Analysis and Comparison of Three Treatments

MEASURES FOR ALCOHOLISM: ANTABUSE, THE ALCOHOLICS ANONYMOUS APPROACH, AND PSYCHOTHERAPY*

British Journal of Addiction, Vol. 50, 1953

by FRANCIS T. CHAMBERS, Jr. of the Philadelphia Hospital Institute

In 1935 I joined the staff of the Institute of the Pennsylvania Hospital, and with the generous support of the senior staff members endeavored to work out a treatment plan to be available for those seeking help for acute problems. This plan had the then unique characteristic of being a positive, rather than a negative approach. By and large, at this period, most treatment consisted of the facilities offered by rest homes and "cures", where the whole emphasis was placed on sobering a man up. Temporary sobriety having been achieved, he was then discharged with little or no understanding of himself or his problem.

Dr. Edward A. Strecker, who held the Chair of Psychiatry at the University of Pennsylvania, collaborated with me in writing ALCOHOL: One Man’s Meat, published in 1938. This book, because it presented a positive treatment plan, had the effect of stimulating a more optimistic approach toward the problem, and we were deluged by requests for help. We did not have the necessary staff, facilities, nor the economic support that would have made help available for all. Fortunately, the Alcoholics Anonymous movement became active at about this time, and has contributed a great deal of help for many alcoholic addicts who could not have received it in any other way.

* Read before the Society for the Study of Addiction at the rooms of the Medical Society of London, 11 Chandos Street, W.l., on Tuesday, 26 August, 1952, the President, Dr. G. W. Smith, being in the Chair.

In 1949, Antabuse was introduced in our country for controlled study, and in 1951 it was released to the medical profession. This release was introduced in part by the following paragraph:

"Antabuse, the drug that builds a ‘chemical fence’ around the alcoholic, is now available for general prescription use in the fight against the Nation’s number one emotional disease."

In sequence, then, we see three positive approaches, each of which was met by great optimism on the part of the public. This optimism has been tempered by the sobering fact that each one of these approaches had, along with successes, many failures, and did not live up to the hope engendered by wishful thinking. This does not mean that Antabuse should be discarded as a treatment measure because there are failures, and sometimes fatal failures; nor does it mean that those who fail to respond to the Alcoholics Anonymous group movement indicate that the A.A. is not a helpful measure; nor again does it mean that psychotherapy should be discarded because it, too, has failures. There is in the United States a number of treatments other than those we are discussing. Dr. Abraham Myerson points out: "The treatment of the individual case has at this time some twenty varieties, ranging from Alcoholics Anonymous and frank religious exhortation to spinal fluid drainage, benzedrine sulfate and the conditioned reflex, not forgetting psychoanalysis, psychotherapeutics, and shock therapy." Add to this the many advertised cures in sanitariums and health farms, and one sees how bewildering the burden of choice can be to the patient or his family seeking help.

Let us first analyze Antabuse as a treatment measure. Bear in mind that it was introduced as "the drug that builds ‘chemical fence’ around the alcoholic." We must first ask ourselves: what about the individuals who do not wish a fence built around them, and is it always wise to do so? In reference to the first group, who do not wish to be protected, there is in the United States not a legal statute to enforce this means toward total abstinence.

In connection with this point whether or not it is always wise to build a chemical fence around the alcoholic, my associates, Dr. Edward A. Strecker and Dr. Vincent T. Lathbury, have discussed two patients in whom the experimental use of Antabuse was followed by a psychotic reaction. A like reaction was discussed by Dr. 0. Martensen—Larsen, and more serious effects by Dr. Erik Jacobsen of Denmark.

Dr. Jacobsen says, in part, that the "effective deprivation of alcohol without adequate psychotherapy can be just as dangerous as the untoward effects of disulfiram." In the same article, Dr. Jacobsen reports that there were 17 fatal cases following treatment with Antabuse among 10,000 patients. Of this total, he cites five cases of death were due to sudden, unexplained causes. Deaths following the administration of Antabuse are cited by R. 0. Jones, M. C. Becker and G. Sugarman, and D. M. Spain, V.A. Bradess and A.A. Eggston. I am quoting only in part from the available literature dealing with such unfavorable reactions.

Briefly, then, we have three contraindications to the use of Antabuse. First, there are those who refuse this treatment; second, those who may develop a psychotic reaction following the treatment; and third, those to whom the treatment may be fatal. Let me add a fourth risk, perhaps the most important; namely that the indiscriminate use of Antabuse on a group of patients most apt to respond to psychotherapy might interfere with or even block their potential accessibility to psychotherapy. Experience with patients who have had previous treatment with Antabuse shows that they have often resented this treatment and discontinued it. As one of them expressed his attitude to me, "I found that my reaction to alcohol after the Antabuse treatment was terrifying. Therefore I was pretty sure to take no more Antabuse." Several patients have told me that while taking Antabuse they found that a very little alcohol plus the Antabuse reaction gave them a desirable result of intoxication.

