Human organization, Vol. 1 O NO.^), 1-13, April-June, 1942.

TYPES OF SOCIAL STRUC’RfBE AS FACTORS IN “CURES” FOR ALCOHOL ADDICTION.

by Freed Bales

I. ALCOHOLICS ANONYMOUS

Alcoholism has presented a serious psychiatric and public health problem for many years both from the point of view of social consequences and from the point of view of effective treatment. Many psychiatrists hesitate to speak of “cures” at all, preferring the terms “improved” or “arrested cases.” Although the problem has been attacked from the most various hypotheses concerning the nature of addiction, “cures” have always been very difficult and uncertain, no matter what type of therapy has been used. Against this background of medical and psychiatric experience the claim of one temperance group stands out in startling relief: “One-hundred-per-cent effectiveness with non-psychotic drinkers who sincerely want to quit is claimed by the workers of Alcoholics Anonymous.”(l) Is this a mere journalistic flourish? In part, yes. The claim is not so astonishing when the qualifications are considered. First, it does not apply to alcoholics who are psychotic. In mill commitments to a large hospital like Bloomingdale in New York, there are psychotic complications in about fifty per-cent of the cases.(2) Second, alcoholics with serious organic impairment, such as Itwet brainw are excluded.(3) Finally, the program is claimed to work only with drinkers who sincerely “want to quit.” “The program will not work, they add, with those who only ‘want to quitt, or who want to quit because they are afraid of losing their families or their jobs. The effective desire, they state,

must be based upon enlightened self-interest; the applicant must want to get away from liquor to head off incarceration or premature death. He must be fed up with the stark social loneliness which engulfs the uncontrolled drinker and must want to put some order into his bungled life.”(4) From a scientific point of view the operational procedures for detecting the existence of “effective desire” as over against a spurious desire are rather poorly defined. The claim is thus considerably vitiated. There is no doubt, however, that a desire of some such nature is of crucial importance, even though the addict who has such a desire is unable to quit drinking without the aid of other persons. This is corroborated by the reports of many psychiatrists. There are thus considerable numbers of alcoholics who are not suitable material for the A.A. program. That they cannot be distinguished accurately is shown by the fact that the degree of actual effectiveness falls far short of the 100% mark. About 50% of the alcoholics taken in recover almost immediately; 25% get well after suffering a relapse or two, and the rest remain doubtful, according to other A.A. claims.(5) However, 75% effectiveness is still a large claim. Accurate and comparable statistics are rare. Very often it is not possible to keep in touch with alcoholics after they leave the hospital or discontinue treatment. Moreover, different hospitals make different sorts of exclusions, so that their percentages or cures are for differently selected groups, and are thus non-comparable. Fortunately however, there are some estimates available for European hospitals which make approximately the same exclusions as do the A.A.’s. Dr. Robert Fleming, who visited a number of European hospitals to observe their methods of treatment reports the following percentages for three of these institutions: ) Institution: cured ” I’ improved” ‘I unimproved ” llunknown’ Kiiron (Salvation Army) in Sweden 40% – – GO% Am Steinhof in Austria 32% 13% 41% 14% Ellikon in Switzerland 5 0% – 5 0% –

In brief, for groups of alcoholics selected in approximately the same way as those in A.A., the proportion of “cured” and “improvedn combined, ranges between forty and fifty per-cent. Dr. Fleming comments: “It is interesting that where reliable information is available these figures seem to hold in a general way in all the Swedish and Central European institutions for treating alcoholics, whether the patients be voluntary or involuntary, the direction lay or medical, and whether the therapeutic approach be colored by a religious point of view.”(6) In the absence of more complete and accurate data on the results of various programs on selected groups of alcoholics, the 75% effectiveness reported by Alcoholics Anonymous must be regarded as remarkable. Is there anything unique in their program which might be expected to be peculiarly effective on grounds of anthropological theory? If SO, it may afford a basic insight as to how we may put our knowledge of human relations to work on a problem of great, practical importance.

11- ANALYSIS OF THERAPEUTIC PROGRAMS

Romantically enough, the claim of organizations known as Alcoholics Anonymous, which now has branches in about fifty towns and large cities (mostly in the East), was started more or less accidently by a New York broker who found that he could stave off his alcoholic craving by returning to the de-toxicating hospital where he had been a patient, and talking to the inmates. Although he effected no cures among them, he was able to deal more or less successfully with his own problem after his attempts to stay on the “water wagon”, supported by the ministrations of the Oxford Group began to fail. Eventually he did make a convert, however, and the two went to work in earnest. Their efforts were successful – they stayed sober, the group grew, and groups were started in other cities. The members of Alcoholics Anonymous make an avocation of helping other alcoholics overcome their drinking habits. They are on

