Resumen:

Dentro de la investigación sobre alcoholismo se atribuye gran importancia a la espiritualidad. Algunos investigadores guardan distancia con este concepto, sin embargo, otros coinciden en señalar que ésta y otras variables protegen a los individuos de la adicción, favorecen el proceso de tratamiento y son mediadores de largos periodos de abstinencia. La suposición de un vínculo entre la espiritualidad y el alcoholismo se debe a la existencia de los grupos de Alcohólicos Anónimos (AA).

Actualmente, el trabajo de AA es una de las aproximaciones más populares en la recuperación del alcoholismo y aunque su efectividad es un tema controvertido, diferentes investigaciones sugieren que la asistencia a este tipo de grupos puede ser benéfica, especialmente para quienes participan más en las actividades y creencias al interior de los mismos.

Un concepto central en AA es la aceptación de una fuerza espiritual procedente de un poder superior para la recuperación del alcoholismo que implica aceptar la espiritualidad, que es vista como una experiencia de transformación o de "despertar espiritual" como resultado de asistir a los grupos AA y de la práctica de los 12 pasos.

En nuestro país hay pocas investigaciones sobre la participación de la espiritualidad en la recuperación del alcohólico. El objetivo de este trabajo es conocer en qué medida la práctica de los 12 pasos y la periodicidad de la misma, además de la experiencia del "despertar espiritual" influyen en el mantenimiento de la abstinencia en miembros de AA.

Se trabajó con una muestra no probabilística de 192 miembros de AA quienes participan en los grupos tradicionales o de "hora y media" del área sur de la Ciudad de México. La muestra se subdividió en dos grupos: recaídos (n=49) y no recaídos (n=143).

Se diseñó una pregunta para explorar la práctica de cada uno de los pasos del programa de inducción a la abstinencia y una escala que exploró la periodicidad de su ejercicio. Dado que AA contempla la idea de un "despertar espiritual" como resultado de la práctica de los 12 pasos, se introdujo una pregunta que exploró su ocurrencia.

Los resultados mostraron que, en promedio, los AA no recaídos han practicado un mayor número de los 12 pasos (Media=9, SD=4.1) que quienes han recaído (Media=7, SD=4.4) con diferencias significativas entre ambos grupos (t=2.304, gl= 190, p=.02).

Dado que AA asume que la práctica de los 12 pasos conduce al despertar espiritual, se realizó un análisis de regresión logística para probar esta asunción. Los resultados sugieren que un mayor involucramiento con los pasos 4° al 12° (convencionalmente considerados por AA como pasos de acción y mantenimiento) aumenta 10% la probabilidad de lograr un "despertar espiritual" (p=.000) y que tal experiencia eleva 2 veces la probabilidad de mantener la abstinencia en los AA que la han alcanzado (Exp[B]=2.095, IC=1.032-4.253, p=.04).

Los resultados de este estudio mostraron que espaciar o nunca practicar los 12 pasos genera niveles bajos de espiritualidad y que éstos pueden causar recaída, en tanto que una mayor espiritualidad tiene implicaciones importantes para la recuperación del alcohólico. Asimismo, en esta muestra, la vía para desarrollar la espiritualidad y el mantenimiento de la abstinencia, requiere de actividad cognitiva, emocional y conductual y no sólo convencimiento de la enfermedad y de su probable solución.

Los 12 pasos representan una forma particular de expresar la espiritualidad que se encuentra limitada por prácticas y cogniciones específicas, por lo que son necesarias investigaciones adicionales para confirmar estos resultados con otras medidas de espiritualidad.

Palabras clave: Espiritualidad; 12 pasos; abstinencia; recaída; Alcohólicos Anónimos (AA); alcoholismo

Summary:

In alcoholism research, the exploration of the spirituality have a great importance. Some authors keep distance from this concept and it has been commonly criticized. However, other researchers (Gorsuch, Connors, Tonigan, and Miller) have agreed in pointing out to this and other variables, like religion for example, as important elements that protect individuals from addiction, also as factors that favor treatment and mediate in long abstinence periods. According to Morjaria and Orford, the assumption of a link between spirituality and alcoholism exist because is one of the principles of Alcoholics Anonymous (AA) foundation.

In the present, the work of AA is one of the most popular approaches in recovering from alcoholism, within Mexico and in other countries as well, and although its effectiveness over alcohol consumption is still debatable, not well documented and inconclusive. There is evidence suggesting that a regular participation in the group meetings could benefit a lot of individuals; especially those whose participation in all the activities is more enthusiastic and those who develop more beliefs inside the groups.

