Social Work Yearbook, Vol. 9, 45-50, 1947.

ALCOHOLISM

By Harry M. Tiebout

ALCOHOLISM. The problem of alcoholism is not a new one. To social workers in every community, large and small, the results of drunkenness have long been apparent. They reach beyond the intemperate individual, who has too often been regarded only as a nuisance or menace, to his wife and children who frequently become burdens on the town or state. Social work in dealing with the alcoholic has had to contend with public indifference, lack of understanding, and a dearth of adequate facilities for care and treatment. Recently, however, alcoholism has begun to be viewed objectively as a problem to be approached in the same scientific spirit that has characterized efforts to solve the problems of cancer, tuberculosis, heart diseases, and mental illness. It is coming to be regarded less as a problem of morals than of health.

Alcoholism Defined

Alcoholism as a term may be used to refer either (a) to the condition which results when a person indulges on occasion in an excessive amount of drinking and thus suffers temporarily from the direct effects of the alcohol imbibed; or (b) to the more serious chronic state of an individual whose use of alcohol has reached problem proportions and who thus may justifiably be called a sick person.

Of the adult Americans who drink alcoholic beverages to some extent, a large majority never take liquor to the point of intoxication. A secons group consists of men and women who occasionally overindulge but go about their daily affairs without any serious interruption occurring. These drinkers can be said to have an occasional period of alcoholism, in the first meaning of the word. Next, there is a group in which the factor of excessive intake assumes a more critical aspect, either because the periods of overindulgence are closer than in the second group or because the quantity taken begins to itpair efficiency. Again in the first meaning of the term, these excessive drinkers may be said to be suffering from frequent bouts with alcoholism. It is estimated that there are about 2,250,000 such persons in the United States. Finally there is a group of individuals who either drink daily more than is good for them or go off on periodic “spreesu during which they are completely at the mercy of alcohol. For these, alcoholism has clearly become a disease in the second sense of the definition. There are estimated to be 750,000 such alcoholic persons in the United States.

Pathology of Alcoholism

Scientific recognition that there is a segment of the drinking population whose drinking is pathological in character constitutes the greatest single recent gain in handling the problem of alcoholism. Opinion is divided as to the homogeneity of this group and the pathology of its individual members but there is no longer any question that such a group exists. In the present state of our knowledge, no final conclusions can be formulated about the nature or treatment of this disease, alcoholism. However certain facts and theories about it are beginning to gain general acceptance. Alcoholism, the disease, may be said to be present when a’ compulsive note is apparent in the patient’s behavior. Certain persons by virtue of forces operating in their unconscious, are compelled to think, feel, and act in ways that are contrary to their

own best interests and judgment. A compulsion, then, is an inner force which drives a person to act and think in a way which he resists either consciously or unconsciously. Will power is superseded by forces over which the individual has no control. The compulsion to drink is as real, and as foreign to the person, as any other compulsive or obsessive act. Unfortunately, the presence of the obsessive component is masked, first, by the similarity of the behavior which it produces to that produced by normal drinking, and second, by the patient’s unawareness of this presence within him until the obsessive force is almost overwhelming. Because of both the similarity and the unawareness, the compulsive element may for a considerable time be ignored or overlooked, accounting thereby for previous failure to identify the factor of illness. Clinically, the compulsive symptomatology is much easier to detect in its final stages. In the course of time the individual so afflicted realizes that he is riding a runaway horse which is taking him along regardless of his own wishes. While the victim may bluff and bluster, the facts to the contrary become increasingly obvious. Friends, job, family, appearance, health, all slowly are lost or affected until it is obvious that the individual’s own welfare is completely at the mercy of alcoholic craving. It is difficult to note the compulsion in its infancy when overt behavior very often in no way differentiates the compulsive drinker from others. The surest criterion, in the writer’s experience, is a slow build-up in frequency of drinking and in the quality of liquor ingested. The build-up is not a matter of days, weeks, or even months; years must elapse as a rule before sufficient perspective is available to afford a basis for judgment. A careful investigation of the drinking history, usually supplemented by reliable informants – when they can be turned to without causing trouble – will generally disclose whether or not the individual’s drinking habits are gradually taking a turn for the worse. When that is noted, the compulsive factor is probably at work. The nature of the pathology underneath the compulsion is obscure. The process of alcoholism may be compared with the process of cancer, as currently conceived. It is now held that the cells of

