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Source: 1975 Denver International Convention – 1975 Denver Int Conv. AA and Hospitals Panel with Jerry D, Dr Samuel Kaim, Dr NJ Bradley Part 1 of 2.mp3 File: 1975-denver-international-convention-1975-denver-int-conv-aa-and-hospitals-panel-with-jerry-d-dr-samuel-kaim-dr-nj-bradley-part-1-of-2.mp3 Duration: 00:57:45
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Thank you, June. Can you all hear comfortably in the back of the room? Thank you. My name is Jerry. I am an alcoholic. This is on AA and hospitals. We have two distinguished doctors and we have a member of AA, a lady here, who will be talking to us. And if time permits at the end and perhaps we will have a little opportunity for questions to the two doctors. Our first medical expert on this subject is Dr. Samuel Cain. The doctor was director of VA's Alcohol and Drug Dependent Service and he is currently vice president for medical relations, National Pharmaceutical Council, Washington, D.C. And here is Dr. Cain.
Thank you very much. I too expected perhaps a couple dozen people at this panel. I am amazed at the size of the audience and I hope that we can get this all together. Can you all hear me in the back? In a way, the theme of this session has a particular significance in the history of AA. I know some of this is going to be old hat to you, but in researching this topic, I did go back into some of the old AA things and found them amazing and very encouraging. And I'm going to tell you some things that you probably already know, but they did gratify me so that I'm afraid I'm going to have to repeat some of this AA material. Forty years ago, a stockbroker was struggling desperately to conquer his chronic and devastating addiction to alcohol. He had sought help from physicians, but to no avail. In 1934, a friend told him how he had achieved success in his fight against alcoholism through a new approach based on the principles of an English religious program, the Oxford Movement. The broker, Bill, who had long been without any religious affiliation, did not accept this religious approach and continued drinking. However, his friend persisted and visited Bill while the latter was hospitalized for delirium tremens.
During the period of convalescence in the hospital, Bill was at his lowest, without hope for the future, feeling powerless to help himself. He felt defeated, unable to recover on his own. At this point, Bill's friend's program seemed to offer him his last chance at improvement. The principles of the Oxford Movement included the following steps. One, the admission of powerlessness to solve one's own problems, examination of one's conscience and the decision to be honest with oneself. Three, taking an inventory of one's personal defects and the admission that they exist. Four, realization that one had had poor interpersonal relationships and had harassed many people, deciding to visit them and make restitution.
Five, helping others without any hope of personal gain, although one appeared to benefit from helping others. And six, by meditation to seek help from God and to practice these principles all one's life. In the hospital, Bill had already taken the first step and had begun to feel better. As he practiced the other steps, he improved further. Bill now felt he must start to work with other alcoholics to attempt to help them as he had been helped. In his search to find alcoholics to help, Bill was directed to a physician with a severe drinking problem.
The program appealed to him, and Dr. Bob and Bill then sought out another alcoholic to whom to offer their help. Again, it was a hospitalized alcoholic who responded to the program. After Bill and Dr. Bob found their method had succeeded, not only in their own cases, but also in that of the third man,
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they felt that the program might work to help others in groups, and this was the birth of the AA. The significance of this account of the founding of AA to the theme of this panel is the fact that two of the first three successful AA cases were hospitalized when they began their successful efforts in AA. I have found that this holds equally true today. When I founded the first Nationwide Alcoholism Treatment Service in the Veterans Administration, I encouraged our hospitals to invite AA chapters to meet in the hospitals. The alcoholic patient recovering from delirium tremens or any of the other numerous other serious sequelae of alcoholism is at a particularly advantageous stage to be reached by AA. Unfortunately, too many hospitals see their mission accomplished when the alcoholic recovers from his acute period of illness.