On the other hand, medical literature is full of successful results obtained by the administration of Antabuse. One patient of mine, a woman of 65, asked for the Antabuse treatment two years ago. My associates, Dr. Kenneth Appel and Dr. Alexander Vujan, after careful tests, administered Antabuse, and this woman has since then made a much better adjustment. We recommended follow-up psychotherapy, which was not accepted. Without such follow-up therapy, we can only guess as to why the Antabuse worked. This woman was highly intelligent, with a strong indication of psychoneurotic nucleus. She came from a protected walk of life. Later on she encountered more than her share of tragedy. The death of two husbands during her young womanhood probably augmented an already established unconscious feeling of rejection. The insidious sway of her addiction held fast through middle life. Now her grown children were repeating the pattern of rejection because of her addiction problem. At this psychologically important moment we supplied, via the Antabuse treatment, a way to make alcohol actually reject her even more severely than did reality from her neurotic viewpoint.

In 1939, the Alcoholics Anonymous group movement published their book Alcoholics Anonymous. It received a tremendous amount of publicity because of the enthusiasm of its members, plus the fact that it had a very understandable popular appeal. In the forward of this book the writers remark that they wish to show other alcoholics "precisely how we have recovered," and they state. "We are not an organization in the conventional sense of the word. There are no fees nor dues whatsoever. The only requirement for membership is an honest desire to stop drinking. We are not allied with any particular faith, sect, or denomination, nor do we oppose anyone. We simply wish to be helpful to those who are afflicted."

Since this book was written, groups of Alcoholics Anonymous have formed in all the large cities of the United States, and in many of the smaller towns. As a movement it has a strong similarity to religious conversion. They state in their book;

"The great fact is just this, and nothing less: that we have had deep and effective spiritual experiences, which have revolutionized our whole attitude toward life, toward our fellows, and toward God’s universe. The central fact of our lives to-day is the absolute certainty that our Creator has entered into our hearts and lives in a way which is indeed miraculous. He has commenced to accomplish those things for us which we could never do by ourselves."

I have gathered from talks with many of the group that the spiritual experience does not always take place, but that even without this experience some are successful in refraining from drinking. With or without the religious experience, members have a very deep sense of Cause, and each becomes an Apostle for this Cause. They insist that members attend weekly or bi-weekly meetings, at which meeting novices hear ex-alcoholics recount the misery of their drinking history, and how they had hurt all their loved ones, but how, now, with the help of the Alcoholics Anonymous group they are no longer hurting those they love, and are happy and successful without alcohol. They recommend twelve steps in their program to recovery:

"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 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 experience as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs."

I understand that you have similar groups in Great Britain. I believe that they work with the same principles as Alcoholics Anonymous in the U.S.A. In the States some of its appeal is because of the go-getter attitude contained in its emotional approach. It savors of the credo of the American success story, and it is colored by the aggressive streamlined glamorization so woven into American custom. My experience with members of this group has been that the successful men and women are those who have made A.A. the most important thing in their lives. They devote a tremendous amount of time to discussion of Alcoholics Anonymous work, they attend meetings regularly, and are willing, at great inconvenience to themselves, to be called out to administer to one of their group who has fallen, or to call on some drunkard in order to persuade him to seek their help. Let me briefly try to analyze some of the aspects of what they have to offer.

Most of those who become members have gone downhill quite far. In fact, many A.A. members say you have to "hit bottom" before you are accessible to their movement. These men and women, due to their abnormal drinking lives, have by and large lost their normal friends and their contact with society. They are lonely, isolated by their addiction problem. To be welcomed again in an uncritical group, where their past alcoholic history can be worn as a badge of honor, provided they recover, must give them a tremendous emotional lift in re-establishing contact with other human beings.

All of us who are interested in the vast problem of mental hygiene owe a debt of deep gratitude to the circumstances that presented this movement at this time. The group is keeping many men and women sober, who otherwise would be cluttering up our jails and our mental hospitals. They are relieving psychiatrists of an already intolerable load, and most important, this approach is keeping many men and women from destroying themselves and crippling their families irretrievably.

With all due credit for A.A.’s valuable work, some of the more fanatical members bring to mind a sketch written by the American humorist, James Thurber, entitled, The Bear Who Let It Alone.

"In the woods of the Far West there once lived a brown bear who could take it or leave it alone. He would go into a bar where they sold mead, a fermented drink made of honey, and he would have just two drinks. Then he would put some money on the bar and say, ’See what the bears in the back room will have,’ and he would go home. But finally he took to drinking by himself most of the day. He would reel home at night, kick over the umbrella stand, knock down the bridge lamps, and ram his elbows through the windows. Then he would collapse on the floor and lie there until he went to sleep. His wife was greatly distressed and his children were very frightened.

"At length the bear saw the error of his ways and began to reform. In the end he became a famous teetotaller and a persistent temperance lecturer. He would tell everybody who came to his house about the awful effects of drink, and he would boast about how strong and well he had become since he gave up touching the stuff. To demonstrate this, he would stand on his head and on his hands and he would turn cartwheels in the house, kicking over the umbrella stand, knocking down the bridge lamps, and ramming his elbows through the windows. Then he would lie down on the floor, tired by his healthful exercise, and go to sleep. His wife was greatly distressed and his children were very frightened."

