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AA: After 75 Years...

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      Alcoholics Anonymous

      Alcoholics Anonymous Website

      The Twelve-Step Program

      Bill W. (William Griffith Wilson)


      By Brendan I. Koerner
      June 23, 2010


      The church will be closed tomorrow, and the drunks are freaking out. An
      elderly lady in a prim white blouse has just delivered the bad news, with
      deep apologies: A major blizzard is scheduled to wallop Manhattan tonight,
      and up to a foot of snow will cover the ground by dawn. The church, located
      on the Upper West Side, can¹t ask its staff to risk a dangerous commute.
      Unfortunately, that means it must cancel the Alcoholics Anonymous meeting
      held daily in the basement.

      A worried murmur ripples through the room. ³WhaŠ what are we supposed to
      do?² asks a woman in her mid-twenties with smudged black eyeliner. She¹s in
      rough shape, having emerged from a multiday alcohol-and-cocaine bender that
      morning. ³The snow, it¹s going to close everything,² she says, her
      cigarette-addled voice tinged with panic. ³Everything!² She¹s on the verge
      of tears.

      A mustachioed man in skintight jeans stands and reads off the number for a
      hotline that provides up-to-the-minute meeting schedules. He assures his
      fellow alcoholics that some groups will still convene tomorrow despite the
      weather. Anyone who needs an AA fix will be able to get one, though it may
      require an icy trek across the city.

      That won¹t be a problem for a thickset man in a baggy beige sweat suit.
      ³Doesn¹t matter how much snow we get -- a foot, 10 feet piled up in front of
      the door,² he says. ³I will leave my apartment tomorrow and go find a

      He clasps his hands together and draws them to his heart: ³You understand
      me? I need this.² Daily meetings, the man says, are all that prevent him
      from winding up dead in the gutter, shoes gone because he sold them for
      booze or crack. And he hasn¹t had a drink in more than a decade.

      The resolve is striking, though not entirely surprising. AA has been
      inspiring this sort of ardent devotion for 75 years. It was in June 1935,
      amid the gloom of the Great Depression, that a failed stockbroker and
      reformed lush named Bill Wilson founded the organization after meeting God
      in a hospital room. He codified his method in the 12 steps, the rules at the
      heart of AA. Entirely lacking in medical training, Wilson created the steps
      by cribbing ideas from religion and philosophy, then massaging them into a
      pithy list with a structure inspired by the Bible.

      The 200-word instruction set has since become the cornerstone of addiction
      treatment in this country, where an estimated 23 million people grapple with
      severe alcohol or drug abuse -- more than twice the number of Americans
      afflicted with cancer. Some 1.2 million people belong to one of AA¹s 55,000
      meeting groups in the US, while countless others embark on the steps at one
      of the nation¹s 11,000 professional treatment centers. Anyone who seeks help
      in curbing a drug or alcohol problem is bound to encounter Wilson¹s system
      on the road to recovery.

      It¹s all quite an achievement for a onetime broken-down drunk. And Wilson¹s
      success is even more impressive when you consider that AA and its steps have
      become ubiquitous despite the fact that no one is quite sure how -- or, for
      that matter, how well -- they work. The organization is notoriously
      difficult to study, thanks to its insistence on anonymity and its fluid
      membership. And AA¹s method, which requires ³surrender² to a vaguely defined
      ³higher power,² involves the kind of spiritual revelations that
      neuroscientists have only begun to explore.

      What we do know, however, is that despite all we¹ve learned over the past
      few decades about psychology, neurology, and human behavior, contemporary
      medicine has yet to devise anything that works markedly better. ³In my 20
      years of treating addicts, I¹ve never seen anything else that comes close to
      the 12 steps,² says Drew Pinsky, the addiction-medicine specialist who hosts
      VH1¹s Celebrity Rehab. ³In my world, if someone says they don¹t want to do
      the 12 steps, I know they aren¹t going to get better.²

      Wilson may have operated on intuition, but somehow he managed to tap into
      mechanisms that counter the complex psychological and neurological processes
      through which addiction wreaks havoc. And while AA¹s ability to accomplish
      this remarkable feat is not yet understood, modern research into behavior
      dynamics and neuroscience is beginning to provide some tantalizing clues.