They discharge him with no thought of referral to a rehabilitation agency or AA, and when the discharged alcoholic inevitably returns with a recurrence of his alcoholic illness, the hospital, which failed in its duty to attempt to prevent relapse, blames the alcoholic for his not having learned his lesson and reverting to drink. In some instances, another factor than neglect may enter into the failure of the hospital to invite the AA into its walls to start the process of rehabilitation. Many AA members find no need for professionals in the rehabilitation process, with the exception of medical care for the physical and psychiatric complications of alcohol abuse.
This attitude may lead to a mutual distrust between a local AA chapter and the hospital, as well as other community professional services. I have personally witnessed this type of conflict between AA chapters and some of the VA hospitals. I am pleased to report that over the years, this type of antagonism has largely faded from the VA scene. Most AA members now accept the need for supplementary help from professionals, and many more physicians welcome the resource of AA for their alcoholic patients. The acceptance of AA by professionals may even go too far.
The recognition of AA success is so widespread that the public and even health professionals may be tempted to delegate all responsibility for rehabilitation to the AA. I think most professionals would agree with Captain Ziska of the Alcohol Rehabilitation Clinic of the Long Beach, California Naval Station. He found a multidisciplinary program centered around AA the most useful, because many different aspects of the alcoholic's life need attention, and no one person is qualified in all fields. Ziska finds the AA especially applicable to the military, as it is an important social outlet for the serviceman and is available all over the world. Ziska says a major part of the recovering alcoholic's difficulty is the fact that he often does not know what to do with himself while on liberty. He formally headed for the nearest bar and returned when his liberty period expired. Now that he is beginning to become sober, he can make friends in AA, drink coffee with them, and socialize in a healthy way.
Through his association and identification with the members in AA, the alcoholic gradually loses his alienation, his rationalizations, and his maladjustment to life. At the St. Louis Detoxification Center, Pittman and Kendis find the recovery period from alcohol intoxication and withdrawal the ideal time to initiate rehabilitation efforts. They urge their patients to attend AA meetings as soon as they can ambulate. Ruth Fox cautions that referral to AA must be done by the personal contact of the professional with a member of AA, introducing the patient to him over the phone. She cites that AA relieves the patient of the need to prove he can drink. When he is in an all-drinking group, he tries again and again
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to prove that he is not different from his friends, only to meet with failure. In AA, the norm is not to drink. Much is made of the observation by many workers in the field of alcoholism that not all alcoholics accept AA. In a study at the Alcohol Rehabilitation Unit of the Spring Grove State Hospital in Baltimore, Curlin found that the frequency of AA attendance after hospitalization correlated positively with three personality features.
One, a strong attachment to group membership. Two, the capacity for serious introspection. And three, a willingness to face up to the problem and do something about it. Stein, Glass, Davis, and Berenson conducted a novel pilot treatment program at the NIAAA Laboratory for Alcohol Research designed to explore the efficacy of multiple complex group therapy techniques applied to alcohol families. The program consists of a six-week intensive treatment experience with a six-month follow-up. The innovative feature is the simultaneous ten-day in-hospital treatment of three couples, one or both members of which was alcoholic. Alcohol is made freely available for the first seven days of hospitalization in a simulated apartment-like setting. The couples are told to drink and behave as they usually do at home. The purpose of this in-hospital study… Well, you know, medical research is based on truth, and truth is where you find it.
The purpose of this in-hospital study is to provide the therapists with the unique opportunity to observe domestic interactions during periods of intoxication as well as sobriety. The authors used this experiment with a total of ten couples to employ videotaped self-confrontation techniques. They found this study to have important implications for current treatment approaches and especially for Al-Anon.
In a study of treatment results in an English mental hospital unit, Glott, Max Glott, outlines how follow-up was facilitated by contacts with the local AA chapters. Glott cites the widespread misconceptions which hamper progress in the field of alcoholism. He especially cites the description of alcoholics as psychopaths who do not really want to give up drinking. In Glott's experience, many alcoholics do behave like psychopaths when drinking.