call twenty-four hours a day, and will leave their work or get up in the middle of the night to go to the aid of one their slipping proteges. Most of these they meet in the de-alcoholizing wards of hospitals or through doctors and physicians who refer their patients to the group. The organization is quite informal, and the medical aspects of treatment, including the sobering-up process, the diagnosis of physiological and organic factors, and nursing back to physical health, are left to the hospitals which are already organized for these functions.(7) Members of the group visit the hospitals periodically, or as called, and sit sympathetically on the chests of patients inclined to violence, administer the small doses of alcohol or paraldehyde which are sometimes used in the tapering-off process, and talk to patients as they improve. As they have been chronic alcoholics themselves, the A.A. members are able to match the stories of the patients, experience for experience, and rationalization for rationalization. They are able to meet the alcoholic on his own ground and convince him that they have been in a situation similar to his. Very often they can build up a “bridge of confidence” that family members, physicians, ministers and priests have tried in vain to establish. From exotic bits of drinking lore the interchange proceeds to life stories, and gradually it is possible to convey the details of the program which the member has found to work for him and believes will work for the patient. There is never any attempt to force reform. Usually the member leaves his card and telephone number after making it plain that he will be willing to come whenever or wherever the patient needs him or wants to see him again. The patient is given to understand, however, that if he does not call he will hear no more from the member. The first approach is thus calculated to bring in only voluntary members. Psychotic and organically deteriorated cases are not attempted. The state of effective desire which seems to be a prerequisite to success is thus partially assured. The program as Alexander describes it may be divided into the following steps:

1. (The voluntary applicant) is first brought around to admit that alcohol has him whipped and that his life has become unmanageable. Having achieved this state of intellectual humility- 2. he is given a dose of religion in its broadest sense. He is asked to believe in a Power that is greater than himself, or at least to keep an open mind on that subject while he goes on with the rest of the program. Any concept of the higher Power is acceptable. A skeptic or agnostic may choose to think of his Inner Self, the miracle of growth, a tree, a man’s wonderment at the physical universe, the structure of the atom or mere mathematical infinity. Whatever form is visualized, the neophyte is taught that he must rely upon it and his own way, to pray to the Power for strength. 3. He next makes a sort of moral inventory of himself with the private aid of another person – one of his A.A. sponsors, a priest, a minister, a psychiatrist, or anyone else he fancies. If it gives him any relief, he may get up at a meeting and recite his misdeeds, but he is not required to do so. He restores what he may have stolen while intoxicated and arranges to pay off old debts and make good on rubber checks; he makes amends to persons he has abused and, in general, cleans up his past as well as he is able to. It is not uncommon for sponsors to lend him money to help out in the early stages. This catharsis is regarded as important because of the compulsion which a feeling of guilt exerts in the alcoholic obsession. 4. As nothing tends to push an alcoholic toward the bottle more than personal resentments, the pupil also makes out a list of his grudges and resolves not to be stirred by them. 5. At this point he is ready to start working on other active alcoholics. By the process of extroversion, which the work entails, he is able to think less of his own troubles. The more drinkers he is able to swing into Alcoholics Anonymous, the greater his responsibility to the group becomes. He can’t get drunk now without injuring the people who have proved themselves his best friends. He is beginning to grow up

emotionally and to quit being a leaner. 6. If raised in a orthodox church he ally^ but not always, becomes a regular communicant again. 7. Simultaneously with the making over of the alcoholic goes the process of adjusting his family to his new way of living. The wife or husband of an alcoholic, and the children, too, frequently become neurotics from being exposed to drinking excesses over a period of years. Re-education of the family is an essential part of a follow-up program which has been devised.(8) 8. In the larger cities A.A.’s meet one another daily at lunch in favored restaurants. The Cleveland groups give big parties on New Year’s and other holidays, at which gallons of soft drinks and coffee are consumed. Chicago holds open house on Friday, Saturday and Sunday – alternately, on the North, West and South Sides – so that no lonesome A.A. need revert to liquor over the week end for lack of companionship. Some play cribbage or bridge, the winner of each hand contributing a kitty for paying off entertainment expenses. The others listen to the radio, dance, eat or just talk.(9) The program of Alcoholics Anonymous can be seen to embrace a wide sector of the social life of its members, cutting down the isolation from other people which the alcoholic often suffers, reorganizing and reinforcing his desire to quit drinking, providing means of adjustment, financial, social, etc., removing frustrating and precipitating factors in his life situation, and furnishing outlets for moral and recreational expression. There is little doubt that all of these are favorable factors in the therapeutic program. For some years, however, various hospitals for chronic alcoholics have employed extra-mural programs quite similar to that of the A.A.’s, apparently with a considerably lower rate of success. What are the differential factors?(lO) Let us compare the programs point by point. 1. One of the essentials of therapy upon which there is practically universal agreement among those who have successfully