      One thing is certain, though: AA doesn¹t work for everybody. In fact, it
      doesn¹t work for the vast majority of people who try it. And understanding
      more about who it does help, and why, is likely our best shot at finally
      developing a system that improves on Wilson¹s amateur scheme for living
      without the bottle.

      AA originated on the worst night of Bill Wilson¹s life. It was December 14,
      1934, and Wilson was drying out at Towns Hospital, a ritzy Manhattan detox
      center. He¹d been there three times before, but he¹d always returned to
      drinking soon after he was released. The 39-year-old had spent his entire
      adult life chasing the ecstasy he had felt upon tasting his first cocktail
      some 17 years earlier. That quest destroyed his career, landed him deeply in
      debt, and convinced doctors that he was destined for institutionalization.

      Wilson had been quite a mess when he checked in the day before, so the
      attending physician, William Silkworth, subjected him to a detox regimen
      known as the Belladonna Cure -- hourly infusions of a hallucinogenic drug
      made from a poisonous plant. The drug was coursing through Wilson¹s system
      when he received a visit from an old drinking buddy, Ebby Thacher, who had
      recently found religion and given up alcohol. Thacher pleaded with Wilson to
      do likewise. ³Realize you are licked, admit it, and get willing to turn your
      life over to God,² Thacher counseled his desperate friend. Wilson, a
      confirmed agnostic, gagged at the thought of asking a supernatural being for

      But later, as he writhed in his hospital bed, still heavily under the
      influence of belladonna, Wilson decided to give God a try. ³If there is a
      God, let Him show Himself!² he cried out. ³I am ready to do anything.

      What happened next is an essential piece of AA lore: A white light filled
      Wilson¹s hospital room, and God revealed himself to the shattered
      stockbroker. ³It seemed to me, in the mind¹s eye, that I was on a mountain
      and that a wind not of air but of spirit was blowing,² he later said. ³And
      then it burst upon me that I was a free man.² Wilson would never drink

      At that time, the conventional wisdom was that alcoholics simply lacked
      moral fortitude. The best science could offer was detoxification with an
      array of purgatives, followed by earnest pleas for the drinker to think of
      his loved ones. When this approach failed, alcoholics were often consigned
      to bleak state hospitals. But having come back from the edge himself, Wilson
      refused to believe his fellow inebriates were hopeless. He resolved to save
      them by teaching them to surrender to God, exactly as Thacher had taught

      Following Thacher¹s lead, Wilson joined the Oxford Group, a Christian
      movement that was in vogue among wealthy mainstream Protestants. Headed by a
      an ex-YMCA missionary named Frank Buchman, who stirred controversy with his
      lavish lifestyle and attempts to convert Adolf Hitler, the Oxford Group
      combined religion with pop psychology, stressing that all people can achieve
      happiness through moral improvement. To help reach this goal, the
      organization¹s members were encouraged to meet in private homes so they
      could study devotional literature together and share their inmost thoughts.

      In May 1935, while on an extended business trip to Akron, Ohio, Wilson began
      attending Oxford Group meetings at the home of a local industrialist. It was
      through the group that he met a surgeon and closet alcoholic named Robert
      Smith. For weeks, Wilson urged the oft-soused doctor to admit that only God
      could eliminate his compulsion to drink. Finally, on June 10, 1935, Smith
      (known to millions today as Dr. Bob) gave in. The date of Dr. Bob¹s
      surrender became the official founding date of Alcoholics Anonymous.

      In its earliest days, AA existed within the confines of the Oxford Group,
      offering special meetings for members who wished to end their dependence on
      alcohol. But Wilson and his followers quickly broke away, in large part
      because Wilson dreamed of creating a truly mass movement, not one confined
      to the elites Buchman targeted. To spread his message of salvation, Wilson
      started writing what would become AA¹s sacred text: Alcoholics Anonymous,
      now better known as the Big Book.

      The core of AA is found in chapter five, entitled ³How It Works.² It is here
      that Wilson lists the 12 steps, which he first scrawled out in pencil in
      1939. Wilson settled on the number 12 because there were 12 apostles.