Years of excess drinking may lead to secondary changes of attitudes and reactions, which may give the appearance of psychopathy. Glott's recovered alcoholics show no psychopathic characteristics after attaining sobriety, but have, on the contrary, been available in a very unselfish way when called upon to help fellow alcoholics. Glott encourages the formation of AA chapters based on hospital groups. He thinks such chapters would be especially useful in collaborating with hospitals in education of the public about alcoholism as a treatable condition, encouraging alcoholics to accept treatment at an earlier stage.
Many of Glott's discharged patients participate actively in their local AA chapters. Glott believes that the activity of medically and psychiatrically treated alcoholics within AA tends to counteract the feeling of some AA members that medicine and psychiatry have nothing to offer to the alcoholic, and that AA is all that an alcoholic needs to recover. When I visited Finland, members of the Alcohol Research Foundation, which is financed by the state alcohol monopoly, took me to visit one of the ten alcohol farm hospitals, which is funded by the government. The hospital I visited was one of seven voluntary stay places. The other three accept alcoholics committed by the social board. Patients pay a small fee. The average stay is two to three months. The director was a psychiatrist.
Two to three months. The director was a psychiatrist. A general practitioner came in part-time for
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physical problems. A psychologist did testing also part-time. Social workers and psychiatric nurses provided the bulk of professional services. Each is charged with the supervision of ten of the seventy patients in the hospital. There is very little drug treatment. Stress is on individual and group psychotherapy. The hospital I visited is an open institution. The patient may leave at any time. If he drinks, he may be discharged. Patients are given passes to seek employment, visit family, and incidentally to test their ability to abstain. The patients work the farm, help in maintenance, and use their work skills to take care of the kitchen, the shoe repair shop, the tailor shop, etc. They appear to respond better to purposeful work than to occupational therapy, which is also available. There are three clubs at the hospital, one for sports activities, one for religion, and one for A.A. The alumni of this farm hospital form A.A. chapters in their hometowns after discharge. Of 419 patients admitted in 1966, 10% were of the upper class, 25% of the middle class, 45% were skilled workers, and 20% were unskilled workers. Now Glatt admits that most of the alcoholics referred for treatment in English hospitals and also those joining A.A. have been members of the upper social classes. In Helsinki, Finland, apparently the opposite is true. The upper class alcoholic is treated in the city's A.Clinic, while the lower class alcoholic is referred to A.A. The A.A. manages a halfway house owned by the city. The 40 patients live in the house but leave for their jobs during the day. They pay for their board and lodging. The house has a home-like atmosphere with much social activity evenings and weekends. In contrast to the A.A. Clinic, the halfway house tolerates no drinking. One slip means discharge. As there is a long waiting list for admission, this is a strong deterrent to drinking. Kissam, in a study at the Kings County Addictive Disease Hospital, found that the patients who benefited most from the use of antabuse were older, socially stable, and either members of A.A.
or who had been sober when they came for treatment. The American literature provides evidence that the social structure of the A.A. reflects middle class goals, interactions, and biases. Social class tends to affect diagnostic considerations in hospitals in our country. Studies at Massachusetts General Hospital and at Duke and the B.A. Hospital at Durham, North Carolina, indicate that alcoholic patients were so diagnosed if they were of the lower social classes or appeared socially unstable, but tended to receive other diagnoses if they were of the middle or upper classes or appeared socially stable. This finding may account, at least in part, for the relatively poor prognosis assigned the patient labeled alcoholic in the hospital. He is the individual who is unemployed, maritally unstable, and in trouble with the law. These are the alcoholics who are also the most resistant to rehabilitation efforts. The employed, maritally stable, middle class patient who would be a good candidate for treatment of his alcoholism is not so diagnosed in the hospital, and thus receives symptomatic treatment only. These patients would also benefit by referral to A.A. It may well be that they do constitute the major portion of the population in industrial alcohol rehab programs and in A.A., and account for the high rate of success of both. Because of the wide variability in the way alcoholism is diagnosed, the National Council on Alcoholism established a committee in 1971 to prepare a set of criteria for the diagnosis of alcoholism.