About ten years ago, I was asked to read a short paper, "Emotional Immaturity in Alcoholics," at the Philadelphia General Hospital. This was followed by a talk given by one of the key men in Alcoholics Anonymous. He began his talk by saying that he agreed with me that all alcoholics were emotionally immature; hence they needed Alcoholics Anonymous to compensate for the deficiency of emotional maturity. This pointed out to me the outstanding difference between their approach and a psychotherapeutic approach; namely, that they accept the emotional immaturity, and supplied a crutch for it, where psychotherapy attempts to supply insight into the emotional immaturity, and helps the patient toward emotional growth and maturity as a necessary adjunct to abstinence.

One of the earliest papers on the subject of alcoholism that I have come upon was by Dr. Benjamin Rush, written in the early eighteen hundreds. He cites religious conversion as the only effective means of bringing about abstinence among his alcoholic patients. This phenomenon, I think, is explained in part by the extraordinary egocentricity we find in alcoholics, and this in turn leads us to uncover the omnipotent infant hidden behind the iron curtain of the unconscious, who is still dictating the personality, policy, and behavior of the patient. We see that these patients are in a way playing God. This highly disguised phenomenon was beautifully revealed in the William Saroyan play, The Time of Your Life. In religious conversion, one admits to an all-powerful God. Therefore the convert is forced to abdicate the throne, but in turn becomes God’s lieutenant. This is an emotional growth step not always possible, not always wise, but where it works effectively and suffices to give a fractional degree of stability to the addicted personality, we should thank God for its occurrence wherever we encounter it.

Psychotherapy may include a great many different approaches and various disciplines and techniques. Alcoholics Anonymous might be described as a simple form of psychotherapy. Freudian psychoanalysis is considered by some as the only thorough approach to a non-addicted readjustment. This could be described as a very complicated and time—consuming psychotherapy. Because of the variant concepts of psychotherapy, I would like to outline briefly the type that we have found practical and effective with a certain group of patients.

"The first and often neglected step in the treatment of pathological drinking is a personality diagnosis. This diagnosis should be avoided during the intoxication symptoms and withdrawal symptoms. Even after a state of sobriety has been reached, the physician should delay opinion as to the best method of treatment until he has had ample opportunity to study the personality of his patient.

"The following classification can be employed advantageously in the clinic devoted to abnormal drinking if it is used in the spirit that Thompson suggests when he says: ‘We have revised this classification to some extent, but we have altered still more extensively our application of it. Many individuals who are examined in this clinic we now regard as normal or average individuals with an exaggeration of some particular personality characteristic, rather than as psychopathic personalities or deviates.’ Even a glance at this classification makes clear how wide is the range of alcoholism. The classification is as follows:

A. Psychosis.

B. Borderline psychosis.

C. Mental deficiency.

D. Psychopathic personalities.

E. Neurosis.

F. Normal individuals with predominant personality characteristics:

Aggressive type.

Unstable type.

Swindler (hysterical type)

Unethical, sly, wily type professional gambler or ‘conman’; professional criminal of the planning, careful type. I think you have a slang word "Spiv" that describes the type.

Shrewd type.

Adolescent type.

(a) Adolescent immature type,

(b) Adolescent adventurous type.

Adult immature type.

Egocentric and selfish type.

Shiftless, lazy, uninhibited, pleasure-loving type.

Suggestible type.

Adynamic, dull type.

Nomadic type.

Primitive type.

Adjusted to lower economic level.

Personality adjusted to ordinary, average life."

We have found that the germ of alcoholism reaches far back into childhood and that most patients are suffering from unconscious feeling of guilt and rejection coming, usually, from these childhood experiences. We are beginning to see more clearly that drinking alcohol in itself did not create their problem. Rather it was their neurotic insecurity which created their addiction. We see in the paranoid patient a tendency to project his personality discomfort outward, in the psycho—neurotic a tendency to project personality discomfort inward, and in the alcoholic a tendency to reach for a drug to anesthetize his personality discomfort.

We have found in the study of the personalities of those who consulted us that emotional immaturity manifests itself prior to drinking, and certainly we have found that emotional immaturity is ever-present in the emotional life of the abnormal drinker. "Man is but a child-born," and I doubt that in our civilization emotional maturity is a completely obtainable goal. When we talk of maturity, we talk of degree. In the abnormal drinker, emotional immaturity plus the addiction problem precludes emotional growth. We see a like reaction in the psychoneurotic, and we see, perhaps, in the psychotic a terrifying regression to the infantile level. Maturity, if we must attempt to analyze it, could be described as an individual’s ability to deal with, compromise with, and sublimate the primitive infantile tendencies that exist in all of us. The alcoholic, when intoxicated, is on an infantile level. When sober, he is a very uncomfortable child in an adult body in an adult world.

I think we often see in the abnormal drinker an actor living a role of pretence that is fooling him far more than the audience. This actor has a complete misconception of the reality of himself. All he knows is that this reality is painful. He does not see that reality is painful because of his maladjustment to it. Having found that alcohol will induce a brief pleasurable fantasy of self, the abnormal drinker seeks more and more the escape mechanism of alcohol. Because such a patient appears to be normal to his family and the public when he is not drinking, the degree of his emotional maladjustment is not recognized by society, nor is it recognized by the patient. In the mind of the public and the patient the problem seems simple, i.e., if alcohol is destroying this man or woman’s potentiality to live a normal, constructive life, then the answer is to give up alcohol. I think we can say that the majority of non—deteriorated and non-psychotic alcoholics want to get well. Despite the contradiction of oft repeated drunken behavior, there is little doubt that somewhere within the mental recesses of the abnormal drinker there lies the desire to rid himself of his addiction. He wants to be normal, but he does not know how to start. To bridge the gap of understanding between the patient and those who want to help him we must first recognize and understand his conception of what constitutes normality. What does he mean when he says; "I want to get well?"

