The Intersection of Psychiatry and 12-Step Recovery

Jason Eric Schiffman, MD, MA, MBA

Until the founding of Alcoholics Anonymous in 1935, there were essentially no standardized treatments for addiction,

and it is likely that few, if any, individuals with addictive disorders prior to that time substantially recovered from the condition. Historically, the field of medicine had little interest in addiction, and for many years after its inception, Alcoholics Anonymous and the numerous other 12-step programs derived from it remained the only standardized interventions for addictive disorders. As a consequence, 12-step based approaches have been a mainstay of addiction treatment and to this day remain one of the most commonly utilized interventions for addictive disorders worldwide.

Because 12-step programs are a non-clinical, communitybased intervention that developed outside of the healthcare field, integrating their use with treatment within the healthcare system has presented some challenges. Three points of intersection in which these challenges are most evident are as follows: 1) discomfort in some factions of the 12-step community with the use of psychotropic medications (particularly opioid agonist/partial agonist maintenance therapy for opioid use disorder), 2) the historical and continuing exclusion of addiction treatment centers from regulation by state medical boards and the corporate practice of medicine laws governing the rest of the healthcare industry, and 3) the fact that 12-step programs claim to achieve their efficacy through a spiritual mechanism.

This third point, which is the focus of this article, has often caused discomfort among physicians who find themselves in the difficult position of defending a treatment recommendation for which there is good empirical evidence but for which the purported mechanism of efficacy is outside the biological model of illness. In the modern healthcare system, prescription of a purportedly spiritual intervention is unlikely to be well received in any other field of medicine, so it should not be surprising that physicians have struggled with finding a way to recommend and explain 12-step based interventions to their patients with addictive disorders.

A series of recent studies have both supported 12-step interventions as effective1 and shed some light on the mechanisms through which this efficacy is mediated2. The studies evaluated the following six potential mediators of Alcoholics Anonymous efficacy: • spirituality • social abstinence self-efficacy (i.e., confidence in one’s ability to remain abstinent when confronted with high-risk social drinking situations) • negative affect abstinence self-efficacy (i.e., confidence in one’s ability to remain abstinent when experiencing • depression/anxiety) • depression symptoms • negative social networks (i.e., removing heavy drinkers from the social network) • positive social networks (i.e., adding abstainers/recovering individuals into the social network).

What was found was that the primary mediators of 12-step efficacy were facilitation of changes in social networks and increases in social and negative affect abstinence self-efficacy. Spirituality did mediate some benefit, particularly among individuals with more severe symptoms, but this benefit was minor compared to social and self-efficacy mediators.3

The fact that spirituality appears to be a minor contributor to 12-step efficacy, despite what 12-step groups say about themselves, is useful in helping the physician recommending 12-step participation explain the recommendation by reference to social and psychological mechanisms rather than spiritual mechanisms.

Nonetheless, given the emphasis 12-step approaches place on spirituality and the fact that spirituality appears to mediate at least some of 12-step’s efficacy, it would be useful to have an explanation for what this mechanism is that uses a psychological rather than spiritual framework that was thus consistent with the biopsychosocial model used in modern medicine. First, let’s summarize how 12-step interventions benefit individuals with addictive disorders according to Alcoholics Anonymous itself.

The following is from a section of the Alcoholic Anonymous literature entitled “How it Works”: (a) We were alcoholic and could not manage our own lives. (b) Probably no human power could have relieved our alcoholism.

(c) God could and would if He were sought.

As stated above, Alcoholics Anonymous believes neither the alcoholic nor other people have the power to relieve addiction, and that 12-step interventions work via facilitation of “conscious contact” with a higher power. It is then the higher power that alleviates the addiction through removal of the individual’s obsession to use the substance or behavior to which they are addicted. The 12 steps are meant to accomplish this connection through removal of ego-related blocks between the individual and their higher power. This is depicted in the following schematic.

Cognitive neuroscience and psychology provide a useful framework for understanding the underlying mechanisms and etiology of addictive disorders. What becomes an addictive disorder typically begins as the non-addictive use of a euphorigenic substance or behavior as a means to manage chronic dysphoric feelings. The repeated use, especially when it is providing both euphoria and relief from dysphoria, hyperactivates the reward pathway. Eventually, the degree of reward-mediated drive (termed “incentive salience”) associated with cues of the substance or behavior becomes so strong that the use cannot be reliably inhibited by the prefrontal cortex.