      In writing the steps, Wilson drew on the Oxford Group¹s precepts and
      borrowed heavily from William James¹ classic The Varieties of Religious
      Experience, which Wilson read shortly after his belladonna-fueled revelation
      at Towns Hospital. He was deeply affected by an observation that James made
      regarding alcoholism: that the only cure for the affliction is
      ³religiomania.² The steps were thus designed to induce an intense
      commitment, because Wilson wanted his system to be every bit as
      habit-forming as booze.

      The first steps famously ask members to admit their powerlessness over
      alcohol and to appeal to a higher power for help. Members are then required
      to enumerate their faults, share them with their meeting group, apologize to
      those they¹ve wronged, and engage in regular prayer or meditation. Finally,
      the last step makes AA a lifelong duty: ³Having had a spiritual awakening as
      the result of these steps, we tried to carry this message to alcoholics and
      to practice these principles in all our affairs.² This requirement
      guarantees not only that current members will find new recruits but that
      they can never truly ³graduate² from the program.

      Aside from the steps, AA has one other cardinal rule: anonymity. Wilson was
      adamant that the anonymous component of AA be taken seriously, not because
      of the social stigma associated with alcoholism, but rather to protect the
      nascent organization from ridicule. He explained the logic in a letter to a

      "[In the past], alcoholics who talked too much on public platforms were
      likely to become inflated and get drunk again. Our principle of anonymity,
      so far as the general public is concerned, partly corrects this difficulty
      by preventing any individual receiving a lot of newspaper or magazine
      publicity, then collapsing and discrediting AA."

      AA boomed in the early 1940s, aided by a glowing Saturday Evening Post
      profile and the public admission by a Cleveland Indians catcher, Rollie
      Hemsley, that joining the organization had done wonders for his game. Wilson
      and the founding members were not quite prepared for the sudden success.
      ³You had really crazy things going on,² says William L. White, author of
      Slaying the Dragon: The History of Addiction Treatment and Recovery in
      America. ³Some AA groups were preparing to run AA hospitals, and there was
      this whole question of whether they should have paid AA missionaries. You
      even had some reports of AA groups drinking beers at their meetings.²

      The growing pains spurred Wilson to write AA¹s governing principles, known
      as the 12 traditions. At a time when fraternal orders and churches with
      strict hierarchies dominated American social life, Wilson opted for
      something revolutionary: deliberate organizational chaos. He permitted each
      group to set its own rules, as long as they didn¹t conflict with the
      traditions or the steps. Charging a fee was forbidden, as was the use of the
      AA brand to endorse anything that might generate revenue. ³If you look at
      this on paper, it seems like it could never work,² White says. ³It¹s
      basically anarchy.² But this loose structure actually helped AA flourish.
      Not only could anyone start an AA group at any time, but they could tailor
      each meeting to suit regional or local tastes. And by condemning itself to
      poverty, AA maintained a posture of moral legitimacy.

      Despite the decision to forbid members from receiving pay for AA-related
      activity, it had no problem letting professional institutions integrate the
      12 steps into their treatment programs. AA did not object when Hazelden, a
      Minnesota facility founded in 1947 as ³a sanatorium for curable alcoholics
      of the professional class,² made the steps the foundation of its treatment
      model. Nor did AA try to stop the proliferation of steps-centered addiction
      groups from adopting the Anonymous name: Narcotics Anonymous, Gamblers
      Anonymous, Overeaters Anonymous. No money ever changed hands -- the steps
      essentially served as open source code that anyone was free to build upon,
      adding whatever features they wished. (Food Addicts Anonymous, for example,
      requires its members to weigh their meals.)

      By the early 1950s, as AA membership reached 100,000, Wilson began to step
      back from his invention. Deeply depressed and an incorrigible chain smoker,
      he would go on to experiment with LSD before dying from emphysema in 1971.
      By that point, AA had become ingrained in American culture; even people
      who¹d never touched a drop of liquor could name at least a few of the steps.

