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.”

The Encultured Brain: A Book Review

How biology and culture jointly define us.

Anyone who follows academia knows that the broad category of courses known as the Liberal Arts has been going through major changes for some time now. In a sort of collegiate scrum to prove relevance and fund-worthiness, disciplines like sociology, anthropology, human ecology, cultural psychology, and even English, have been subjected to a winnowing process. The clear winner seems to anthropology, which has expanded its own field by connecting with modern findings in neuroscience while simultaneously swallowing up what was left of sociology.

It makes sense. Take addiction for an example. Anthropology is a natural and accessible discipline within which to connect the two often-conflicting facets of addiction—its fundamental neuroarchitecture, and the socioenvironmental influences that shape this basic biological endowment. In The Encultured Brain, published this year by MIT Press, co-editors Daniel H. Lende and Greg Downey call for a merger of anthropology and brain science, offering ten case histories of how that might be accomplished. The case histories are lively, ranging from the somatics of Taijutsu martial arts in Japan, to the presence of humor among breast cancer survivors. These attempts to combine laboratory research with anthropological fieldwork are important early efforts at a new combinatory science—one of the hot new “neuros” that just might make it.

I have corresponded with Daniel Lende, one of the book’s co-editors, and I am happy to disclose a mention in the book’s acknowledgements as one of the many people who formed a “rolling cloud of online discussion” with respect to neuroscience and the new anthropology. I am pleased to see that the thoughts of Lende and Downey and others on the emerging science of neuroanthropology are now available as a textbook.

The term “neuroanthropology” was evidently coined by Stephen Jay Gould. A number of prominent thinkers have dipped into this arena over the years: Melvin Konner, Sarah Hrdy, Norman Cousins, Robert Sapolsky, and Antonio Damasio, to name a random few, but the term didn’t seem to get a foothold of note until Lende and Downey began their Neuroanthropology blog, now at PLOS blogs.

The term has the advantage of meaning exactly what it says: an engagement between social science and neuroscience. Lende and Downey look ahead to a time when field-ready equipment will measure nutritional intake, cortisol levels, prenatal conditions, and brain development in the field. As such, neuroanthropology fits somewhere in the vicinity of evolutionary biology and cultural psychology. As a potential new synthesis, it is brilliant and challenging, representing an integrative approach to that ancient problem—how our genetic endowment is influenced by our cultural endowment, or vice versa, if you prefer.

 Lende is no functionalist when it comes to the neuroscience he wants to see incorporated in anthropology. His approach calls for applying a critical eye to any and all strictly brain-based explanations that ignore both environmental influence and biochemical individuality. The possibility that anthropologists may be incorporating neuroimaging technology into their working tool kit is a heady notion indeed. Anthropology may be a “soft” science, but it has always been about the study of “brains in the wild.”

Here, from the introductory chapter, is the short definition of neuroanthropology by Lende and Downey: “Forms of enculturation, social norms, training regimens, ritual, language, and patterns of experience shape how our brains work and are structured…. Without material change in the brain, learning, memory, maturation, and even trauma could not happen…. Through systematic change in the nervous system, the human body learns to orchestrate itself. Cultural concepts and meanings become neurological anatomy.” From the point of view of actual study, there is no choice but to join these two when possible—a task make more difficult by the rampant “biophilia” found among anthropologists and sociologists, as well as the countering notion among biologists that anthropology does not make the cut as a “real” science.

We have come a long way from the simplified view of the brain as some sort of solid-state computer, or, alternatively, a lump of custard waiting to be endowed with functionality by selective pressures from “outside.” We know by now that neural resources are frequently reallocated; that “physiological processes from scaling to connectivity shape what brains can do and why.”  We need to stop viewing culture as “merely information that is transmitted over evolutionary time and recognize that enculturation is, equally, the ways that our interaction with each other shapes our biological endowment, and has been doing so for a very long time,” Lende writes.

