Book review: the science behind 12 Step recovery

Nowinski’s excellent popular science book If You Work It, It Works! The Science Behind 12 Step Recovery (2015) makes it pretty clear: AA only works if you participate.

Dr Joseph Nowinski’s name came up a bunch of times when I was doing research into international best practice in treatment and support for alcoholics and risky drinkers.  I was completing this work at the same time my drinking was at its white-spirit-worst and, because of that, I nearly lost the job for good.

In fact I’m pretty sure Nowinski’s Twelve Step Facilitation Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence(1999) was even on the shelf when I was poking around in the literature cupboard at my last rehab. By that stage I had decided AA was definitely some kind of cult. Why else would people willingly go out of their way to help perfect strangers? Surely they had some other motive?

It turns out they did have an alterior motive. But they weren’t trying to sell me salvation proportionate to my income. No, helping others made them feel better.

Nowinski

Project MATCH :/

Dr Nowinski contributed to Project MATCH (1989-97), the largest alcohol treatment trial ever conducted involving 1726 alcohol dependent volunteers over several treatment sites in the US. The aim of Project MATCH was to find out if different types of ‘alcohol abusing or dependent patients’ respond differently to the most widely used treatments for alcohol dependency: Cognitive Behavioral Therapy (CBT), Motivation Enhancement Therapy (MET) or Twelve-Step Facilitation (therapists introduce patients to AA, explain some of the concepts and get them to attend meetings. The focus is on AA’s steps one to five).

Project Match’s data dissapointed a lot of people in the addiction and recovery field. It reinforced what many suspected: that matching the right treatment to individual alcoholics is difficult, and that treatment outcomes are similarly dissapointing across the board. In other words, Project Match didn’t offer a silver bullet for treating alcoholism.

Yet, the fact that a treatment protocol based on AA’s 12-steps – an unscientific, quasi-religious oddity – could achieve similar results as CBT and MET was notable, given that AA costs nothing to taxpayers and provides critical post-intervention (e.g. hospital E.R., detox, rehab) support in the community.

AA only works for those who take action

The title of If You Work It, It Works! is intentional because, as Nowinski points out, only half of us who attend AA stay active in the fellowship after three months.

I recently lost 20kg because I changed my diet and started running. Thinking about it didn’t get me healthy.

Nowinski analysed AA member surveys to find out what actions people take in AA to stay sober and found attending at least two and preferably three meetings a week, joining a home group, and getting a sponsor were the top three responses. These same three actions kept me sober in my early days of sobriety.

Nowinski examined a range of research on AA attendance and involvement, and treatments that encourage AA attendance. The results show that:

  • Getting into some form of counseling and starting AA at the same time is a winning combination if you want to stay sober.
  • Getting involved in the AA Twelve Step fellowship leads to superior results than simply attending meetings.
  • Identifying yourself as an AA member makes a positive difference.
  • Therapy that actively facilitates AA involvement is superior to treatment that does not include this focus.

He also notes that there is a spectrum of alcoholism and problem drinking and that, for some, controlled drinking may have its place after a period of conditional abstinence.  For those like me, who have tried and failed at controlled drinking and have ridden the ‘just one’, drink-drank-drunk *crash*, remorse cycle so many times the very idea of controlled drinking is laughable, Nowinski says that abstinence should be ‘the most appropriate goal’.

How it works

1. Social networks

Like me, Nowinski attributes much of AA’s value to the relationship between social networks and recovery. He uses a number of published studies to show how both involvement in AA, and the people in an alkie’s regular social network, are critical to long-term recovery. AA involvement seems to act as a buffer, particularly where a person’s regular social network includes frequent or heavy drinkers. Some people use AA as an alternative social network, particularly when there is always drink at home. I’m lucky that my immediate family are not huge drinkers and my best mates, while still capable of epic feats of party mayhem, are generally pretty sensible and respectful of my non-drinker status.

Interestingly, problem drinkers in a person’s social network exert a more powerful and negative influence on recovery than non-drinkers. In other words, surround yourself with drunks and you’ll probably end up just that – drunk. Surround yourself (at least some of the time) with AA members and you’ll probably stay sober. Dead simple.

2. Spirituality and sponsorship

As a scientist, Nowinski doesn’t engage in spiritual or theological argument. Instead, he presents published studies that have examined the role of spirituality in recovery. Obviously there are limitations in this data because concepts like spirituality are open to interpretation – particularly by sick people responding to surveys. The studies show that greater involvement in AA leads people to become ‘more spiritual’ over time, which is, in turn, positively associated with sobriety. This is not suprising, since AA is a program that emphasises the benefits of spirituality, particularly prayer and meditation.

The other aspect of AA’s spirituality Nowinski finds beneficial is the focus on personal values and self-reflection. He concludes that ‘spirituality, as it is reflected in AA’s emphasis on honesty, humility, and personal renewal, as opposed to formal religious observance, may be the key dynamic responsible for this change’ (p.148).

Nowinski’s message is clear: AA spirituality is not about joining a cult or a church. It’s about ‘pursuing a life of meaning and values. These include honesty, the courage to admit to shortcomings, humility, and altruism. Within the AA culture these values are demonstrated through action’ (p. 160).

