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A few Fridays ago, “Keith” said, in an Alcoholics Anonymous (AA) meeting I attended, that his niece is an addictions counselor, and that she does not recommend AA for her clients, that AA “is a cult, and all my clients would do is switch dependencies”. At another meeting, “Jasmine” said that her therapist told her that AA is okay for the first few weeks of recovery, but that she should not come to depend on anything but herself for her addictions recovery. “Mike”, a school counselor, believes that he would never recommend AA to an addicted student, since it is too full of God-talk and is not for young people. Finally, a counselor named Jackson says, “I went to a few AA meetings, and I hated them—too many slogans, rules, and corny sayings.” In an article entitled “Why the Hostility Toward the 12 Steps?”, Dr. David Sack (2012) stated that false beliefs about 12-step programs keep many addicts away from resources that could change the trajectory of their lives, and that the 12 steps have worked when many other approaches have failed. In a later article, Dr. Sack (2014) cited the research of Dr. Marc Galanter, professor of psychiatry and founding director of the Division of Alcoholism and Drug Abuse at New York University, who has found that many of the cognitive and emotional experiences and changes that occur in 12-step meetings can be explained with neuroscience.
Mental health professionals who reject the relief and recovery offered by adjunct helping groups such as AA and other 12-step programs do a dangerous disservice to their clients. Every sort of satirical and critical remark can be made, and is made, about the 12 steps and AA. People make fun of the call-and-response format of the meetings: “My name is Lissa, and I am an alcoholic.” . . . “Hi, Lissa!” I have heard the slogans (“one day at a time”, “first things first”, “keep coming back”) articulated with derision, and seen the “recovering type” satirized both in print and on programs like Saturday Night Live (e.g., by the comedian Stuart Smalley). More disturbing, though, than this stereotyped ridicule is the antipathy on the part of some mental health professionals dealing with addiction, who maintain hostility toward AA. I strongly suggest that this could be foreclosing a possibility of recovery for their addicted clients.
Perhaps we should take a look at professional arrogance and territoriality in the therapeutic community. A practitioner who cleaves too closely to one school of practice to the exclusion of others runs the risk not just of obsolescence but, more critically, of disservice to clients. In my roles as counselor and counselor–educator, I have encountered therapists who identify as CBT (cognitive-behavioral therapy) or DBT (dialectical behavioral therapy) or Freudian or Adlerian practitioners, who reject findings, or even possibilities, that supersede or refute the effectiveness of their particular therapeutic point of view. And in my roles as coach and coach–educator, I have encountered therapists who look askance at coaches, who see coaching not as a legitimate helping profession but as a suspect advice service with the added implication that one has “gone over to the dark side”.
Mental health workers need at least a passing understanding of neurobiology to contend that they are current in their field. Just as we need to adapt to changing ideas and practices, we need open minds to look at old systems afresh. Neuropsychotherapy and AA are not uneasy bedfellows: I suggest they are a pretty solid marriage, in fact. Further, I suggest that people who claim to help others ignore either of these partners at their peril. More and more professionals and lay people understand terms such as “mirror neurons” and “neuronal pathways”, and therapists who are willing to embrace new ideas will be more likely to discover interventions that can work in the lives of their addicted clients (Hall, Carter, & Morely, 2004). It is my hope that henceforth neuropsychotherapists will strongly and enthusiastically recommend working through a 12-step program as a complementary practice to counseling with addicts and their families, if they are not already doing this.
The 12 steps and, especially, the customs of AA, underscore several crucial aspects of neuroscience. For example, Dr. David Sack asserts in his article, “Mapping AA: The Neuroscience of Addiction” (2014), that not only does chronic substance abuse rewire the neural pathways but that 12-step recovery can be of great help by correcting the faulty wiring that chronic substance abuse has caused.
Alcoholics Anonymous meetings can be of utility concerning this rewiring in three main ways, by
- providing a safe, enriched environment;
- giving opportunity for strong social connections; and
- offering repetitive, positive experiences.
