The Science Behind A.A.
by Charlotte Wincott
If you’ve ever struggled with a substance use disorder (or addiction, as I still like to call it), you know that beating it is one of the most challenging things you will ever have to do. If you are anything like I was seventeen years ago, you may question whether or not overcoming this disease is even possible. Perhaps you’ve seen your friends and loved ones struggle. Maybe you have buried people much earlier than they should’ve been buried and it’s left a gaping hole inside of you that feels raw every single day. That’s the hole that I have had since I lost my mother to alcohol use disorder (AUD) and a number of other diseases that she had acquired because of her inability to overcome her addictions.
When I went back to school fifteen or so years ago, I wanted to try and understand why substance use disorder was killing the people that I cared about. Back then, it was so incredibly baffling to me because it seemed like a disease that was either curable or preventable since there appeared to be free will involved but I didn’t really understand how much. Now, after many years of study that includes a Ph.D. in neuroscience, I’m still not quite sure how much free will is involved. If you’ve ever been addicted to a drug (or to food or sex), you know what it feels like to crave that one particular thing that you’ve found so powerful so many times before. You know that you MUST have it, even though it is ruining your life. When you break down and take that drug, have that drink, or eat that chocolate cake, you feel like a failure because you were supposed to have free will. (We will save the philosophical debate about free will versus determinism in the context of addiction for another day.) As scientists, we can wax intellectual all day long about which parts of the striatum are most active during impulsivity versus compulsivity while scratching our chins, but knowing what it feels like to desperately need something that is wreaking indescribable havoc on your life takes this quandary to a whole different level. Why is it so hard to say “no thanks” to the very substance that is sabotaging your entire life? This is the million-dollar question that has been studied in laboratories for years and why researchers now generally agree that addiction is a brain disease and not the result of moral weakness.
Addiction is a complicated problem with a variety of solutions, some of which may work for some people and some of which may not. Different treatments may fit different individuals’ habits, goals, genetic makeup, and drug use history and I don’t rule out any of them as having the potential to help. Everyone has a different definition of what recovery means to them, and I’m of the mind that there shouldn’t be black and white rules as to right and wrong ways to recover. I have my own opinions, but I also try to listen to the opinions of others and have an open mind.
All of that being said, when my friends ask me what I think they should do if they want to stop drinking, I usually give them my opinion. I’m not a medical doctor and the advice that I give them is based on my personal experience and the information I gained from my education in neuroscience. If the person is drinking very large quantities every day, they would likely need to be supervised in a medical setting to detox. If not, and the person does not have comorbid social anxiety, I will tend to suggest that they try a 12-step program. I believe that going to 12-step meetings, putting a dollar in the basket each time, and finding a sponsor can put many on the path to recovery. Alcoholics Anonymous (AA) is cheap, meetings are easy to find, and it works. (Opioid use disorder is an entirely different beast, so I would likely give different advice to a friend struggling with OUD and that advice would include medication.)
You may be wondering why a scientist would advise friends to go to a program where the main premise in combating substance use disorder relies on the belief in God. “God” is not a welcome term in the halls of academia, and scholars may, in fact, look at you like you’re off your rocker if you dare to admit that you pray. Nevertheless, from a scientific point of view, the existence or nonexistence of God may be beside the point. The belief in God (or a higher power) may be the critical element in improving one’s functioning enough to make recovery more likely.
Frequently those with substance use disorder started using drugs or drinking because they have comorbid anxiety and other mood disorders.1,2 Having a belief in God may protect against unpleasant emotions like anxiety by relieving some of the negative effect involved in fear and uncertainty.3 Religious conviction has been shown to be associated with decreased activity in certain brain areas in response to error and uncertainty,3 and a secure attachment to God may also increase self-esteem.4 In those with SUD, an individual may fear his/her actions based upon behavior patterns of the past. Step 3 of the 12 steps (making the decision to turn one’s will and life over to the care of God as he/she understands him) may help to lower an individual’s anxiety based upon the notion that a higher power would finally be in control.
Other aspects of 12-step programs are also conducive to recovery, including community involvement and social interaction. In animal studies, rats will choose social interaction with another rat over heroin or methamphetamines,5 which indicates that even at a primitive level, social engagement is powerful. In humans, social interaction and reinforcement may have the capacity to replace some of the rewards or “highs” that a person feels when he/she drinks or uses drugs. 12-step programs are a perfect venue to absorb some of these types of rewards. You hit milestones and people clap, new friends call to find out how you are doing, and you have the opportunity to help others (which is another central component of the program).
Anecdotally and in my own microcosm, I have observed the effectiveness of 12-step programs (especially in the beginning of recovery). Friends of mine have inspired and amazed me at their ability to completely turn their lives around. The literature, however, is somewhat mixed. I only recently began combing through some of the studies as I have always heard that 12-step programs are challenging to investigate and are generally dismissed during scientific discussions. Regardless, I reached out to Dr. John F. Kelly, Professor of Psychiatry at Harvard Medical School, to ask about his research on them. He was incredibly helpful and mentioned that a soon-to-be-published systematic review and meta-analysis of the research on AA and Twelve-step Facilitation (TSF) treatments will reveal that “in 27 included trials with about 11,000 participants, AA/TSF treatments did as well as more well-established treatments (like cognitive behavioral therapy) on various clinical outcomes and did significantly better at producing higher rates of complete abstinence compared to more well-established treatments.” He also added that “compared to well-established treatment, AA/TSF substantially reduces health care costs while enhancing abstinence rates.” I was pleasantly surprised to learn of these data as they were not at all what I was expecting to hear. Because 12-step programs do not cost individuals huge sums of money, they are accessible which makes them a viable option for many.
12-step programs are a potential solution to a problem that is killing people every day. Even still, many will disparage 12-step programs for a number of reasons, including their basis on the belief in a higher power. Others might vilify medication-assisted treatment as not being congruent with 12-step programs. Some think that only one medication should be used but not another. While everyone is entitled to her/his own opinion, I am of the mind that we try to remain open to all potential solutions. If people weren’t dying in droves on a daily basis, it wouldn’t matter so much about different philosophical perspectives but the truth is, they are; and as a community, we need to put aside our differences, put together our resources, and come together to beat this deadly epidemic.
1 Robinson, J., Sareen, J., Cox, B. J. & Bolton, J. Self-medication of anxiety disorders with alcohol and drugs: Results from a nationally representative sample. J Anxiety Disord 23, 38-45, doi:10.1016/j.janxdis.2008.03.013 (2009).
2 Turner, S., Mota, N., Bolton, J. & Sareen, J. Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depress Anxiety 35, 851-860, doi:10.1002/da.22771 (2018).
3 Inzlicht, M., McGregor, I., Hirsh, J. B. & Nash, K. Neural markers of religious conviction. Psychol Sci 20, 385-392, doi:10.1111/j.1467-9280.2009.02305.x (2009).
4 Kent, B. V., Bradshaw, M. & Uecker, J. E. Forgiveness, Attachment to God, and Mental Health Outcomes in Older U.S. Adults: A Longitudinal Study. Research on aging 40, 456-479, doi:10.1177/0164027517706984 (2018).
5 Venniro, M. et al. Volitional social interaction prevents drug addiction in rat models. Nat Neurosci 21, 1520-1529, doi:10.1038/s41593-018-0246-6 (2018).
Charlotte Wincott, PhD is an Associate Director at Pear Therapeutics. All opinions and views expressed in this article are her own and not necessarily those of Pear Therapeutics.