Monday, October 29, 2012

Looking For the Science Behind the Twelve Steps


Transcendence, or nonsense?

What is it with the Twelve Steps? How, in the age of neuromedicine, do we account for the enduring concept of spiritual awakening available through “working the steps?” In Hijacking the Brain, Dr. Louis Teresi, former chief of neuroradiology at Long Beach Memorial Medical Center, along with Dr. Harry Haroutunian of the Betty Ford Center, sets themselves a formidable goal: “The sole intention of Hijacking the Brain is to connect the dots between an ‘organic brain disease’ and a ‘spiritual solution’ with sound physical, scientific evidence.” (For those who have grown weary of the overuse of “hijacked” brains in science writing, Teresi notes that an earlier term for the same idea was “commandeered.”)

Twelve Step programs remain popular, work for some addicts, and have their very vocal advocates in the recovery community. Outsiders are sometimes surprised to learn, writes Keith Humphreys, research scientist with the Veterans Health Administration and a professor at Stanford, that many of the people most profoundly and successfully affected by the 12-Step Program had “little or no interest in spirituality.”

The primary manifestation of this is the Twelve-Step Facilitation model (TSF), or Minnesota model, in honor of the Hazelden treatment facility in that state. Put simply, how do we go about explaining, in scientific terms, how a program like AA can have direct effects on a disease of the brain?

According to one strongly held view, we can’t. If there is something spiritual about recovery, it’s not anything that a medical doctor, who should have oversight of drug recovery and treatment programs, ought to be directly concerned with. Since the Twelve Step principles are explicitly spiritual in nature, how they apply to an organic brain disease is not at all clear. If you have cancer, your oncologists first line of thought is not usually, “why don’t you join a self-help group?” Writing for The Fix, health journalist Maia Szalavitz notes that “for no other medical disorder is meeting and praying considered reimbursable treatment: if a doctor recommended these religious or spiritual practices for the primary treatment of cancer or depression, you would be able to sue successfully for malpractice.” 

At an immediate level, the “power of the group,” which AA and other Twelve-Step Programs seems to tap into isn’t so hard to understand. Here are some of the obvious advantages of group work, as Teresi sees it:

--A reduction in the sense of isolation addicts feel.
--Useful information for addicts who are new to the processes of recovery.
--A way for people to see how others have dealt with similar problems.
--Additional structure and discipline for people whose living situations are often chaotic.

Teresi follows a common methodology, splitting the question into three dimensions: physical (an “allergy of the body driven by exaggerated limbic activity), mental (cognitive obsessions and compulsive drug use), and spiritual (an existential dilemma; a malady of the “soul”.) But the “spiritual awakening” that relieves this feeling and allows the addict to enter sobriety remains maddeningly ineffable: “The personality change sufficient to bring about recovery from alcoholism (addiction) has manifested itself among us in many different forms,” the Big Book cryptically affirms.

What makes it click for many addicts is what Teresi terms “empathic socialization,” defined as follows: “Positive socializing experiences received in support and therapeutic groups, such as praise, affection and empathic understanding, activate the brain’s reward centers as much as other natural rewards and similar to addictive substances. More importantly, belonging to an empathetic group reduces stress, a predominant cause and catalyst of addiction.”

Most people have only a hazy idea about what the Twelve Steps entail—something about admitting powerlessness over drugs, making amends for past wrongs, invoking a vague power higher than oneself. And the payoff? The reward for all the strenuous self-searching and personal honesty?

As Teresi sums it up: “inner peace, freedom, happiness, intuition, and alleviation of fear.” A heady package, indeed. All in return for achieving an emotional state called gratitude. Where are we to find the science in these claims?

Even though he doesn't solve the mystery, Dr. Teresi does offer  thoughts on some of the mechanisms in question, one of which is commonly referred to as an “attitude of gratitude” among Twelve-Step practitioners. “Gratitude for blessings received,” as it says the Big Book, is biochemically effective, Teresi argues. “In this regard,” Teresi writes, “grateful people show less negative coping strategies; that is, they are less likely to try to avoid the problem, deny there is a problem, blame themselves, or use mood-altering substances. Those with gratitude express more satisfaction with their lives and social relationships.”

And stress is where Dr. Teresi focuses his argument. More precisely, the working of the steps in Alcoholics Anonymous and kindred organizations involves “letting go” of high-stress states such as fear, guilt, self-loathing, and resentment. In Teresi’s thinking, the “power of the group” resides in its ability to reduce stress responses—and to raise levels of the “tend-and befriend” hormone, oxytocin. Oxytocin interacts with dopamine to increase maternal care, social attachments, and other affiliative behaviors and emotions. Thus, social rewards stir up a fair share of dopamine in reward centers of the brain, too. When alcoholics admit to powerlessness over alcohol, they are moving from a state of high autonomic nervous system tone to a more relaxed, “thank goodness that burden has been dropped” modality. This admission, when made as a conscious cognitive choice, and internalized through repetition and group motivation, lowers blood pressure and stress hormone levels, creating a more relaxed metabolic tone.

