the change in cognitions, emotions and behaviour that occurs in alcoholic recovery [41].
The AA God had its origins as a transcendent Christian entity. Bill Wilson and Dr Bob Smith both belonged to the Oxford Group, a non-denominational, evangelical Christian movement, which peaked in the late 1920s and early 1930s and later became known as the Moral Re-Armament movement [40]. However, the AA concept has developed as a highly inclusive one and in the increasingly secular modern world, conceived by individual AA members in a vast array of ways. The AA God is normally some entity outside of the person themselves, but God or ‘higher power’ can also refer to a ‘higher self’ within [42] or the power of the group, or AA itself. In fact, being an atheist or agnostic is not a contraindication for belonging to AA [43].
Rational recovery (RR) is approaching 20 years of existence. It is a self-help group, set up in reaction to AA in the USA and based on Albert Ellis’ rational emotive therapy [44]. Rather than a big book RR has The small book [45], and instead of emphasizing the importance of surrender to a higher power (God) and group support in the struggle against the disease of addiction, RR insists on self-action in recovery from a cognitive behavioural perspective. RR instructs its members to take individual responsibility for their aberrant behaviour and change: ‘You drink or use because you love to get high. Admit it!’ [46]. This stands in contrast to the 12-step philosophy of admitting defeat and reaching out to God for assistance.
There is no place for a transcendent God in RR. ‘To seek God while in the grip of addiction is absurd; addicted people cannot conceive of a power higher than their own addiction’ [46]. Instead, there is strong exhortation for people to use their internal ‘higher power’ and act more responsibly. RR admits that it promotes a rather ‘old-fashioned view’ of addiction as voluntary conscious misconduct, related to obtaining physical pleasure. However, the group is not overtly anti-God; it simply de-emphasizes the importance of a God-inspired spiritual experience in recovery. ‘Seek God only if you are interested, once you are fully recovered’.
The addiction treatment field then has two self-help group movements, which have seemingly opposing philosophies. The 12-step movement with AA at its core but having branched out to include other addictive areas (Narcotics Anonymous, Gamblers Anonymous and an increasing range of others catering for modern behavioural addictions, including most recently online auction addiction) and RR. AA is God-driven whereas RR is a self-driven movement. Which is the most effective?
There have been no randomized controlled trials testing differential effectiveness of the two self-help groups. But anecdotal information suggests that there is just as high a recovery rate in RR as in AA without an experience of God involved [47]. Differences between the spirituality of members of AA and RR have been investigated and shown, not unexpectedly, that those who recovered through AA had a greater belief in divine intervention than RR members [48]. The pre-eminent Project MATCH found equivalent outcomes from 12-step facilitation treatment and cognitive behavioural therapy [49], which represents the best data available comparing the essence of AA and RR.
Finally, the development of kaupapa M
Recovery from drug addiction
Supernatural assistance can bring about sudden transformation and recovery [38]. White examines seven very high-profile examples of dramatic transformational change of individuals who had experienced an addiction recovery through a religious, God-like experience. In each case, following the religious experience, the individual subsequently went on to influence many other people through the founding or promotion of new therapeutic social movements including AA (Bill Wilson), the National Committee for Education on Alcoholism (Marty Mann) and Malcolm X's six-point process for addiction recovery for the Nation of Islam. The nature of the experience varied from feeling the presence of spiritual beings, visions and spiritual encounters, voices, physical touch, and a sense of love, hope and well-being, but in each case a profound experience changed the attitude of the person and resulted in enduring charismatic behaviour [38]. Spiritual growth and personal transformation have also been identified as common elements in recovery for more typical samples of addiction patients [52]. But is a supernatural experience necessary for recovery from drug addiction?