Mental exploration uncovers an apparent contradiction of sane thinking; i.e., normality is synonymous in the mind of the alcoholic with only one thing - drinking normally. He really believes he wants to drink in a normal way. Most patients give a history of repeated determination to drink in moderation, which attempt eventually ends in acute alcoholic episodes. This self deception on the patient’s part, of wanting to be temperate in the use of alcohol, should be discarded with the insight gained in psychotherapy. It is not easy for the patient to see that the one or two cocktails he thinks would suffice actually would be as unsatisfactory to him as one or two aspirin tablets would be to the morphinist awaiting his customary dose of morphine.

Therefore, in dealing with patients, we must realize that a mental condition exists which renders a normal response impossible. We do not tell our patients that they are normal and that all that is wrong with them is that they drink too much. If this were only true, everything would be so beautifully simple. We would only have to say, "Please stop drinking, and everything will be all right." Obviously if they stop drinking they will be more acceptable to society, but otherwise nothing has been accomplished toward curing the state of mind that originally sought escape from their personality discomfort by blunting this discomfort with alcohol. When the stream of alcohol is dammed but nothing else is done then there is merely produced a condition of suppressed alcoholism that could be rightly described as an alcoholic complex, or a partially repressed but imperative urge, that becomes endowed with a super—emotional content. In all probability this is the condition of many successful non-drinking alcoholics, wherein hate and fear have supplanted the love of and depending on alcohol. The partially repressed but imperative urge becomes endowed with a superemotional redirection. The truth is that abstinence frequently means the discarding of an all important crutch by a sick personality. This may be the right moment for psychotherapy to be substituted for the crutch, not as something to lean on, but as a means of gaining insight into the little boy or girl who never grew up emotionally.

It is obvious to anyone who ever studied the problem of addiction that the abnormal drinker is playing a very passive role no matter how well he may disguise it by over—compensating action. The very role of drinking is passive. Without being conscious of it, he is asking a drug to change his ways of thinking and being and feeling. The addict carries the passive role to its extreme in deep intoxication. He is helpless.

With this hidden passivity in mind I endeavor to lead a patient into an active role toward treatment. I ask him to read and analyze the book, Alcohol: One Man’s Meat, underscoring any passages that he thinks might give us insight into his own problem. By the very act of doing this he is taking an active rather than a passive role toward his recovery.

I inform the patient at the first contact that he and he alone will effect his recovery, that I can only help him to gain understanding of himself and his problem. If a good rapport is established I find it is helpful to anticipate with the patient the emotional growing pains that he will encounter during the beginning of his non-alcoholic readjustment. The patient puts much emphasis on the immediate withdrawal symptoms from alcohol. He has experienced these and knows how dreadful they are. He has no understanding of or preparation for the secondary emotional withdrawal symptoms that he will encounter during the first year or two of abstinence. These secondary withdrawal symptoms seem to take place in insidiously disguised protests against reality and in bombardments of rationalization urging him to return to alcohol. The late Richard Peabody contributed great insight into this phase of readjustment. In his book, The Common Sense of Drinking, he supplies this insight to the patient, as well as forearming him against the extraordinary rationalizing technique that he will uncover from time to time during his struggle to make readjustment without alcohol.

We encounter in alcoholism an age—old phenomenon of politics; the political psychology of the dictator. Dictator ideology survives only by creating and then enlarging the enemy without, in order to take the focus off the real enemy within -i.e., the dictator. With this technique whole populations are seduced into relinquishing their freedom. They become willing slaves to their State, hypnotized through propaganda by the imagined enemy without. In the addicted personality, alcohol is the dictator and here, too, the enemy without is created and becomes part of the rationalizing process of alcoholism. The typical alcoholic drinks because his wife nags him, or because he does not get the promotion he thinks he deserves, or because his friends let him down or shun him. In effect each aspect of reality soon becomes the threatening enemy without and the patient relinquishes his freedom to the alcoholic dictator in order to save himself from his own misconception of a hostile reality. There is always a paranoid-like rationalizing system in alcoholism. Understanding the abnormal psychology of addiction, one sees that rationalization is a necessary support to the alcoholic disease that has taken over the personality. Outside of delirium tremens, alcoholic psychosis and the occasional psychotic reactions following the administration of Antabuse, it does not reveal itself overtly, but it is there nonetheless, and it is very important that the patient gain insight into its abnormal mechanisms.

During therapy the patient will under our guidance gain insight into his unconscious feelings of rejection and guilt. If he is successful he learns to deal with these feelings instead of running away from them, and if acquired his insight into their source may help to allay a great deal of his personality discomfort.