I chair this committee, which invited input to its deliberations from sixty-five experts in the field of alcoholism. I believe Dr. Bradley was one of our experts. Is that right? That the product of this committee filled a real need is attested to by the fact that
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two major medical journals accepted it for simultaneous publication, a most unusual occurrence. In the publication of the article, the National Council on Alcoholism had to fill requests for some thirty thousand reprints, again witness to the need for firm criteria for the diagnosis of alcoholism. Shielding the alcoholic by the use of an evading diagnosis does him more harm than good, leading to postponement of treatment of his underlying condition, often until it may be too late to be effective. It also reinforces the alcoholic's denial process, which in turn interferes with his acceptance of A.A. In fact, hospitalization of the alcoholic for a medical complication may be the first step towards his rehabilitation if the diagnosis of alcoholism is honestly made and then leads to treatment and to the A.A. Thank you.
Thank you, Dr. Kamm. Our next medical expert is Dr. Nelson J. Bradley. Dr. Bradley started the alcoholism—louder? Better? Okay. I know some of you who are standing in the doorway have got a little bit of a problem. Now is that better? Okay. Coming. One, two, three, four, five. One, two, three, four, five. Okay, we'll see how it goes. Dr. Bradley started the alcoholism program in 1950 at the Wilmer State Hospital in Wilmer, Minnesota. Since 1960, he has been chairman of the Division of Psychiatry Alcoholism Rehabilitation Center, Lutheran General Hospital in Park Ridge, Illinois. We now welcome Dr. Bradley.
This is the second time I've been privileged to talk to this convention. Previously in 1960 in Long Beach, I followed Sister Bob's sponsor, and my speech was interrupted by Bill himself. Bill made a custom to go to all the meetings and say hello, and Bill's idea of hello was about 20 minutes. An intelligent person like myself, raised in a sophisticated society, you learn to assume that people that say hi, hello, smile at you, are at least people you know or have met or been introduced to, but around here, they last 12 hours. They don't even dare go in a restaurant here without some clown saying sit down. It's a beautiful thing, and I'm sure we're all sharing the same experience. Where we are at this point in time in the treatment of alcoholism is the subject of my talk. Dealing with what presents is essential to most of us in our working philosophies. In spite of easy does it, and one day at a time, however, most of us attach some significance to where we were and where we're going from here. It's difficult for me personally not to make the reflecting somewhat nostalgic. I was first involved professionally with an unrecovered alcoholic as far back as 1947. The involvement was not only because I was working in a hospital setting, but the secretary of my chief in this hospital happened to be a well-known recovered alcoholic. His drinking episodes had been legendary, and the miracle and caliber of his recovery became equally legendary. By 1950, when the responsibility of mounting a full-fledged alcohol treatment program per se in another state hospital presented itself,
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I had been thoroughly A.A. brainwashed. In actuality, Fred E. led me to believe there was really nowhere else to turn but the fellowship of A.A. The statewide A.A. became our model, our consultants, and our advisory board. They were eager to advise, but without fail backed their good counsel with an unbelievable energy and with a joyfulness and thoroughness that would move mountains. The only credit the professional can accept in such a situation was we were good listeners, and that quality is rare, and we were impressed. The combination of the offer of this simplistic enthusiasm and unselfish activity and the naive, possibly prophetic acceptance of this phenomena had a profound impact, and in fact the reverberations of which I would like to think are still active. We had also two well-established A.A. conceived, A.A. conducted treatment programs already operational in the state. They became a great source of inspiration and duplication. It wasn't until years later that we were aware that both Hazelden and Pioneer House had scarcely celebrated their first birthdays when we so brively accepted them as models of experience and skill. Just how far have we traveled and how dramatic have been the changes and improvements in the diagnosis, treatment, rehabilitation of the alcoholic from the early fifties to the mid-seventies is the approach I would like to present in talking about what I'm supposed to talk about, the medical model of the treatment of alcoholism. The understanding and management of the alcoholic