I hear a single voice as I walk up the steps to the meeting room. It reminds the men and women gathered in a half circle that, yes, they admitted powerlessness over alcohol, and that only a power greater than themselves could restore their sanity. Drunks-R-Us is held in a sunlit room at a liberal church in Berkeley, California. Inside, there are more than 30 people, most looking like they just arrived from the farmer's market. They confess to numerous trespasses against strangers, friends, family and themselves – betrayals wrought by a lifetime of addiction. A tanned gentleman, nearing 60 years old, dressed in a lime-green button-up shirt and khaki pants, describes four court orders for driving under the influence, time spent in San Quentin prison, owning his own business, years of sobriety lost to 'a damn quart of vodka'. But, first, he says: 'I ask God that his words come out of my mouth.'
Almost 2 million people in some 80 nations currently claim membership in 12-step programmes. Members belong to what's called the fellowship, a convening of men and women trying to recover from addiction through peer support. There are no membership fees, no formal membership, no official leadership. The adherents of Alcoholic Anonymous (AA) live by 12 principles first set out in 1939 in what's known as the Big Book, a conversion story written largely by a layman, Bill Wilson, a Wall Street stockbroker from rural Vermont who wrenched himself free from the clutches of alcoholism.
Wilson's 12 steps are a set of spiritual principles meant to teach alcoholics how to tame their darkest impulses. The first step involves admitting powerlessness over the addiction. The second and third steps involve turning oneself over to a higher power, some form of God. Other steps include a 'fearless moral inventory' of the self, a deep relationship with a higher power through prayer and meditation, and subsequent reckoning with those who have been harmed. The act of making amends, step eight, is perhaps the best known of the 12. A final step involves carrying the message to other alcoholics and practising 'these principles in all our affairs'.
Wilson's treatise has long served as a template for deliverance, and not just from the bottle, but also drugs (Narcotics Anonymous), gambling (Gamblers Anonymous), overeating (Overeaters Anonymous) and other destructive behaviours. The teachings of the Big Book are the basis for treatment at many rehab facilities operating today. Across these programmes, the onus of recovery rests with the addict – if he fails, he must not have worked the steps hard enough and should try again.
Throughout the 20th century, before the addict's plight could be explained by neuroscience or subdued by medication, the AA philosophy of liberation was embraced. Compelling tales of recovery were justification for the 12-step programme's adoption into the criminal justice system as well. In towns and cities that lacked drug courts or funding for substance abuse treatment, AA and NA were the affordable choice.
The surprising thing is how dominant the approach remains. Even though the literal circuits of addiction in the brain have since been found, and a host of new cognitive and drug therapies can help those with specific issues such as impulse-control, or with accompanying psychiatric disease, AA remains the overwhelming treatment of choice. 'Standing up and saying AA doesn't work at a science meeting is like standing up at an atmospheric conference and saying climate change doesn't exist', said the Stanford University psychiatrist Keith Humphreys, who takes a more nuanced stance. Humphreys told me that the programmes can work, but calls it 'terrible' to ask people to rely on a single recovery method, including AA, when there are so many variations and causes of this neurobiological disease.
Despite a revolution in addiction research, the latest version of the Big Book stays firmly rooted in the past – a time-capsule that hasn't updated its science at all. Instead of outtakes from the latest peer review, the tome still features a letter from the late physician William Silkworth, who describes alcoholics as uniquely sensitive to spirits: 'These allergic types can never safely use alcohol in any form at all…' Wilson portrays the required vigilance as a matter of will. Even one slip, one drink, can bring the addict tumbling down. 'Opinions vary considerably as to why the alcoholic reacts differently from normal people … we cannot answer the riddle,' Wilson wrote in 1939.
addiction is a habit rooted in brain circuitry, and frequently a consequence of a traumatic experience from childhood
Yet, by 2014, this curious thing known as addiction has been pinned down. George Koob, director of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (NIH) in the US, has written at length about how alcohol and drugs work on the brain. By over-engaging the reward system – the circuitry of brain networks that send pleasant chemicals coursing through the body – drugs and alcohol can trigger a stress response, he told me. The brain then begs for relief, which is often delivered in the form of more mind-altering substances. And every time that respite comes, the body and brain are a little more sensitive to stress. 'Alcoholics are drinking to control a system that's out of control,' Koob said.
The one-size-fits-all therapy of AA can't possibly address every facet of the disease: addiction is a habit rooted in brain circuitry, but also frequently a consequence of a traumatic experience or exposure from childhood onwards. Most of us just flirt with addiction, stopping our habit without any formal treatment or intervention from self-help groups such as AA. Others struggle mightily over a lifetime, their addiction a spectre – an ever-present haunting.