That is, in any event, how Teresi sees it. By confronting stress in this fashion, he believes that people with addictions can draw strength from group experience, even in the absence of personal religious belief.

Measures of Twelve-Step success will never be as precise as people would like. Not only does the national organization of AA generally avoid engaging in follow-ups, but the structure, or lack of it, works against precision measurements as well. As Teresi writes, “Anyone can start a Twelve-Step group by contacting the general service counsel of the organization of their interest, finding a meeting place (sometimes a person’s home) and adopting a readily available meeting protocol.” In fully monetized form, the Twelve Steps become Hazelden, or the Betty Ford Center. In supercharged upper income mode, it’s Passages and Promises. There is more going on here than simply a call to the pre-existing church-going addict. “AA,” says Keith Humphreys,  “is thus much more broad in its appeal than is commonly recognized.”

Teresi’s stated goal of connecting the dots isn’t an easy one. AA Twelve Steps and Twelve Traditions states unambiguously that the steps are “a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole.” In another passage, the Big Book refers to this as a personality change “sufficient to bring about recovery from alcoholism (addiction).” The explanations and definitions are maddeningly circular—unless you happen to be one of the people for whom the obsession to drink has been expelled through this practices.

Teresi believes it is possible to explore this terrain in a “belief neutral” manner, “with findings applicable to those who believe in a single God, multiple gods, or no God at all." Spiritual practices, Teresi believes, promote recovery in three ways. Meditation and some forms of prayer reduce stress levels. Techniques that lower stress have also been shown to stimulate limbic reward centers, “modulating emotion while strengthening attention and memory.” Finally, “spiritual practices, through improving morals and interpersonal behavior, foster closeness and a sense of community with one’s fellows and satisfy our instinctual need for social connection, also reducing stress.”

4 comments:

FredT said...

yes, well maybe.
For those of us who have had some recovery, you miss the main points. It is also a change of attitude and social support, and time displacement. It is also refocusing interests elsewhere. It is identification of many of the issues we face, and finding other solutions to these problems. It is a sense of being part of, not separate, not excluded. It is understanding how we fit into society, our family, and social culture. It is a beginning of a rational life, where we correct our current mistakes, and fix up the damage of our past mistakes as best we can. We see it is possible to live clean, and free. Opinions of others cease to mater, which provides freedom like we have never known. We learn to live in the now, not the past or future. We can recover, we can learn to recover. Why it works is another matter. We need the desire to recover and the willingness to do what is necessary. Those who do not want to recover, will not. It is that simple. Courts can mandate treatment, but the individual must want recovery to get it. There are many who would like to be "recovered" and go on using. That is the issue of wanting, they must want recovery and to be clean of there drug of choice. Having both recovery and the relief using brings is not an option. It is your(their) choice.

Marc Lewis said...

Beautifully written, Dirk, as usual. You also supply us with a very comprehensive picture of how the 12-step philosophy fits with the rest of the addiction world and the problems people have in making sense of it. And yes, one of these problems is: where's the science?

But I find Teresi's argument, which you are trying to convey, quite lacking in scientific substance. You say that he says: “power of the group” resides in its ability to reduce stress responses—and to raise levels of the “tend-and befriend” hormone, oxytocin. Fair enough, oxytocin has many known and unknown social functions, and it generally helps people to like each other and get along better. Then you say that he says it's the interaction of oxytocin and dopamine that really does it. And that that helps alleviate stress? Nonsense!

The old idea of dopamine as a pleasure chemical has been sliding into disrepute for at least 10 years. See Berridge's website (http://www.lsa.umich.edu/psych/research&labs/berridge/research/affectiveneuroscience.html) if you want to know the facts. Dopamine is about attraction, not pleasure. Oxytocin + dopamine = courting and sex, not stress relief. Amphetamine ups your dopamine metabolism, but we wouldn't want to say that meth reduces blood pressure and induces a "relaxed metabolic tone", would we?

If someone were to honestly outline a link between the psychological and social effects of 12 step programs and a SCIENTIFIC account of recovery, I'd want there to be a little more science involved.

Dirk Hanson said...

I must admit I'm not convinced by Teresi's argument, either. But I do think he's onto something here. One problem is that we really don't have a vocabulary in science for this kind of thing: "higher consciousness," "spirit," "spiritual awakening." Whether you can unite brain science with this kind of transcendentalism remains an open question.

aidel said...

Interesting post. Being of a scientific turn of mind (but also an addict) I've always wondered how it is that 12 step programs work (and for many people, they do!) I've been to my share of meetings, have not had anything even close to a "spiritual awakening," but then again, I continue to relapse. For some reason, going to meetings does help. And it is not the case that at meetings we "sit around and pray." I am not the only atheist in the room, ever. I think it works partly because of the unconditional positive regard that you find, but also the social support, changing the life patterns that are associated with using, and the power of the group. It is also very inspiring to see people who have 20+ years of clean time -- and somewhat comforting to know that everybody in the room has been through exactly the same thing that you are going through. Yet, I haven't found a satisfactory scientific explanation.

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