Psychological Rehabilitation of Alcoholics

By William D. Silkworth, M.D.

The Medical Record, July 19, 1939

This is an expanded letter from Silkworth, parts of which can be found in the Big Book pages xxiii to xxx called "The Doctor's Opinion".

In a study of carefully recorded histories of alcoholics in our hospital, two important facts appear to be outstanding. Expressed briefly, they are:

1) A majority or our patients do not wish to have an alcoholic problem. They lead busy lives & would like to enjoy the fruits of their efforts, but they cannot stop the use of alcohol.

2) These patients cannot use alcohol in moderation.

The allergic nature of true alcoholism was postulated in a previous paper. We then endeavored to show that alcohol does not become a problem to every person who uses it, & that the use of alcohol in itself does not produce a chronic alcoholic.

The phenomenon of craving must be present as a manifestation of an allergy. Once established in an individual, one drink creates a desire for more. It sets this person aside as a separate entity. It creates a conflict that ends in a form of neurosis.

Looking further at the record of these unfortunates, we find that the majority could not drink in moderation from the very beginning. Whether 20, 30, or 50 years of age, they soon become a problem to themselves & to their friends.

Now in analyzing these alcoholic-minded persons, there is no one physical or psychical fact that is sufficiently constant to justify its use as the basis of an accepted theory. Such phrases as "escape from reality" & "inferiority complex" hold true for some, but not all, while heredity, only son, & implied spoiling in childhood, account for a few more. They all lead to confusion & have no answer.

Eliminate the constitutional psychopaths, the moral & mental defectives, & there remains a large class, neurotic in type, for whom something is worth doing. Remember we are discussing the chronic alcoholic, not the man who drinks more than is good for him but has no resulting problem.

Apparently all these people - good, bad & indifferent - have one thing in common: they cannot drink in moderation. We believe they show manifestations of an allergy to alcohol. They may abstain from use of alcohol for a month or a year, but on taking it again in any form, they at once establish the phenomenon of craving. This fact is well known to all alcoholics & creates their major problems in the early stages of their drinking habits. They complain about it, too.

Why, we naturally ask, in the early years of drinking, while they still have the ability to choose, do these people not solve this problem by the complete discontinuance of alcohol? Some do, but many are like the rest of us who do things we know we should not, but like to do them anyway. Many really believe they can drink as they see others doing, & enjoy themselves. For many reasons, most of which are social or even physical, the idea of drinking is developed gradually. As this idea advances, daily life becomes more secure, but these men are unwilling to accept the facts as presented to them. The act of drinking (in the end damaging) is followed by certain comfortable emotional states that make it a pleasure. They prove to themselves that they can stop drinking by going on the wagon for varying periods, but even as life becomes more complicated, they still persist in that old, original idea. Up to this time, in what one might call the first period of alcoholism there are methods employed to help these persons return to a normal life & accept the fact that their old idea of drinking must be discarded forever. We ourselves have treated some of them with permanent results, but the majority continues along the primrose path. The history of these people & their families present from now on, one of the real tragedies of human life & is too well known to comment on further here.

This begins the second stage. Understood by no one & not understanding themselves, they enter an ever-widening circle, remorse, penance, new transgressions, new penance, until they lose all capacity for spontaneous action. They sacrifice themselves for a perversive idea & defying the law of nature (allergy) operating in their case, pay the penalty. They have lost all pleasure in normal life. Based on their underlying neurotic nature, they develop a compulsion type of thinking, and, although not a true compulsion neurosis, it is surely a borderline type. The patient now acts under what has been called by Wechsler a psychic imperative, the dreaded terminal state of paralysis of the will. The predisposing factor in bringing about this definite state of insecurity is the conflict brought about by alcoholism.

It is not within the scope of this paper to discuss the complications of the obsessional neurosis, which are, in fact, the most elastic of all the neuroses, but in this particular type it seems to permit a retreat from the ever-increasing anxieties induced by the advancing chronic alcoholism. This compulsive thinking is apparently a purely intellectual process occurring more frequently among persons of relatively higher intellectual attainment, from which class, by the way, comes the average chronic alcoholic.

Characteristic of all compulsion types of thinking is the relatively good insight that accompanies them. The victim knows his impulse to drink is wrong but he is helpless before it. Wives may plead, friends argue, & employers threaten, but he is no longer amenable to impression. He is unable to resolve between opposing impulses. He cries out in agony, "I must stop, I cannot be like this; but I cannot stop; someone must help me."