Studies on sponsorship are pretty unequivocal: getting a sponsor early greatly increases your chance of not drinking again. However, this effect seems to decrease with time. Nowinski says that the adage ‘better late than never’ probably applies here, and I have to agree with him.

3. Neurological factors

Alcohol kills brain cells. That bit we knew already. But, if you drink like I did, it also greatly increases your chance of suffering from depression and/or anxiety, as well as PTSD and schizophrenia. The point is that most alkies seem to have some sort of psychiatric comorbidity or dual-diagnosis to party with their alcoholism and other addictions.

Nowinski reviews the evidence on recovery for alcoholics with dual-diagnosis and finds that, as long as people work their AA program, these illnesses ‘do not appear to consitute a major barrier to recovery’ (p. 181).  He concludes that recovery (and particularly Twelve Step recovery) has healing powers of its own.

Is it worth reading?

In a word, yes. Nowinski’s book is:

  • a much needed kick in the pants for alcoholics like me who forget to put in the action each day. Treatments for diabetes and heart disease are never effective 100 percent of the time, because they are dependent on whether or not a patient follows the treatment recommended by their doctor. As Nowinski puts it: ‘the best we can say, then, is that these treatements are likely to work if the individual works them’; and,
  • an excellent introduction to the medical literature on alcoholism and recovery, which shows that AA has some good, recent scientific studies supporting its approach to recovery.

Working with others

Alcoholism is a chronic, relapsing condition that, if left untreated, can be fatal. The main treatment I and millions of others around the world find effective is to work with fellow alkies and follow a few very simple principles based on honesty and respect for others. But, for me, it’s primarily about a unique human connection – one that is based on empathy. Or, as the old timers say, ‘the magic happens when one alcoholic works with another alcoholic’.

A great example of this is found in the AA Big Book in chapter 11 (pp.156-8). The story refers to Bill and Bob’s first visit to a guy who would become AA’s third member; a visit that resulted in AA’s first group at Akron, Ohio in 1935.

Bill W and Dr Bob had only just figured out that they needed to ‘keep spiritually active’ by working with other alcoholics, so they called up a local hospital and spoke to the head nurse:

They explained their need and inquired if she had a first class alcoholic prospect.

She replied “Yes, we’ve got a corker. He’s just beaten up a couple of nurses. Goes off his head completely when he’s drinking. But he’s a grand chap when he’s sober, though he’s been in here eight times in the last six months. Understand he was once a well-known lawyer in town, but just now we’ve got him strapped down tight.”

…Two days later, a future fellow of Alcoholics Anonymous stared glassily at the strangers beside his bed. “Who are you fellows, and why this private room? I was always in a ward before.”

Said one of the visitors, “We’re giving you a treatment for alcoholism.”

Hopelessness was written large on the man’s face as he replied, “Oh, but that’s no use. Nothing would fix me. I’m a goner. The last three times, I got drunk on the way home from here. I’m afraid to go out the door. I can’t understand it.”

For an hour, the two friends told him about their drinking experiences. Over and over, he would say: “That’s me. That’s me. I drink like that.”

The man in the bed was told of the acute poisoning from which he suffered, how it deteriorates the body of an alcoholic and warps his mind. There was much talk about the mental state preceding the first drink.

“Yes, that’s me,” said the sick man, “the very image. You fellows know your stuff all right, but I don’t see what good it’ll do. You fellows are somebody. I was once, but I’m a nobody now. From what you tell me, I know more than ever I can’t stop” At this both the visitors burst into a laugh. Said the future Anonymous: ‘Damn little to laugh about that I can see.”

The two friends spoke of their spiritual experience and told him about the course of action they carried out.

He interrupted: “I used to be strong for the church, but that won’t fix it. I’ve prayed to God on hangover mornings and sworn that I’d never touch another drop but by nine o’clock I’d be boiled as an owl.”

Next day found the prospect more receptive. He had been thinking it over. “Maybe you’re right,” he said. “God ought to be able to do anything.” Then he added, “He sure didn’t do much for me when I was trying to fight this booze racket alone.”

Bill and Bob continued to work with the man, and after three days he had become ‘willing to do anything necessary’, including to give his life to the ‘care and direction of his Creator’.

That afternoon he put on his clothes and walked from the hospital a free man…He never drank again. He too, has become a respected and useful member of his community.

Eight decades have passed since two alkies working together became three, then four, and now millions worldwide. And yet, the story remains relevant.

Aside from my wish to resurrect the phrase ‘as drunk as a boiled owl’, this is one of my favourite sections of the Big Book because it provides hope to those of us who are still suffering and can see no way out.

Most of the people I know in AA who have been to a rehab or detox have also drunk either on the way home from their treatment, or soon after. Just like our formerly-respected-lawyer-Anonymous #3. I did too, on two separate occasions. When we discuss these events we speak of unnatural, sanitised environments that do not prepare us for life after our time in confinement is up, certainly not if we return to our communities with no lifelines (I have many AA members’ numbers in my phone who I can call on at any time). This phenomenon – the relapsing nature of the condition – continues to challenge the medical profession and policy-makers alike.