I hope it will be seen from my very brief description of a treatment approach that I attempt to deal with a patient’s personality problem as well as his alcoholic problem. Personality problems presented by patients vary enormously, as do the underlying causes for their addiction. They have, however, an extraordinarily similar system of irrational thoughts about drinking which will apply to all of them. Just as the understanding of the warped thought process in the paranoid schizophrenic will help to make the diagnosis and indicate the type of treatment, so also will the understanding of the warped thought process in the alcoholic help us to treat him.

A criticism of this type of psychotherapy is that it is limited to a group who can afford the expense involved in such a treatment. Many of our patients are out—patients, and do well on an out-patient status. In this way, the expense can be kept down so that it is within the reach of nearly everyone. However many of our patients need psychotherapy and would not respond to it without an initial and sometimes prolonged hospital stay, and this is, of course, expensive.

In order to make a treatment plan available to a greater number of people it has been suggested that group therapy might be instigated. Unhappily group treatment precludes the rapport which has been shown to be so necessary. It has been tried by some of my associates, but the results have not been favorable.

In my attempt to analyze and compare three treatment measures, I have clarified for myself, and I hope for you, the fallacy of finding the treatment for alcoholics. Far better, and much more rewarding in results, is to find the form of treatment best suited to each type of personality afflicted with alcoholism.

Note: Francis T. Chambers, Jr. was a lay—therapist and was trained by Richard R. Peabody.

A Psychological Approach in Certain Cases of Alcoholism

Francis T. Chambers, Jr.

Mental Hygiene, 21:67-78, 1937

I realize that it would be impossible in the short space available to describe the various subdivisions of the psychotherapeutic treatment advocated by the late Richard Peabody, which I am using in treating abnormal drinkers; at best, I could leave only a vague impression of the treatment as a whole. Therefore, I will limit this paper to the approach that may lead up to a successful termination of a very common and destructive addiction.

My work with abnormal drinkers has been made possible by the generous help and cooperation of the psychiatric group and the general practitioners in Philadelphia and its vicinity, as my layman status makes it impossible for me to treat the condition in any but a non-medical field. This has a psychological advantage in that those who consult me, with the approval of a physician, come with a beginning already made.

First, they have admitted that they are abnormal drinkers, an essential admission before treatment can be given.

Second, the suggestion has been given by a physician whom they respect that there is a way to overcome alcoholism for a group of addicts, who are not psychopathic, but who have sprung from a vast legion of psychoneurotics, those so-called nervous individuals who have found that a perverted indulgence of the intoxication impulse may serve as a temporary compensation for a maladjustment of personality. This type of neurotic alcoholic is unwilling to be considered either insane or stupid; for this reason the best approach to a specialized treatment can be made by the physician, who is usually present at the psychological moment when the patient cries for help.

Once a patient has sought aid, the clinical picture of alcoholism permits little opportunity for a misdiagnosis. You distinguish the neurotic from the normal, though perhaps heavy drinker by his inability to control his drinking and the stupidity of his sacrifice of the most valuable things in life for the state of mind produced by his alcoholic indulgence. Usually we find an uncontrolled drinker utilizing self-deception, one phase of which is his forever blaming his addiction on the conditions of his environment. In so doing he is only following in an exaggerated way the same procedure practiced by his controlled-drinking brothers, whose nervous systems are resistant to alcohol.

The controlled drinker usually wishes to have an excuse for indulging himself. He drinks because it is hot, or because it is cold; he drinks to prolong a pleasant occasion, and hi cheers himself up with a drink when he is unhappy. In fact, to him alcohol is a sort of psychic Aladdin’s lamp, which he uses to alter mentality. There is a vast difference between this type and the uncontrolled drinker. The line separating abnormal drinking from social drinking is a matter of the degree to which the drinker is psychologically dependent on the drink. This in itself is a fairly accurate indication whether the personality has or has not made a good adjustment to reality. We find well-adjusted people using alcohol in its accepted legitimate field, and though they may be far more addicted to it than they wish to admit, they are able to limit their indulgence in it to given occasions, because, having made good adjustments to reality, reality is acceptable to them. They may for a little while put on the mask and costume of a psychic harlequin, but after an hour or two they are quite ready to get back into their own more sober psychic garments, even though they know that this change may be accompanied by headache and frazzled nerves. On the other hand, the alcoholic, with his psychoneurotic maladjustment, is searching for the psycho-medicinal properties of alcohol rather than the pleasurable intoxicating effects.

Physicians who are familiar with the anesthetics, ether and chloroform (the medicinally used narcotic intoxicants), have ample opportunity to observe, in the operating room, the exciting phase followed by complete anesthesia. At cocktail hour in any hotel or club bar, you will see the social use of narcotic intoxicants by an earnest group who are searching for and finding the exciting phase and the relaxing phase in a narcotic intoxicant disguised as a highball or a cocktail, and having found this pleasurable phase, they are satisfied. The abnormal drinker in the same situation is getting drunk quickly because he is searching for the anaesthetic properties or deeper narcotizing effects of alcohol. Hence we observe him hurrying through the exciting pleasurable and relaxing phase brought about by drinking in much the manner of one anaesthetizing himself. When you question the abnormal drinker about this peculiarity, he assures you that he did not mean to get drunk, nor did he want to get drunk; and I believe that consciously he means what he says, not recognizing the tact that unconsciously there is a demand for the oblivion of drunkenness, once the higher nerve centers have been affected by alcohol.

