The new science of addiction makes 12-step programs seem like folk medicine.

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Is the concept of a higher power obsolete?

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.

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