cured alcohol addicts is that the patient must recognize that he can never be a controll led,^ “moderate,” or “social” drinker, but must reconcile himself to a life of total abstinence. Just why this is so necessary is not entirely clear, but probably an important factor is that alcohol is often used as a means of adjustment in the first place, (rather than some other neurotic form of behavior) because of certain opportunities for behavior afforded by it. For example, in our culture there is a common belief that being able to drink a lot means virility, potency, and manhood. It is thus often possible to evade certain responsibilities of adult life by becoming irresponsible through intoxication, while at the same time “saving face” and preserving adult status because intoxication commonly signifies robust manhood. There is also the common idea that one proves he is a “good fellowll’one of the group by drinking. Intoxication may open the way to the expression of mildly anti-social tendencies (such as aggression, unpermissible sexuality, obstinacy, etc.) and at the same time protect the person from too much disapproval, since drinking provides the excuse for the behavior. Because drinking is socially approved in certain situations and thought of as social drinking,” the person who is actually an addict may take advantage of these situations to avoid becoming known and disapproved as a “solitary drinker.” These ideas about alcohol, provide protected channels, as it were, through which emotions and desires can be expressed, which if expressed in other ways, would receive more social disapproval. So long as these channels are available and protected, persons maladjusted in many different ways may be led to use alcohol to obtain their particular means of adjustment. Unless these channels can be closed by abandonment of all ideas, conscious and unconscious, upon which they depend, it is much harder to mobilize “effective desirew around new, and at first, more difficult means of adjustment. However, as this is emphasized in nearly all therapeutic programs, it is not the factor which differentiates the A.A. program from others. 2. The religious orientation of the A.A. program, broad and embryonic as it is, may possess some advantages in its wide

acceptability, but is not a factor unique to the A.A. program. Kuron, the Salvation Army’s institution in Sweden, exerts what Fleming calls a “peculiar brand of colorful religious influence.” “The personnel feels that the success or failure of the patient s ‘curet during his sojourn depends upon his conversion, an emotional experience because of which he acquires a special relation to ‘God and the Gospel,’ and is made a different man for the rest of his life. Great emphasis is placed on total abstinence. Moderate drinking is distinguished from heavy drinking only as a different degree of the same sin and carries about the same stigma.”(ll) At Ellikon, in Switzerland, the number of patients is small and – “the director is better able to develop a strong personal feeling between the patients and himself, and with this friendly relation as a basis, almost every variety of social, moral and ethical influence is brought to bear, collectively and in informal interviews, to convince the patient that his only hope lies in continued and total abstinence. The utilization of this ‘one big family idea plus the usual farm work and occupational therapy, and a carefully organized daily routine, make up the program at Ellikon.”(l2) Ellikon was founded in 1889 by Professor Forel, who is regarded as one of the first to apply modern methods to the treatment of chronic alcoholism. Professor Fore1 arrived at some of his essential ideas through a small temperance society in Basel, which cured a patient he had pronounced incurable. Some time later Fore1 discovered the chairman of the society and sent more patients to him. Many of them were cured, in spite of some relapses. Fore1 was much impressed and finally had a conversation with Mr. Bosshardt, which he reports as follows: “Well, dear friend, it is nearly two years now you have devoted yourself in such a disinterested way to my alcoholic^^ and that many get well is something I never saw before. Please

explain to me how it is. I am paid by the state to cure these people and I cannot do it. You are the one who cures the drinkers, not I. Why can I not do it?” “I am deeply ashamed,” he answered briefly with a smile: “it is very simple, Director; I am an abstaniner and you are not. That is the secret. You can not teach others convincingly that which you do not do yourself.” “You are more than right,” I answered, and I put an end to my wine drinking.”(l3) Forel found himself able to cure alcoholism. “Through this work,” he reports, “I had at least twenty times as many positive results of cure as in all the rest of my twenty-four years of psychiatric activity. This fact cannot be shaken.”(l4) One of the aspects of the groups organized on a religious basis is the uniform practice of a set of behaviors, and it is undoubtedly a factor of major importance, as will be discussed later. It may be that this element of the integrated religious group is the critical factor to be stressed, rather than the matter of “substitution,” which Fleming stresses: “Religious conversion is an almost ideal substitute for alcohol – especially the red-blooded Salvation Army variety – because it supplies in a socially acceptable form so many of the satisfactions which drinking itself supplies: companionship, music, a feeling of personal importance, spiritual exaltation, and above all a follow-up system that presumably extends throughout eternity. No other substitute does more than approach religious conversion in effectiveness…”(15) That formalized theology itself is not the crux of the matter is indicated in the stress on the emotional type of religion which welds together a more or less distinct group, and by the fact that many alcoholics rejoin their orthodox church only after their attachment to an abstinence club with religious elements, like the A.A.’s. 3. The moral inventory sponsored by the A.A.’s has its counterpart in various psychiatric programs, such as that of Chambers and Strecker, and to a certain extent probably in the European institutions under discussion. The religious emphasis of

Kuron and Ellikon in particular would presumably include something of this kind. In each of the three institutions regular conferences are held with the patient for discussion of the program, his worries and problems; and there is an attempt to establish rapport on a friendly basis. As for the adjustment of the patient’s past misdeeds and economic aid, no information is available. Judgement on this factor should therefore be reserved. 4. The recognition and listing of grudges and the resolve not to be stirred by them is not mentioned in any of the therapeutic programs under consideration, although this factor would likely be given some attention in the religious program of Kuron, as fflovethy neighbor” is definitely a part of the Salvation Army teaching. The device of explicitly recognizing impulses and then repeating to the self all of the reasons why they should be denied instead of summarily repressing them is a part of the Chambers and Strecker program. 5. The policy of working with other alcoholics as a special and agressive task of every member is entirely unique to Alcoholics Anonymous, so far as can be discovered. In no other program is this factor mentioned at all. It is possible that something of the sort is characteristic of Kuron, as the Salvation Army is an active missionary religious group, but the indication is that the aggressive role is taken by the personnel, not by the individual alcoholics themselves. The A.A.’s on the contrary, speak of their drunk-rescuing as “insurancev for themselves.” “Experience within the group has shown, they said, that once a recovered drinker slows up in this work he is likely to go back to drinking, himself. There is, they agree, no such thing as an ex-alcoholic. If one is an alcoholic – that is, a person who is unable to drink normally – one remains an alcoholic until he dies, just as a diabetic remains a diabetic. The best he can hope for is to become an arrested case, with drunk-saving as his insulin. At least, the A.A.Is say SO, and medical opinion tends to support them. All but a few said they had lost all desire for alcohol. Most serve liquor in their homes when friends drop in and they still go to bars with companions who

