Bill Wilson would never have another drink. For the next thirty-six years, until he died of emphysema in 1971, he would devote himself to founding, building, and spreading Alcoholics Anonymous, until it became the largest, most well-known and successful habit-changing organization in the world.
An estimated 2.1 million people seek help from AA each year, and as many as 10 million alcoholics may have achieved sobriety through the group. [75] [76] AA doesn’t work for everyone-success rates are difficult to measure, because of participants’ anonymity-but millions credit the program with saving their lives. AA’s foundational credo, the famous twelve steps, have become cultural lodestones incorporated into treatment programs for overeating, gambling, debt, sex, drugs, hoarding, self-mutilation, smoking, video game addictions, emotional dependency, and dozens of other destructive behaviors. The group’s techniques offer, in many respects, one of the most powerful formulas for change.
All of which is somewhat unexpected, because AA has almost no grounding in science or most accepted therapeutic methods.
Alcoholism, of course, is more than a habit. It’s a physical addiction with psychological and perhaps genetic roots. What’s interesting about AA, however, is that the program doesn’t directly attack many of the psychiatric or biochemical issues that researchers say are often at the core of why alcoholics drink. [77] In fact, AA’s methods seem to sidestep scientific and medical findings altogether, as well as the types of intervention many psychiatrists say alcoholics really need.1
What AA provides instead is a method for attacking the
Bill Wilson didn’t read academic journals or consult many doctors before founding AA. A few years after he achieved sobriety, he wrote the now-famous twelve steps in a rush one night while sitting in bed. [79] He chose the number twelve because there were twelve apostles. [80] And some aspects of the program are not just unscientific, they can seem downright strange.
Take, for instance, AA’s insistence that alcoholics attend “ninety meetings in ninety days”-a stretch of time, it appears, chosen at random. Or the program’s intense focus on spirituality, as articulated in step three, which says that alcoholics can achieve sobriety by making “a decision to turn our will and our lives over to the care of God as we understand him.” [81] Seven of the twelve steps mention God or spirituality, which seems odd for a program founded by a onetime agnostic who, throughout his life, was openly hostile toward organized religion. AA meetings don’t have a prescribed schedule or curriculum. Rather, they usually begin with a member telling his or her story, after which other people can chime in. There are no professionals who guide conversations and few rules about how meetings are supposed to function. In the past five decades, as almost every aspect of psychiatry and addiction research has been revolutionized by discoveries in behavioral sciences, pharmacology, and our understanding of the brain, AA has remained frozen in time.
Because of the program’s lack of rigor, academics and researchers have often criticized it. [82] AA’s emphasis on spirituality, some claimed, made it more like a cult than a treatment. In the past fifteen years, however, a reevaluation has begun. Researchers now say the program’s methods offer valuable lessons. Faculty at Harvard, Yale, the University of Chicago, the University of New Mexico, and dozens of other research centers have found a kind of science within AA that is similar to the one Tony Dungy used on the football field. Their findings endorse the Golden Rule of habit change: AA succeeds because it helps alcoholics use the same cues, and get the same reward, but it shifts the routine.
Researchers say that AA works because the program forces people to identify the cues and rewards that encourage their alcoholic habits, and then helps them find new behaviors. When Claude Hopkins was selling Pepsodent, he found a way to create a new habit by triggering a new craving. But to change an old habit, you must address an old craving. You have to keep the same cues and rewards as before, and feed the craving by inserting a new routine.
Take steps four (to make “a searching and fearless inventory of ourselves”) and five (to admit “to God, to ourselves, and to another human being the exact nature of our wrongs”).
“It’s not obvious from the way they’re written, but to complete those steps, someone has to create a list of all the triggers for their alcoholic urges,” said J. Scott Tonigan, a researcher at the University of New Mexico who has studied AA for more than a decade. [83] “When you make a self-inventory, you’re figuring out all the things that make you drink. And admitting to someone else all the bad things you’ve done is a pretty good way of figuring out the moments where everything spiraled out of control.”
Then, AA asks alcoholics to search for the rewards they get from alcohol. What cravings, the program asks, are driving your habit loop? Often, intoxication itself doesn’t make the list. Alcoholics crave a drink because it offers escape, relaxation, companionship, the blunting of anxieties, and an opportunity for emotional release. They might crave a cocktail to forget their worries. But they don’t necessarily crave feeling drunk. The physical effects of alcohol are often one of the least rewarding parts of drinking for addicts.
“There is a hedonistic element to alcohol,” said Ulf Mueller, a German neurologist who has studied brain activity among alcoholics. “But people also use alcohol because they want to forget something or to satisfy other cravings, and these relief cravings occur in totally different parts of the brain than the craving for physical pleasure.”
In order to offer alcoholics the same rewards they get at a bar, AA has built a system of meetings and companionship-the “sponsor” each member works with-that strives to offer as much escape, distraction, and catharsis as a Friday night bender. If someone needs relief, they can get it from talking to their sponsor or attending a group gathering, rather than toasting a drinking buddy.
“AA forces you to create new routines for what to do each night instead of drinking,” said Tonigan. “You can relax and talk through your anxieties at the meetings. The triggers and payoffs stay the same, it’s just the behavior that changes.”
KEEP THE CUE, PROVIDE THE SAME REWARD, INSERT A NEW ROUTINE
One particularly dramatic demonstration of how alcoholics’ cues and rewards can be transferred to new routines occurred in 2007, when Mueller, the German neurologist, and his colleagues at the University of Magdeburg implanted small electrical devices inside the brains of five alcoholics who had repeatedly tried to give up booze. [84] The alcoholics in the study had each spent at least six months in rehab without success. One of them had been through detox more than sixty times.
The devices implanted in the men’s heads were positioned inside their basal ganglia-the same part of the brain where the MIT researchers found the habit loop-and emitted an electrical charge that interrupted the neurological reward that triggers habitual cravings. After the men recovered from the operations, they were exposed to cues that had once triggered alcoholic urges, such as photos of beer or trips to a bar. Normally, it would have been impossible for them to resist a drink. But the devices inside their brains “overrode” each man’s neurological cravings. They didn’t touch a drop.
“One of them told me the craving disappeared as soon as we turned the electricity on,” Mueller said. “Then, we turned it off, and the craving came back immediately.”
Eradicating the alcoholics’ neurological cravings, however, wasn’t enough to stop their drinking habits. Four of them relapsed soon after the surgery, usually after a stressful event. They picked up a bottle because that’s how they automatically dealt with anxiety. However, once they learned alternate routines for dealing with stress, the drinking stopped for good. One patient, for instance, attended AA meetings. Others went to therapy. And once they incorporated those new routines for coping with stress and anxiety into their lives, the successes were dramatic. The man who had gone to detox sixty times never had another drink. Two other patients had started drinking at twelve, were alcoholics by eighteen, drank every day, and now have been sober for four years.
Notice how closely this study hews to the Golden Rule of habit change: Even when alcoholics’ brains were changed through surgery, it wasn’t enough. The old cues and cravings for rewards were still there, waiting to pounce. The alcoholics only permanently changed once they learned new routines that drew on the old triggers and provided a familiar relief. “Some brains are so addicted to alcohol that only surgery can stop it,” said Mueller. “But