      ³For nearly 30 years, I have been saying Alcoholics Anonymous is the most
      effective self-help group in the world,² advice columnist Ann Landers wrote
      in 1986. ³The good accomplished by this fellowship is inestimable Š God
      bless AA.²

      There¹s no doubt that when AA works, it can be transformative. But what
      aspect of the program deserves most of the credit? Is it the act of
      surrendering to a higher power? The making of amends to people a drinker has
      wronged? The simple admission that you have a problem? Stunningly, even the
      most highly regarded AA experts have no idea. ³These are questions we¹ve
      been trying to answer for, golly, 30 or 40 years now,² says Lee Ann
      Kaskutas, senior scientist at the Alcohol Research Group in Emeryville,
      California. ³We can¹t find anything that completely holds water.²

      The problem is so vexing, in fact, that addiction professionals have largely
      accepted that AA itself will always be an enigma. But research in other
      fields -- primarily behavior change and neurology -- offers some insight
      into what exactly is happening in those church basements.

      To begin with, there is evidence that a big part of AA¹s effectiveness may
      have nothing to do with the actual steps. It may derive from something more
      fundamental: the power of the group. Psychologists have long known that one
      of the best ways to change human behavior is to gather people with similar
      problems into groups, rather than treat them individually. The first to note
      this phenomenon was Joseph Pratt, a Boston physician who started organizing
      weekly meetings of tubercular patients in 1905. These groups were intended
      to teach members better health habits, but Pratt quickly realized they were
      also effective at lifting emotional spirits, by giving patients the chance
      to share their tales of hardship. (³In a common disease, they have a bond,²
      he would later observe.) More than 70 years later, after a review of nearly
      200 articles on group therapy, a pair of Stanford University researchers
      pinpointed why the approach works so well: ³Members find the group to be a
      compelling emotional experience; they develop close bonds with the other
      members and are deeply influenced by their acceptance and feedback.²

      Researchers continue to be surprised by just how powerful this effect is.
      For example, a study published last year in the journal Behavior Therapy
      concluded that group therapy is highly effective in treating post-traumatic
      stress disorder: 88.3 percent of the study¹s subjects who underwent group
      therapy no longer exhibited PTSD symptoms after completing their sessions,
      versus just 31.3 percent of those who received minimal one-on-one

      The importance of this is reflected by the fact that the more deeply AA
      members commit to the group, rather than just the program, the better they
      fare. According to J. Scott Tonigan, a research professor at the University
      of New Mexico¹s Center on Alcoholism, Substance Abuse, and Addictions,
      numerous studies show that AA members who become involved in activities like
      sponsorship -- becoming a mentor to someone just starting out -- are more
      likely to stay sober than those who simply attend meetings.

      Addiction-medicine specialists often raise the concern that AA meetings
      aren¹t led by professionals. But there is evidence that this may actually
      help foster a sense of intimacy between members, since the fundamental AA
      relationship is between fellow alcoholics rather than between alcoholics and
      the therapist. These close social bonds allow members to slowly learn how to
      connect to others without the lubricating effects of alcohol. In a study
      published last year in Alcoholism Treatment Quarterly, Tonigan found that
      ³participation in AA is associated with an increased sense of security,
      comfort, and mutuality in close relationships.²

      And close relationships, it turns out, have an even more profound effect on
      us than previously thought. A 2007 study of a Boston-area community, for
      example, found that a person¹s odds of becoming obese increase by 71 percent
      if they have a same-sex friend who is also obese. (Wired covered the study
      in more detail in ³The Buddy System,² issue 17.10.) And in April, a paper
      published in Annals of Internal Medicine concluded that a person is 50
      percent more likely to be a heavy drinker if a friend or relative is a
      boozehound. Even if an alcoholic¹s nonsober friends are outwardly
      supportive, simply being around people for whom drinking remains the norm
      can nudge someone into relapse. It is much safer to become immersed in AA¹s
      culture, where activities such as studying the Big Book supplant hanging out
      with old acquaintances who tipple.

      As for the steps themselves, there is evidence that the act of public
      confession -- enshrined in the fifth step -- plays an especially crucial
      role in the recovery process. When AA members stand up and share their
      emotionally searing tales of lost weekends, ruined relationships, and other
      liquor-fueled low points, they develop new levels of self-awareness. And
      that process may help reinvigorate the prefrontal cortex, a part of the
      brain that is gravely weakened by alcohol abuse.

      To understand the prefrontal cortex¹s role in both addiction and recovery,
      you first need to understand how alcohol affects the brain. Booze works its
      magic in an area called the mesolimbic pathway -- the reward system. When we
      experience something pleasurable, like a fine meal or good sex, this pathway
      squirts out dopamine, a neurotransmitter that creates a feeling of bliss.
      This is how we learn to pursue behaviors that benefit us, our families, and
      our species.