Both the addictive process and the process underlying the chronic dysphoric feelings for which the addictive substance or behavior was initially a solution, can be understood as manifestations of a particular type of learning fundamental to how human (and likely other animal) brains encode information about the world. The primary mechanism through which previously gained knowledge is used to understand the present and make predictions about the future is the creation and application of templates. A general description of this process is as follows: • Experiences which are either common or associated with intense emotion (or both) result in the creation of an associated template in the mind of the individual. • The template retains the core features of the original experience but with the specific elements replaced with general categories. • The template retains the core thoughts, feelings, and behaviors associated with the original experience, particularly as they relate to the individual’s ability to function or survive. • When the individual encounters similar scenarios in the future, the template is activated and applied to the present situation, imbuing it with the knowledge, feelings, and behaviors contained in the template.

For example, if you are attacked by a bear and survive, your brain forms a template of the event which helps protect you in the future, not just from another attack by the original bear but from bear attacks in general.

When experiences are either very distressing or very rewarding, the templates formed from them contain powerful feelings and are often easily triggered. This is the basis for both addiction and for the chronic states of depression and anxiety that are so often its precursor.

As depicted in the schematics below, both traumatic and hedonic (rewarding) experiences create templates which may then become the basis for chronic problematic emotions and behaviors. The extent to which these emotional states and behaviors become dysfunctional is dependent upon how easily the templates to which they belong are triggered which in turn depends on how distressing or rewarding the original events were. Thus, individuals who experience many or severely distressing events, particularly during development, are vulnerable to developing chronic feelings of anxiety and depression. When these individuals discover a euphorigenic substance or behavior that ameliorates their chronic dysphoria, they are apt to chronically repeat its use and are thus vulnerable to developing hedonic templates associated with the powerful cravings which characterize addiction.

How might we use the concept of trauma templates and hedonic templates to explain why “conscious contact with a higher power” as described by Alcoholics Anonymous may help those with addictive disorders? A clue may be found in the unofficial advice sometimes given at 12-step meetings that your higher power can be anything you choose; it just can’t be you and it has to be loving.

Secure attachment is the bedrock of psychological and emotional wellbeing. This is particularly true of attachment with important adults when we are children, which becomes the basis for our attachment templates later in life. Unlike most other animals, human children are essentially incapable of surviving on their own for the first decade of life and evolution has thus fashioned children’s cognitive/emotional system to prioritize establishing and maintaining secure attachment to stable parent figures above all else. The emotional manifestations of this system are that secure attachment results in rewarding feelings of self-worth, validity, lovability, and peacefulness and

lack of secure attachment results in feelings of anxiety, shame, and emptiness and a drive to determine what we need to change about ourselves in order to become loveable.

By positing the existence of a “higher power” and developing a practice of making “conscious contact” with it, it is likely that 12-step participants who are benefitting from the spiritual aspect of the program are doing so by inducing an experience of secure attachment with a loving authority.

When a template is triggered, the thoughts and feelings associated with it are experienced as being about what is happening in the present moment even though their origin is something that happened in the past. For example, if you ask a person who was mauled by a dog when they were young what they are afraid of when they are in the presence of a dog now, they will point to the animal in front of them. Strong templates have low activation thresholds, i.e., are easily triggered, and for individuals in whom these exist, the present moment may be consistently flooded with the intense anxiety and shame or intense cravings derived from past experiences. The ability to exit these templates by entering into a state of secure attachment with a loving authority may be a particularly useful skill for managing dysphoric feelings and cravings and is likely how a “conscious connection” with a higher power benefits individuals with addictive disorders.

While this article has focused narrowly on the mechanism by which the spiritual aspect of 12-step interventions may benefit individuals with addictive disorders, the methodology employed here of using a psychological framework to understand a spiritual experience may be useful in understanding how other spiritual practices mediate emotional benefits to their practitioners.

Jason Eric Schiffman, MD, MA, MBA is a psychiatrist and board-certified addiction medicine specialist. He is the founder and Director of the UCLA Dual Diagnosis Program and Camden Center, a mental health and addiction treatment program in Los Angeles and the San Francisco Bay Area.

References

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