Unbroken Brain: A Revolutionary New Way of Understanding Addiction

by Maia Szalavitz

That’s not to say that AA is useless, however. When you look at people who voluntarily continue to attend, like I did, they do h...

The problem is that as a result, it’s hard to tell if these folks stay sober because they join AA—or if they join AA and stick with it because they are already highl...

At the end of the study, however, 67% of those who’d attended AA for 27 weeks or more in their first year were abstinent. Those who attended for over 52 weeks during years four through eight were nearly twice as likely to stay sober than those who went less often—with 71% of the frequent attenders achieving abstinence, compared to 39% for the others. That seems like quite a respectable success rate—until you start counting the dead and considering that only 28% of the group attended AA for 27 weeks or more initially. And there are numerous other studies that report roughly the same disappointing results.

On average, 70% of those referred to AA drop out within six months, according to Scott Tonigan, a researcher at the University of New Mexico who has studied 12-step programs for decades.

However, the minority who do find these programs amenable are mor...

Greater participation in recommended activities like helping others and having a sponsor is also co...

Some of its concepts, like the idea of hitting bottom discussed in chapter 14, are used to uphold harsh criminalization of drug use and punitive methods of treatment—both of which are ineffective and often harmful. Others—like the idea of powerlessness and the claim that the steps are the only way—can actively interfere with recovery if they are taken to heart.

Further, the 12-step idea of powerlessness is disempowering.

Research shows that the more someone believes in the idea that addiction is a disease over which he is powerless, the worse and more frequent a person’s relapses tend to be.

While some people can interpret “being powerless” in a benign way, others decide that it means they have no control not just over drugs but also over multiple spheres in their lives, including political action. This can be particularly damaging to women and members of minority groups, who are already faced with far too much powerlessness and do not have anything of t...

Teaching women that their only hope is 12-step groups can also leave them vulnerable to sexual predators. Unfortunately, predators are overrepresented in the program both because of the elevated prevalence of antisocial personality disorder among the ad...

One study found that 50% of women in AA had experienced behavior often euphemized as the “13th step,” in which men try to seduce or co...

bad or inappropriate treatment can demonstrably make things worse. Because of these risks, 12-step groups should never be mandated for teens—and if attendance is suggested as an adjunct to treatment, it should be accompanied by clear warnings and only done in cases that are already severe.

Fortunately, though, it is possible to reduce the risks of 12-step programs while preserving potential benefits.

First, addiction is far from unique in affecting the way the brain determines the motivational value of specific experiences like food, relationships, drugs, and romance.

addiction affects the brain’s valuation systems in much the same way that overwhelming thirst or starvation does.

Neurodevelopmental disorders like depression can also change how the brain sets its values, stunting lives by draining the pleasure from them and making nothing seem worthwhile.

Our brains are embodied—much of the problem with the debate over addiction and psychiatry more generally is a refusal to accept this and our ongoing need to see “physical,” “neurological,” and “psychological” as completely distinct.

12-step programs are meant to be lay groups where afflicted people help each other. Just as no one would trust a brain surgeon whose only training was having had a brain tumor removed, we shouldn’t think that simply having recovered from addiction makes someone an expert.

The risks of allowing providers to use punishment, humiliation, and emotional attacks to attempt to create a sense of powerlessness or force a “bottom” are too great. Abuse in institutions is common and difficult to rein in even when punitive measures are banned. It’s inevitable when staff are instructed to see patients as liars and con artists and told to deliberately try to make them feel helpless.

AA’s own guidelines say that members should never be paid to “carry the message” of the program to others.

For me, AA’s most important slogan was “Take what you like and leave the rest”—and this message should be strongly imparted to anyone who is referred.

lawyers were white, while the accused were primarily people of color. Although studies show that whites use drugs at the same rates as African Americans and actually sell more—and I certainly saw high rates of use and sales by whites in the Ivy League in the ’80s—people like me aren’t typically the ones being arrested and prosecuted.

This shouldn’t be surprising, given the racist origins of our drug laws, all of which, as we’ve seen, were passed by stirring fear and using blatantly racist images and rhetoric. And it has been enabled by a concept of addiction that remains more moral than medical and was born in the same racism as drug prohibition.

That made the crime I was charged with, possession with intent to distribute more than four ounces, an A-1 felony. It was equivalent to the sentence for second-degree murder and more serious than rape—and because those violent crimes did not have mandatory sentencing requirements, the result was that, in New York and many other states that followed its lead, first-time nonviolent drug offenders often served more time than rapists and killers.