or alcoholism is best accomplished at this point in time, 1975, in these six parameters. They're somewhat in the order of significance. Number one, alcoholism is the cytotoxic effect or the toxic effect on the body cells of the prolonged abuse of a toxic substance, ethyl alcohol. Two, the psychosocial impact of the phenomena of alcohol addiction on the individual and his environment. Three, the concomitant use and abuse of other chemicals. Four, the high incidence of medical emergency in the alcohol population. Five, the significant prevalence of psychiatric disability. And six, the complications of malnutrition. In 1950, we said the number one problem in alcoholism was the complications of malnutrition. As in other areas of science, there was more learned about the effect of the chemical ethyl alcohol on cell metabolism, cell function, cell structure in the 50s than had been known in all previous recorded time. This phenomena of accumulating new knowledge was duplicated in the 60s and I'm sure is in the process of being repeated in the 70s. The impact of this great amount of new knowledge concerning the effect of alcohol on the human body is, however, subject to concerned conjecture. It has certainly made the diagnosis of alcoholism much more scientific and accurate, but it always was an easy diagnosis to make. It certainly has modified our treatment routines, but not in any startling or remarkable way. How much of our treatment goals changed?
The well-informed physician today who is treating chronic brain syndrome, hepatitis, cirrhosis, portal hypertension, pancreatitis, is very dry, but not any drier than implied in the old adage, one drink is one too many and a thousand is not enough. How much impact has this new information had on the individual, on the attitude of our society towards drinking, on our social systems, the health, the legal, the legislative? We ask these questions in the 50s and we ask how can any culture deny so specific, so immense a problem as alcoholism and be fully aware it's doing so and that it has been doing so as far back as recorded time. Deny so specific, so immense a problem as alcoholism and be fully aware it's doing so and that it has been doing so as far back as recorded time. A great deal…
A great deal of the same antipathy, negativism, and confusion of the fifties still prevails
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in most of the existing structure of our society in the seventies. We just camouflage our denial of the scar in more modern and presently acceptable ways. All of the major disciplines now in our culture not only acknowledge but advertise their acceptance of the disease concept. This to me seems to make their inaction all the more deceitful and all the more confusing. Some alcohol treatment programs are now reporting recovery rates of 70, 75, even 80 percent. These astronomic figures are even better documented than our old 20, 30 percent recovery rates. These types of successful rehabilitation programs invariably include at least a successful progressive industrial empire, a reputable alcohol treatment center, an active coordinated AA program with both paid and voluntary energy, plus a comprehensive health plan negotiated by the company with their health carrier. There's nothing anonymous or coy about these programs. The industry is usually anxious to demonstrate to the public and to the unions their great concern for their employees' welfare. Most treatment centers have some ambitious soul who is anxious to publish, and the news media are now competing for stories. The health carrier has valuable ammunition for his sales brochure. I will admit there's been more activity and more progress made in this area probably than any other aspect of the alcohol field. But in our free competitive society it does not really impress one on just how contagious success can be.
We have the comedy or tragedy of the federal government pushing alcohol legislation, much to our delight, with great energy, while their own sponsored alcohol programs are treacherously financed. Today the federal employee, from a fiscal standpoint, is never welcome in any self-supporting alcohol program. Medicare, armed services, public aid, federal employees would all have to be, from the standpoint of health coverage, considered second-rate citizens and at best a nuisance. The psychosocial impact on the individual of of alcohol addiction is really the ballpark we've been playing in in the last 25 or 30 years.
What new knowledge has added to this arena is also subject to conjecture. It's my impression that it actually has just divided the camps further into those of whom the phenomena of addiction and Jelinek's 44 steps always were a very real and therefore vulnerable and modifiable phenomenon, and those who have a great scientific need and an urge to question the ability of anyone to change or modify any kind of behavior.