But, for eight decades, AA has been keeping people sober on little more than a pay-it-forward faith in something more powerful than the individual.

The Big Book likes to call this something God. Today, AA teaches that it just has to be something other than ourselves. Even the AA group – a thoroughly humanistic Higher Power if ever there was one – can be this special something.

But, most of us have found that we can’t just rely on gods and goddesses to get us well. We have to put in some work too.

 

The knife

I’ve just spent some time at my folk’s place in coastal Victoria, Australia. It was my annual, seasonal ritual delayed: family (and dogs) converging for ham and plumb pudding in the second week of January. The sun was hot and the March flies (who clearly don’t give a toss about human inventions like the Gregorian Calendar) were hungry for blood.

My parents gave me a knife as a sort of weird family heirloom, given that it was thrown at, and narrowly missed, my grandfather during a post-footy game riot in Melbourne’s Western Suburbs not long after WW2.

Pa was a VFL (aussie rules football) club champion during those years. A quiet family man and boilermaker – not the type to attract would-be knife throwing ninjas, but a prime target for pissed idiots nonetheless.

The knife has an iron cross and some other etchings, suggesting it was made for the German army, most likely the Luftwaffe or so I’ve been told. Anyway, it has the balance of a throwing knife (the chips out of the bone handle suggest it has seen some use).

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My grandparents old house was up for sale, a few doors down from my parent’s place and where my dad and aunt grew up. Apart from a lick of paint, the house and large block of land with the tennis court my Pa built remains unchanged and miraculously undeveloped.

I had a walk through the ‘classic beach shack’ and viewed the realtor’s slick promotional video for the sale, complete with aerial drone footage. I’m not sure what Pa would have made of all that fuss. He was a no-nonsense kinda guy.

Going home always seems to bring back memories.

I had my first alcoholic dream in what feels like an eternity the other night: the full-bore, wake up in a cold sweat, dry mouth, heart palpitations, ‘oh fuck I’ve drank’ panic. In the dream, I was drinking in my old haunt, at the pub down the road from my folk’s place, and got so pissed I couldn’t climb the hill to get home. The road turned into a vertical cliff face before the dream dissolved and the panic of a bust subsided into lingering feelings of remorse and guilt.

During my 20s  and early 30s I used to go to that pub with the intention of having a couple of drinks. Instead, I routinely woke up on various mates’ couches among the empty bottles, ciggie butts and drug paraphernalia – evidence of the previous night’s hedonism. On those mornings, that damn hill felt like a cliff face.

Fortunately, I don’t plan on scaling any cliffs today. Just some hills with the scent of eucalyptus in the air.

One day at a time (still)

I had to come home early from my planned trip away because I needed to get my back fixed (official story) and my head fixed (most importantly). You see, if I drink again I’ll end up back on the couch passed out most of the time, which is about the worst thing you can do for a crook back.

The back took 35 minutes with the physio.

The head? I’ve been to a bunch of meetings and spoken with other alcoholics. I’ve gained a fresh perspective and have become right sized again. Not a mean, small little man who is resentful when things don’t go his way. Or the grandiose, obnoxious oaf. Just right sized.

I have also finished an inventory and have realised a few things:

1 I am still an alcoholic and even if I don’t drink today, my addiction is still there lurking. Like a fucking lurker. If I don’t treat it, I turn into an asshole and nobody needs that.

2 The symptoms of my untreated alcoholism, for example feeling restless and irritable seem to increase as I take more things for granted. My sponsor said to start doing a gratitude list again, so I have. Right now, I’m grateful I’m not dead in a ditch, am living in Australia where I don’t have to worry about getting shot walking down the street, and for mangos. Mangos are amazing.

3 When I’m not working my program I tell more people, more regularly, to fuck off. This is unfair to them and marks me as someone incapable of polite conversation. I will also busy myself taking other people’s inventory: I’ll believe it is my right to find the error in someone else’s ways and (worse still) I am arrogant enough to think I can change them. Rather, I should concern myself with cleaning up my side of the street in personal relationships. After all, the only person I can really change is myself.

The other night I went to a meeting in a small coastal town, which was unlike any other I have ever been to. It seemed to be operating more like a personality cult than a healthy AA group, with one guy completely dominating proceedings, including sharing and questions and answers from the floor. I heard that the group doesn’t encourage newcomers to share, with the message they have nothing useful to contribute. What a load of crap.

I believe newcomers are the lifeblood of meetings. I still attend meetings every few days, when I can, to remind myself that I can’t take my eye off the ball. Don’t get me wrong, newcomers aren’t like poverty porn. There is no voyeurism in AA. I just need to hear their stories and see their shakes to remember my own worst moments. To feel my own worst moments.

I also believe AA is at its best when its traditions are observed, particularly the principle that the group is more important than the individual and that no-one is ‘in charge’ in AA. Still, I bit my tongue: it is up to the group to work it all out.

I just wish I could bite my tongue more when I speak to loved ones and people that piss me off in the street.

In sum: AA is not just about putting down the bottle. It’s about learning to live without alcohol. I need to be willing to change the way I think about things and how I react to situations.