American Journal of Psychiatry, Vol.100 (4), Jan. 1944, 468-473

THERAPEUTIC MECHANISMS OF ALCOHOLICS ANONYMOUS

Harry M. Tiebout, M.D., Greenwich, Conn.

Read at the ninty-ninth annual meeting of The American Psychiatric Association, Detroit, Michigan, May 10-13, 1943.

Alcoholics Anonymous is the name applied to a group of ex-alcoholics who, through a therapeutic program which includes a definite religious element, have successfully combated alcoholism. The group stems from the effort of one man, Mr. William Wilson, who in 1934 found an answer to his drinking problem in a personal religious experience. This experience he was able to translate into terms which were meaningful for others. Since then, many alcoholics have become sober by using his approach. The work of Alcoholics Anonymous has a threefold aspect. First, the group has weekly gatherings where experiences are related and problems discussed. Second, all are urged to read their book, “Alcoholics Anonymous”, which contains their basic tenets and must be read if one is to arrive at any understanding of their program. Third, the members work with prospects who are making their initial contact with the group. Helping others is a two-way situation since it not only assists the beginner in his first efforts but it also aids the helper who derives from his efforts something which is essential for his continued sobriety. Statistics at the New York office of the organization read as follows:

5 recovered at the end of the first year. 15 recovered at the end of the second year. 40 recovered at the end of the third year. 100 recovered at the end of the fourth year. 400 recovered at the end of the fifth year. 2000 recovered at the end of the sixth year. 8000 recovered at the end of the seventh year.

Alcoholics Anonymous claims a recovery rate of 75 per cent of those who really try their methods. This figure, coupled with their mushroom growth, commands respect and demands explanation. While fully cognizant of the fellowship values of the group, of the help accruing to each member from his efforts to help new ones and of the general atmosphere of hope and encouragement which emanates from any successfully treated person. I regard them as accessory to the central therapeutic force, religion – a truth, which hopefully, will become clear by the end of the paper, and a realization of which developed from many long talks with Mr. Wilson. My first contact with the group came through the medium of a thirty-four year old women patient who had been under my care at Blythewood for several months. She had been a chronic alcoholic for many years and, despite intelligence, family position and early successes, had literally hit the gutter, after

a steady decline in her fortunes had left her all but penniless. Although no patient ever wanted to get well more desperately or cooperated more wholeheartedly in a treatment program than she, the results were very unsatisfactory. Finally, it became clear that she possessed a character structure which, despite her best efforts and mine, persisted unshaken and was clearly responsible for the continuance of her drinking. One day a copy of “Alcoholics Anonymous”, while yet in multilith form , came into my hands. I read it, and found it contained a most accurate description of the character problem I had been facing in my patient. In an effort to jar her a bit, I gave her the book to read. To my surprise she was so greatly impressed that she arranged to go to an Alcoholics Anonymous meeting and very shortly she became an active and successful member of the group. Even more surprising was the discovery that, with the process of assimilation of that program, her character structure, which had been blocking any help, dissolved and was replaced by one which enabled its possessor to remain dry. Something had taken place under my very nose which could not be doubted and which could not be explained away as mere coincidence. I found myself facing the question: What had happened? My answer is that the patient had had a religious or spiritual experience. The answer, however, did not prove particularly enlightening and it was not until much later that I began to appreciate the real meaning of the answer. Before attempting to explain how further understanding of the significance of the religious factor developed, it is necessary to discuss the character structure which had dissolved. Despite most reports to the contrary, there is a growing recognition of certain common qualities which are regularly present in alcoholics excepting those who have a frank underlying mental condition. Characteristic of the so-called typical alcoholic is a narcissistic core, dominated by feelings of omnipotence, intent on maintaining at all costs its inner integrity. While these characteristics are found in other maladjustments, they appear in relatively pure culture in alcoholic after alcoholic. In a careful study of a series of cases, Sillman recently reported that he felt he could discern the outlines of a common character structure among the problem drinkers and that the best terms he could find for the group of qualities noted was “defiant individuality” and “grandiosity.” In my opinion, those words were accurately chosen. Inwardly the alcoholic books no control from man or God. He, the alcoholic, is and must be master of his destiny. He will fight to the end to preserve that position. Granting then the more or less constant presence of these character traits, it is easy to see how the person possessing them has difficulty in accepting God and religion. Religion by its demand that the individual acknowledge the presence of God challenges the very nature of the alcoholic. But, on the other hand, and this point is basic to my paper, if the alcoholic can truly accept the presence of a Power greater than himself, he, by that very step, modifies at least temporarily and possibly permanently his deepest inner structure and when he does so without resentment or struggle, then he is no longer typically alcoholic. And the strange thing is that if the alcoholic can sustain that inner feeling of acceptance, he can and will remain sober for the rest of his life. To his friends and family, he has gotten religion! To psychiatrists, he has gotten a form of self-

