February 1954

rective 11~syet been found and so- tion in personality; untruthfulness in called “cures” are merely aids to keep- regard to alcohol consumption tends ing the patient abstinent. An addict to invade other spheres of life; the may ncver again be a moderate drink- addict becomes unreliable, inefficient, er. 011ce addiction has been estab- Imastful or secretive. The inevitable lished,. the patient presents some or personal, social and economic sepelrle all of the following clinical character- of this personality change are familiar. THE TREATMENT istics. By the time intellectual deterioration, H e drinks secretly, urgently and un- psychotic reactions and physical diseasily; he repeatedly drinks more than order have been reached, the progno- OF ALCOHOLISM* he intends; he drinks because he must, sis is usually hopeless. Sometimes the not because he wants to; earlier boasts story is not onc of uninterrupted de- By J. N. P. MOORE, M.D.,F.R.C.P.I., D.P.M. about his capacity tend to be replaced terioration, and long periods of so- Medical Superittteadent, St. Putrirk’s Hospital, Dublin by subterfuges to minimize the amount briety are interspersed between bouts he drinks. Almost invariably the fa- of addictive drinking. These bouts miliar pattern follows: lies, excuses, tend to become longer and more fremorning “cures,” “blackouts,” hidden quent and the final stages are much “cacl~es.” The most sinister feature of the same as when the illness is steadily the illness is a progressive detcriora- progressive from the beginning.

of people habitually otliers fails in their twcntics. What- THE P S Y C H O L O G I C A L A P P R O A C H A drinksvariety WIDE to excess–the tired busi- ever the psychologicid disharmony 111 treating alcoholism, the first es- and self-disgust, is easily rlrivcn to nessman, the over-wrought profes- which leads an individual to use al- sential from the psychological point of further excesses by such reproaches. sional man, the convivial adolescent, cohol as a drug in excessive doses, view is a correct attitude of mind in The threats of physical catastrophes the inadequate ne’er-do-well, frustrat- once the constitutional barrier has both doctor and patient. may be welcomed as a way of escape ed men and women from every walk broken down, the patient is in the The doctor-Even it one is intel- from undesirable reality. of life, and some in whom this is the grip of a progressive disease over lectually convinced that alcoholism is If one is to treat alcoholism successonly obvious symptom of an inner which he has a swiftly declining con- a disease and that the addict is a sick fully it is necessary to feel as well as disharmony. All these people have in trol. man, the emotional reaction of most believe that the patient is ill. T o excommon a desire to escape unpleasant The physical basis of addiction is doctors, like most laymen, tends to be tend sympathy and understanding to reality. Alcohol is the medium which an irreversible process. Once the tinged with a certain amount of im- an alcoholic, at first requires a conenables them t o view the world in a change has taken place, even a small patience and sometimes it is one of scious effort. The practitioner who rosier light. Some of these heavy quantity of alcohol after many years ill-concealed contempt. Too often the bristles with righteous iridignation and drinkers will in time become addicts. of abstinence will re-awaken a physio- rcproachcs of the patient’s family and upbraids and exhorts his patient does The age of onset of addiction and the logical craving and r’esult in a relapse. friends arc repeated by his doctor, as much:harm as his more urbane colextent of over-indulgence necessary to It follows from what has been said who lends the weight of his authori- league u h o evades the issue and tells produce it are probably determined that there can be no cure for alco- tative position to threaten the patient his patirpIt “to ease up,” cut out spirby constitutional factors. Some can holism until a physiological corrective with the dire req~delue,both physical its,” “stick to beer,” “nothing before drink heavily for a lifetime without has been found for the underlying and mental, of his continued intcm- six.” Addiction is a chronic illness and hecominp; addicted; the resistance of metabolic disturbance. N o such cor- prance. The patient, already fully treatment must be on a long-term aware of his failure, ladcn with guilt basis. Tiding the patient over a drink- * Abridged, w i / b )ermirrion. Jronr The Prar/i/inner, Sept. 1953, Lotrrlotr. Eag1,rtr.i. -.