If he has sufficient means, he has by now been treated by psychiatrists, good men, who fully realize the unfavorable prognosis, but who, often without remuneration, give freely of their time to help the victim. I have often seen psychoanalysis of an alcoholic, instead of breaking up the compulsive thinking; start the person further theorizing on his own illness.

We know that, as a rule, the only relief from psychoanalysis is in making the so-called transfer, & experience has taught us that this is gratifyingly successful if accomplished. If successful, it must be based on respect & confidence on the part of the patient. It can seldom be accomplished in this class of patients, except by one who has suffered in the same manner & has recovered. In other words, to accomplish the transfer of this compulsive idea by the plan we have seen developed, an ex-alcoholic who has recovered by the same means be the medium employed. Such a medium can explain convincingly, not only that the transfer of the compulsive thinking can be made, but also he can prove how he did it himself successfully.

We physicians have realized for a long time that some form of moral psychology was of urgent importance to alcoholics, but its application presented difficulties beyond our conception. What with our ultramodern standards, our scientific approach to everything, we are perhaps not well equipped to apply the powers of good lying outside our synthetic knowledge.

About four years ago, we hospitalized a young man for severe chronic alcoholism, &, while under our care he developed a plan that seemed to me to be a combination of psychology & religion. He never drank any form of alcohol again.

Later he requested the privilege of being allowed to tell his story to other patients &, perhaps with some misgiving, we consented. The cases we have followed through have been most interesting: in fact many of them are amazing. The unselfishness of these men as we have come to know them, the entire absence of profit motive & their community spirit, are indeed inspiring to one who has labored long & wearily in the field of alcoholism. They believe in themselves, & still more in the Power which pulls chronic alcoholics back from the gates of death.

Of course, prior to & in preparation for the application of this plan, it is, in my opinion, essential to detoxicate the alcoholics by hospitalization. You then have a subject whose brain is clear & whose mind is receptive & temporarily free from his craving. I hesitate here to attempt even an outline of the plan as employed by these men. Sufficient to say, perhaps, that following many failures, they gradually devised a plan or procedure that led them to make this so-called transfer to one greater than themselves, to God.

The whole story is admirably told in a book written by them entitled "Alcoholics Anonymous". It would seem to me that they have wrung from the Eternal a new application of an old truth that is sufficient equipment to restore the patient in his fight for sobriety. The results seem to flow naturally from a follow-up of honest effort.

To make any such plan practical they have also projected this transfer beyond the individual to the group. The information of these men into groups, each one with the hand of fellowship passing on his experiences to others, helping those who have newly joined to adjust themselves, actively engaged in gathering in new members, seems to me the most practical application of their moral psychology, to assure their "transfer" of being permanent. (Although I have met some 30 or more of these ex-alcoholics. I relate my experience with two of them.)

About one year prior to this experience a man was brought in to be treated for chronic alcoholism. He had but partially recovered from a gastric hemorrhage & seemed to be a case of pathological mental deterioration. He had lost everything worthwhile in life, & was only living, one might say, to drink. He frankly admitted & believed that for him there was no hope. Following the elimination of alcohol there was found to be no permanent brain injury. He accepted the plan outlined in the book. One year later he called to see me, & I experienced a very strange sensation. I knew the man by name & partly recognized his features, but there all resemblance ended. From a trembling, despairing, nervous wreck, had emerged a man brimming over with self-reliance & contentment. I talked with him for some time, but was not able to bring myself to feel that I had known him before. To me he was a stranger, & so he left me. More than three years have now passed with no return to alcohol.

When I need a mental uplift, I often think of another case brought in by a physician, prominent in New York City. The patient made his own diagnosis, & deciding that his condition was hopeless, had hidden in a deserted barn, determined to die. He was rescued by a searching party, & in desperate condition brought to me. Following his physical rehabilitation, he had a talk with me in which he frankly stated he thought the treatment a waste of time & effort, unless I could assure him, which no one ever had, that in the future he could have the will power to resist the impulse to drink. His alcoholic problem was so complex, & his depression so great, that we felt his only hope would be through what we then called "moral psychology," & we doubted if even that would have any effect. However, he did adopt the ideas contained in this book. He has not had a drink for more than three years. I see him now & then, & he is as fine a specimen as one could wish to meet.