hypnosis or what you will. Regardless of what has occurred inside the alcoholic, he can now stay dry. Such is the Alcoholics Anonymous contention, and I believe it is based upon facts. Let us go back to my patient and describe her after experience in Alcoholics Anonymous. In her original state she corresponded perfectly with the description already given of the alcoholic character structure. After Alcoholics Anonymous began to take hold, changes in her personality became apparent. The aggression subsides materially, the feeling of being at odds with the world disappeared, and with it vanished the tendency to suspect the motives and attitudes of others. A sense of peace and calm ensued with real lessening of inner tension; and the lines of her face softened and became gentler and more kindly. That hard inner core was being altered, altered sufficiently to bring about the patient’s sobriety for a period of five years. What was the nature of the experience which stirred this patient when she joined Alcoholics Anonymous? The answer is that some sort of religious or spiritual force was awakened. Wilson states that the success of the group with any alcoholic depends upon the degree to which the individual goes through a conversion or spiritual activation. His own experience was of the sweeping, cataclysmic type which lifted him out of a slough of despond and transported him to heights of ecstatic joy and happiness where he stayed for some hours. This state was then succeeded by a feeling of peace, serenity and the profound conviction that he was freed from the bondage of liquor. He states that roughly 10 per cent enter Alcoholics Anonymous on the strength of such an experience. The remaining 90 per cent who stay dry achieve the same result by developing slowly and much more gradually the spiritual side of their nature through following the various steps in the program already outlined. According to Alcoholics Anonymous experience, the speed with which the spiritual awakening takes place is no criterion of either depth or permanence of cure. The religious leavening, however little at first, starts the process; the program helps to bring it to a successful conclusion. What then is a spiritual awakening? Here the personal experience of Mr. Wilson is again informative. A man of energy, drive and great ability, in his thirties, he found himself completely bogged down by drink. For at least five years he fought the downhill process that was going on in him without success. Two weeks before his last hospital stay, he was visited by a former alcoholic crony, who had achieved sobriety through Buchmanism. Wilson tried unsuccessfully to avail himself of his friend’s teachings and finally decided he would get sobered up by entering a well-known drying-out place where he could clear his brain of liquor and have a chance to try out his friend’s ideas with his, Wilson’s, system free from the drag of alcohol. He was desperate, depressed with all the fight knocked out of him. He was willing to try anything because he knew the alternative facing him was a state hospital and a life of permanent insanity. The evening of his first day of admission, he was again visited by his friend who once more expounded the principles which he felt had brought him health. After he left, Wilson sank into an even deeper depression, which he described as a “profound sense of melancholy and utter hopelessness.” Suddenly in this agony of spirit, he cried

aloud. “If their is a God, let Him show himself now.” And with this plea his religious experience started. He points out, and I think rightfully, that it was not until he became utterly humble that he could and did turn to God for the help that was there. In other words, in light of Mr. Wilson’s own experience, a religious or spiritual awakening is the act of giving up one’s reliance on one’s omnipotence. The defiant individuality no longer defies but accepts help, guidance and control from the outside. And as the individual relinquishes his negative, aggressive feelings toward himself and towards life, he finds himself overwhelmed by strongly positive ones such as love, friendliness, peacefulness and pervading contentment, which state is the exact antithesis of the former restlessness and irritability. And the significant fact is that with the new mental state the individual is no longer literally “driven to drink.” Further insight into the phenomenon of spiritual change came from another patient whose case I now wish to cite. He is a man in his early forties. From a family of wealth, and the youngest of several children, he was the pampered darling of a neurotic, hypochondriacal mother. Drinking began in late adolescence. Almost at once he learned to rely on liquor to help him meet social situations, and as the years rolled on, this reliance became more pronounced. Finally after one long spree, he was admitted to Blythewood. He proved to be an exceedingly responsive patient, readily acknowledging his alcoholic tendency, and quickly becoming interested in Alcoholics Anonymous. After residence of about a month, he left quite convinced that he had the problem in hand. Within a short time however nipping set in and four months later he returned after some weeks of steady drinking. Again he showed himself responsive to interview, but it now became apparent that there was a real battle ahead and that it was exactly the same battle previously faced in the patient first discussed. The traits already described reared themselves as insuperable barriers to therapy. During the weeks that we were discussing these obstacles the patient began again to nip on the sly and finally went off on a full-fledged spree. He was brought back to Blythewood to terminate it. As usual with all alcoholics, as he sobered up he was filled with remorse, guilt and a tremendous sense of humility. The defiant personality was licked by the very excesses of its own behavior and, in that mood, he was utterly sure he would never take another drop. On the third day of his recuperation, however, he informed me during an interview that I had better do something about it, and when I asked him what “it” referred to, he replied, “My old feeling is coming back over me; I can feel myself closing in from you and all that has just happened.” The indifference to his problem, the aggressive sureness, the utter lack of any sense of humility and guilt, all the character traits which he had come to identify with the frame of mind that led to drinking were returning and crowding out the feelings, the thoughts, almost the sensations which filled him as he came out of his drinking bout. He knew that if these returning feelings again took hold of him sooner or later he would go on another alcoholic spree. He realized that somehow he must cling to the attitudes he had as he came out of the bout.

