John M. Talmadge, M.D.

A Blog Covering Many Topics

Science on Will and Willpower - Part I

The fellowship of Alcoholics Anonymous is one of the few places where we will hear discussion of will, willpower, and willingness. Most recovering individuals have never heard of one of the finest philosophers of the 20th Century: Professor Harry Frankfurt of Princeton University. His focus on human will is brilliant, but often overlooked. His analytical philosophy is described in a collection of essays titled The Importance of What We Care About. Early in his career he referred to the study of human will as "the most neglected area in modern philosophy," and he asserted that human will is the characteristic that makes us uniquely human.

We are the only sentient creatures having the capacity to know our own will and assert our will. Frankfurt also observes, in his elegant essays, that human beings are uniquely capable of knowing that there are times when "the will that I have is not the will that I want to have." For example, someone may want to learn to play the piano, but they may say, "I can't find the will to practice." They want to have the will to practice, but somehow it's not there, or it's subordinated to a different expression of will. The same is often true of addicts and alcoholics. Wanting to stay sober, the alcoholic/addict yearns for "the will to stay sober," but often the search for the will comes up empty. Alcoholics Anonymous teaches that alcoholics cannot will themselves to quit drinking—indeed, that self-will and self-centeredness are likely a root cause of the drinking. Yet recovering addicts must be willing. That is, they must be open to the possibility that the group and its principles are powerful enough to trump a compulsive disease.

For decades Frankfurt's scholarship failed to receive the attention it deserved, and then neuroscience became an unexpected ally in the philosophical inquiry. At the University of Illinois, for example, Dr. Ibrahim Senay has studied the concepts of will and willingness from the perspective of clinical psychology. Senay figured out an intriguing way to explore possible connections among will, willingness, intention, motivation and goal-directed actions. In short, he identified some key traits needed to achieve any personal objective, from losing weight to learning to play play piano.

Senay did this by exploring self-talk. Self-talk is just what it sounds like—that voice in your head that articulates what you are thinking, spelling out your options and intentions and hopes and fears, and so forth. It is the ongoing conversation you have with yourself. Senay thought that the form and texture of self-talk—right down to the sentence structure—might be important in shaping plans and actions. What’s more, self-talk might be a tool for exerting the will—or experiencing willingness.

Senay's study involved two groups. One of the groups was told that they might be working on a task (solving a puzzle), and the other group was told that they actually would be working on a task. The first group was instructed to think about whether they would, or would not, be asked to work the puzzles. The second group was told that in a few minutes they would definitely be doing the puzzles. In this clever way, Senay created one group contemplating the question, "Will I be doing this?", and another group thinking, "I will be doing this," declaring their objective to themselves.

As it turned out, people with wondering minds (contemplating what might possibly happen) completed significantly more puzzles than did those with willful minds (thinking what they definitely were about to do). In other words, the people who kept their minds open were more goal-directed and more motivated than those who declared their objective to themselves.

The point is that questions, by their nature, speak to possibility and freedom of choice. Meditating on them might enhance feelings of autonomy and intrinsic motivation, creating a mind-set that promotes success. There is a scientifically verifiable difference between asking, and contemplating, the question "Will I?" versus narrowing the focus to a willful, determined statement, "I will."

What’s more, when the volunteers were questioned about why they felt they would be newly motivated to get to the gym more often, those primed with the question said things like: “Because I want to take more responsibility for my own health.” Those primed with “I will” offered strikingly different explanations, such as: “Because I would feel guilty or ashamed of myself if I did not.”

According to Wray Herbert, who summarized the research in Scientific American magazine, "This last finding is crucial. It indicates that those with questioning minds were more intrinsically motivated to change. They were looking for a positive inspiration from within, rather than attempting to hold themselves to a rigid standard." And there was more: "Those asserting will lacked this internal inspiration, which explains in part their weak commitment to future change. Put in terms of addiction recovery and self-improvement in general, those who were asserting their willpower were in effect closing their minds and narrowing their view of their future. Those who were questioning and wondering were open-minded—and therefore willing to see new possibilities for the days ahead."

In terms of Professor Frankfurt's metaphysical philosophy, the individual who thinks about his will and asks, "Will I?" opens the door to possibility and freedom of choice. The key to satisfaction, Frankfurt says, is "taking ourselves seriously, and getting it right."

In terms of Alcoholics Anonymous, the person who seeks to exercise willpower and "an iron will with grim determination" is much less likely to succeed. The person who struggles with AA is the person who says, "I know what I need to do, and now I just need to do it." The more successful person asks, "If I knew what I need to do, I probably would have done it by now, so I wonder what I will do?"