Vaillant's research of nearly 20 years ago, from long-term follow up of addicted patients, has not been surpassed in terms of identifying factors in determining recovery from drug addiction. He concludes that for a person to recover, they need not necessarily have an experience of God but, nevertheless, must make substantial changes to their lifestyle: ‘their whole pattern of living’ [33]. He identifies four general factors associated with relapse prevention as: compulsory supervision, substitute dependence, new relationships, and inspirational group membership. These factors emphasize that enduring change is associated with buttressing against relapse with external reminders of vulnerability, filling in the time previously occupied by addictive behaviour with something compelling, experiencing a fresh start interpersonally and developing a new sense of self as part of a renewing experience. Profound attitudinal change that is enduring might involve a ‘psychological rebooting’, which is then reinforced over time so that a new set of consolidated behaviours are established within this ‘new non-stigmatized identity’ [53]. This process of consolidation of change over time is illustrated by the well-known catch-cry of 12-step Minnesota model treatment that ‘treatment is discovery, AA is recovery” and confirmed in research that indicates that the best treatment outcomes for addiction are those in long-term methadone maintenance programmes and among those who participate in ongoing AA support groups [54].
Where does this leave God in terms of recovery from drug addiction moving into the future?
Future of God in recovery from drug addiction
Addiction is a behavioural disorder mediated by neurobiological changes in the brain. Compulsive drug seeking and drug using is initiated out of consciousness through limbic structures and results in an increasingly autonomous and inflexible state divorced from normal adaptive functioning guided by executive functions of the prefrontal cortex.
The state of relative divorce of conscious prefrontal cortical guidance from hijacked primitive reptilian consumption drives (RR refers to these drives as the beast brain ‘it’, in contrast to the human brain ‘you’) [45] suggests that something profound in a person's life is necessary for recovery from drug addiction to be initiated. For some, this is an event not dissimilar to a religious conversion in which the person finds new meaning in life and a new identity to live it with. Profound change occurs as if there is a ‘re-booting of the computer’ and a fresh start in life initiated. From a traditional religious perspective this process is finding new meaning in a relationship with God.
AA has developed as a prototypical therapeutic religion by which renewing spiritual experiences are encouraged and facilitated. Four key factors determining recovery emanating from longitudinal research (external supervision, substitute dependency, new caring relationships and increased spirituality) have provided an explanation of the general mechanism by which AA acts [55] and presumably RR as well. In fact, there may not be as much opposition between AA and RR, when viewed from a psycho-spiritual perspective as well. A Jungian analysis of the psyche proposes that belief in God is a projection of the archetype of the self, as distinct from the conscious ego [56] (cf. Feuerbach at outset), the AA adherent, by his or her belief in God, is consciously calling upon the spiritual power of the self. The RR person is doing the same but in a more rational and materialistic sense of conscious self and in the process avoiding the necessity of belief in a supernatural God. In the end both are utilizing the same psychological and, therefore, brain processes. Self-management and recovery training (SMART), a more recently developed self-help movement based on a cognitive behavioural model, is less strident than RR about the differences between a self- and a God-based approach and encourages each individual to find their own unique path to recovery [57].
Clearly not all recovery is associated with a white-light-God-discovery religious experience but, nevertheless, significant change in orientation to life in terms of self and relationships remains fundamental to the process. Transformational change through an expansion of a patient's vision of themselves and their life, whether it be through a new love relationship, a supernatural spiritual experience or cultural discovery, is likely to involve those parts of the brain associated with distant extrapersonal space and time, which have been proposed to be the same parts associated with dreams and hallucinations: dopaminergic cortico-limbic pathways from the medial temporal lobe to the anterior cingulated and prefrontal cortex [7].
