Where Science Meets the Steps

The new science of addiction

Mapping AA: The Neuroscience of Addiction

Research is dispelling the notion that addiction is simply a disease of craving

I’ve often commented that the distance between the addiction research community and the 12-Step community polarizes treatment and undermines creative collaboration.

When the professional community devalues 12-Step recovery as a lay cult, it heightens the mistrust within the 12-Step community and reinforces the tendency of its members to conflate the idea of a non-professional organization with hostility toward all medical research and advances. This problem explains in part why it has been so difficult to bring clinical advances developed in academic settings to the broader recovery community. 

While the medical community defines addiction as a disease of the brain's reward circuitry, the 12-Step community sees addiction as a spiritual malady of self-centeredness.  So how does one reconcile fundamentally distinct views on the nature of addiction?

A central question, particularly for critics, is why, exactly, does 12-Step recovery work? A new study appearing in the May-June issue of The American Journal of Addiction does an excellent job of bridging that divide.

Your Brain on 12-Step Recovery

In a comprehensive look at the neuroscience behind the 12-Step process, Dr. Marc Galanter, a professor of psychiatry and founding director of the Division of Alcoholism and Drug Abuse at New York University, explores how the basic elements of 12-Step recovery — including relationship building, telling one’s personal story and changes in self-perception — can be understood as cognitive interventions that treat known neuropsychological deficits associated with addiction.

Neuroscience is a relatively new field of inquiry that draws on biology and neurology to explain how we think and why we behave in certain ways. In recent years, the field has gotten a major assist from functional magnetic resonance imaging (fMRI), which can be used to take an inside look at how the brain is functioning during certain tasks. By examining changes in blood flow in the brain, scientists can determine what regions of the brain are active during specific cognitive or emotional tasks. 

Dr. Galanter performed a comprehensive review of the neuroscience behind specific behaviors and applied those findings to the cognitive and emotional experiences that occur in 12-Step recovery; that is, during 12-Step meetings and when interacting with sponsors and other role models. As he pored over these studies, he found that many of the subjective experiences that occur in 12-Step meetings that promote recovery can be mapped neurologically.

One example is a brain process called mirroring, which studies relate to empathy and self-awareness. Humans tend to copy the behavior of individuals with whom we are in close contact. When talking with a friend across a dinner table, for example, we might unconsciously mimic the friend’s facial expression or hand gestures. It turns out that when we mirror behavior, a specific area of the brain known as the inferior frontal cortex is activated. This response is conceptually similar to AA’s emphasis on mutuality over self-help and identification and alignment with a sponsor.

Other elements of 12-Step recovery line up with neural sites as well. Storytelling, which is a core tenet of AA, activates the mesolimbic dopamine system, giving the speaker a powerful reward. In fact, studies have found that we are willing to forego money in order to share our stories. This summing up of past reactions and experiences – AA calls it “qualifying” – helps the speaker become part of a shared identity and lays the cognitive foundation for the conception of a sober self that helps stabilize abstinence.

Even the concept of turning will and life over to a higher power – the third of the 12 Steps and one that many find difficult to accept – can be understood neurologically. Those who are struggling with substance abuse are likely to have conflicting views of themselves as both able and unable to control their actions. The result is cognitive dissonance. Accepting that you are powerless and calling on a higher power to guide and govern you relieves that dissonance, a mental process that is played out in the anterior cingulate.

Addiction as a Disease of Learning and Memory

Some might ask, so what? Many of these experiments have taken place in a laboratory setting; what do they have to do with recovery in the real world? The neuroscience of substance use disorders and recovery matters because the more we understand the science, the better we can address recovery in a clinical setting.

This type of research also brings us closer to dispelling the notion that addiction is simply a disease of craving. We have a growing body of evidence that addiction is a disease of learning and memory. We know that chronic substance abuse rewires the neural pathways that affect learning and memory. In this regard, 12-Step recovery can be of great help by correcting the faulty wiring that chronic substance abuse has caused. The better we understand the workings of 12-Step recovery, the more we are able to shift the focus from pathology and intervention to the pathways and processes that lead to lasting recovery. In addition, the more we know about recovery’s powerful effect on learning and memory, the better equipped we are to develop new and better biological targets for treatment.

I suspect that over time, the scientific and 12-Step communities will join forces to address one of the biggest, costliest health crises of our time. I don’t expect it to take another 75 years. The stakes are too high.

Dr. David Sack is board certified in psychiatry, addiction psychiatry and addiction medicine. As CEO of Elements Behavioral Health, he oversees addiction treatment programs at Promises Treatment Centers in California and Texas, Clarity Way in Pennsylvania, and The Sundance Center in Arizona.

David Sack, M.D. is board certified in Addiction Psychiatry and Addiction Medicine and serves as CEO of Elements Behavioral Health and Promises Treatment Centers.

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