Do 12-Step Programs Work?

Do mutual help organizations like Alcoholics Anonymous really work? Last year, The Carlat Report on Addiction Treatment reviewed the research on AA and reported positive findings. I've summarized that report and included the references here. AA and other 12 Step programs provide many of the elements found in formal treatment. More importantly, the recovering fellowship creates a framework for support over the long term, helping individuals stay sober longer, have fewer drinking days, and have shorter periods of relapse. Twelve Step Facilitation (TSF) has been found as effective as cognitive behavioral therapy in addressing alcohol-related issues.

Since the 1930's when Bill W. and Dr. Bob started Alcoholics Anonymous (AA) the fellowship has grown to over two million members. Meeting in rented rooms, school halls, hospitals, and the storied church basement, AA and similar 12-step organizations (eg, Narcotics Anonymous [NA]) remain the most commonly sought sources of help for substance-related problems in the United States (Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2008).

Research has shown that attending AA, either alone or during and following professional treatment, enhances outcomes. One naturalistic study, for example, followed 466 previously untreated individuals with problem drinking for eight years. Participants self-selected into one of four groups: no treatment, AA alone, formal treatment alone, and formal treatment plus AA. Those who received some sort of help—AA, formal treatment, or both—had higher rates of abstinence at all time points. At eight years, 26% of patients in the no treatment group were abstinent from alcohol compared to 49% who received AA alone, 46% who received formal treatment alone, and 58% who received the combination of treatment plus AA (Timko C et al, J Stud Alcohol 2000;61(4):529–540).

A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment, but found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri M et al, Cochrane Database Syst Rev 2006;(3):CD005032).

Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas LA, J Addict Dis 2009;28(2):145–157). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit and increasing meeting frequency is associated with progressively greater rates of abstinence. In addition, research has shown that women engage with AA as much as men, become more involved with the 12 Steps, and derive similar benefit. In 1990, the Institute of Medicine called for more research on how AA works. Since then, research has revealed that AA aids recovery through multiple mechanisms, many of which are also activated by professional behavioral treatments (Kelly J et al, Addict Res Theory 2009:17(3):236–259).

Most consistently and strongly, AA appears to work by helping people make positive changes in their social networks (eg, by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers), and by enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).

Among more severely addicted people, AA also appears to work by enhancing spiritual practices, reducing depression, and increasing individuals’ confidence in their ability to cope with negative emotion (Kelly JF et al, Addiction 2012;107(2)289–299). Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way: individuals may use AA differently, depending on their unique needs and challenges.

Research has shown that involvement in 12-step work can reduce the need for more costly treatments while simultaneously improving outcomes. A large multicenter study of over 1,700 patients found those treated in professional 12-step treatment went on to participate in community-based AA and NA meetings at a higher rate than those from professional cognitive behavioral therapy (CBT) programs, who relied more heavily on professional services. This translated into a two-year savings of over $8,000 per patient among 12-step treated patients, without compromising outcomes. In fact, those treated in the 12-step treatment programs had one-third higher rates of abstinence across follow-up (Humphreys K & Moos R, Clin Exp Res 2001;25(5):711–716; Humphreys & Moos, Alcohol Clin Exp Res 2007;31(1):64–68).

Project MATCH was a large randomized trial comparing three individually-delivered psychosocial treatments for alcohol use disorder—TSF, CBT, and Motivational Enhancement Therapy (MET)—that was funded by NIAAA. It included 1,726 patients from nine clinical sites across the US (Project Match Research Group, J Stud Alcohol 1997;58(1):7–29). TSF was found to be as effective as the more empirically supported CBT and MET interventions at reducing the quantity and frequency of alcohol use post-treatment and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence, such that 24 percent of the outpatients in the TSF condition were continuously abstinent at one year after treatment, compared with 15 percent and 14 percent in CBT and MET, respectively (Tonigan JS et al,Participation and involvement in Alcoholics Anonymous. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press;2003:184–204).

Abstinence rates at three years continued to favor TSF, with 36 percet reporting complete abstinence, compared with 24 percent in CBT, and 27 percent in MET (Cooney N et al. Clinical and scientific implications of Project MATCH. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press; 2003:222–237).

In light of findings from several such RCTs that demonstrated the efficacy of TSF, this therapy was added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Practices and Programs (NREPP) in 2008.

The overwhelming majority of research has been conducted on AA. More research is needed on other MHOs, such as SMART Recovery, LifeRing, Celebrate Recovery, Women for Sobriety, Moderation Management, and others, so that more objective evidence is gathered on secular, religious, and non-abstinence-based AA alternatives (see the article "Alternatives to 12-Step Recovery" for more on these groups).