The next day he began his interview with the statement, “Doc, I’ve got it.” He then went on to report his experience of the previous night. This experience I label for want of a better term, “a psychological awakening.” What happened was a sudden flash of understanding about himself as a person. This occurred around 11 o’clock, and he lay in bed, wide awake until four o’clock in the morning fitting his new insights and understanding to his knowledge of himself. It is not easy to reconstruct the events of that five hour period, yet those events constituted a major experience in the life of that patient which gave him a basic appreciation of himself as an alcoholic. Moreover, for the first time, he could see himself as he had always been, and in addition he could sense the sort of person he must become if he were to remain sober. Without being aware of it at the time, he had switched from a completely egocentric, subjective point of view to an objective, mature understanding of himself and his relationship to life. In retrospect, it is apparent that the patient became aware of his basic egocentricity. For the first time he was able to penetrate behind the facade of his rationalizations and defense reactions and to see that always hitherto he had put himself first. He was literally unaware that other souls existed except so far as they affected him. That they too, might have separate existences, similar yet different from his, just never had taken on the aspect of reality. Now he no longer felt himself the omnipotent being who viewed the world only in relation to himself. Instead, he could see himself in relation to the world and could realize that he was but a small fraction of a universe peopled by many other individuals. He could share life with others. He had no further need to dominate and to fight to maintain that domination. He could relax and take things easy. His new orientation can best be described in the patient’s own words. As he put it, “Why, Doc, do you know I’ve been a fraud all my life, and I never knew it. I used to think I was interested in people, but that wasn’t really so. I wasn’t interested in my mother as a person who was sick. I didn’t realize that she as a person might be suffering; I only thought what will happen to me when she is gone. People used to point me out as a dutiful son and as example, and I believed it. But there wasn’t anything to it. I was just anxious to keep her near, because she made me feel better. She never criticized me and always made me feel that whatever I did, I was O.K.” New insights illuminated his previous relationships with people. With respect to this point, he remarked, “Do you know, I’m beginning to feel closer to people. I can think of them sometimes. And I feel easier with them, too. Maybe that’s because I don’t think they’re fighting me, since I don’t feel I’m fighting them. I now think maybe they can really like me.” Other enlightenments about himself and his relationships to the world could be cited, but they would only add further proof that the thinking of this patient for the first time in his life had become truly objective. This switch to objectivity is, however, but half the story. Associated with the switch, there was an equally striking alteration in the prevailing feeling tone. In words that were reminiscent of Wilson’s in his spiritual experience, the patient described his new attitudes, “I feel wonderful but not like I do when I’ve been drinking. It’s very different from that; I feel quiet, not excited and wanting to rush around. I’m more

content to stay put, and I don’t think I’m going to worry so much. I’m relaxed, yet I feel better able to cope with life now than I ever did.” He then went on, “I have a different feeling about God. I don’t mind the idea of Some One up there running things now that I don’t want to run them myself. In fact, I’m kind of glad that I can feel there is a Supreme Being who can keep things going right. I guess maybe this is something like that spiritual feeling which they talk about. Whatever it is, I hope it stays, because I never felt so peaceful in all my life.” In this statement, the patient manifests different attitude towards God, and he also shows that he has become aware of the fact that, as he ceases the effort to maintain his individuality, he can relax and enjoy life in a quiet, yet thoroughly satisfying way. Such feelings are, as he intimates, distinctly spiritual in quality, and he was correct in their appraisal, because he has been able to remain dry for a period of nearly a year. The change to objectivity and the altered feeling tone have proved to be what he needed to stay sober. Despite this relatively brief period of sobriety, the patient feels that he is on much firmer footing. Hitherto, during periods of dryness, he was constantly fighting liquor. Now he has real peace of mind, because he knows what it takes to keep thinking soberly. This case was cited because it represents an individual who underwent a rapid psychological reorientation, the result of which was an entirely new and different life pattern and life outlook. While one can question the permanence of this new pattern, there can be no question as to the fact that the experience itself occurred. Of even greater significance for the purpose of this paper is the fact that the patient, as a result of his experience, used the same words to describe his feelings as did Wilson following his religious experience, and as did my other patient after the activities of Alcoholics Anonymous began to take hold and work upon her. Wilson informs me that of the 10 per cent who have a result of a rapid awakening, some achieve it on the basis of a true religious experience and others as a result of a sweeping psychological event such as happened to my patient. The other 90 per cent attain the same result more gradually, as did the woman patient cited. Irrespective of the path by which that outcome is achieved, there seems to be no doubt that all end up with this feeling of peace and security, which they link with the spiritual side of life. The narcissistic component in the character is submerged, at least for the time being, and in its place there is a much more mature and objective person who can meet life situations positively and affirmatively without escape into alcohol according to Wilson, all members of Alcoholics Anonymous who succeed in remaining dry, sooner or later undergo the same change in personality. They must lose the narcissistic element permanently; otherwise the program of Alcoholics Anonymous works only temporarily. Here let me make two additional observations. First, there is all the difference in the world between a true, emotional, religious feeling and the vague, groping, skeptical, intellectual belief which passes as a religious feeling in the minds of many people. Regardless of his final conception of that Power, unless the individual attains in the course of time a sense of the reality and the nearness of a Greater Power, his egocentric nature will reassert itself with undiminished