At bottom, says Lende, it is a simple notion: “Biology and culture jointly define us.” For example, Lende points to the way tool use affects cortical organization. Monkeys trained to use rakes to fetch food “evidence increasing cortex dedicated to visual-tactile neurons.” Lende wants us to incorporate neuroscience into the broader study of man. He writes that “the activation of neural reward centers, such as the mesolimbic dopaminergic system, is inherently bound up in sociocultural contexts, social interactions, and personal meaning-making.”

As an example, Lende contributes a chapter on “Addiction and Neuroanthropology,” in which he describes research he conducted on drug abuse among young people during a decade he spent in Colombia. Lende found that the addictive spiral “was not merely a neurological transformation, but a shift in habits, clothing, friends, hangouts, and other external factors that re-cued drug seeking behavior, drove addicts to take drugs, even when the young people sought to stay clean. Addiction is not simply in the brain, but in the way that the addict’s brain and world support each other.” And now, he writes, “This combination of neuroscience and ethnography revealed that addiction is a problem of involvement, not just of pleasure or of self. That decade showed me that addiction is profoundly neuroanthropological.”

In other words, tolerance and withdrawal aren’t enough. It is fiendishly complex: “The parts of the brain where addiction happens are not single, isolated circuits—rather, these areas handle emotion, memory, and choice, and are complexly interwoven to manage the inherent difficulty of being a social self in a dynamic world.”

Trying to pick apart the relative influences of nature and nurture comes to look, ultimately, like a fool’s game, “because changes in behavior exposed users to situations in which specific neurophysiological effects were cued with greater frequency; both environment and biology were moving together into a cycle of addiction.”

In a chapter titled “Collective Excitement and Lapse in Agency: Fostering an Appetite for Cigarettes," Peter G. Stromberg of the University of Tulsa argues that the dissociative environment in which college students often try cigarettes for the first time can lead to the loss of “the sense of agency,” meaning that people sometimes carry out activities without taking full responsibility for the decision to do so. As Stromberg writes, “Early smoking experiences typically occur in effervescent social gatherings marked by a high level of excitement and highly rhythmic activities, such as conversation and dancing." Cigarettes acquire a “symbolic valence” in such settings, and the ability to handle a cigarette adroitly confers what Stromberg terms “erotic prestige.” Furthermore, “As anyone who has ever been in a conga line can attest, we humans can be strongly motivated to entrain with rhythmic activities, even if those activities might be judged as unappealing in other contexts.”

If young people smoke at parties for many of the same reasons that they dance at parties—a “desire to increase status” and enter into “joint rhythmic play”—then potential nicotine addicts will be gently nudged into a position of associating party feelings with cigarette feelings, regardless of the actual physiology of nicotine. And, by fostering a dissociative mode of consciousness, college parties help foster the conviction that the use of cigarettes is not completely under one’s volitional control (“I was going to leave, but we danced all night.” Or, “the next thing I knew, the pack was empty”). The smoker may falsely attribute these feelings to the direct effect of the drug, rather than the set and setting.

This is only one example of the many ways in which a combination of neurobiology and anthropology can lead to new questions and fresh approaches. Where might all this be heading? “As research continues,” write Lende and Downey, “greater recognition of neural diversity as a fundamental part of human variation will surely become an even more substantive part of the neuroanthropological approach.”

Does Marijuana Withdrawal Matter?

What happens to some smokers when they cut out the cannabis.

People who say they are addicted to marijuana tend to exhibit a characteristic withdrawal profile. But is cannabis withdrawal, if it actually exists, significant enough to merit clinical attention? Does it lead to relapse, or continued use despite adverse circumstances? Should it be added to the list of addictive disorders in the rewrite of the Diagnostic and Statistical Manual of Mental Disorders (DSM) currently in progress?