Addiction, moreover, often exists in tandem with other neuropsychiatric disease – a find that the Big Book has not been revised to include. Nearly a third of adults who experience mental illness have an addiction. This number skyrockets for jail and prison inmates. Three quarters of those with mental health problems also have a substance use disorder.
This dual suffering is palpable at AA meetings. A young woman wearing a coral sundress at the Drunks-R-Us gathering seemed to gently shake, holding back tears, as she spoke of relentless depression and anxiety. She didn't want to sacrifice several years of sobriety, but she'd found little success with the mood stabilisers recommended by her doctor. 'They don't know jack about the brain,' she said. Heads nodded in agreement.
When participants share their life stories at an AA meeting, they often reflect on psychological terror or physical trauma at the hands of people who were supposed to protect them as children. At another meeting in Berkeley, a woman spoke of her 'rage-a-holic' father who drunkenly lumbered around the house, smelling like 'metabolised vodka' and swinging his fists into the walls. It wasn't long before she turned to booze as a teenager and spent decades trying to break free.
Her multiple relapses, according to recent science, are no ethical or moral failing – no failure of will. Instead, they are the brain reigniting the neurological and chemical pathways of addiction. Ruben Baler, a health scientist at the National Institute on Drug Abuse in the US, told me that, once the circuitry of habituation is in place, it cannot be destroyed or fully overwritten. 'The brain will never go back to a pristine, naïve, drug-free state,' Baler said. It would be like reversing time itself.
This permanence is the result of a process that researchers call 'chunking': a person using drugs or alcohol experiences a burst of the activating neurotransmitter, dopamine, encoding memories and stimuli associated with that high in the brain. As substance use turns chronic, that same networks in the brain are increasingly engaged, and eventually the habit becomes automatic. Baler likens it to riding a bicycle – once the brain knows what to do with the pedals, brakes and handlebars, the action is inevitable. When any part of this chain, or chunking, is triggered – maybe it's a visit from an addict friend, or the sight of a McDonald's where you once got high in the bathroom – it can lead to a full-blown relapse. That's why lifelong abstinence can be such an impossible goal for even the most committed of recovering addicts.
In an AA meeting, such setbacks are often seen as an ego out of control, a lack of will. Yet research describes a powerful chemical inertia that can begin early in life. In 96.5 per cent of cases, addiction risk is tied to age; using a substance before the age of 21 is highly predictive of dependence because of the brain's vulnerability during development. And childhood trauma drives substance use in adolescence. A study of 8,400 adults, published in 2006 in the Journal of Adolescent Health, found that enduring one of several adverse childhood experiences led to a two- to three-fold increase in the likelihood of drinking by age 14.
Perhaps because the latest round of research is so new, therapies emerging from it are too green to claim potent results. Compared with more recent behavioural and motivational therapies, AA – folk medicine or not – holds its own. In one ambitious trial published in BMC Public Health in 2005, researchers from the University of Miami School of Medicine compared three approaches: 12-step facilitation; cognitive behavioural therapy focused on dealing with urges; and motivational therapy, designed to provide feedback about substance use and increase a sense of individual agency. According to the study, all three therapies improved abstinence by some 10 per cent – hardly a stellar result.
Alleviating the suffering of even a small percentage of addicts in voluntary programmes is surely significant – and until new therapies are developed and improved, the folk-medicine approach of AA deserves as much clinical credence as anything else. But those results don't shed light on efficacy for offenders forced into treatment by courts, a population currently in the cross-hairs of the 12-step debate.
Lee Ann Kaskutas, a senior scientist at the Alcohol Research Group in Emeryville, California, says ideally a clinical trial could show how well 12-step programmes work for this second group – and there is reason to think it falls short. 'I've wondered if it really makes sense to ask a court-mandated drunk-driver to be abstinent all the time,' she said. In other words, sending someone who is not alcohol-dependent but made a regrettable decision to AA might not be the most effective thing to do. That person might benefit more from cognitive behavioural therapy, a skills-based intervention that helps a patient identify both the triggers that lead to excessive drinking and the coping skills to defuse those trying moments. 'We need to think about what the problem is,' Kaskutas said.
The criminal justice system has deferred that task. Take the case of Barry Hazle, who was convicted of methamphetamine possession and had already served a year in a southern California correctional facility by February 2007. Prior to his release, he told officials that, as an atheist, he could not abide a treatment programme that asked him to submit to a higher power. Still, he was assigned to a 12-step residential facility for 90 days.