intensity, and drinking will again enter into the picture. Second, most of the individuals who finally reach the necessary spiritual state do so merely by following the Alcoholics Anonymous program and without ever consciously experiencing any sudden access of spiritual feeling. Instead they grow slowly but surely into a state of mind which, after it has been present for a time, they may suddenly recognize is greatly different from the one they formerly had. To their surprise, they discover that their point of view and outlook has taken on a real spiritual coloring. The central effect, therefore, of Alcoholics Anonymous is to develop in the person a spiritual state which will serve as a direct neutralizing force upon the egocentric elements in the character of the alcoholic. If and when that state becomes completely integrated into new habit patterns, the patient will remain dry. Wilson says that this process of integration takes place over a period of years, and that if there is no noticeable change in personality structure after six months , the spiritual side will likely succumb to a return of the submerged alcoholic self. In other words, unless the religious impetus of Alcoholics which Anonymous effects a change in the deeper personality components, the influence of the program is not lasting. Significantly, this change, which is typical, takes place without psychiatric help; yet as Wilson describes it, it has characteristics which we, as psychiatrists hope for in our improved patients. Briefly, he sums up his observations with the words, “The alcoholic must gain in objectivity and maturity, otherwise he doesn’t stay sober.” In conclusion, it is my belief that the therapeutic value of the Alcoholics Anonymous approach arises from its use of a religious or spiritual force to attack the fundamental narcissism of the alcoholic. With the uprooting of that component, the individual experiences a whole new series of thoughts and feelings which are of a positive nature, and which impel him in the direction of growth and maturity. In other words, this group relies upon an emotional force, religion, to achieve an emotional result, namely the overthrowing of the negative, hostile, set of emotions and supplanting them with a positive set in which the individual no longer need maintain his defiant individuality, but instead can live in peace and harmony with and in his world, sharing and participating freely. One final comment. Present day psychiatry is properly chary of purely emotional cures. Until the change is firmly linked up with the mind and the intellect, the cure is considered suspect. The emphasis today is on analysis which relies upon the mind to ferret out the causes for the failure to achieve a state of synthesis, which is actually an emotional condition of feeling free of conflict and strain. It is presumed that, as the blocking emotions are uncovered and freed through analysis, positive, synthetic ones will appear instead. It is just as logical, though, to change emotions by using emotions and then, after the change has been brought about, to bring the mind and intellect into play to anchor the new set of emotions into the structure of the personality. In a sense, this is what occurs in Alcoholics Anonymous; religion plays upon the narcissism and neutralizes it to produce a feeling of synthesis. In referring to his own spiritual experience, Wilson often calls it a “great synthesizing experience in which everything for the first time became clear to me. It was as though a great

cloud had lifted and everything took on an indescribable illumination.” My second patient, in reference to this point, said this: “I feel all of one piece now. I feel all together, not rushing around in all directions at once.” And it was in the light of his new set of emotions that the patient could and did respond more satisfactorily to a discussion of what his previously difficulties had been and what he could do now to avoid any further trouble. After his synthesizing experience, he was for the first time really able to do an honest, decent job of self-understanding. The lesson for psychiatrists is clear, it seems to me. Although we admittedly deal with emotional problems, we, as a group which tends to be intellectual, distrust emotions too much. We are self-conscious and a little ashamed, when we are forced to use them, and always apologetic with our confreres if we suspect they have reason to think our methods are too emotional. In the meantime, others, less bound by tradition, go ahead and get results denied to us. It is highly imperative for us as presumably open-minded scientists to view wisely and long the efforts of others in our field of work.. We may be wearing bigger blinders than we know.