drink. The A.A.’s tipple on soft drinks and coffee.”(l6) 6. The recommendation that the patient rejoin his church if he had belonged to one is probably important as a reinforcement of the rather simple religious ideas encouraged by the group, but it stands as a refinement of the most elementary religious needs already satisfied by the A.A. group, rather than as a separate therapeutic measure. 7. Extra-mural work with the family of the patient is rather usual with the hospitals treating alcoholics. At Am Steinhof regular Sunday conferences are held with the patient’s relatives in order to make them understand the purposes of the treatment and to enlist their cooperation. Definite information regarding Kuron and Ellikon is lacking. The thoroughness of this aspect of the program might make considerable difference, but its importance in some form is generally recognized. 8. Finally, the importance of organized clubs for alcoholics who have received hospital or more thorough treatment and are nominally “cured” is being more generally recognized. Such a group, called the “Jacoby Club” exists in Boston. Am Steinhof sponsors a club of this kind: “At the time of each patient’s discharge from the hospital, arrangements are made for him to become a member of the Abstinence Union, “Future,” which is a sort of alumni organization composed exclusively of former patients of the alcoholic division of “Am Steinhof.” This club was founded in 1926 by Wlassak to provide an alcohol-free social life and fellowship for former patients and as one means for the physician to keep in touch with them after discharge. In the 10 years of its existence the abstinence club has grown from an average attendance of 50 to 135 members and their families at the weekly evening meetings (lectures, dances, excursionsr movies, and so forth.)”(l7) Ellikon also has a group organized for recreational and follow-up purposes: “When a patient is discharged it is arranged for him to become a member of the branch nearest his home of the Swiss Abstinence

Union, Sobrietas, and each summer the ‘alumni1 come back for a weekend of festive, non-alcoholic reunion with speeches, testimonials, renewals of acquaintance…”(18) The activities and organization of these clubs would have to be analyzed in great detail to assess the comparative efficiency, but at least their existence is not peculiar to the A.A.’s. This review of therapeutic programs here is not intended to be exhaustive. Miles gives a general review of the medical, psychiatric, psychological, psychoanalytic, and psycho-social aspects of treatment.(l9) Fleming holds that: “Practically every form of therapeutic approach has been successful; religious conversion, psychoanalysis, apomorphine contra-conditioning, hypnosis, abstinence clubs, legislative and economic reforms, the several varities of institutional routine – all have their coterie of enthusiastic advocates, all fanatically intolerant of any approach but their own, and doubtless all may have their place in a rational therapy of chronic alcoholism.”(20) The purpose of this section has been to compare the program of the A.A.’s with those of Kuron, Am Steinhof, and Ellikon, all of which select patients on approximately the same basis, and for which the percentage of cures is known. The analysis has revealed a number of factors beyond routine medical treatment which appear to have importance in the therapeutic program, centering around the participation of the alcoholic in an organization of which the religious sect may be considered a prototype. The one clear-cut differential factor between the A.A. program and the others is that the A.A. members work constantly and consistently at reforming other alcoholics. Can this factor be considered adequate to explain the twenty-five percent more cures obtained under the A.A. program?

I11 GROUP STRUCTURE AND PERSONALITY PATTERNS.

Statistical data on the differential incidence of chronic alcoholism (whether on the basis of death rates, rates of alcohol

consumption, or rates of alcoholic first admissions to hospitals) shows two differentials with great uniformity. First, rates for males tend to be around six times as high as rates for females. Second, rates for urban areas tend to be around four times as high as for rural areas. In addition, there is good evidence, though not quite so conclusive, that rates tend to be higher for weaker types of religious organizations such as Protestant, than for stronger types such as Catholic, Mormon, and Jewish. Moreover, for males at least, the rates tend to be higher for widowed and single men than for married men. This picture of differential incidence is remarkably like that Durkeim found for suicide, and in a general way his thesis that the differential rates are best explained in terms of I1social solidarity” seems to hold good for alcoholic addiction. Low social solidarity seems to be a generalized type of situation in which alcohol may come to serve all sorts of purposes. One implication of this view of the problem is that the creation of a highly solidary group may be a generalized factor in controlling addiction. In such general terms, this insight is not much help in dealing with specific practical problems of addiction, although it suggests that community reorganization among many lines may be in the end the only satisfactory solution. Perhaps, however, a more detailed analysis of group structure in the temperance societies just discussed will make the solidarity factors more specific and immediately applicable. It is not possible with the data available to assess the degree of solidarity in any of the actual groups by actual observation. It is possible, however, to follow out some of the implications of the known group activity as it may result in types of group structure. It is logical to assume that the unique missionary activity of the A.A.ls would result in greater solidarity of the group than prevails in the European institutions? The factor of common experience has already been mentioned. The members of Alcoholics Anonymous are homogeneous in that they have all been victims of an uncontrollable urge to drink which was not, as a rule, understood or sympathetically regarded by their