      When alcohol hits the mesolimbic pathway, it triggers the rapid release of
      dopamine, thereby creating a pleasurable high. For most people, that buzz
      simply isn¹t momentous enough to become the focal point of their lives. Or
      if it is, they are able to control their desire to chase it with reckless
      abandon. But others aren¹t so fortunate: Whether by virtue of genes that
      make them unusually sensitive to dopamine¹s effects, or circumstances that
      lead them to seek chemical solace, they cannot resist the siren call of

      Once an alcoholic starts drinking heavily, the mesolimbic pathway responds
      by cutting down its production of dopamine. Alcohol also messes with the
      balance between two other neurotransmitters: GABA and glutamate. Alcohol
      spurs the release of more GABA, which inhibits neural activity, and clamps
      down on glutamate, which stimulates the brain. Combined with a shortage of
      dopamine, this makes the reward system increasingly lethargic, so it becomes
      harder and harder to rouse into action. That¹s why long-term boozers must
      knock back seven or eight whiskeys just to feel ³normal.² And why little
      else in life brings hardcore alcoholics pleasure of any kind.

      As dependence grows, alcoholics also lose the ability to properly regulate
      their behavior. This regulation is the responsibility of the prefrontal
      cortex, which is charged with keeping the rest of the brain apprised of the
      consequences of harmful actions. But mind-altering substances slowly rob the
      cortex of so-called synaptic plasticity, which makes it harder for neurons
      to communicate with one another. When this happens, alcoholics become less
      likely to stop drinking, since their prefrontal cortex cannot effectively
      warn of the dangers of bad habits.

      This is why even though some people may be fully cognizant of the problems
      that result from drinking, they don¹t do anything to avoid them. ³They¹ll
      say, ŒOh, my family is falling apart, I¹ve been arrested twice,¹² says Peter
      Kalivas, a neuroscientist at the Medical University of South Carolina in
      Charleston. ³They can list all of these negative consequences, but they
      can¹t take that information and manhandle their habits.²

      The loss of synaptic plasticity is thought to be a major reason why more
      than 90 percent of recovering alcoholics relapse at some point. The newly
      sober are constantly bombarded with sensory cues that their brain associates
      with their pleasurable habit. Because the synapses in their prefrontal
      cortex are still damaged, they have a tough time resisting the urges created
      by these triggers. Any small reminder of their former life -- the scent of
      stale beer, the clink of toasting glasses -- is enough to knock them off the

      AA, it seems, helps neutralize the power of these sensory cues by whipping
      the prefrontal cortex back into shape. Publicly revealing one¹s deepest
      flaws and hearing others do likewise forces a person to confront the
      terrible consequences of their alcoholism -- something that is very
      difficult to do all alone. This, in turn, prods the impaired prefrontal
      cortex into resuming its regulatory mission. ³The brain is designed to
      respond to experiences,² says Steven Grant, chief of the clinical
      neuroscience branch of the National Institute on Drug Abuse. ³I have no
      doubt that these therapeutic processes change the brain.² And the more that
      critical part of the brain is compelled to operate as designed, the more it
      springs back to its pre-addiction state. While it¹s on the mend, AA
      functions as a temporary replacement -- a prefrontal cortex made up of a
      cast of fellow drunks in a church basement, rather than neurons and

      Finally, the 12 steps address another major risk factor for relapse: stress.
      Recovering alcoholics are often burdened by memories of the nasty things
      they did while wasted. When they bump into old acquaintances they
      mistreated, the guilt can become overwhelming. The resulting stress causes
      their brains to secrete a hormone that releases corticotropin, which has
      been shown to cause relapse in alcohol-dependent lab rats.

      AA addresses this risk with the eighth and ninth steps, which require
      alcoholics to make amends to people they¹ve wronged. This can alleviate
      feelings of guilt and in turn limit the stress that may undermine a person¹s
      fragile sobriety.