The other day one of my friends who was consulting me about his abnormal drinking said, "If you would only say that you could teach the abnormal drinker how to drink in moderation, you would have thousands flocking to your door." This is undoubtedly true, but if I made any such claims, I should be the most unmitigated liar, and those who consulted me would be doing so with no chance of success, for the simple reason that normal intoxication is not what the alcoholic is after, nor is he ever satisfied with it. The proof of this statement is obvious. No one makes these people seek drunkenness, and yet that is the state in which they inevitably arrive, if they use alcohol in any form whatsoever.

It is difficult to give a textbook definition of the underlying neurotic condition that makes alcoholism possible in certain individuals. It is perhaps most nearly covered by the definition of "compulsion neurosis" as given by Professor Horace B. English:

"Group of mental disorders characterized by an irresistible impulse to perform some apparently unreasonable act or to cherish an unreasonable idea or emotion. Generally the patient is not deluded and frankly admits the unreasonableness of his attitude."

This definition would, of course, apply to the alcoholic only when he has been sobered up, as the effects of alcohol may create a delusional state.

The causes of an alcoholic compulsion neurosis are soon apparent in a cooperative patient anxious to aid therapy by unburdening himself of his innermost thoughts and reaction. Usually we find a marked lack of mental hygiene in the early parental environment. Often one or both parents have failed to make adequate adjustments to reality and they pass on to their offspring, by suggestion and tactless handling, a predisposition to maladjustment in maturity.

Citing from cases which I believe I have analyzed correctly, I find overprotection in childhood is often projected into adolescence and maturity as an abnormal dependence on the state of mind produced by alcohol. For instance a mother consulted me about her grown son. She was active in the prohibition movement and a strict disciplinarian in the home, over which she domineered in a tyrannical manner, utilizing her fanatical interpretation of right and wrong to justify her every intolerant attitude. At thirty-one, her son was ruled by, and depended on, his forceful mother. He was still waiting for her to manipulate the puppet strings. At the same time he resented this forced dependence, and so he rebelled and hurt her in her tender spot-prohibition - by seeking escape in chronic alcoholism, ironically enough still depending on her in a way that she decidedly did not like.

Not infrequently the overprotection resulting from inherited wealth seems to turn out ill-equipped personalities that find an escape solution in alcohol. Man rich men, free from the necessity of earning their bread in a business or a profession, seek to suppress their creative urge by substituting alcoholic phantasies. Such men find in alcohol a synthetic existence which apes the give and take of normal life (emphasis always being on the take). This type might be described as perpetual euphoria seekers. They usually must endure a severe alcoholic breakdown before they learn the primary equation of life - that "you can’t get something for nothing."

Among the neurotics who become alcoholic we occasionally find an initial adjustment to a smooth, uneventful environment, with no abnormal dependence on alcohol until an emotional shock is experienced. Then they start searching for a stabilizer and often find it and utilize it with little realization that they have developed a psychopathological addiction; War experiences and business failures have produced a group of these men who might under other circumstances have gone through life as normal drinkers. Occasionally a gonorrhea infection and the mental reaction to it have seemed to herald an abnormal addiction to alcohol. One man traced his narcotic use of alcohol to the fact that, after a severe infection, the doctor who was treating him said that if he started to drink and there was no return of his symptoms, it would be a proof that the condition was cured. He went on a drinking spree and though he had been a controlled drinker up to the time of this incident, he found, after his humiliating experience, that alcohol offered him a solace for the shame and feelings of inferiority which the disease had caused. From this time on, he said, he used alcohol more and more as a psychic cure-all.

Marital discord is often used as a reason for drinking, but this is usually a cart-before-the-horse explanation whose falsity is evident as soon as the patient gains real insight into his personality maladjustment. The truth is that marriage enlarges the field of reality and increases responsibility, the very thing the alcoholic was seeking to. avoid by his narcotic use of alcohol. Hence the conspicuous failures of those women who marry in order to reform their inebriate lovers.

An arrested psychological sexual development is sometimes found at the bottom of discord between wife and alcoholic husband. The husband blames his drinking, of his wife’s lack of affection. The wife, on the other hand, is sexually and growing more so because of the impotency of her husband, which is exaggerated by alcohol. Such a circle becomes ever more vicious, the husband’s sense of inferiority being increased by his wife’s attitude, which further inhibits the possibility of a normal sexual adjustment. To add to the confusion, the husband considers alcohol as an aphrodisiac, not realizing that the drug that narcotizes his inhibitions is equally narcotizing his sexual power, so that metaphorically he is using gasoline to put out a fire. I have recently had the pleasure of seeing a case of this sort gradually work out into a normal adjustment. The insight gained and the readjustment of the personality after reeducation, which was undertaken to overcome the alcoholism, automatically took care of the sexual immaturity. This adjustment could never have been made on any but a non-alcoholic basis.

The double standard of drinking which came about during prohibition has increased the number of feminine inebriates. I have found this condition harder to treat in the limited number of women who consult me. They seem to find it more difficult to be absolutely frank about themselves. However, where they can see the necessity of strict truthfulness and are sincere in their desire to overcome abnormal drinking, they respond to therapy in much the same manner as men. The underlying cause in women and in men is the same - i.e., emotional immaturity, which renders their personalities unequal to the task of facing reality. In their narcotic use of alcohol they find the answer at least temporarily, and to the emotionally immature the temporary solution is sufficient’. This temporary escape from reality is soon extended into days and weeks.