A safe, enriched environment
Of crucial importance in neuropsychotherapeutic interventions are enriched environments and social wellness, which includes interpersonal connectivity (Rossouw, 2013a). AA meetings provide instances of both these basic requirements. The format of most meetings includes readings that establish a safe and accepting environment. Similar passages are read at meetings the world over—so if you are in the English-speaking world, you are likely to hear the AA “Preamble” or “How It Works”. I have heard these read in at least 11 States of the USA, in London in the United Kingdom, and in Grand Bahama Island. I have heard similar readings in French and Spanish, as well. Every time the old rhythm of “How It Works” initiates a meeting, I remember that I am in a safe environment. The language itself is reassuring: “Rarely have we seen a person fail who has thoroughly followed our path” (Alcoholics Anonymous, 2008, p. 58). Most meetings include a reading of the 12 steps where newcomers and old-timers alike come to understand that there are pathways to maintaining a new way of living, and that many of us have traveled them to success. The newcomer is assured that one does not need “perfect adherence” to these principles and that Step 12 means that others are available to help if it is requested. Safety is enhanced by the knowledge that all attending have a clear purpose: to remain sober and to help other alcoholics achieve sobriety.
There are dozens of other examples in AA meetings of what LeDoux (2003) calls an enriched environment—a place where the brain can flourish, and stress is effectively managed. In his discussion of interpersonal connectivity, Pieter Rossouw (2013b) underscored the importance of environment when he wrote that the brain processes and responds “as a result of interplay with its environment [and that] it also adjusts itself and changes as a result of such interactions” (para. 11). A brain that is exposed to a healthy environment will develop new, stronger neuronal networks that will help develop resilience when faced with adverse conditions; in contrast, a brain that is exposed to adverse circumstances results in “an increasing inability to manage life’s challenges” (para. 10).
If therapists are to believe that talking therapies facilitate enriched environments and can elicit structural changes in the brain (Feldstein Ewing & Chung, 2013), then it seems reasonable to suggest that therapists would do well to recommend other environmentally enriching opportunities to clients as well—ones that might supply a more consistent reinforcement beyond weekly therapy sessions. With online and phone sessions available, and with almost ubiquitous face-to-face meetings, AA can be accessed at times when a therapist is not reachable or available. The AA practice of sponsorship, for example—where a more experienced recovering alcoholic agrees to provide support to a person new to sobriety—offers 24/7 encouragement even when a talking therapy is out of reach.
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The second and perhaps more important way that AA supports healing the neuronal pathways and provides for recovery is social connection. AA is people reaching out to the alcoholic to provide loving but “boundaried” guidance and support, from the start and through a lifespan, if the person so chooses to remain involved with 12-step recovery. At the outset, newcomers get a list of phone numbers of AA members (of the same sex) and are urged to call. New members are also encouraged to choose a sponsor, and to begin calling and working with them. AA supplies role models for newly sober alcoholics: as stated in Chapter 5 of the Big Book: “If you have decided you want what we have, and are willing to go to any length to get it—then you are ready to take certain steps” (Alcoholics Anonymous, 2001, p. 58). David Sack refers to the natural benefits of mirroring, where people tend to copy the behavior of individuals with whom they are in close contact, with the result that positive behavior changes can occur when people identify and align with a sponsor (Sack, 2014). He further asserts that hearing stories and sharing their own experiences helps AA members become part of a shared identity that helps stabilize abstinence.
We are social creatures, and social isolation can be both cause and effect of alcoholism. A famous experiment was conducted by Canadian psychologist Bruce Alexander, who worked with rats in isolated cages and tested their preference for pure water or heroin-infused water; (see https://www.summitbehavioralhealth.com/blog/overview-rat-park-addiction-study/ for an overview of the experiment). When the rats were alone, in separate cages without social interaction, they would drink the heroin water until addicted and would finally overdose. But when Alexander placed the rats in a far larger cage, with toys and wheels and enrichment, and with 19 fellow rats he created what he called a Rat Park, at which time the rats began ignoring the heroin-infused water and addiction was rejected in favor of social stimulation and connection.
