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Curing addiction: Twelve Steps or fixing the brain?

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…

AA’s Twelve Steps program emphasises spiritual awakening and is not at all medical. Nikhil/Flickr

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.

Arthur Caranta

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.

The ‘brain-based’ model of addiction directed research until the 1980s and 1990s. Aigars Mahinovs

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.

This is part four of Medical Histories - click on the links below to read other articles:

Part One: Hypochondriac disease - in the mind, the guts, or the soul?

Part Two: Spermatorrhoea, the lesser known male version of hysteria

Part Three: Culture and psychiatry: an outline for a neglected history

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15 Comments sorted by

  1. Mike Bogle

    Educational Technologist

    A thought occurred to me while reading this article:

    One of AA's guiding principles is to maintain anonymity at the level of press, radio and film. So given The Conversation requires both first name and surname to comment you may find a relative absence of self-identified AA members posting responses.

    Secondly, have you examined other non-12 Step Recovery Programs, such as Rational Recovery? I'd be interested in hearing whether you think recovery programs in general might "affect the course of [an addicts] condition" or if it is something specific to the AA model.

    1. Gemma Lucy Smart

      MSc Candidate in History and Philosophy of Science at University of Sydney

      In reply to Mike Bogle

      Rational Recovery looks a lot better than AA for a number of reasons, it's definitely something I've looked at myself. In Nancy Niquist Potter's piece in Addiction and Responsibility she covers it too.

  2. Jane Kyle

    Social Policy Analyst

    I struggled to find a conclusion in this article - I am left without a clear understanding as to the point the authors were wishing to convey - is it that the jury is still out on the effectiveness of AA?

    Certainly in the Australian context, where 'God' is far less entrenched in our culture than in the US, I believe many would squirm at the 12 steps. The Rational Recovery method mentioned by Mike Bogle may have some merit, but is presented in such an off-the-wall way, as to look like complete…

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    1. Gemma Lucy Smart

      MSc Candidate in History and Philosophy of Science at University of Sydney

      In reply to Jane Kyle

      The focus of this article was a historical look at AA in the context of the history of addiction, rather than a discussion of the merits of ways of dealing with addiction. Hans and I have slightly different views on the latter. I think you might find the book 'Addiction and Responsibility' interesting:

  3. Peter Andrew Smith


    The reality is that managing addiction is not brain vs culture or AA vs medicine. Furtheremore AA, like cultures, is highly varied including at the one extreme "God-botherers" and at the other atheists. A problem in Australia, as elsewhre, is that over several decades there has been a shift towards the voluntary sector as a primary support for recovering addicts. This has reduced both the quantity and the range of support available to addicts and their families. For example, it is far from simple for an addict who has been "clean and sober" for 10 years to get sound advice on the safety of taking a particular medication prescrobed by her or his doctor.

  4. Maxwell Warren

    logged in via Facebook

    The 12 steps of AA read more like a codified means of reinforcing an External Locus of Control. I'd predict that those people who respond to the 12 steps already have an External Locus of Control, and those people with an Internal Locus of Control are more likely to leave the program.

  5. Steve Brown

    logged in via email

    "For better or worse, this means that we are stuck, for the time being, with the Twelve Steps program."

    Hey, how about all the people like yours truly who overcame addiction using other methods like meditation?! Not sure if any studies exist but I've known more than my fair share who have followed the path and freed themselves.

    AA and NA always struck me as having many of the same characteristics as an organized religion and the same appeal (none).

    The most unhelpful approach towards the…

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    1. Gemma Lucy Smart

      MSc Candidate in History and Philosophy of Science at University of Sydney

      In reply to Steve Brown

      That may be so, however I'm definitely interested in AA as a cultural force, and how this has shaped the field of addiction research and addicts themselves.

      And as for the sub-classification point, I think there are some interesting things to look at there too. I wonder, have you seen my piece on Videogame Addiction, I'm personally researching along a similar line to your comments.

  6. Tom Hennessy


    When the 12 step program was initially designed , niacin was one of the KEY players. During the implementation of the program niacin was removed from the treatment plan.

    One might wonder at the 'connection' proposed in the similarities of nicotine and niacin ? It has been proposed , nicotine and niacin are the WHY in families who have a propensity to catch Alzheimer's , those who smoke don't get it but those who don't smoke DO, and they propose the same pathway for niacin and nicotine , wherein…

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    1. Tom Hennessy


      In reply to Tom Hennessy

      This is a snip from a conversation in which the researchers are of the mind the TLR4 inhibition is important and coincidentally it mentions the lecithin but in regards to sepsis prevention.

      "TLR4 is also one of the main mediators of septic shock, which causes over 10 million deaths/year world-wide, and even in industrialized countries is the #1 cause of death in ICU’s.
      Something that block it could be useful for more than just opiate addiction/pain relief."

      Studies show the same reduction…

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    2. Tom Hennessy


      In reply to Tom Hennessy

      "Niacin works the same way as nicotine in that it protects the brain by stimulating the production of acetylcholine."

      So the question might be , are they trying to raise acetylcholine in people with addiction such as alcohol or gambling and if they are , did they drop the niacin from the program too soon ?
      They are targeting acetylcholine in alcohol.

      "Alcohol depletes acetylcholine levels in the brain thus accounting for some of the cognitive impairments and withdrawal symptoms associated…

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    3. Tom Hennessy


      In reply to Tom Hennessy

      There may be a connection here as to why lecithin seems to work in opiate addiction ?

      "Lecithin Raises S-Adenosylmethionine"
      "Metallothionein might be regulated by the dietary content of
      "Supplementation with lecithin, choline, or betaine resulted in a
      significant increase in plasma methionine"

    4. Tom Hennessy


      In reply to Tom Hennessy

      "The symptoms resulting from malfunctioning metallothionein"
      "Autism spectrum"
      "ADHD and other behavioural disorders, fibromyalgia, ME and CFS (chronic fatigue syndrome)"

  7. Jock Mackenzie

    Research Assistant (Treatment and Systems) Turning Point Alcohol and Drug Centre at Monash University

    I too struggle to find what the point of this confused article is. More worryingly it is so ill informed not only about AA but the nature of addiction and drug and alcohol treatment.

    Things go badly right from the start with the headline which suggests that the solutions on offer are a cure.

    Neither does AA or biomedicine aim to provide a cure. Addiction medicine views addiction as a ‘chronic, relapsing condition’ which corresponds to the similar concept of a ‘disease’ which in AA is used…

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