Alcoholics Anonymous: Part 2: The good, the bad, and why I didn’t join.

pexels-photo-924004.jpegA quick note before I begin: I have received feedback that the science can be a bit hard to follow in this blog. From now on I will signal the sciencey bits with *Warning Sciencey bit” and signal the end of it with *End Sciencey bit* and if you choose to skip these bits, the rest of it should still make sense. Hope that helps, but open to more feedback if anyone has better suggestsions.

The Scientific Perspective on AA
For the most part (although this is not a consensus by any means) scientists do not particularly rate AA. To them it is a program that was made up by a guy a long time ago (1935) without being based on any kind of scientific evidence, and due to its anonymous nature is difficult to study in a systematic manner. What this means is, that the studies that have been done are largely observational, and do not involve participants being randomly assigned to AA vs. other treatments and control groups to infer outcomes in a more causal manner. And then there’s the God thing. For those who don’t know, a large part of the AA program involves putting faith into a ‘higher power’ – defined as a ‘God of your choosing’ which doesn’t necessarily HAVE to be God Himself, but often is.

*Warning Sciencey bit*
The notion of a higher power is inherently non-scientific. This is because it is non-falsifiable. What this means is that, because it can never be proven wrong, it can never really be tested. In other words, the concept of a higher power can be altered to fit any situation. For example, if someone prays for something, and subsequently receives what they asked for, a believer will assume that their higher power has answered their prayers. On the other hand, if someone prays but doesn’t get what they ask for, this doesn’t change the beliefs of that individual. Instead, a believer will assume that their higher power has a different plan or destiny for them. In this way, a person’s faith can be used to justify any outcome, and therefore can never be proven wrong. And although things are never proven ‘right’ in science, if something is non-falsifiable then we also cannot provide solid scientific evidence suggesting its existence. So at least within the realm of our capabilities right now, the concept of a higher power can never be proven or disproven.
*End Sciencey bit*

What the Soberverse thinks of AA
It is worth mentioning that this view of AA and other anonymous programs by scientists is far from a consensus, and some do have a positive view on it. But the soberverse (my made up name for the online recovery world) has a different perspective altogether: anonymous programs are still by far and away the most popular treatments for addiction. They are the most accessible as there are many such meetings at convenient times, all over the world, and all you need to attend is to give a gold coin donation. Even without that, you will not be turned away. Furthermore, within the soberverse you will find many people who have gotten sober using these programs, who swear by their efficacy, and become very attached to the ’12-step program’.

As for my point of view, as a ‘Neuroscientist in recovery’, I suspect the truth lies somewhere in between these two points of view. Whilst it is not the panacea that some people believe it to be (although it can be for many individuals), it is not completely useless either.

The Positives
The biggest ‘pro’, in my opinion, is that AA provides a way for people in recovery to connect. Furthermore, it provides an opportunity to connect with active and ex-addicts, and other people who generally understand what an individual might be going through. It gets people out of the isolation they might have been suffering, which even in basic neuroscience we know to be important because of studies such as the famous ‘rat park’ experiment.

*Warning Sciencey bit*
In brief, rats who were kept in isolation without enrichment were easy to train to self-administer cocaine or opioids and to became ‘addicts’, whereas rats that were given access to other animals in an enriched environment (i.e. rat park) were not. The implication, of course, is that individuals with good social connections and opportunities are less likely to become drug addicts than isolated individuals with little opportunity. I should mention that this finding hasn’t always been well replicated since the original, something else I will touch on in future posts.
*End Sciencey bit*

I think most people in recovery will tell you, and from my personal experience I totally agree, that connections are vital to recovery. So in this respect, AA does a good job. It is often said within the soberverse that “connection is the opposite of addiction” and I agree, although most of my connection has been achieved online.