Most of those who wish to take formal steps to overcome their alcoholism are between the ages of thirty and fifty. This is perhaps a psychological time, because under thirty the driving force of youth and a nervous system that can withstand repeated alcohol shocks are reasons for not taking the alcohol problem seriously. After thirty the abnormal drinker gradually becomes aware that his drinking is forcing him to pay an exaggerated price mentally, morally, and physically, and his inability to limit his drinking to even the dissipated variety of indulgence is brought home to him by repeated unsuccessful attempts. By this time the penalty that one must pay for breaking any law of nature has become an obvious fact, no longer to be dismissed with a shrug and a smile as it was in young manhood. In the last analysis, I should say that the instinct of self-preservation is aroused only when the situation is so bad that’ it cannot fail to cause the gravest apprehension and alarm.

Having experienced fifteen years, as a chronic alcoholic, I doubt whether any of us in the alcoholic brotherhood want to get, well without reservations. Alcohol means too much to the man who is using it psycho-medicinally for him to want to give it up in’ its entirety. The best that can be hoped for is that he shall want to get well. Such a state of mind is sufficient at least to get him to consult some one who can show him how to help himself. Whether or not he will undergo treatment is another matter, but usually if he gets as far as this, he is on his way to a more mature handling of his problem. Bringing himself to this point amounts to a formal admission on his part that something definite must be done.

In the first interview with the patient I explain that I have been alcoholic and that I understand and sympathize with what he is going through; after which I ask him to describe his own case in his own way. I take down the history of his case as he gives it. I ask him to state when he realized that his drinking was abnormal. I ask him his reasons for consulting me and get him to describe his early environment and his present environment. This may take several interviews during which I do not commit myself as to whether or not I think he is a fit subject for this type of work. I give him a copy of Richard Peabody’s book, The Common Sense of Drinking, and ask him to mark any passages in it that he thinks are applicable to his case. Though I find that many of these men have read Peabody’s book, they have little more than a superficial understanding of their own problems, probably because, at the time they read it, they were unwilling to project themselves into the position of one in need of treatment. This marking of the book and the subsequent discussions of it put psychotherapeutic treatment on a sound basis from the start. The patient has shouldered the full responsibility of the admission that he is one of those with a nervous system non-resistant to alcohol. It is a form of self-analysis, and the patient usually appreciates, and is impressed by, the fact that he is believed in and to a certain extent is allowed to act as his own analyst.

It has been my experience in this type of treatment that it is best never to attempt to convince a man that he is an abnormal drinker; rather I put it to him that he must convince me, and incidentally himself; that he is in need, of instruction in methods of helping himself. I take my cue from Peabody with this approach, and I remember my own shocked amazement in one of our early talks when he said somewhat as follows: "If you have any, idea that you can still drink in moderation, there is absolutely no use in your consulting me. If you really believe that you can drink in a controlled manner despite what you have been through, the best thing for you to do is to go out and try. Then if you fail, come back to me and I will be glad to go into the matter further." This approach is a shock to most men who have spent many years as abnormal drinkers. Heretofore they have been surfeited with advice as to what they can and what they cannot do. They have been told that they must never have liquor in the house, they must avoid associating with their friends who drink, their wives must under no consideration take anything to drink. Very often they have been advised to leave their environment and attempt to make a new start in a community in which there is no drinking. In the first place, I don’t know of any such community, and in the second place, such advice amounts to telling a man that he is a weakling and advising him to escape reality, which is the very thing he has been attempting to do by his abnormal use of alcohol. The psychological approach which I have found effective is that of accepting the prospective patient as an individual who is perfectly able to stand on his own two feet, provided he will apply himself to the work that is outlined for him in a conscientious manner. It is up to him to prove whether or not he is in need of hospitalization. Many men come to me in bad shape nervously, despite which they say that they can pull themselves up in their own homes. My reply to this is, "Fine, I hope you can. But, if you find you cannot, it is then up to you to admit it, and we will make arrangements for you to go somewhere and get physically and nervously in shape." The purpose of this is twofold - to get the patient to act entirely on his own, and to allow him to determine his own degree of stability or instability. The man who can not pull himself out of an alcoholic rut in his own environment, and who admits it, is in a position to benefit by institutional treatment without the resentment that usually results when outsiders frighten or overpersuade one to go to an institution.

As I wish to keep my contact with the patient on a basis of friendship and mutual trust, I try to be entirely frank and honest in my approach. For instance, I tell him that I am going to instruct his wife, with his full consent, to let me know if he has a relapse. I explain to him that this is not done because I feel that he will not be perfectly honest with me, but because a man who has started to drink and is in the throes of an alcoholic breakdown is not capable of acting in a mature or reasoning manner. I always try to keep the patient informed of the reasons for everything that has to do with treatment. In fact, I consider him more of a student than a patient - a student who his failed to pass the final entrance examination into a mature existence. It is up to him to gain insight as to why he failed and how he can succeed. There is only one thing that will prevent his passing this examination, and that is retaining the state of mind that sought an escape from reality in the use of alcohol. This is the reason why this psychotherapy has been an effective treatment in a great many cases of chronic alcoholism. It is well called reeducation, which is a word implying the possibility of a new and successful adaptation to life. For this reason, the insane and the imbecile must be excluded from the group who may be said to have a favorable prognosis.