One judge, upon sentencing a defendant whom he believed did not deserve a lengthy sentence, said, “[T]he mere possession of four ounces of this controlled substance is considered by the State of New York to be just as serious as the taking of a human life. That to me is an absolute atrocity.… However, I am obliged to enforce the law however stupid and irrational and barbarous it be.” The percentage of New Yorkers in state prison for drug crimes more than tripled between 1973 and 1994 as a consequence of the Rockefeller laws. More than 80% of those sentenced—who had to serve many years with no possibility of parole—had no history of violence.

By 2008, more than 90% of New York State’s drug prisoners were minorities.

although the press claims that heroin use is now a white thing for the first time, in fact, the majority of heroin users have been white since the 1970s.

Unlike current policies, harm reduction recognizes the crucial role of learning in addiction and the failure of punishment to solve drug problems.

Harm reduction’s fundamental principles are these: stop trying to fight drug use, most of which does not cause harm. Don’t focus on whether getting high is morally or socially acceptable; recognize that people always have and probably always will take drugs and this doesn’t make them irrational or subhuman. Instead, work to find practical methods that reduce risk and minimize damage—and understand that everyone can learn, just not all in the same way.

From the harm reduction perspective, drug use and even addiction isn’t necessarily irrational; it’s a response to the environment and people can learn to make better choices about it.

Because harm reduction recognizes that people learn best when they feel welcomed, respected, and safe, it reaches people who were thought to be beyond help and hope.

The idea that someone sees you as both being able to behave responsibly about your health and worthy of a chance to live is even more powerful.

Needle exchange and harm reduction don’t say: Go on and kill yourself with drugs, no one cares. They tell people—both drug users and non-users—that everyone deserves life and dignity and that being addicted shouldn’t be a sentence of death or exile from humanity.

When people start to be valued by others, they start to value themselves. And even when their drug use remains unchanged, harm reduction nearly always increases the amount of warm, social contact that the most traumatized and marginalized people have. Because this is essential to coping with trauma, it provides a foundation for further growth. Harm reduction is the opposite of tough love—it is unconditional kindness and imbues what looks to outsiders like irredeemable ugliness with startling moments of transcendent beauty.

MY PERSONAL BREAK with 12-step programs began when I learned about harm reduction and what the science really shows about addiction. But I didn’t act on it until I developed serious depression in my seventh year of recovery.

I’d not even been aware of their absence until they came back.

While some studies suggest that all antidepressant action is actually a placebo response, this “numbing” effect of SSRI’s is consistently replicated. In fact, even some of the psychiatry critics who think that these drugs are mainly placebos see this reduction in emotional sensitivity as a true pharmacological effect. Somewhat illogically, however, many of the same critics denounce it as a horrifying side effect, ignoring the possibility that these “placebos” may work for some people through precisely

As with similar claims that methadone and other types of maintenance automatically turn people into emotionless zombies, however, this defies more than logic. Not everyone has the same wiring and not everyone needs to be more sensitive. Sometimes, less is more. Too much emotion can be just as likely to cause social problems as too little.

For people whose addictions are driven by sensory and emotional overload, such...

because learning matters, there are commonalities that all successful approaches to addiction will share.

For one, to help people overcome learning problems, they must be treated with compassion and respect.

As harm reduction pioneer Alan Marlatt put it, “Harm reduction does not try to remove a person’s primary coping mechanisms until others are in place.”

just as both children and adults learn better when they feel secure and wanted, so, too, do addicted people respond better to treatment that is calming rather than threatening and sees them not as bad people, but as those who are lacking information and skills that teachers can share.

Being a student is a more empowering role than being a patient,

The idea is not to make more drugs available but to try to get safer ones to push out the more dangerous and recognize that regulation offers more control than prohibition. “We are reversing the onus of proof. If they cannot prove that a product is safe, then it is not going anywhere near the marketplace,”

The law mandated that legal psychoactive substances could only be purchased by an adult at a licensed outlet. To determine which substances ought to be legal, it required manufacturers to conduct clinical trials and sell only “low-risk” products that passed those tests.

Whose values should determine how much risk is acceptable from a drug, particularly one that can be addictive and therefore entangle some proportion of its users in a state that is antithetical to enjoyment and that typically reduces productivity? When is it okay to value pleasure over health? Why is potentially fatal skydiving okay but not LSD—a drug that is not linked with addiction, mental illness, or overdose death?

ARRIVE’s developers also realized that in order for people to learn to make healthier choices, they needed to feel capable of achievement and have attainable goals.

Josepher starts each semester with a motivational speech that takes a very different perspective on power than 12-step programs do. Instead of focusing on the weaknesses of those with addiction, ARRIVE highlights their strengths. “How many times did you go to bed with no drugs and no money and get up the next day and get high?” he asks—and participants always smile or laugh in accord. “That’s power,” he says, explaining that what his program will teach is ways of focusing this drive and strength in a new direction.