Another thing AA gets right is that it provides a program of positive reinforcement of ‘good’ or productive actions that are learned in sobriety, such as paying bills, cleaning your house, getting a job and generally getting your shit together. That is, when good things start happening to the addict in recovery (because they are sober, no longer isolated, have help etc), not only do they feel the intrinsic happiness of getting their shit together, but they have the added feeling of a spiritual guide, a ‘higher power’ that helps the addict feel like they are not alone, and that they are being guided on the right path. Moreover, addicts often feel like the higher power affords them a strength to get better that they didn’t have alone. Over the months I have spent in recovery, I have really begun to appreciate the positives people get out of having a higher power. Although my beliefs prevent me not only from believing in a higher power, but really in any type of spirituality, over time I have honestly come to see this as a bit of a shame, because I see how much contentment such beliefs can provide.

These are not the only benefits of AA by any means. It provides a program of accountability, allows a person to address the issues in their past or in their current life with a new perspective (in particular changing from seeing themselves as as a helpless victim), and eventually provides a way for addicts to help others. Therefore I believe the AA program provides many things that even a scientist or skeptically-minded individual can appreciate.

The Negatives
So, given all those positives, why haven’t I been back to AA? In all honesty, I’m not really sure. For a long time I told myself I’m too busy as my job can be very demanding. But I’m sitting here writing this blog when I could be at a meeting, so I guess I would have time right now! Also as I mentioned, as much as I can see the benefits of believing in a higher power, I just can’t. As far as I can tell, even the agnostic or atheist alternatives involve some kind of higher power or spirituality – just not one based on God. This is just a 100% no from me.

I think that another reason for not attending is that I don’t think I need to. Whilst I have no problem admitting that I am an alcoholic, my life is not ‘unmanageable’ and never really has been. I have a family, I have a good job, I have a lot of friends and happiness, and I am relatively fit and healthy. I also have expert knowledge of the neural circuitry of decision-making, and that helps a lot. Further, if I’m going to be totally honest, the idea of walking into a room of people I don’t know to talk about being an alcoholic is terrifying, even if I have done it once before. I know that this is a weak reason, but I’d be lying if I said it wasn’t a factor.

So there’s all my excuses. I recognise that they are all excuses. If I really needed a program like AA, none of these excuses would get in my way – just as they didn’t when I was in Bali. However, my last and most important reason for not attending, I feel is not just an excuse, and this reason is the rigidity/inflexibility of thinking I see it produce in people. Although of course it is possible that it is the addiction that produces such rigidity, not the program, but there does at least seem to be a correlation even if the link is not causal. And of course I should mention that this does not go for everyone who attends AA, there’s plenty of people with their own take on things

*Warning Sciencey bit*
There is evidence in the lab, that even in animals that have been trained to be alcoholics or drug addicts, then their ability to make decisions is impaired. Specifically, if rats learn to press a left lever for sugar water, and a right lever for pellets, when later given a choice between levers a normal rat will choose the one that earns whichever (pellets or sugar water) is most valuable to them at the time. An alcoholic/drug-addicted rat, on the other hand, will choose both levers equally. This demonstrates that on a fundamental level, drug addiction impairs the capacity to make decisions. This impairment appears to be accompanied by alterations in neural activation and other structural changes in the striatum, which is part of the brain’s hub of action selection. Similarly, human drug addicts show reduced activity in prefrontal cortices and striatal regions associated with decision-making (see the figure below for a highly simplified diagram of this pathway, taken from http://addictionpathology.wikia.com/wiki/The_Reward_Pathway). I know for me personally, when I was drinking, a lot of the time my decisions were impaired because I just didn’t really care. All I cared about was my next drink.

The_reward_pathway_3.png
*End Sciencey bit*

So it is possible that the rigidity of thinking was there prior to attending AA. Alternatively, it is possible that because of the alcoholic’s impairment in their ability to make good decisions, it makes sense for them to ‘surrender’ this process to others, and to ‘take the cotton out of their ears and put it in their mouth’ as a common saying goes. Suddenly, when the program works for them like nothing ever has before, they start to believe that this is the only way to get sober.

It is this rigid attachment to the ideas and traditions of AA is that keeps me away. I am sure there is wisdom in the twelve steps, and as mentioned the higher power provides an important service. But the rigidity is very difficult to accept for people like myself, whose entire world view is built around scepticism, questioning, and the necessity of empirical evidence. I have had an MD in recovery say to me that he had to suspend his scientific thinking in order to go through the program, but I just don’t think this is possible (or necessary) for me.