The transcendent God of the West may be dead [58], or at least dying [9], and belief in God viewed by leading scientists as a delusion [6], but the human brain, refined through millions of years of evolutionary selection processes, remains. Through this, the inclination in humans for calling on the heavens to provide assistance in times of trouble can be expected to continue. With scientific knowledge about the heavens, especially research into the beginning of the universe [59], along with advancing technology associated with life and its creation, it might be expected that a variety of new religious forms providing comfort, strength and meaning will develop in one form or another in the foreseeable future. However, given the apparent hardwiring in human brains brought about by evolutionary history, at least some of these new religious forms are likely to continue to include magical supernatural ideas. Intercessory prayer for improving health has not been demonstrated to be effective [60] and could possibly have a negative impact when the prayed upon are aware of being the object of prayer [61]. However, this information is unlikely to stop people praying, given the biological makeup of Homo sapiens. The human ability to create solutions to problems (such as addictive behaviour) through accessing (imagined) sources of supernatural help appears set to remain as a fundamental coping mechanism for many.
Where does this leave treatment of drug addiction from a scientific perspective? Clinicians need to remain pragmatic and utilize whatever natural healing processes are available to help bring about change in their patients, remembering that formal treatment is only one small piece of the recovery process for many.
If patients ‘find God’ in a different form from that of the clinician and attribute their recovery from their drug addiction to these experiences rather than the formal treatment provided, the clinician must work hard to remain professional, contain countertransferential reactions and continue to provide support in consolidating behavioural change [62]. Careful attention must be given to ensure that the incongruence of values and spiritual beliefs between clinician and patient does not erode the therapeutic relationship. A skilled clinician will have a set of culturally sensitive proficiencies that facilitate: an empathic therapeutic relationship; an openness to really understand the patient's spirituality; familiarity with the patient's cultural beliefs and values; comfort in discussing spiritual issues; and willingness to consult [63]. There is evidence that highly religious patients prefer therapists with similar values [64, 65]. However, the effect of matching patient and therapist according to spiritual and religious values on outcomes is so far inconclusive [66].
At the present time addiction treatment is limited by the lack of predictability in its ability to intervene in this spiritual domain of treatment by which a person's life changes through expansion of his/her personal horizon and identity. There is little evidence that 12-step facilitation therapy is more likely to help people recover through a spiritual experience than others, such as cognitive behavioural therapy or motivational enhancement therapy. Reaching rock bottom is anecdotally an important state for reaching out and initiating change, but facilitating a rock bottom experience for therapeutic purposes is generally likely to be unethical and, in any event, it is largely impossible to be confident of predictably bringing about positive treatment outcomes.
In the future pharmacotherapeutic procedures designed to assist people become amenable to change through a profound spiritual experience induced by specific drugs (therapeutic entheogens) could again become a promising area of research and development of effective interventions; Aldous Huxley's ‘neurotheology’ [67] with a therapeutic twist. But a psychotherapeutic drug intervention is only one of a larger class of factors that may bring about enduring change. Nevertheless it may turn out to have acceptable predictability to be termed a ‘treatment’ compared with harnessing life events for the hope that an auspicious moment of change will occur, which is the basis of current practice. Identifying the most effective putative therapeutic entheogen is likely to be an emerging research endeavour. This may vary according to patients’ temperament and primary drug of dependence. LSD might be the key for one person, whereas a ketamine or MDMA (methylenedioxymethylamphetamine, “ecstasy”) experience could be the right intervention for others. The hallucinogenic alkaloid ibogaine is a supposed anticraving agent in alcohol, cocaine and opioid addiction [68] that has a large grass-roots following in the USA but which struggles for legitimacy in the absence of scientific research support [69].
In the meantime, utilization of life events (positive and negative) are to be harnessed by clinicians and woven into treatment plans as patients discover and develop their ‘higher power’. This may occur religiously through an experience of finding God and consolidation of this experience in spiritual practices. Alternatively, a person's higher power may be ignited through alternative spiritual experiences or cultural discoveries. Finally, others’ psychological awakening may come about through working on developing a mature and responsible self and consolidation of this experience through behavioural practice. In all cases, a strengthening of the executive functioning of the person's prefrontal cortex (the brain's higher power) will be the outcome when effective, which will be maintained by the individual through their unique human engagement of the world and its meaning to them reflected in their day-to-day lifestyle. Addictive self-deception is replaced by the pursuit of higher ideals.