      Bill W., as Wilson is known today, didn¹t know the first thing about
      corticotropin-releasing hormone or the prefrontal cortex, of course. His
      only aim was to harness spirituality in the hopes of giving fellow
      alcoholics the strength to overcome their disease. But in developing a
      system to lead drunks to God, he accidentally created something that deeply
      affects the brain -- a system that has now lasted for three-quarters of a
      century and shows no signs of disappearing.

      But how effective is AA? That seemingly simple question has proven
      maddeningly hard to answer. Ask an addiction researcher a straightforward
      question about AA¹s success rate and you¹ll invariably get a distressingly
      vague answer. Despite thousands of studies conducted over the decades, no
      one has yet satisfactorily explained why some succeed in AA while others
      don¹t, or even what percentage of alcoholics who try the steps will
      eventually become sober as a result.

      A big part of the problem, of course, is AA¹s strict anonymity policy, which
      makes it difficult for researchers to track members over months and years.
      It is also challenging to collect data from chronic substance abusers, a
      population that¹s prone to lying. But researchers are most stymied by the
      fact that AA¹s efficacy cannot be tested in a randomized experiment, the
      scientific gold standard.

      ³If you try to randomly assign people to AA, you have a problem, because AA
      is free and is available all over the place,² says Alcohol Research Group¹s
      Kaskutas. ³Plus, some people will just hate it, and you can¹t force them to
      keep going.² In other words, given the organization¹s open-door membership
      policy, it would be nearly impossible for researchers to prevent people in a
      control group from sneaking off to an AA meeting and thereby tainting the
      data. On the other hand, many subjects would inevitably loathe AA and drop
      out of the study altogether.

      Another research quandary is how to account for the selection effect. AA is
      known for doing a better job of retaining drinkers who¹ve hit rock bottom
      than those who still have a ways to fall. But having totally destroyed their
      lives, the most desperate alcoholics may already be committed to sobriety
      before ever setting foot inside a church basement. If so, it might be their
      personal commitment, rather than AA, that is ultimately responsible for
      their ability to quit.

      As a result of these complications, AA research tends to come to wildly
      divergent conclusions, often depending on an investigator¹s biases. The
      group¹s ³cure rate² has been estimated at anywhere from 75 percent to 5
      percent, extremes that seem far-fetched. Even the most widely cited (and
      carefully conducted) studies are often marred by obvious flaws. A 1999
      meta-analysis of 21 existing studies, for example, concluded that AA members
      actually fared worse than drinkers who received no treatment at all. The
      authors acknowledged, however, that many of the subjects were coerced into
      attending AA by court order. Such forced attendees have little shot at
      benefiting from any sort of therapy -- it¹s widely agreed that a sincere
      desire to stop drinking is a mandatory prerequisite for getting sober.

      Yet a growing body of evidence suggests that while AA is certainly no
      miracle cure, people who become deeply involved in the program usually do
      well over the long haul. In a 2006 study, for example, two Stanford
      psychiatrists chronicled the fates of 628 alcoholics they managed to track
      over a 16-year period. They concluded that subjects who attended AA meetings
      frequently were more likely to be sober than those who merely dabbled in the
      organization. The University of New Mexico¹s Tonigan says the relationship
      between first-year attendance and long-term sobriety is small but valid: In
      the language of statistics, the correlation is around 0.3, which is right on
      the borderline between weak and modest (0 meaning no relationship, and 1.0
      being a perfect one-to-one relationship).

      ³I¹ve been involved in a couple of meta-analyses of AA, which collapse the
      findings across many studies,² Tonigan says. ³They generally all come to the
      same conclusion, which is that AA is beneficial for many but not all
      individuals, and that the benefit is modest but significant Š I think that
      is, scientifically speaking, a very valid statement.²

      That statement is also supported by the results of a landmark study that
      examined how the steps perform when taught in clinical settings as opposed
      to church basements. Between 1989 and 1997, a multisite study called Project
      Match randomly assigned more than 1,700 alcoholics to one of three popular
      therapies used at professional treatment centers. The first was called
      12-step facilitation, in which a licensed therapist guides patients through
      Bill Wilson¹s method. The second was cognitive behavioral therapy, which
      trains alcoholics to identify the situations that spur them to drink, so
      they can avoid tempting circumstances. And the last was motivational
      enhancement therapy, a one-on-one interviewing process designed to sharpen a
      person¹s reasons for getting sober.