So if not AA then what?
There are a number of alternatives. If you are looking for face-to-face meetings, there’s SMART recovery which is a research-based program. I was quite drawn to the idea of SMART but I couldn’t find a convenient meeting. This is one area in which AA beats SMART hands down, there are far more AA meetings than SMART meetings. Other than that, there are also medications such as the Sinclair method (an opioid receptor antagonist [i.e. blocker] taken in pill form that blocks the pleasurable effects of alcohol). I haven’t had personal experience with these, but the science suggests they are relatively effective.

For me personally to stay sober, I haven’t tried medication, SMART recovery or AA (other than that one time in Bali). But that doesn’t mean I haven’t worked hard on recovery, and I am still working hard. Online connection has been a big part of it. Of course I should acknowledge that, being a functional alcoholic, I was not too isolated already a close family, a good job, and a pretty good social network which already included some sober people. Perhaps if I were missing just one of these factors I would have needed face-to-face meetings to get sober. Perhaps I still will need such meetings one day, I certainly wouldn’t rule it out. As mentioned previously, I have also read every sobriety memoir going, listened to recovery podcasts (especially the Shair podcast), and joined recovery groups on facebook and elsewhere. I also do regular sessions with a recovery coach.

This blog is the next step on my journey. Writing here will keep me accountable, will allow me a way to express my feelings and thoughts. I am not doing this alone by any means. “Connection is the opposite of addiction” indeed. So welcome on my journey, let’s see where it takes us.

Alcoholics Anonymous Part 1: Bali

Bali Cravings
About 4 months into sobriety, I visited Bali with my family (including my parents and mother-in-law). When I got there, a feeling came over me… a peace and tranquillity like I’d never before experienced. Then I got in touch with my spiritual side and found God. Next I saw unicorns flying through the sky whilst pooping rainbows…

NOT!

Yeah OK, that never happened. I mean, I did go to Bali but faaaark me. It was hard. I experienced something that in the lab we refer to as ‘context-induced reinstatement’. Basically, it has been known for sometime, that addictions can be context-specific – one well-known example from real life is when many heroin-addicted soldiers returned home to the United States from the Vietnam war. Surprisingly, once home about 90% of these soldiers were able to shed their addiction, and only 10% remained addicted. However, what this also means is that addictions and can be ‘reinstated’ (i.e. the addict can relapse) when they return to a ‘context’ (place) previously paired with alcohol/drugs, or even visit a new place that is similar to the one associated with alcohol drugs, like a new pub or restaurant etc.

Contextually-mediated relapse in the lab
Similar effects have been shown in rats and mice too. The typical experiment goes something like this: the rat or mouse is first trained to press a lever for alcohol, or cocaine, or amphetamine, or whatever the drug of interest is, in a particular context, usually a skinner box with stripey walls, a grid floor, and vanilla odour. That same rat is then put into a different box with spotty walls, a smooth floor, and a peppermint odour, but in this box, the lever doesn’t earn the drug. In fact, in this box, the lever doesn’t earn anything (known as ‘exinguishing’ the lever press-drug association). If you put that rat back into the ‘extinction’ (lever-no drug) box the next day, s/he will press the lever at a low rates. If, however, you put the rat back in the original box, however, responding will be high again.
In drug addiction, this effect is mediated in the brain by circuits that regulates decision-making generally; structures such as the nucleus accumbens (often reported to be the brain’s hedonic ‘hot spot’, although it does more than just detect pleasure) and its projections to the ventral pallidum and lateral hypothalamus. Further, such ‘relapse’ isn’t only bought on by contexts (places), but can be caused by cues such as the sight of a particular beer label or a wine glass. It makes evolutionary sense for a brain circuit to ‘hold on’ to the knowledge that an action previously earned a reward in a particular place, or to explore whether that action earns a reward in a new place, because if it didn’t the person/animal might miss out on a reward. Unfortunately, however, in drug addicts this effect provides another example of circuitry that evolved to optimise receiving useful rewards, like food or sexual pleasure, going awry and supporting drug-seeking when this is not adaptive.