If we accept alcoholism as a compulsion neurosis, psychotherapeutic measures at once suggest themselves, and we see that insight, reeducation, and readaption of the personality must be brought about before the condition can be cleared up. This, I think, is the correct approach and one more hopeful and helpful than the defeatist stand so often taken, or the limited objective of keeping a man sober by any means that occur to an adroit mind.

The following quotation from Dr. Abraham Myerson, in his book, The Psychology of Mental Disorders is of interest. He says:

"The alcoholic’s mental disease disappears with abstinence and there is nothing to distinguish him from other people except his reaction to alcohol." I beg to disagree. There are many things, besides his reaction to alcohol, by which he may be distinguished from other people. That reaction is definitely and recognizably abnormal, but so is the state of mind back of that reaction. Peabody referred to the alcoholic’s conflict in sobriety and pointed out that until this conflict - whether or not to drink again - is settled on a lasting basis, nothing of a permanent curative nature has taken place. Settling this conflict once and for all time is not the simple proposition that many non-addicted seem to think. The man who has not experienced the state of mind of alcoholism usually has little realization of the bombardment of alcoholic impulses that besiege such a mind in periods of sobriety. Nearly, every association of life has an alcoholic tie- up. Without alcohol the mental process is a painful one which the addict knows can be temporarily relieved by a reversion to his habit. The state of, mind denied alcohol could be compared to a dull perpetual ache rather than an agony. I asked one man who had been off alcohol for three weeks before he consulted me how often the thought of drinking came up in his mind. "It is much less now," he said, "I only average an alcoholic thought about every fifteen minutes."

The gesture of making a formal effort to give up alcohol creates an added mental conflict. Baudouin, in describing the difficulties of a patient overcoming a neurosis, used a very apt simile which I think is particularly applicable to the man undertaking treatment for alcoholism. He compared the neurotic to one who is learning to ride a bicycle. Ahead of him looms a large dangerous rock and, despite himself, he seems drawn towards it and usually comes a cropper on it. Probably we have all experience this in learning to ride a bicycle, and we know that confidence and technique soon enable us to avoid the rock. To the alcoholic the rock signifies drinking: He wishes to avoid it, yet seems irresistibly drawn toward it. Psychologically the job is to teach him how to ride the bicycle and to show him how to avoid the rock, so that with a new technique he may learn to travel the pleasant road of reality that lies on the farther side.

To sum up the psychological approach to certain cases of alcoholism, the following methods of treating these cases have been of the greatest help to me:

1. Letting the patient convince me, and incidentally himself, that he is an abnormal drinker.

2. Allowing him to pick out his own characteristics in Peabody’s book, The Common Sense of Drinking.

3. Always taking the scientific psychological approach to the problem, which is usually welcomed as a relief from admonitions and emotional approaches.

4. Helping him to gain a psychological insight into his alcoholic problem and discussing his other problems with him during frequent appointments.

5. Instructing him how to relax physically, and mentally and following this with suggestion while he is in a relaxed state.

6. Discussing alcoholic dreams. It is significant that every cooperative patient who has worked with me has, after a period of abstinence, experienced dreams of an alcoholic wishfulfillment nature.

7. Giving the patient for exhaustive study some 80 notes by Richard Peabody which he kindly allowed to use in my work. These notes are of particular interest in that they cover and redirect certain trends of mind that inevitably occur to the man undergoing treatment. The vivid imagination of some of my patients has enabled me to add to these notes from time to time.

8. Mapping out a course of outside study so that it is interesting to the individual case.

9. Systematizing a daily routine, which includes the keeping of a schedule, exercise, recreation, study, business, and hobbies.

The length of time necessary for adequate treatment is usually from 80 to 100 hours over a period of a year. With the beginning of treatment, two or three "hourly appointments a week are necessary. Where patients are in hospital, daily appointments for several weeks, in conjunction with medical care, physio and occupational therapy, and a scheduled existence, constitute an ideal beginning for treatment.

The major advantage of this form of therapy, however, is that it is carried on after the patient has returned to his environment. Here he has a chance to apply his newly learned’ psychological reapproach on the actual battle front, where the real test must take place. It is the adjustment in his environment with a sympathetic instructor that is the most important phase of readjusting the point of view of the chronic alcoholic. The battle front is life, his life, with its sorrows and joys, perhaps complicated by a nagging ,or flirtatious wife, or domineering parents, a vicious business partner, or personal failures and successes, or just monotony and boredom. These are the offensive and defensive engagements that the partially rehabilitated personality must face. It seems reasonable that this best be done with some one who understands the condition and who can discuss the problems of adjustments as they occur, in conjunction with the opening of the mind and reeducation along modern scientific methods.

The successful patient is one who realizes that alcohol is a mental poison for him, and who has learned, by repeated actual experiments over a long period of time, that the technique of, facing reality is a far more pleasant and dividend-paying proposition than finding a miserable escape in alcohol.