family and friends. They have been exposed to all sorts of smugness, self-righteousness, pity, condemnation, pleading and pampering – all of which failed to comprehend or remove their fundamental difficulties. But each prospective member is introduced to the group and its methods through someone who has once been in his own predicament, has a genuine feeling for his difficulties, and refuses to accept his rationalizations because he knows them too well from his own case. This member like himself in other respects, has found a way out. Why can he not also succeed? On the other hand, the member sees in his prospective convert himself as he once was, and by teaching the other, becomes his own therapist. He is able to “see himself as others see himv with a degree of clarity otherwise unattainable. Professor Forel, mentioned earlier, learned the effectiveness of a moral example. The interesting thing about Alcoholics Anonymous is that they have institutionalized a missionary activity in such a way that every member behaves as a moral example toward some other, and from this perspective learns by teaching. Consider next the bond of duty or obligation. That such bonds are an important aspect of organization in informal groups is pointed out by William Foote Whyte in his study of “corner boys” in Boston. He writes: “The structure to be observed is a product of past interactions. Out of these interactions there arises a system of mutual obligations which is fundamental to group cohesion. If the men are to carry on their activities as a unit there are many occasions when they must do favors for one another. Frequently one member must spend money to help another who does not have the money to participate in some of the group activities. This creates an obligation. If the situation is later reversed, the recipient is expected to help the man who gave him aid. The code of the corner boys requires him to help his friends when he can and to refrain from doing anything to harm them. When the life of the group runs smoothly, the mutual obligations binding members to one another are not explicitly recognized.”(Zl)

These networks of obligation give internal structure and solidarity to the group and form channels of social control. The leader avoids borrowing and favors from the other members, and takes care to put them under obligation to him. Something of this sort is undoubtedly characteristic of the A.A. groups. It has been noted that it is not uncommon for the sponsor to lend his protege money in order to help him straighten out his debts. There is no record of such a procedure on the part of members in any of the European institutions. At Ellikon the patient pays from one to two dollars per day. Am Steinhof and Kuron are apparently maintained from other sources, but at any rate, it is not probable that the patients have financial obligations to each other, or to the directors personally. But this is not the most important aspect of the network of obligations we should expect to find in an A.A. group. Let us hypothetically construct the network of obligations centering on a typical member. (See Fig. 1) The method of entry into the group practically guarantees that each member is under obligation to at least one other for such reform of himself as he has been able to accomplish. If he has followed the pattern of the group, he has recruited one or more other alcoholics who are in turn under obligation to him. Further, his relationship to those whom he has brought into the group is strengthened by the expectation of each of his converts that he, who persuaded them that the program would work, will remain abstinent. He is, in fact, under obligation to each of these converts because of their dependence upon him. If he fails in his example to them, they may fail also. His failure cannot be a matter of purely personal concern, but involves the repudiation of accepted obligations. The success of each is to a peculiarly high degree contingent upon the success of the others in the group. The effect of this mutual dependence would certainly be an important factor in the degree of solidarity obtained. In both the A.A. groups and the European groups, friendships and personal attractions no doubt develop to complicate and increase the degree of solidarity. It is important to note, however, that

these would be more or less random in the European groups, that is they might or might not appear. The particular method of induction of A . A . members adds to these random attractions an habitual network of personal relations made up of obligations, friendships and other personal influences. The network insures that each person is a focal point of strong inter-personal relations. The contrast of the two types of group structure may be illustrated by diagrams:

I J

1. Alcoholics Anonymous 2. European Groups

In the first case (1), the habitual relation between members is that of “friend to friend,” “helper to dependent,” sponsor to protege , II “moral example to struggling convert,” and each person plays not only one of these roles, but both in relation to different persons in the group. The lines represent the inter-personal relations through which each member initiates and responds to controlling activity. In the second case (2) the habitual relation is primarily “doctor to patient.” The alcoholic never initiates controlling activity. The fundamental difference between them seems to be that the first type provides a structural framework in which each member has the opportunity to act as moral authority toward others who are acting as moral dependents, whereas in the second type, he is confined to the status of the moral dependent as “patients.” To be recognized and respected are strong supports to motivation, needed by the patient more than by the doctor. The structure of A . A . groups exploits this Pact; the structure of the ~uropean group does not.