the body tissues, in widely varying degrees, all have a cancer potential which can flower into cancer under suitable external provocation. Once the stimulus from without has goaded the potential into action, the time comes sooner or later when the action continues automatically of its own momentum. Then, even if the irritant outside of the cell is withdrawn, the cancer continues to develop along lines characteristic of its particular type. Similarly within the psyche of the future alcoholic there resides a potential psychic mechanism which, under proper nourishment from external sources, gradually moves into action until finally the individual realizes the potential has grown into an actuality which has usurped control over behavior and become a compulsion. This is not to say that the alcoholic is a person who has a continual compulsion to drink; what he does have somewhere in his mental makeup is a set of factors which, when aroused, result in an unconquerable craving to take alcohol. And the unfortunate fact for the alcoholic is that this set of factors is somehow touched off with considerable regularity. Moreover, as with cancer, the alcoholic process once started and under sufficent impetus will carry on automatically, growing worse and worse until death or mental disintegration results. Unless some treatment arrests the process, deterioration is inevitable; hence the significance in the symptomatology of noting accurately any steady shift for the worse in the patient’s drinking habits. As an aid in determining the presence of a compulsive element, there is no substitute for an accurate history of the drinking behavior. Any endeavor to be specific about the compulsive pathology of the alcoholic is at the present time impossible. The necessary knowledge simply does not exist. Actually there is no present agreement as to whether there is more than one basic type of compulsive activity, nor for that ,matter is there any agreement as to whether or not there is a type of compulsion which characterizes the alcoholic and distinguishes him from other sufferers from compulsive ways of thinking and feeling. Most authorities see psychoneurotic features in the alcoholic. Only a few, however,

including the present writer, believe that there is a specific constellation which may be considered typically alcoholic and which accounts for a significant number of the group. For the most part, alcoholism as a sickness is held to be a manifestation of some underlying, nonspecific psychoneurotic distortion, varying widely both in nature and expression and alike only in the common symptom of excessive drinking. Moreover, there is still no accord on the question of a physical component in alcoholism, the disease. Many side-step the issue by referring vaguely and in nonspecific terms to the allergy of the body. Others are searching for a unknown factor which may explain the selectivity which picks from the large mass of drinkers a certain few who are destined for trouble. Here, again, the writer finds himself in a minority which dissents from the majority opinion that there is a physical factor concurrent with whatever psychic elements exist. It is the two combined, according to most workers in this field, which bring about the illness. In the light of the fragmentary knowledge of pathology, treatment still must, and does, remain largely on the empirical level. At present, of the three treatment approaches usually adopted, two are empirical and the third is based merely upon the stubborn belief that, ultimately, psychological understanding can be attained and that when it is, psychotherapy will be available. In the main, empiric measures succeed when the more scientific method of understanding still largely fails.

Alcoholics Anonymous

The first of the empirical techniques developed in recent years is that used by the group known as Alcoholics Anonymous. Founded in the spring of 1935 with two members, this organization has experience a remarkable growth. New members were slowly added until the success of the method began to be noised about. Then the gain in members gathered momentum until in February, 1946, the central office estimated the membership to be 24,000 with 752 groups scattered all over this country and Canada, and extending to