ing bout is only the bcginn~ng, al- Iic sliould v~sitregularly. and unemotional way, thc patient will movement has a strong appeal for the though often a useful one, because the Doctors should be slow to prescribe often respond with confidence and co- extrovert and tlie fellowship of this state of remorsc following such an alcohol to a neurotic patient; it is a operation. In the case of the uncon- group replaces tlie conviviality and episode may malie the patient more dangerous drug in most neuroses. It is vinced and unwilling patient it may friendly atmosphere of the ” p u b or receptive to information about his ill- especially inadvisable to encourage a be wiser, when explanations have bcen club. The kind of metamorphosis t ness. Much can be done by the prac- tcetotaller to drink, since ahstmcnce given, not to try and insist on treat- which can take place in a personality titioner who is prepared to take the may be an unconscious defensc gain st ment but to encourage him to come under the influence of a religious contime and trouble to get his patient’s a constitutional predisposition to ad- back when he himself feels the need version is sometimes seen among the confidence, to give him an intellectual diction. 1 havc treated a nu111bc.r of of help. AA members. Their whole outlook . understanding of his addiction and to addicts who took aIcoliol in the first Alroholic~ A)wt~ynrorrs-The most and way of life change and their dehelp him to find new outlets for his instance on the advice of a doctor as important recent advance in the treat- sire to help other alcoholics bas a misemotional energy. Psychotherapy of a sedative, tonic or pick-me-up. ment of alcoholism has not been the sionary fervor. I make a practice cjf this kind is difkult and time-consum- The pa~ietjr-Until the patient re- discovery of any new wonder drug giving all my patients AA literature, ing, but the success of treatment often alizes that his drinking has got out of or cure, but the spread of a more en- encourage them to attend a meeting dcpcnds upon it. It cannot be replaced control and that he needs help to deal lightened attitude towards the prob- or, if they wish, arrange an introby any magic pill or injection, 11- with his problem, nothing in the way lem among both the medical profes- duction to a member of the organlzathough physical measurcs may make of curative treatment can bc attempted. sion and the general public. Novels, tion. its application easier. A patient brought to sce a doctor un- films, periodicals and articles in the Occasionally AA members who The treatment of the average alco- willingly, through force of circum- popular press have had as their theme havc become abstinent without medholic lies well within the scope of the slanccs such as domestic or financial the drunkard, his downward path and ical assistance decry the help which general practitioner, provided he un- crises or lcgal trouble, is unpromising his eventual curc. Although not a11 can be given by doctors and regard derstands the extent of the problem material. Efforts may be made to con- this propaganda has bccn enlightened, thc taking of “antabuse” tablets as and is willing to devote himself to its vincc liim of his need by explaining on the whole it has been good and evidence of lack of faith in the AA solution. He’ is in a position to spot some of the characteristics of addic- in the main the alcoholic has been program. Such an attitude is to be the incipient addict among his pa- tion. An explanatory talk sucli as one depicted as a sick person for whom deplored. It is important that there tients at a stage when friendly advice miglit give to patient suffering from treatment is possible, rather than a should be close cooperation between and information may still be success- a physical ailment is a useful begin- figure of fun, an object of ridicule practitioners and their local AA group ful. H e may influence the patient in- ning. The analogy of some physical or a creature to be upbraided and so that no such dissension should directly by teaching his family that illness, e.g. diabetes, may be used– despised. interfere with their common objective. their relative is ill and in nced of the tlic diabctic may be healthy and happy In this respect, the work of the Although not every alcoholic is atsympathy and care which they would if he sticks to his insulin and avoids Alcoholics Anonymous organization tracted by the AA program, those who normally extend to a sick person. The certain foods; the alr.holic, if he which has spread rapidly throughout do join the group find the activities education of the relatives is a nec- ;woitls alcohol and adjusts himself to the world in recent years, has done of the organization of very.great help, cessary part of the treatment of every living contentedly without it. This an immense amount of good. This is and the practitioner finds that he is case of alcoholism. In most cases the first interview is of vital importance an association of people who have in often relieved of some of the timespecialized physical aids to treatment and may determine whether the pa- common the fact that they are alco- consuming burden of a dependent are better arried out in hospital, but tient cooperates in trcatmcnt or is holics and wish to remain abstinent. patient. when the patient returns to ordinary driven to further excesses. If all sug- The rules of the organization are The psychialrilr-When the patient life again he is fortunate if he has the gcstion of disparagement and reproach sound and, although non-sectarian, has achieved abstinence a d has resupport and guidance of a sympathetic is kept from the conversation, and ex- they stress the help which mny be covered from the physical effects oP and understanding physician, whom planations are given in an objective obtained from spiritual sources. The his drinking, it may be necessary to