Robert Weiss asserts that much of the recovery work in 12-step programs comes from connecting the addict to other people, specifically supportive, reliable, and empathetic people (Weiss, 2015). As Dr. David Sack observed, everyone needs support, not just addicts (Sack, 2012). In AA, the overwhelmingly positive support of addicts who have themselves overcome addiction provides a constant social network to sustain alcoholics from their early days in recovery until, hopefully, they die a sober death, if that’s what they choose.
The importance of social connection should not be underestimated. John F. Kelly and Gene Beresin (2014), both of Harvard Medical School, reiterate that the reason 12-step interventions work is that when people engage with groups like AA, this increases their ability to cope with the demands of recovery and to foster critically important changes in their social networks within their own communities.
The human need for social connection, and its profound effects on recovery, reinforces the idea that people do not get better in isolation. AA is unusual in that it is effectively everywhere and largely free of charge. It is quite possible that a therapist may be unavailable at times when an addict is at their most vulnerable—in the evening, at night, on weekends, and on holiday. AA can bridge that disconnection and help the addict navigate daily living until the next appointment.
Another important benefit of the AA program is the repetition that reinforces the connecting, enriching, and down-regulating behaviors that neurobiology contends promote long-term change. AA recommends that newcomers go to “90 meetings in 90 days”. After 90 days, members can lead meetings and tell their story, after which members report feeling an increased sense of belonging and identification. The meeting routines, the sharing of stories, and the mantras, help addicts to focus on the next “right thing to do” even when their thinking may still be muddled (Sack, 2012). Individual routines are further reinforced by sponsorship, as many sponsors ask for daily contact with their sponsees. The phone lists given to new members are another repetitive device for introducing new patterns of thought and behavior for addicts.
All of this is to say: if you are a psychotherapist with an appreciation of the role of neurobiology in addictions, I strongly urge you to not reject the free aid that AA could supply to your clients.
Some psychologists and researchers have published anti-AA articles or books, among them Dr. Lance Dodes and Zachary Dodes whose book, The Sober Truth (Dodes & Dodes, 2014), was critically reviewed in the New York Times by Dr. Richard A. Friedman (2014), who strongly challenged the claim that addiction is merely a “psychological compulsion” that cannot be explained in terms of altered neurobiology.
A second critic, author Gabrielle Glaser (2015), argued that alcoholics can use medication and right thinking to get their drinking under control, and that AA was established “when knowledge of the brain was in its infancy”. Though medication helps many, and is well-accepted in most healthy AA meetings, the rejection of abstinence in favor of controlled drinking sets Glaser’s argument far apart from the beliefs at AA. I have known people who quit drinking without AA, but I have not known a single alcoholic who decided to try controlled drinking and was successful. This anecdotal evidence is also supported by research carried out at the University of Gothenberg showing that controlled consumption is difficult even with a care provider (University of Gothenberg, 2016).
You might be surprised that people in recovery, like many others outside the therapeutic field, are coming to an understanding of neurobiology put forth in readable books like The Body Keeps the Score by Bessel van der Kolk (2014) and The Brain that Changes Itself by Norman Doidge (2010). A week or so ago, I heard “Eric” describe “laying new tracks in my brain . . . by coming to meetings regularly”; “Cindy” spoke of “rewiring”, and “Cathy” said, “I’m thinking I can grow a new brain.” Maybe they are a little naïve, but their simple comments imply familiarity with the idea that recovery is assisted by safe environments, social connections, and the repetition of improved thinking that can be found in church basements and town hall meeting rooms around the world, and that this can make lasting effective changes to the brain as a biological basis for recovery and maintenance.