He attended the programme, but implored state and clinic officials to find a secular alternative. 'Let me begin by assuring you that my aim in this endeavour is not to get out of having to complete my parole requirements,' Hazle wrote. 'I have committed myself to a full and lasting secular recovery and complete abstinence from illegal drugs.'
But the recovery centre told Hazle's parole officer that he was 'sort of passive aggressive' and 'disruptive, though in a congenial way, to the staff as well as other students'. Correctional officers deemed Hazle in violation of his parole and sent him back to prison for 100 days. Demanding that Hazle participate in a religious-based treatment was unconstitutional at the time, according to previous federal court cases, but the correctional officers claimed that they had no other alternative for Hazle. Later in 2007, California courts affirmed the unconstitutionality of coerced AA, NA and 12-step rehab in a separate case.
His request to attend a non-12-step programme at his own expense was devastating: the legal battle sent him into bankruptcy and the board suspended his licence
The California Department of Corrections and Rehabilitation (CDCR) is taking note. Bill Sessa, a spokesman for the CDCR, told me that the agency has recently reviewed its addiction treatment programmes to ensure that they are based on clinical and scientific evidence. 'The only programmes that we mandate for inmates and parolees are based on that criteria,' he wrote in an email. 'As a result, none of our sponsored or contracted drug or alcohol treatment programmes are "religious based".'
Yet the perspective is hardly widespread. In recent years, even physicians have been forced by other doctors to take the 12-step route. In one recent North Carolina case, an emergency medicine doctor voluntarily reported a single arrest for driving under the influence to the state's physician health programme, which is designed to help clinicians with psychiatric and substance abuse disorders. The doctor, James David Fenn, was subsequently diagnosed an addict and ordered to undergo expensive treatment at one of three out-of-state 12-step facilities. He disagreed with the board's assessment, but failing to comply would cost Fenn his licence. Like Hazle, Fenn's request to attend a non-12-step programme at his own expense was devastating: the legal battle sent him into bankruptcy and the board ultimately suspended his licence.
Without consensus over science-based addiction treatment, chaos abounds: a 2012 report from the National Center on Addiction and Substance Abuse at Columbia University holds that most doctors are 'uninformed' about addiction and can rarely diagnose, treat or refer patients to specialists. Staff at treatment facilities often lack training in addiction, and programmes aren't held accountable for delivering treatment that works.
Optimal treatment for addiction, of course, is still a work in progress. Even neuroscience, with its sophisticated understanding of the brain, has yet to deliver on the promise of a radical new surgical intervention that might repair the damaged circuits that rev on the addict. Every circuit, Baler explained to me, has several functions, and we don't yet possess the technology to repair the defective ones. The best hope so far might be deep-brain stimulation via implanted electrodes or targeted electroshock therapy, which could potentially moderate neuronal activity. But this research is in the very early stages for treating addiction.
Instead, Baler told me, patients should look to prescription drugs to help create the 'space where long-term healing can occur'. These include methadone and naltrexone, which pre-emptively bind to receptors in the brain to block the effects of the drug or alcohol, and disulfiram, which prevents the body from metabolising alcohol, causing unpleasant symptoms such as vomiting, sweating and vertigo. Some AA members don't look kindly on prescription drug use, insisting that it replaces one substance with another. But Baler has his own perspective: a patient cannot begin to curtail his habit while experiencing craving or withdrawal. Drugs that provide even a brief reprieve from the intensity of addiction are key to starting that process.
What these patients require, he says, is a holistic approach that accounts for forces such as mental illness, unemployment, chronic stress, and childhood abuse. This might look something like the science-based treatment that patients receive at a Minnesota clinic called Alltyr, founded by Mark Willenbring, the former director of the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism at the NIH. The wounds of addiction, Alltyr holds, must be tended along with the disease itself before an addict can be restored to health. And that, Baler says, happens most effectively through adopting new coping skills and behaviours developed and tested by researchers.
Some argue that AA offers just that opportunity, with its steps, affirmations and peer support. Back in that sunlit room in Berkeley, surrounded by recovering addicts who share testimony about the salvation of AA, I can see their path to redemption. The suffering in the room feels like the movement of a wave – that moment when the ocean's water is pulled back into the abyss and the sand disintegrates beneath your feet. The hour-long ritual of sharing and grieving and lamenting is a way of resisting the void, of pushing it back so that it doesn't consume you again. With newer therapies so emergent, with research ongoing and trials incomplete, this seems a proper way.
Outside of this room, though, there are many whose lives were touched by alcohol or drugs but somehow remained whole. Even if those lives cracked, conversion to the AA way of life might not be the answer. And that must be acceptable. Those who suffer must be afforded the right to mend and atone according to their own beliefs.
6 August 2014