More than eight decades after its beginning, the 12-Step program of Alcoholics Anonymous continues to dominate addiction treatment in the United States. But not everybody is happy about that. Scientific American summed it up in 2015: “Hospitals, outpatient clinics, and rehab centers use the 12 steps as the basis for treatment. But although few people seem to realize it, there are alternatives, including prescription drugs and therapies that aim to help patients learn to drink in moderation. Unlike Alcoholics Anonymous, these methods are based on modern science and have been proven, in randomized, controlled studies, to work.” Despite this perceived lack of evidence, 12-Step programs are often the default option in addiction treatment, not just for alcohol use disorder but for other substances as well. Beginning in the 1950s, the AA approach was adapted to narcotics by the founders of NA, and later expanded to other addictions. Twelve Step programs are also used for behavioral disorders, such as gambling or overeating. In his comprehensive report on addiction, the Surgeon General accorded AA and other recovery support services an important role. “Mutual aid groups and newly emerging recovery support programs and organizations are a key part of the system of continuing care for substance use disorders in the United States.” The report also states that “well-supported scientific evidence demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions.” Marc Galanter, M.D., is a professor of psychiatry and the director of the Division of Alcoholism and Drug Abuse at the New York University School of Medicine. He looked at the medical efficacy of the AA method in his book, What is Alcoholics Anonymous?, and concluded: “Professionals and treatment programs that maintain a Twelve Step orientation are increasingly finding that this approach is compatible with the variety of psychotherapeutic and pharmacologic approaches now available.” One of the main criticisms of the approach today is the use of appeals to a “higher power” and God in the 12 Steps, which was developed in the 1930s by the founders of AA. In the 21st century, this appears too faith-based and unscientific to many people. Some have even compared AA to a cult. Dr. Galanter examined cults and how they effect radical behavioral changes in their members because—when it works—AA does just that. In many cases, the fellowship is able to get members to “willingly give up an agent to which they are addicted,” which is not an easy task. “My hypothesis was that distressed young people were somehow drawn in by the support of existing members who appeared caring and provided emotional support. Importantly, it appeared that the very experience of this support led to a relief in recruits’ distress, generating involvement that yielded a compliance with the group’s expectations,” writes Galanter. If a new member accepts the basic creed of the fellowship—the 12 Steps—it can achieve what Galanter calls a “relief effect” with the resulting improved well-being reinforcing continued participation. The methods providing this relief are the AA meetings and the sponsorship. “An addicted person need never feel that the fellowship’s spirit and practice are far away” and in big cities fellow members are available every day at all hours. Almost no physician can guarantee that kind of access which offers a sense of security to struggling addicts, especially in early recovery. Stress is an important factor known to increase relapse risk in patients with substance use disorders. Working with a sponsor can be seen as a stress-reducing “therapeutic alliance”—in psychiatric terms the trusting relationship between patient and therapist that is widely considered to be the key to successful therapy. An even more positive effect can be observed in people who serve as sponsors. Galanter credits Frank Riessman’s “helper therapy principle,” which suggests that when an individual provides assistance to another person, the helper may benefit. “This benefit is evidenced in the outcome of one large-scale federal study, which showed that helping other alcoholics and serving as a sponsor was more likely to yield a positive outcome than the number of meetings a member attended.” Galanter also looked at the psychological benefits of the spiritual aspects in the 12 Steps. “The Twelve Step approach to recovery is distinguished from professionally grounded treatments like cognitive behavioral therapy by one of its most prominent features: It conveys a system of values that extends beyond just being abstinent.” It’s the spiritual awakening for which 12-Step programs aim that takes them beyond medical treatment. Even so, the prayer and meditation called for in step 11 can still yield a measurable medical effect. “I had been struck by how committed AA members could draw on prayer to bolster their sobriety in the face of triggering circumstances,” Galanter writes in What is Alcoholics Anonymous? He tested the effect by asking long-term AA members to participate in an fMRI protocol. The results were quite telling. When shown trigger pictures subjects were able to control their cravings with prayers. “It appears that the experience of AA over the years had left these fellowship members with an innate ability to use the AA experience—prayer in the case of this study—to minimize the effect of alcohol triggers in producing craving.” Galanter and his team found that the craving did not show up in the striatum, where it typically would in detoxified alcoholic patients. Instead, the decrease in craving after prayer was associated with “brain areas that regulate self-control and interpret the meaning of outside stimuli.” Apparently, the AA experience can effectively turn recovering alcoholics into persons who no longer crave alcohol in the face of temptation. Unfortunately, this “unlearning” of addiction is neither guaranteed nor necessarily permanent. The vulnerability to relapse even after years of sobriety continues to be puzzling for Galanter and other addiction professionals. More research into the nature of addiction is certainly necessary. In the meantime, both treatment and mutual aid groups like AA offer the possibility of a successful recovery. Galanter found that “both AA participation alone and formal treatment alone were associated with improved outcomes. Those with the best outcome, however, had both AA and treatment.”