A key element in AA's philosophy is the acceptance of a spiritual strength that comes from a bigger power than themselves (Higher Power: can be understood as a "whole" or the power represented by God), which helps in the recovery process. AA acknowledge the importance of religious thoughts, and the relevance of spiritual tradition in the recovery of each alcoholic, however, the core of the treatment is not placed on these aspects, but it is on spirituality. According to AA, every individual may have his own definition of spirituality and it is outlined by his personal orientation. In that respect, Forcehimes, Kurtz, and Ketchman said that spirituality is a transformation breakthrough marked by a personal experience of "spiritual awakening", all resulting from regular participation to the meetings and from the daily practice of the twelve-step program.

The twelve-step program represents one of the most important components in the recovery strategy of AA and reflects the spiritual nature of the program. DiClemente and Gabhainn have noted that the practice of the steps has fundamental implications in reaching and maintaining abstinence, especially for those who practice them on a regular way. However, available evidence about the benefits that each step brings to the alcoholics is still limited and sometimes controversial.

There are very few investigations in Mexico about the role of spirituality in the alcoholic recovery process. AA have not been sufficiently studied and there is a lot unknown about their treatment strategies.

The objective of this study is to know if the effectiveness of the practice of the 12 steps, the frequency of their practice, and the experience of the "spiritual awakening" (that AA consider as a consequence of practicing the steps) influence on the maintenance of abstinence in members of AA.

The sample was non probabilistic and included 192 AA members from traditional groups (or "an hour and a half" groups, named after the time meetings last) from southern Mexico City area. Individuals were divided in two groups: relapsed and not relapsed. The first group included 49 alcoholics (90 percent of males, 10 percent of females) who relapsed after an abstinence period of three or more months within AA (abstinence mean = 2.4 years). The second group included 143 subjects (86 percent of males, 14 percent of females) who have not relapsed since they entered AA or for a ten year period or longer.

To determine the influence of the spiritual principles of the 12 steps program, a question was designed to measure the practice of each one of them, as well as a scale to explore the frequency of such practice. Also, since AA considers the "spiritual awakening" as a result of working with the steps, a question about its occurrence was included.

Results showed that not relapsed individuals have practiced significantly more steps (mean=9, SD=4.1) than the relapsed ones (mean=7, SD=4.4) (t=2.304, df=190, p=.02). Results also showed that frequency in the practice of: thinking about events that led to alcoholism (steps 4 and 5), humbleness to accept help from a Higher Power (steps 6, 7, and 11), acceptance of responsibility to reduce the consequences of addiction (steps 8, and 9), and helping other alcoholics (step 12), is significantly different between both groups; not relapsed individuals had a more frequent practice of these steps.

Since AA assumes that working the steps leads to experience a spiritual conversion or "spiritual awakening" (it implies a change in the self-concept, in the view of the world, and stop being self-centered), a regression analysis was performed to test this assumption. Results suggested that a greater involvement in steps 4 to 12 -usually considered as steps for action and maintenance- increases 10 percent the probability for experiencing the "spiritual awakening" (p=.000). Besides this experience increases two times the probability for staying sober in not relapsed subjects (Exp[B]=2.095, CI=1.032-4.253, p=.04).

No statistical differences were found in the practice of steps 13, but this does not mean that they are not important, for these are the most practiced steps in both groups. However, the fact that relapsed alcoholics put great value upon these steps, points out their willingness to stop consuming (apparently they have accepted being powerless before alcohol, and to surrender their will and life to a Higher Power), but it also underlines their difficulty in attaching to some of the beliefs and activities that AA consider as base to complete the practice the steps and to develop spirituality. Several of these activities are related to elements in the program that mean more action and certain degree of confusion and discouragement for those who focus in staying sober only based on a vague idea of what constitutes the Higher Power.

AA recognizes the first three steps as the facilitators of abstinence and as the beginning of the path to "spiritual awakening" through an aid that transcends the individual (Higher Power), but they also emphasize that many times this is not enough for the recovery. Paradoxically, they state that this condition could lead to a feeling of false security that could invite the alcoholic to flirt with the idea of having "just one drink". Therefore, it is not casual that relapsed individuals in the sample of this study focus on practicing the first three steps, though more research is needed to further confirmation.

These results allow concluding that spacing out the practice of the 12 steps or not practicing them at all, produces low levels of spirituality, which could be the cause of a relapse. Results also showed that a higher level of spirituality (linked to the practice of more steps) has an important influence on the recovery of alcoholics, particularly for those whose practice of the steps is more regular. The sample of this study showed that its particular way to develop spirituality (spiritual awakening) and therefore maintain abstinence requires of a process that involves cognitive, emotional, and behavioral activity (steps 4-12), and not only to embrace the conviction of alcoholism as a disease susceptible of being cured (steps 1-3).

Finally it is important to indicate that the 12 steps program represent a particular way of expressing spirituality, and that they are limited to specific cognitions and practices; thus, more research is required to replicate these results with other measures of spirituality.

Key words: Spirituality; twelve-step program; abstinence; relapse; Alcoholics Anonymous (AA); alcoholism