explorc thr psychological disharmony interest in life which will effectively employed to make the patient absti- seen any untoward results such as dewhich, in the first instance, made him guard against relapse. When addiction ncnt. Alcohol should be stopped at lirium tremens follow immediate withdrink to excess. In relatively stable has developed on the basis of a deep- once cxcept in the presence of grave drawal and it is much quicker and personalities who have developed their seated neurosis or psychosis, psychia- physical disability, such as cardiac easier for the patient than a tedious addiction largely as a reaction to cir- trict treatment should follow the failure or pneumonia. I have never tapering off. cumstances or environmental factors initial measures, and the ultimate which are alterable, little in the way prognosis will dcpend upon its effccof specialized psychological treatment tiveness. Jn my experience, only a minority ANTABUSE, “AVERSION TECHNIQUES, HORMONE THERAPY is necessary. With simple advice and guidance, the patient himself will find of caws require such specialized treat- I have found “antabuse” of great workers and a variety of techniques new outlets for his energies and new ment. value in the cooperative addict who has been evolvcd. The aim is to estabwishes to remain abstinent but who lish a conditioned reflex so that the PHYSICAL METHODS is prone to relapse impulsively in a sight, taste and smell of alcohol acting moment of tension or in convivial as the conditioned stimulus will in- In most cases when the patient other alcoholics. In hospital, one usu- duce nausea and distaste. company. Such patients often feel comes to a doctor he is still drink- ally finds they gravitate to one another, happy in the knowledge that they can- The emotional state accompanying ing. Treatment must therefore have discuss their symptoms, compare notes, not drink because they have taken thc the hardships of the treatment seems . a two-fold objective-the usc of some find they are not alone in their ex- drug. They need no longer live in to satisfy an unconscious desire for physical method to achieve immediate periences and often form lasting and constant dread of a momentary im- punishment in some guilt-laden adand complete abstinence, as well as valuable friendships. The insight pulse. Alcoholics who arc basically dicts. After such an ordeal a patient the employment of some psychological gained in these talks may achieve more psychopathic personalities will not may feel a sense of achievement and a p p m c h which will elicit the patient’s for the patient than anything his doc- continue the drug; those who are be able to refer to his “cure” with cooperation and later enable him to re- tor can do for him. basically psychotic should not be given pride. main a content abstainer. Early cases who can stop drinking it. Its use is thercfore limited to the Results so far do not encourage If the patient is unable to stop temporarily of their own accord may most favorable therapeutic group. the earlier hope that hormone drinking even temporarily by h’IS own be treated as out-patients. Although The principle of the conditioned re- therapy will alter the physical basis of. unaided effort, then he must be ad- these patients are apparently the most flex as a basis for the treatment of alcoholism and enable the addict to mitted to some form of institution, favorable type for treatment, results alcoholism has attracted a number of become a normal drinker again. preferably one which specializes in the are sometimes disappointing and, in treatment of alcoholism, whether it my own experience, many of them be a nursing home, general hospital relapse and eventually require to enter or mental hospital. In many cases, hospital. It almost seems as if in many SUMMARY entering a mental hospital or psychi- cases the psychological surrender in- Over-indulgence in alcohol will of the doctor and some-insight on atric clinic as a voluntary patient is a volved in admitting defeat to the ex- sooner or later lead to addiction in thc part of the patient are prerequiworthwhile procedure. Provided the tent of entering hospital and putting those constitutionally predisposed. sites of successful therapy. alcoholic is not allowed to mix with himself entirely in the hands of his There is probably an irreversible The medical profession should enchronic cues, and provided he is therapist is a neccssafy emotional ex- physical basis for addiction. courage intelligent propaganda about treated with sympathy and under- The addict is incurable in that hc alcoholism and show a sympathetic instanding, the regimen of a well-run ,nerience before the ~ a t i e n tcan achieve I

true insight and lasting stability. can never drink again in moderation. terest in such movements a s Alcoholics mental- hospital is well adapted to the So-called “cures” aim at making the Anonymous. management of an alcoholic. Certainly On admission to hospital, there is patient a contented teetotaler. When a patient stops drinking, the an alcoholic is best treated along with a variety of techniques which may be An enlightened attitude on the part initial disharmony which led to his

ovcr-iaclulpcnce [nay nccd expert ncccssary to initiate treatment which trc~tmcntby a psychiatrist. sliould be continued undcr the supcr- Admission to 1rospit;d is often vision of tlic practitioner.