The framework of relations is not complete within the group however. The A.A.Is work consistently at reforming other alcoholics. We may say that the group is driven to act upon the unorganized out-group of unreformed alcoholics, who, with their difficulties, their uncontrolled drinking, their socially disapproved role, epitomize those things which group members are reacting against. The addicted out-group is a group of “scapegoatsw and by acting upon them (even though kindly) the A.A. group can increase its solidarity. By contrast, the behavior of the groups is restricted to that of total abstinence with no hope of ever being able to be a “normal” or usocialn drinker. The role of social drinker is widely approved in our society, connected as it is with so many contexts of good fellowship, social celebration and social communion. This permissible type of behavior is undoubtedly a factor which operates to channelize neurotic deviations in the direction of alcoholic addiction. By drinking in the approved contexts and creating excusable occasions the incipent addict can for some time conceal from others, and even from himself, his actual state of dependence upon alcohol. Indeed, it tends to be only when the incipient addict can no longer confine his drinking to the approved social contexts, but drinks on the job, early in the morning to “brace himselfu when the social occasion is over, or alone as a “solitary drinker,” that he becomes defined as a “drunkard.” In our society the line is vague and ambiguous – the limits to this behavior are not adequate to the needs of the addict who is struggling to reform himself. The needed repudiation of all performance of social drinking, the mobilization of behavior in terms of total abstinence and the provision of activity outlets to take the place of drinking are all insured by the organization of the A.A. groups. Thus a good deal is seen to depend upon the apparently simple expedient of converting other alcoholics. It seems logical that this one factor, unique to Alcoholics Anonymous, provides the framework of behavior which ,makes for a higher degree of solidarity than we would expect to find in the European groups. But something yet more specific can be said about the peculiar way in which this framework may fit the needs of the alcohol addict.

In the light of the foregoing analysis, the following incidental remarks of Chambers and Strecker assume a new significance: “One of the authors has an amusing collection of alcoholic dreams which have been brought to him. They are all dreams in which the therapist has become intoxicated in the most bizarre and degrading fashion. It is interesting to note in these dreams that the dreamer usually remains sober, devoting his full time and thoughtful care to the drunken image of the therapist.” Dream interpretation is a dangerous field for a priori theorizing, but the fact that such dreams have appeared repeatedly in different addicts strongly suggests that there is a need on some level of generality to take such a role in overt activity. In other words, a nurturing mothering, protective, benevolent, morally ascendant type of behavior toward someone who needs care, guidance, and protection would provide emotional satisfactions to the addict, and such a dream provides the rationalization of this need. Superfically it would seem that such a desire stands in direct contrast with the personality pattern of “dependencew which has been discovered by a number of investigators. The structure of the families of a good many male alcohol addicts seems to be rather similar in broad outlines. These similarities may be discussed in the same terms employed for the previous examination of the structure of the A.A. group. Let us consider first the degree and direction of “identification.” In his study of 100 male alcoholics Wall found that 37 of the men had a striking uniformity in type of mother: “These typical mothers were inclined to have an exaggerated emotional attitude which manifested itself in spoiling, pampering, indulging and overprotecting their sons, the patients… and out of this situation there developed a feminine identification, a dynamic factor of determined force in leading to a feminine approach to life as observed in these unfortunate individuals. There lack of masculine security and agression was obvious, oftentimes portrayed in a dramatized beaten attitude toward life in general. They were envious of successful males

in their families and frequently admitted feelings of inferiority.”(22) Such a feminine identification, also emphasized by Chassell(23) and Moore(24), is a crucial handicap in later adjustments to the demands of the male occupational and sexual roles in our culture. It may be that the “homosexuality” so often mentioned as a characteristic of addicts traces in part to such conditioning.(25) This conditioning may, indeed, very well have something to do with the conspicuously higher rates of alcoholism and suicide among males, by increasing their difficulties in fitting into adult male roles. Tillotson and Fleming found that two-thirds of their 100 patients showed a strong maternal attachment as against one third with a strong paternal attachment. By follow-up studies they found that “male patients who gave evidence of strong paternal attachment were four times as frequent in the recovered group as in the unrecovered.”(26) “IdentificationM of the son with the mother which implies an over-active adjustment in their relationship does not necessarily presuppose solidarity in other respects. One of the most frequent findings of those who have made special studies of family relationships of alcohol addicts is a condition in which it is almost impossible for the child to build up stable expectations. The mother may tend to be “neuroticu in handling her son: sometimes indulging him to excess, leading him to expect more attention, power, gratification than he will be able to realize in any other relation of adult life; and then without warning she may scold him, make excessive demands for obedience, punish him for faults he is not aware or guilty of, withdraw gratifications, and in many other ways subject him to intolerable disappointments. In such a case the child does not know what his behavior should be and can not plan on his mother living up to any set pattern of demand and reward. The other side of the picture shows us the mother in an intimate situation which, within peculiarly broad limits, she can define for the helpless child as she wishes. Her tendencies toward neurotic deviation may find a suitable outlet in manipulation of the child. She lives in the home situation in which she can compensate in a way congenial to her personal conflicts. Her neurotic tendencies, which otherwise might result in severe neurosis

