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Curing addiction: Twelve Steps or fixing the brain?

Hans Pols – Associate Professor, History and Philosophy of Science at University of Sydney

MEDICAL HISTORIES – The fourth instalment in our short series provides a brief overview of Alcoholics Anonymous and considers the reasons for its success.

Alcoholics Anonymous provides a non-medical intervention for problem drinking. It’s based on a Twelve Steps program of spiritual and character development, and tends to polarise the medical field, largely because of its emphasis on spirituality.

AA is arguably one of the only treatments effective for alcoholics wishing to become sober. And few, if any, support groups or organisations can claim the widespread acceptance and awareness of Alcoholics Anonymous. But AA’s approach to curing addiction is not medical at all.

Why is it that an organisation founded on the idea of a spiritual awakening has been able to cement itself firmly in the history of addiction research and treatment? Has this been a help or a hindrance to understanding the condition?

In the nineteenth century, physicians considered all forms of addiction to be a sign of akrasia, or weakness of will. This developed into a view that addiction is a consequence of an individual’s psychological development interacting with their social environment.

Alcoholics Anonymous was founded by Bill Wilson and Dr Bob Smith in 1935. It was largely after 1956, when the American Medical Association recognised alcoholics as legitimate patients requiring medical care, that the idea that alcoholism was a disease took hold. But physicians were not able to come up with a medical cure that worked.

The now familiar concept that the cause of addiction is to be found in the brain appeared after this. Advancements in technology allowed researchers to pinpoint some of the pathways of addiction.

In 1979 Avram Goldstein argued that heroin and all narcotics work on our brain’s reward system. These drugs hijack the regular pathways of dopamine, wreaking havoc on the brain’s ability to regulate it and endorphins. This havoc, he argued, leads to addiction.

This “brain-based” model of addiction directed research until the 1980s and 1990s, when Dr Stanton Peele and Dr Bruce Alexander independently began to question the isolation of addiction research from cultural contexts.

Both Peele and Alexander wrote that addiction is more than just the effect of a drug on the brain. The context in which an individual engages in drug taking is equally important as the drug itself. Alexander went as far as to argue that the idea of drug-induced addiction was a myth.

In contrast, in 2004 the World Health Organization released the report Neuroscience of Psychoactive Substance Use and Dependence, summarising the advancements of the neurosciences in the early parts of the twenty-first century. The report concluded that substance dependence is a disorder of the brain like other brain disorders. It also suggested that addiction was largely determined by biological and genetic factors.

Throughout this, Alcoholics Anonymous and its fellowship organisation Narcotics Anonymous steadily gained momentum as the frontline treatment for alcohol and narcotic addiction. Alcoholics Anonymous is not well-known for promoting the disease model of addiction, though it usually steers clear of any discussion of its medical aspects. It wasn’t until 1973 that the organisation’s conference literature contained reference to alcoholism as a disease.

Research into the effectiveness of Alcoholics Anonymous is made difficult by the self selection of members, which leads to sampling bias. In all, these studies produced inconsistent results.

The organisation provides a free service with non hierarchical system of governance and a good track record of individual testimonies. It has made its way into many treatment plans and strategies for recovering addicts. But it is not without critique. As early as 1964, Arthur H Cain, a member of AA himself referred to the organisation as a “cult” and a “hindrance” to research and psychiatry, suggesting the model didn’t allow addicts to obtain other kinds of help should they need it.

The narrative of addiction that Alcoholics Anonymous and the Twelve-Step program provides addicts and clinicians is a pervasive one. It was a powerful contribution to the way that substance users created and developed their identities as “addicts”.

The personal stories that have emerged out of addiction literature reveal that the Alcoholics Anonymous model has been thoroughly ingrained into the wider story of addiction. This may affect individuals’ experience of the condition.

It’s possible that this has been to the detriment of clear research. By defining themselves as “addicts” and assimilating the model of addiction that Alcoholics Anonymous provided, substance users may have unwittingly affected the course of their condition. Yet as suggestive as neurological research may have been, it did not provide the miracle cure some hoped for. For better or worse, this means that we are stuck, for the time being, with the Twelve Steps program.

Reproduced with Permission The Conversation