Contextually mediated relapse in real life
If you are an addict like me, the likelihood is that you have experienced this. You might never experience cravings anymore in your normal surroundings, having ‘extinguished’ the association between walking to your local pub and buying a beer. But then you go on holiday, or into a new environment and see a different pub and the craving comes back to you with full force. Well that’s what happened to me in Bali.
Bali ticked a lot of boxes driving me to drink: 1) it was sunny which I always associate with drinking, 2) I was on holiday so I didn’t have work, 3) my parents were there to be responsible adults and help out with my daughter so I didn’t have to be as responsible, and 4) parents were there being parents (i.e. driving me slightly nuts – love you Mum!). It was very, very, very hard. So I posted in my lovely facebook group about my troubles and so many of them said what I often hear in the group: go to a meeting. And I thought, “actually yeah, why the hell not? So I found the nearest meeting that was on in one hour, started walking there before I lost my nerve, got lost on the way so was a little bit late, but I got there. And it was good.

AA
When I got to the meeting I mentioned straight away that I was a first-timer and I was welcomed with open arms. Then people started to share. To begin with, it was only the men that shared, and they talked about many things. Some talked about how they had ended up in jail, or mental institutions, or how they had lost custody of their children and so on. This was bad. I couldn’t identify with this at all. After several days in Bali with a little voice in my brain (which part of my brain? That I can’t tell you sorry!) telling me I am not really an alcoholic, this was not what I needed to hear. Suddenly that voice started getting louder. “I’ve never experienced consequences like those, so maybe I’m not really an alcoholic?” “Maybe I can get out of here and go drink! And party! Woooo Hoooooo”
But then another voice (in my head) chimed in and asked: “why the hell are you sitting here if you don’t have a problem?” “And if you really don’t have a problem, how come pretty much every area of your life (work, health, fitness, relationships, happiness, anxiety) has gotten so much better since you quit drinking?”. If it wasn’t a problem, that wouldn’t have happened, surely.
So I shared. Can’t remember exactly what I said, but I sat there with my fake tan, thinking that all these people just think I’m some dumb blonde with resting bitch face (oops there’s those self-esteem issues again) and here I am talking about the fact I have a good job, and a loving family, but that alcohol has caused a lot of problems for me, so am I really an alcoholic after all?
But after I spoke up the other women in the group started to speak up. It was at this point that I heard my own story reflected back to me, over and over and over. Being there for your kids but not really being present. Waiting until they go to bed so you can drink. Getting angry with their partners over nothing. Dragging their sorry butts to work hungover and giving a sub-optimal performance. I realise now what I didn’t at the time: that alcoholism seems to manifest differently in men and women. I’m not sure why this is (scientific studies in rodents have by far and away used mostly males, although this is now starting to change). I know that in the human research there have been some differences found in how reactive men and women are to cues, but I’m not sure how that might translate to different manifestations of addiction.
In any case, that meeting saved me from a major relapse. I stayed and had coffee with some of the members afterwards, and they all were so welcoming and lovely and non-judgemental. Noone seemed to judge me for my resting bitch face, or blonde hair. No-one seemed to change their manner immediately and start acting a little self-consciously when I said that I was a behavioural neuroscientist, as often happens when meeting new people. Two of the women gave me their email addresses and numbers, and I messaged them a few times throughout the rest of the trip. And most importantly I didn’t drink.

Returning Home
So you would think that after I returned home after such a positive experience that I would continue to attend AA. Initially I did intend to, I looked up the beginners meeting and there was one nearby. I told my husband I was going to go that night. It was all sorted. Then I got to the evening and I just… didn’t. The cravings certainly dissipated when I returned home (i.e. as I returned to the extinction context), but I knew enough to be wary of this lack of craving, and that it could return at any time. However, I did think long and hard about it, and eventually decided instead to sign up to recovery coaching with the person who runs the podcast I had been listening to instead. In my next post I will elaborate on why.