I would not be sober today, and might not be alive, without AA, my sponsor, and friends who understand depression and alcoholism. As it is, I took my last drink on October 21, 1986. Almost every Saturday morning at 8:30 you can find me in a room, reciting the Serenity Prayer and saying, “My name is Lissa and I am an alcoholic.” It’s only part of my story—I am many other good things, too. There are other places where my recovery has been enhanced, such as at meetings for adult children of alcoholics—but that’s a story for another time. For now, let me just ask you to consider the evidence that AA would be a life-saving adjunct to your therapeutic interventions. Really—it’s a no-brainer, even for brainy people.[/wlm_private]
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Alcoholics Anonymous. (2001). AA big book (4th ed.). Retrieved from https://www.aa.org/pages/en_US/alcoholics-anonymous
Dodes, L., & Dodes, Z. (2014). The sober truth: Debunking the bad science behind 12-Step programs and the rehab industry. Boston, MA: Beacon Press.
Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York, NY: Penguin.
Feldstein Ewing, S. W., & Chung, T. (2013). Neuroimaging mechanisms of change in psychotherapy for addictive behaviors: Emerging translational approaches that bridge biology and behavior. Journal of the Society of Psychologists in Addictive Behaviors, 27, 329–335. doi:10.1037/a0031491
Friedman, R. A. (2014). Taking aim at 12-step programs [Book review]. The New York Times. Retrieved from https://www.nytimes.com/2014/05/06/health/the-sober-truth-seeing-bad-science-in-rehab.html
Galanter, M. (2014). Alcoholics Anonymous and twelve-step recovery: A model based on social and cognitive neuroscience. The American Journal on Addictions, 23, 300–307. doi:10.1111/j.1521-0391.2014.12106.x
Glaser, G. (2015, April). The irrationality of Alcoholics Anonymous. The Atlantic. Retrieved from https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/
Hall, W., Carter, L., & Morley, K. I. (2004). Neuroscience research on the addictions: A prospectus for future ethical and policy analysis. Addictive Behaviors, 29, 1481–1495. doi:10.1016/j.addbeh.2004.06.001
Kelly, J. F., & Beresin, G. (2014, April 7). In defense of 12 steps: What science really tells us about addiction. Retrieved from http://www.wbur.org/commonhealth/2014/04/07/defense-12-step-addiction
LeDoux, J. (2003). Synaptic self: How our brains become who we are. New York, NY: Penguin.
Rossouw, P. J. (2013a, January 19). The end of the medical model: Recent findings in neuroscience regarding antidepressant medication and the implications for neuropsychotherapy. The Neuropsychotherapist. Retrieved from http:// www.neuropsychotherapist.com/the-end-of-the-medical-model/
Rossouw, P. J. (2013b, September 30). The neuroscience of interpersonal connectivity: Benchmarking strategies for effective interventions. The Neuropsychotherapist. Retrieved from https://www.thescienceofpsychotherapy.com/the-neuroscience-of-interpersonal-connectivity/
Sack, D. (2012, November 20). Why the hostility toward the 12 steps? Psychology Today. Retrieved from https://www.psychologytoday.com/au/blog/where-science-meets-the-steps/201211/why-the-hostility-toward-the-12-steps
Sack, D. (2014, July 7). Mapping AA: The neuroscience of addiction. Psychology Today. Retrieved from https://www.psychologytoday.com/au/blog/where-science-meets-the-steps/201407/mapping-aa-the-neuroscience-addiction
University of Gothenburg. (2016, September 14). More difficult to achieve controlled drinking than to give up alcohol entirely. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2016/09/160914090314.htm
Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Viking.
Weiss, R. (2015, September 30). The opposite of addiction is connection. Psychology Today. Retrieved from https://www.psychologytoday.com/au/blog/love-and-sex-in-the-digital-age/201509/the-opposite-addiction-is-connection
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