can become channelized in the direction of emotional exploitation of her child and so alleviated and she may escape social disapproval by various skillful disguises. This possibility may have a great deal to with the conspicuously lower rates of alcoholism among females. But there are other crucial relations in which inconsistency of behavior may have lasting effects, discipline for example. Knight cites cases in which the mother tends to become an intercessor for the child with a father who is cold, inconsistent, and unpredictable. Whether it is the mother herself who treats the child inconsistently, or the father, or whether by sporadic intervention either one interferes with a constant discipline from the other, the stability of expectations so necessary for the security of the child is broken down. No exhaustive scheme of these types of situation and types of factors can be undertaken here. This much may be said, however, that statement of the problem in terms of the stability of expectations in the child’s relations to others seems to harmonize most of the conflicting claims in the literature which are stated in terms too specific to hold generally. For example, whether a child is an only child, a youngest child, or a middle child(27), does not of itself produce an automatic and predictable result, but rather becomes significant as it may result in lack of, or disappointment of legitimate expectations, so producing insecurity, anxiety, hostility, guilt, and the like. Mowrer’s conclusions point in this direction: “It would seem that ambiguity in role is what characterizes the alcoholic – a role in which his status is superior and assured in relation to some members of his family and uncertain and challenged in relation to others.”(28) The unstable character of the adjustment may exist at least between (a) one person and one other, (b) one person and each of two or more others, inconsistent with each other, (c) between one time and a later time with the same person(s), (d) between a habitual relation and a new relation into which the person makes a transition, and so on. The classification is by no means complete.

This means that specific hypotheses about the type of mother, the type of father, the typical ordinal position among siblings, the typical effect of “broken homes,” the typical effect of transition from childhood to adult status, etc., are all likely to yeild unsatisfactory generalizations because they do not generalize in the proper direction. They fail to pay enough attention to the meaning of the situation for the child. They depend too much on assumptions which are justified only if crucial adjustment factors involved are the same everywhere. This cannot always be assumed. The uniformities which do appear, (and some do) should be examined in each case to determine the necessary accompanying structural background of the situation so that proper qualifications can be made. The feminine identification mentioned earlier seems to be such a uniformity holding for a considerable number of cases, though by no means all. The uniformity which does exist is very likely dependent upon the sexual division of labour in our culture by which women care for children to the exclusion of the father, who is away at work. Also inherent in our culture is the necessity of an abrupt transition from childhood to adulthood.(29) It is against this background that the “dependency patternu discovered repeatedly, in different specific forms, should be viewed. “Dependencyn is a very general term, broad enough to include a number of different types. The child, and the “adultw which he becomes, may be dependent upon one or both parents for his decisions, for ecomonic support, for attention, recognition and affection; yet, he also learns to respond to the type of disapproval, punishment, which goes with it and which he comes to expect. Alcohol apparently takes a very involved place in this structure of interpersonal relations: a means of restoring infantile states of satisfaction, of escaping adult responsibilities, of escaping decisions, of agressing or revolting against parents, of calling down disapproval, of self-punishment, of escape from intolerable tensions, and so on ad infinitum. The fact that alcoholic intoxication has a social effect, as well as physiological and psychological ones makes it an effective outlet. There are thus

many variations and complications which must be analyzed in each particular case, but insofar as they may be intimately tied up with preservation or reinstatement of some emotional significant aspect of the childhood relationships they may be summed up conveniently as “dependency patterns.” Accepting the dependency pattern in its various complications as characteristic of at least a large portion of alcohol addicts in our culture, the question may be asked again: is not the desire to nurture or mother (indicated by Chambersf and Strecker’s dream material) at variance with the dependency pattern? Not necessarily. The two may very well be included within the same personality. The hypothesis to which this discussion has been leading is precisely that the presence of ambivalent, conflicting, or contrasting behavior in the same personality is to be expected. When (1) in the learning situation the relation between the child and mother is prolonged and emotionally intense, and (2) the relation involves behavior (such of the extreme dominance – submission, punisher – punished, moral authority – moral delinquent, protector protected types), and/or (3) there is such a contrast between the relation of the child with one person, the mother for example, and his relation with another the father perhaps. (These types of situations are emphasized, though others are important as noted above. ) This hypothesis rests partly on logical grounds, partly on observation. It states nothing particularly new. Many students of personality, including Royce, James, Baldwin, Cooley, Mead, and Freud as notable examples have held that the personality can be permanently modified by the emvironment. An adequate review of these theories cannot be undertaken here, but the clear implication is that the ideas, sentiments and activity patterns of others condition the individual’s personality. One may assume further – and it is here that the hypothesis becomes significant in the present context – that these learned activity patterns are not simply “falloww parts of the personality, called into a reflected existence when the person is in interaction with the other from whom he takes the patterns over, but that they are active tendencies which press

for expression and exercise when the person responsible is not present. According to this hypothesis, we would expect this conflict behavior which took place between an over-dominant, over-protective mother and her child to become habitual in the personality of the child. That is, he would not only react to her dominance by submissiveness, and her protection by dependence, but also would tend to be over-dominant and over-protective toward her when possible and toward other suitable persons when she was away. And the conflict between these action patterns would appear as a conflict of tendencies within himself in the absence of suitable persons toward which he could act one way or the other. We would expect however, that his own dependent role would be more pronounced, and would be maintained in overt form so long as the relation to the mother or suitable substitute existed in his life situation. Once the alcoholic addiction becomes the specific means of adjustment to this conflict in interpersonal relations, we would expect it to remain a tenacious reaction so long as the type of situation remained the same. It seems to be true that pleading, preaching, reproaching, protecting, shaming, and all other techniques commonly resorted to by the family have no lasting effect in reforming the confirmed addict. There is every reason to expect this tenacity if the alcoholic resort has arisen within this situation in the first place as a necessary adjustment to it. Intensification of the precipitating pressures would only tend to reinforce the adjusting technique. If this is the case, what are the possibilities of reform? Logically we might suppose that a major change in the personality brought about through disorganization of some kind and re-integration into a new situational pattern might accomplish the desired result. This sometimes takes place in radical religious conversion. If the pattern is deep-seated, however, the possibilities of a major reorganization of this kind seem quite remote. One alternative remains. A reversal of roles in another relationship where the pattern is basically the same would seem to