      Project Match ultimately concluded that all three of these therapies were
      more or less equally effective at reducing alcohol intake among subjects.
      But 12-step facilitation clearly beat the competition in two important
      respects: It was more effective for alcoholics without other psychiatric
      problems, and it did a better job of inspiring total abstinence as opposed
      to a mere reduction in drinking. The steps, in other words, actually worked
      slightly better than therapies of more recent vintage, which were devised by
      medical professionals rather than an alcoholic stockbroker.

      AA is still far from ideal. The sad fact remains that the program¹s failures
      vastly outnumber its success stories. According to Tonigan, upwards of 70
      percent of people who pass through AA will never make it to their one-year
      anniversary, and relapse is common even among regular attendees. This raises
      an important question: Are there ways to improve Wilson¹s aging system?

      AA is obviously not about to overhaul its 75-year-old formula. But there are
      a few alterations that would almost certainly make the program work for more
      people, starting with better quality control. Since no central body
      regulates the day-to-day operations of local groups, some meetings are
      dominated by ornery old-timers who delight in belittling newcomers. Others
      are prowled by men looking to introduce nubile newcomers to the ³13th step²
      -- AA slang for sexual exploitation. Finding a way to impose some basic
      oversight of such bad behavior would likely reduce the dropout rate.

      Some AA groups would also do well to shed their resistance to medication.
      There is nothing in the Big Book that forbids the use of prescription drugs,
      but there are plenty of meetings where such pharmaceutical aids are frowned
      upon. Perhaps this sentiment made sense back in AA¹s formative years, when a
      variety of snake oils were touted as alcoholism cures. But today there are
      several medications that have been proven to decrease the odds of relapse.
      One such drug, acamprosate, restores a healthy balance between glutamate and
      GABA, two of the neurotransmitters that get out of whack in the brains of
      alcoholics. Naltrexone, commonly used to treat heroin addiction, appears
      effective at preventing relapse by alcoholics who possess a certain genetic
      variant related to an important mu-opioid receptor. Both can be valuable
      aids in the recovery process.

      But the best way to bolster AA¹s success rate may be to increase the
      personalization of addiction medicine. ³We¹re starting to get an inkling
      that something about the initial state of the brain prior to therapy may be
      predictive as to whether that therapy will be a success,² says Grant of the
      National Institute on Drug Abuse. In other words, certain brains may be
      primed to respond well to some therapies and less so to others.

      NIDA and other government agencies are currently funding several studies
      that aim to use neural imaging technology to observe how various therapies
      affect addicted brains. One alcoholic might have a mesolimbic pathway that
      normalizes quickly after receiving a certain type of therapy, for example,
      while another will still suffer from dopamine disregulation despite
      receiving the same care. The hope is that these studies will reveal whether
      neurobiology can be used to predict a person¹s odds of benefitting from one
      treatment over another. Perhaps there is one sort of mind that is cut out
      for the cognitive behavioral approach and another that can be helped only by
      the 12 steps.

      A person¹s openness to the concept of spiritual rebirth, as determined by
      their neural makeup, could indicate whether they¹ll embrace the steps. Last
      September, researchers from the National Institutes of Health found that
      people who claimed to enjoy ³an intimate relationship with God² possess
      bigger-than-average right middle temporal cortices. And a Swedish study from
      2003 suggests that people with fewer serotonin receptors may be more open to
      spiritual experiences.

      For the moment, though, there is no way to predict who will be transformed
      by AA. And often, the people who become Wilson¹s most passionate disciples
      are those you¹d least expect. ³I always thought I was too smart for AA,² a
      bespectacled, Nordic-looking man named Gary shared at a meeting in Hell¹s
      Kitchen this past winter. ³I¹m a classical musician, a math and statistics
      geek. I was the biggest agnostic you ever met. But I just wrecked my life
      with alcohol and drugs and codependent relationships.²

      And now, after more than four years in the program? ³I know God exists,² he
      says. ³I¹m so happy I found AA.²

      Maybe one day we¹ll discover that there¹s a quirk in Gary¹s genetic makeup
      that made his prefrontal cortex particularly susceptible to the 12 steps.
      But all that really matters now is that he¹s sober.


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      Published by David Sunfellow
      NewHeavenNewEarth (NHNE)
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