LITMIR.BIZ

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His understanding of alcoholism involved balancing a succession of models like spinning plates. The disease was primarily genetic, but social and psychological factors were very much involved. There isn’t an alcoholic personality per se, as early theorists suggested there might be, but alcohol does bring with it a constellation of behaviours (lying, stealing, cheating; the usual car crash) that will in all probability subside or disappear entirely when sobriety is attained; although – and here he laughed a little – there are plenty of jerks who become alcoholics and continue to be jerks after they’re dry.

      Near the beginning of the conversation he used a phrase that intrigued me. He mentioned a process called the brain switch. If someone is particularly prone to alcoholism – if the genetic and social and psychological factors are all stacked against them – then they are likely to experience a change in brain function. As Dr. Levounis put it, ‘it seems that they engrave the addiction at the more primitive part of the brain, the mesolimbic system, and from that point on the addiction tends to have a life of its own, to a large extent independent of the forces that set it into motion to begin with’. He called this lively, liberated monster the big bear, and later the big beast. ‘Unfortunately,’ he added, ‘the majority of people do not really see that and have the false hope that if they go back to the root of the problem and yank out the root cause of what happened then they will be addiction-free for the rest of their lives.’

      The brain switch wasn’t a concept I’d come across before. It was initially proposed about fifteen years earlier by Alan Leshner, then director of the National Institute on Drug Abuse. He suggested that neurobiological changes took place around the nucleus accumbens, the part of the mesolimbic system that deals with pleasure and reward, where addiction takes hold most strongly. These neural pathways, Dr. Levounis explained, ‘don’t only signify for pleasure and pain; they also signify for salience. Essentially, they tell us what is important and what is not. So instead of having all kinds of things that are pleasurable and rewarding and salient in your life, all these things start becoming less and less important and the one that remains is primarily the drug of abuse. It’s alcohol.’

      The permanence of this hijack is due primarily to the geography of the pleasure-reward pathways, their anatomical position within the nutshell of the human skull. He mapped it out for me with his hands, showing how the mesolimbic system is sandwiched between the hippocampus, which is the memory centre of the brain, and the limbic system, which is its emotional core. It made sense to me. Memory and emotion. How else do we make decisions, except by cognition, by the pure application of reason? But that region of the brain, the frontal lobes, is far away, anatomically speaking, and imperfectly connected, especially in the young. Little wonder that alcoholism was once characterised as a failure of will. The frontal lobes weigh right and wrong, apportion risk; the limbic system is all greed and appetite and impulse, with the hippocampus adding the siren’s whisper: how sweet it was, remember?

      I shifted in my seat. I could see The Line of Beauty on the shelf in front of me, filed among the blue books. There were pigeons outside. The city was hammering against the window, insistent as a drill. Dr Levounis was talking now about the long-term picture: how the pleasure-reward pathways stay hijacked even in sobriety, so that although the alcoholic might stop drinking they remain vulnerable to addiction. For how long, I asked, and he replied: ‘Although a lot of people manage to beat the illness, the risk of using stays with you for a long, long time, if not for the rest of your life.’

      We turned then to a discussion of treatment. Dr Levounis outlined the two basic options for recovery: the abstinence-based model and the harm-reduction model. In the abstinence-based model (the version favoured by Alcoholics Anonymous), the alcoholic stops drinking entirely, concentrating on the maintenance of sobriety. In the harm-reduction model, on the other hand, the focus is on improving the conditions of one’s life and not necessarily on stopping drinking. He thought, pragmatically, that both were efficacious, depending on the individual’s circumstance and needs.

      There was a lot to think about in this conversation, but it was the big beast that stayed with me when I went down into the street. What would Tennessee Williams have made of it, the idea that addiction has its own momentum, its own articulated presence within the skull? I’m not sure he would have been surprised. He had a gut sense of how people are driven by irrational cravings. I thought of poor Blanche DuBois, sneaking shots of whiskey in her sister’s house in New Orleans; of Brick Pollitt, hobbling back and forth to Echo Spring, saying to his dying father, ‘it’s hard for me to understand how anybody could care if he lived or died or was dying or cared about anything but whether or not there was liquor left in the bottle’. Williams might not have known where the frontal lobes were located (although he probably did, being a dedicated hypochondriac whose sister’s lobotomy left him with a lifelong terror of psychiatric care), but he certainly understood how a human being can navigate without the use of reason. I’m not sure Cat on a Hot Tin Roof is about much else besides irrational compulsions – alcohol, money, sex – and how they can unshape a life.

      The AA meeting was on the Upper West Side at 6 p.m. I slept a while at the hotel and then cut across Central Park, eating a hot dog on the way. The trees were maybe a fortnight away from coming into leaf and as I walked I saw a red cardinal in a bush beside the path. Nothing except changes in climate and language communicate so thoroughly a sense of travel as the difference in birdlife. A week later, on the way to Key West, I’d see vultures circling above Miami, ospreys in the Everglades, an ibis picking its way through a tropical graveyard. Another week on and thousands of miles north, on the outskirts of Port Angeles, I’d watch bald eagles fishing in a river and clouds of violet swallows swarming above a gorge. But the red cardinal was the first purely American bird of my trip and it heartened me. Whatever happens, happens here, in the populated earth. I was grateful for the science lesson, but I didn’t want to divorce the neural drama of alcoholism from the world, the quick and grubby world in which it takes place.

      No chance of that at AA. I sat at the back, with an old-timer, Andi, who’d offered to show me around. People were drifting in, clutching coffees, in baseball caps and suits. It seemed at first glance almost comically New York, right down to the couple in the front row who looked like rock stars, one in enormous sunglasses and leather shorts, the other swaddled in a floor-length fur coat.

      There was a sign on the wall that displayed the Twelve Steps, next to one that read ‘No spitting. No eating food on shared computers.’ The combination would no doubt have amused John Cheever, who struggled for a long time with the democracy of these dingy rooms, though in his last years he softened in his loathing of AA, becoming vocally grateful for its role in his sobriety. I read through them, step by step, for the hundredth time.

      1.We admitted we were powerless over alcohol – that our lives had become unmanageable.

      2.Came to believe that a Power greater than ourselves could restore us to sanity.

      3.Made a decision to turn our will and our lives over to the care of God as we understood Him.

      4.Made a searching and fearless moral inventory of ourselves.

      5.Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

      6.Were entirely ready to have God remove all these defects of character.

      7.Humbly asked Him to remove our shortcomings.

      8.Made a list of all persons we had harmed, and became willing to make amends to them all.

      9.Made direct amends to such people wherever possible, except when to do so would injure them or others.

      10.Continued to take personal inventory and when we were wrong promptly admitted it.

      11.Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

      12.Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

      No one knows for

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