offer a chance for the obverse type of behavior to become overt. It is exactly here that the framework provided by an A.A. group becomes significant. The alcoholic integrated in such a group is enabled to behave in a morally ascendant, protective, mothering way toward another who in turn behaves as he once did. He is at the focal point of obligations he himself has initiated. The conflict within him is externalized as a conflict between himself and a scape-goat with whom he can adjust. The dependency pattern is not eliminated, but his own behavior is no longer overtly the dependent one. This may not be an ideal solution – probably it is an unstable adjustment – but is is dynamic, leading to activity which creates new personality elements; and it is practical. Until we are able to attack the problem of alcohol addiction at its roots by community reorganization the program of Alcoholics Anonymous is certainly worth wider application.

Bibliography

1. Alexander, Jack, “Alcoholics Anonymous,” The Saturday Evening Post, March 1, 1941. 2. Cf. Wall,J.H., “A Study of Alcoholism in Men,” Amer. J. Psychiat, 92, 1389-1401.

3. Alexander, Op. Cit., P.lO.

5. Ibid., p. 11.

6. Fleming, Robert, M.D., “The Management of Chronic Alcoholism in England, Scandinavia, and Central Europe,” New England J. of Medicine, 216, 279-289, Feb. 18, 1937. 7. Physical well-being seems to be a sine qua non upon which the therapeutic programs to be analyzed are essentially alike in their insistence and technique, hence no further mention of this very important factor will be made. 8. Alexander, Op. Cit., p. 90.

9. Ibid., P. 92.

10. There may be many, of course, including the complex fact that the program simply makes up a more adequate totality, or that it employs a unique combination of measures, or that the persons who administer the programs are more efficient for one reason or another, but these factors would be difficult if not impossible to determine. Attention will therefore be confined to facts more easily determined from published information. 11. Fleming, Op. Cit., P. 283. 12. Ibid., p. 287-288. 13. Quoted by Seliger, R.V. “The Problem of the Alcoholic in the Community,” Amer. J. of Psychiat., 95, 701-716. Forel1s article: “The Alcohol Question,” Amer. J. of Insanity, 57: 297, (Oct., 1900). 14. Ibid. 15. Fleming, R., “The Treatment of Chronic Alcoholism,” New England J of Medicine, (1937), 217: 779-783. 16. Alexander, Op. Cit., p. 11. 17. Fleming, R., “The Management of Chronic Alcoholism in England, Scandinavia, and Central Europe,” p. 206. 18. Ibid., P. 288. 19. Miles, Walter, R., l’PsychologicalFactors in Alcoholism,” Mental Hygiene, XXI, (October, 1937), p.529. 20. Fleming, R., “The Treatment of Alcoholism.” 21. “Corner Boys: A Study of Clique Behavior,” Amer. J. of Sociology, (March 1941) V., 647-664. 22. Chambers and Strecker, Alcohol. One man’s Meat, New York: Op. Cit., pp. 1389-1391. Macmillian, 1938, p. 100. 23. Chassell, Joseph, “Family Constellation in the Etiology of Essential Alcoholism, Psychiatry (1938) 1: 473-503. 24. Moore , Merrill, M.D., uAlcoholism, Some ‘Causes1 and Treatmentsrw The J. of the Tennesseee State Medical Association, XXXV, (January 1942) pp. 3-12.

25. Cf. “latent heterosexuality” in Chambers and Strecker, Alcohol, One Man’s Meat, New York: Macmillian, 1938, p.82 & 112. 26. Tillotson, K.J. and Fleming, R., “Personality and Sociological Factors in the Prognosis and Treatment of Chronic Alcoholism,” New England J of Medicine, 217: (1937) 611-615.

27. Regarding ordinal position among siblings, cf. Strecker and Chambers (Op. Cit., p. 82) who find a preponderance of only and youngest children; Mowrer,B.C. (“A Psycho-Cultural Analysis of the alcoholic^^), American Sociological Review, V, (1940 546-557) who find clusterings around the next to oldest, youngest, and next to youngest; Wittman, M.P. (Developmental Characteristics and Personalities of Alcoholicsw) J. Abn. and Soc. Psy. XXXIV (1939) 361-378, who attacks the emphasis on youngest and only children, and Knight, R.P., “Psychodynamics of Chronic Alcoholism,” J. of Nervous and Mental Diseases, 86: (1937) 538-548, who finds “nothing specific at all about sibling position.” 28. Mowrer, Op. Cit.

29. Cf. Benedict, Ruth, “Continuities and Discontinuities in Cultural Conditioning,” Psychiatry, I (1938) pp. 161-167.