Secret of AA: After 75 Years, We Don't Know How It Works
This can alleviate feelings of guilt and in turn limit the stress that may undermine a person's fragile sobriety.
Bill W., as Wilson is known today, didn't 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 AA's success rate and you'll 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 don't, 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 AA's 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 that's prone to lying. But researchers are most stymied by the fact that AA's efficacy cannot be tested in a randomized experiment, the scientific gold standard.
"If you try to randomly assign people to AA, you have a problem, because AA is free and is available all over the place," says Alcohol Research Group's Kaskutas. "Plus, some people will just hate it, and you can't force them to keep going."
In other words, given the organization's 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 who've 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 investigator's biases. The group's "cure rate" 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-it's 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 Mexico's 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).
"I've been involved in a couple of meta-analyses of AA, which collapse the findings across many studies," Tonigan says. "They 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 . I think that is, scientifically speaking, a very valid statement."
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 Wilson's 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 person's 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 program's 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 Wilson's 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 "13th step"-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 AA's 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 AA's success rate may be to increase the personalization of addiction medicine. "We're 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," 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 person's 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 person's openness to the concept of spiritual rebirth, as determined by their neural makeup, could indicate whether they'll embrace the steps. Last September, researchers from the National Institutes of Health found that people who claimed to enjoy "an intimate relationship with God" 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 Wilson's most passionate disciples are those you'd least expect.
"I always thought I was too smart for AA," a bespectacled, Nordic-looking man named Gary shared at a meeting in Hell's Kitchen this past winter. "I'm 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."
And now, after more than four years in the program? "I know God exists," he says. "I'm so happy I found AA."
Maybe one day we'll discover that there's a quirk in Gary's genetic makeup that made his prefrontal cortex particularly susceptible to the 12 steps. But all that really matters now is that he's sober.
Contributing editor Brendan I. Koerner (firstname.lastname@example.org) wrote about the pathogen UG99 in issue 18.03.
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