Australia, Brazil, Finland, Mexico, and New Zealand. These groups function actively to keep their own members sober and try with equal vigor to bring in others, an essential step in maintaining the sobriety of the already “dryu members. The Alcoholics Anonymous program, which in essence amounts to a therapeutic procedure, is codified into 12 steps which, if followed out sincerely, will stop the drinking. As one of their leaders has pointed out, these steps include many different psychological maneuvers of known therapeutic value. Alcoholics Anonymous, in addition, has provided a resource in the group itself, an additional one in the work with other alcoholics, and probably the keystone resource of all, the religious factor, which permeates the whole program and is undoubtedly essential to the success of the organization. Since Alcoholics Anonymous got underway the percentage of success has been remarkably high, the New York office stating that roughly 50 per cent stay “dryw from the start and that another 25 per cent after some initial difficulties, achieve sobriety. As time goes on the percentage who remain permanently “dryu may slowly decline, but the program has been in effect long enough to establish its value as a treatment of the disease.

The Conditioned-Reflex Treatment

Second of the empiric methods is the conditioned-reflex treatment. It is based upon the induction of automatic reflex vomiting of alcohol by giving an emetic and then having the patient drink just before the emisis is due. The psychological aversion thus created frees the person from his obsession. A course of treatment is often followed, in four to six months, by a reinforcing treatment which helps to insure more lasting results. A leading exponent of this method of therapy, and the originator of it in its present form, claims 50 to 60 per cent success in establishing sobriety. Another gives a figure of 60 per cent. Other clinics are as yet unwilling to offer any statistics, as they are both new at the

procedure and have not had enough time to evaluate results. Without exception all practitioners of the conditioned-reflex treatment advocate psychotherapy as an essential additional element in their curative program, and some have advised patients to join the local Alcoholics Anonymous group. Why the practitioners resort to psychotherapy even if only on the guidance level is not at all clear, but it seems to suggest that they view the aversion set up as merely one step in providing a sufficient period of abstention to establish a new and different way of life.

Psychotherapeutic Treatment

The third type of treatment approach is psychological. Unfortunately, while no one questions the importance of underlying emotional factors in contributing to alcoholism, psychotherapy with an occasional notable exception has proved disappointing. Many psychoanalysts refuse to accept alcoholic^, deeming them not suitable for that method of therapy. Re-education, guidance, environmental readjustment, all have their triumphs but too infrequently to warrant any hope that a successful method transmittible to others has been derived. Although one or two practitioners claim considerably better results, a 10 to 15 per cent recovery rate is average. The Yale Plan Clinics, combining psychotherapy with the help of a social worker, report that nearly 60 per cent of the patients who accept treatment attain sobriety. It is too soon to say whether or not this figure will persist.

Prerequisites to Successful Treatment

Despite the lamentable state of the psychotherapy of alcoholism, and for that matter any kind of therapy for a vast number of cases, agreement has been won on certain major points. First, all authorities agree that no type of treatment can succeed if the alcoholic himself does not want help. Assistance cannot be imposed. Second, once the disease has developed its own

automaticity, there can never be a return to normal drinking. In other wordsI the only safe goal for the abnormal drinker is total and complete abstinence. ThirdI all the physical factorsI including alcohol, must be eradicated before the drinking habit can be tackled. Even more hopeful than the establishment of these hard-won areas of agreement is the certainty that the large number of investigators at work on the problem will in time clear the way for increasingly sharper and more precise understanding. No one who knows the field would today call it static. Ten years ago such a note of optimism could not have been struck.

Agencies in the Field

For a long time the only group in any way attempting to meet the problem of alcoholism were the temperance forcesI who chiefly relied upon prohibition to combat the condition. After the setback of their efforts by the repeal of the prohibition amendment to the Constitution, in 1933, the next organized effort to grapple with the problem was the founding in 1937 of the Research Council on Problems of Alcohol. Stimulated by the belief that in the scientific method lay the only possible chance of solving the problem and backed by far-seeing individuals from both the prohibitionists and the liquor interests as well as by scientists in the fields of psychiatry and allied disciplines, the Council was established to foster research and to provide a medium for the dissemination of the known facts about alcoholism to the lay and scientific public. Under the scientific of Dr. A.J. CarlsonI it has proceeded steadily with its emphasis upon research as the sine qua non of future progress in the field. Its sponsors, initiates, and occasionally is in a position to finance the work of various investigators. It also engages in educational activities through the issuance of literature for both lay and scientific readers. Next to enter the field was a group of scientists at Yale University where, since 1930, Dr. H.W. Haggard had been engaged in

