A scientific explanation of a spiritual solution: why Twelve-step recovery works

Incentive Sensitization The dopamine system is ‘sensitized’ to drugs & to drug cues: ingestions of drugs produce powerful urges to use more (what AA calls the ‘allergy’); drug cues become salient and attractive and produce powerful urges to use (which explains the obsession/pre-occupation). (Robinson & Berridge)

These urges to use are called ‘wantings’. They are probably unconscious, but usually cause conscious cravings, feelings of need or desires to use. ‘Wantings’ are neurally realized by spurts of dopaminergic activity.

Sex & Drug Images to Cocaine Users

Incentive sensitization explains what AA calls the ‘allergy’ and ‘obsession’ (preoccupation). It also helps explain the ‘insanity’ implied by Step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.”

In interesting cases an addict who was previously persuaded by a mass of evidence from his own and others’ experience that he cannot use in a moderate, controlled fashion, suddenly thinks that he can do so.

The information that using again would very likely cause a relapse does not appear in full consciousness or cognition and fails to affect action.

These are cases of major cognitive breakdown. They are like temporarily forgetting that if you pull the trigger of a gun, it might well fire.

My hypothesis: the cause of relapse among addicts who want to stay clean is ‘stress’. (‘Stress’ explains the ‘insanity’ and other causes of relapse) Twelve-step programs work because they are effective, comprehensive ‘stress’-management programs.

‘Stress’ is what we normally think of as stress, conscious or unconscious, plus ‘happy’ or ‘reward’ stress. It correlates reasonably well with release of corticotropin-releasing hormone, ‘CRH’.

‘Stress’ ‘Stress’ has three or four independent effects. 1.It is (normally) by far the most extensively conditioned cue. 2. CRH is released inside the dopamine system and sensitizes it to all stimuli. 3. ‘Stress’ adversely affects recall and thinking. 4. There is evidence from rats that there is cross-sensitization between ‘stress’ and drugs. It may be that this effect enhances incentive-sensitization to drug cues. It is this triple (or quadruple) whammy of ‘stress’ that causes the insanity that often causes relapse.

I informally surveyed over 15,000 members and ex-members of A-fellowships, looking for people who had completed all 12 steps and were continuing the maintenance program and yet relapsed, and found.... ONE (1) (possible).... I think this is strong anecdotal (unscientific) evidence that the program is around >99% effective!

The Steps promote ‘spiritual’ awakening. This is a process of becoming less self-centered. Self- centeredness (directly or indirectly) causes: resentment, fear, jealousy, frustration, guilt, dissatisfaction with one’s lot, low self-esteem, self-satisfaction, etc.. These cause ‘stress’. Working the Steps keeps ‘stress’ under control, hence prevents relapse.

Talk drawn from “How an Addict’s Power of Choice is Lost and can be Regained” in: Addiction & Choice: Rethinking The Relationship eds. Nick Heather & Gabriel Segal, Oxford University Press (forthcoming)