Marijuana fits in fairly well with the existing criteria for clinical addiction—except for one common diagnostic marker. Among the identifying criteria currently used in the DSM, we find: “The presence of characteristic withdrawal symptoms or use of substance to alleviate withdrawal.” Opponents of marijuana’s inclusion as an addictive drug have long insisted that cannabis has no characteristic withdrawal symptoms, but this position has been severely eroded of late, as new research has consistently identified a withdrawal syndrome for marijuana, which includes drug cravings, despite decades of controversy over this basic medical question.

A group of researchers at the University of New South Wales, Australia, along with Dr. Alan J. Budney of the Geisel School of Medicine at Dartmouth, New Hampshire, writing in PLOS ONE, presented evidence that the characteristic withdrawal symptoms displayed by addiction pot smokers are in fact strong enough to be considered clinically significant.
(For more on the marijuana withdrawal profile, see HERE, and HERE. For a bibliography of relevant journal articles, go HERE).

But how does one go about determining if withdrawal reactions rise to the level of clinical significance? The researchers wanted to know whether functional impairment reported during abstinence was clinically significant, whether it correlated with severity of addiction, and whether it was predictive of relapse. 46 survey volunteers who were not seeking any formal treatment for marijuana addiction were recruited in Sydney, Australia. Users ranged in age from 18 to 57, with an average age of 30. After a one-week baseline phase, the participants underwent two weeks of monitored abstinence. Using a “Severity of Dependence Scale” (SDS) to measure variability in functional impairment, the researchers compared a high SDS subgroup to a low SDS subgroup in an effort to tease out whether functional impairments in high SDS participants were predictive of relapse. The researchers noted that earlier work had established that the symptoms most likely to cause impairment to normal daily functioning were: Trouble getting to sleep, angry outbursts, cravings, loss of appetite, feeling easily irritated, and nightmares or strange dreams.” The investigators broke these symptoms into two groups: “somatic” and “negative affect” variables.

The researchers then examined self-reports about the impact of cannabis withdrawal on normal daily activities.  While the common yardstick for withdrawal is typically taken to be intensity of cravings, the authors argue that this reliance on craving “may mask the extent to which symptoms led to functional impairment, as those who maintained abstinence may still have experienced clinically significant negative consequences from cannabis withdrawal (e.g. relationship or work problems resulting from the withdrawal syndrome.”)

As might have been expected, higher levels of cannabis dependence were associated with greater functional impairment. And while the average level of functional impairment caused by cannabis is “mild for most users, it appears comparable with tobacco withdrawal which is of well established clinical significance.”

And certain symptoms were, in fact, correlative: “Increased somatic withdrawal symptoms are predictive of relapse, and…. increased physical tension is a significant predictor of relapse.”

 Physical distress, a “somatic” variable, mattered more, in terms of relapse, than the amount of marijuana smoked, or any other symptom on the roster of functional impairments—including mood and other negative affect variables.

“In conclusion,” the investigators write, “cannabis withdrawal is clinically significant because it is associated with elevated functional impairment to normal daily activities, and the more severe the withdrawal is, the more severe the functional impairment is. Elevated functional impairment from a cluster of cannabis withdrawal symptoms is associated with relapse in more severely dependent users.”

Furthermore: “Targeting the withdrawal symptoms that contribute most to functional impairment during a quit attempt might be a useful treatment approach (e.g. stress management techniques to relieve physical tension and possible pharmacological interventions for alleviating the physical aspects of withdrawal such as loss of appetite and sleep dysregulation.)”

As with most studies, there are limitations. As noted, the participants were not in a formal cessation program. And while urine tests were used, there was no external corroboration of the self reports.

Allsop, D., Copeland, J., Norberg, M., Fu, S., Molnar, A., Lewis, J., & Budney, A. (2012). Quantifying the Clinical Significance of Cannabis Withdrawal PLoS ONE, 7 (9) DOI: 10.1371/journal.pone.0044864

Graphics Credit: http://www.addictionsearch.com/