the study of the influence of alcohol upon the human body. As an outgrowth of these studies, his interests broadened to cover the personal and social aspects of the problem, with the result that the program began to expand and assume national significance. In 1940 the Quarterly Journal of Studies on Alcohol was started by the Yale group. In 1941 Dr. E.M. Jellinek joined the staff and a special University section on studies of alcohol was formed. Summer institutes on alcoholism have been held each summer since 1943. In 1944 the Yale Plan Clinics were opened, the first extramural clinics limited exclusively to the handling of the alcoholic. At present they represent probably the only university activity along these lines. In September, 1944, a new type of organization was formed. Sponsored and backed by the Yale group, the National Committee for Education on Alcoholism was set up to educate the public with respect to alcohol. With an executive director selected from the ranks of Alcoholics Anonymous, and utilizing that group as a channel to the more general public, it has focused its efforts upon spreading knowledge of the disease concept of alcohol through local groups specially formed for the purpose. It has, in addition, served as a source of information about alcoholism to other groups, such as social workers. The latest organization to join the fight is the National Committee on Alcohol Hygiene. The Committee was established in October, 1944, under psychiatric leadership, with the purpose of furthering the correlation of the knowledge about alcohol and the education of the public along scientific lines. It issues the bimonthly bulletin, Alcohol Hygiene. Programs on both the sate and local level have recently been initiated. New Jersey and Connecticut have passed laws creating commissions especially designed to combat alcoholism and to promote prevention, the latter state having adopted the principle of utilizing a certain percentage of the funds obtained from the tax on liquors. At least four other states have appointed committees with funds to examine the possibilities for state action. New York City

recently opened a retreat operated by the Welfare Department Bureau of Alcoholic Therapy. Other communities have taken or are planning to take steps to meet the issues which alcoholism creates. Developments along state and local lines are a welcome sign, since only through action which reaches individuals can effective measures for either treatment or prevention be adopted.

Bibliography

Alcoholic Foundation, Inc. A.A. 29pp. New York, March 1945. —- , Medicine Looks at Alcoholics Anonymous, 19pp. 1944. Alcohol Hygiene. Bimonthly. Bacon, Selden D., alcoholi ism: A Major Social ProblemfW in Public Welfare, July 1946. Corwin, E.H.L. and Cunningham, Elizabeth V. Institutional Facilities for the Treatment of Alcoholism. A report of the American Hospital Association. Research Report No. 7. 85pp. Research Council on problems of Alcohol, New York. 1944. Includes a bibliography. Jellinek, E.M. I1Alcohol Problems Dissected: Report on the Summer School of Alcohol Studies at Yale University.” Entire issue of Social Action, March 15, 1945. McGoldrick, Edward J., Jr. “New York City’s Bureau of Alcohol Therapy,” in Public Welfare. September 1946. Research Council on Problems of Alcohol. The Scientific Approach to Chronic Alcoholism: An Outline. 32 pp. New York. 1946. Seliger, Robert V. and Cranford, Victoria. Alcoholics Are Sick People. 80 pp. Alcoholism Publications, Baltimore. 1945. —- , A Guide on Alcoholism for Social Workers. 94 pp. Alcoholism Publications, Baltimore. 1945. Shadel, Charles A. “Aversion Treatment of Alcohol Addiction,” in Quarterly Journal of Studies on Alcohol. September 1944. Tiebout, Harry M. “The syndrome of Alcohol Addiction,” in Quarterly Journal of Studies on Alcohol. March 1945. Yale University. Alcohol, Science and Society: Twenty-nine Lectures with Discussions as given at Yale Summer School of Alcohol Studies. 473 pp. Quarterly Journal of Studies on Alcohol, New Haven, 1945.