The millions of sick alcoholics have made it difficult over the years, because of their large numbers, to even compare them to a problem, to other problems equally serious but much less frequent. When you think of the alcoholic in terms of an addiction, with all his fellow travelers, the food addict, the cigarette addict, the work addict, the gambling addict, the sedative addict, tranquilizer, analgesic, mood elevator, narcotic addict, etc., means that the alcohol addict is in turn almost lost in the vast estimates of these seriously affected people, sufficient to say that the studied pessimism towards these areas of concern, obesity, cigarettes, sedatives, gambling, the useful drug abuser, is not going to be changed by recrimination or isolation or by the most diligent application of any specific professional skill known to us at this time. The only real and significant hope for these entities will be a program of total involvement of the whole person, as exemplified by the 12-step and 12-tradition approach to the disease alcohol addiction.
The most significant drug abused by alcoholics is, of course, the cigarette. Repeated surveys of hospital alcohol populations show at least 90% smoke and about 60% smoke over
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30 cigarettes a day. We were concerned in the early 50s with a double problem, and by this we were primarily referring to the short-acting barbiturates, seconal and nembutal. There was some problem of garbage drugs at that time, such as terpenhydrate and codeine, paragloric, pyraldehyde, amphetamines, etc. We have in our time seen a minor epidemic of milltown abuse. We are now using 5 billion valium and libriums a year.
Alcoholics always get a new pet among the garbage drugs. Darvon, doradine, chloral, etc. The adolescent alcoholic has become seriously contaminated with mood elevators, hallucinogens, and even in part the hard narcotics. The alcohol patient, and even the AA community, continues to promiscuously consort with such acceptable but treacherous fellow travelers as gambling, cigarettes, aspirin, and work.
The high incidence of emergencies, medical, surgical, psychiatric, continue to play a significant role in any comprehensive approach to the alcohol program. I'll not burden you with these awful statistics, and I think we've all shared the same crisis situations that result from these emergencies. It is one area where professional intervention has always played a significant and not too ineffective role. The tragedy over the years has been that after so dramatically intervening, and in many cases successfully, the alcohol victim was not then projected into a long-term rehabilitation program if it had been, in fact, available. Being so very much more available now, we are still too often amiss in these referrals, and it seems that so much more inexcusable today.
We like to say in the 50s that alcoholism was a defense against psychiatric illness. By psychiatric illness, we mean the official classification of mental illness, the psychosis, some of the classic neuroses, hysteria, obsessive-compulsive, the various psychosomatic illnesses, personality and character disorders. In hospitalized alcoholics, these disease entities are more prevalent than they are in the general population, and they are concurrent phenomena.
Not resultant phenomena. They are not the cause of alcoholism, nor are they caused by alcoholism. They may be precipitated by the consequences of alcohol behavior, or they may in turn precipitate alcoholic behavior. They may well be treated concurrently with alcoholism. The converse is not so. And a very excellent effort at intervention in a psychiatric disease that is complicated by alcohol addiction has classically been a very pessimistic experience.
There are treatment methods and treatment opportunities that are very helpful to the mentally ill person, and in some cases are quite specific for mental illness in general. Some of the most specific and most effective treatment includes the use of psychotropic drugs. Because of the long history of chemical abuse by the alcohol population, and also because much of the opportunity for medical abuse has been offered by the medical community, there is a great antipathy to giving alcoholics medication. The new medication routines that are available for the various phases of alcohol addiction, in particular withdrawal, are effective, sometimes miraculous, and not infrequently life-saving.
It is interesting that the sedatives and tranquilizers that are significantly helpful in the withdrawal process are significantly harmful on a long-term basis. Alcoholics Anonymous should continue their antipathy towards any of their practicing members using sedation or any of the minor tranquilizers outside of a hospital setting. The antipsychotic drug and some of the antidepressant drugs, however, are seldom indicated in the withdrawal process, but they may well play a significant role in helping a psychological sick person to recover. In the AA community, and in some of the AA-orientated treatment facilities, and in particularly the so important
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follow-up facilities, they deny this kind of unfortunate alcoholic the opportunity to participate fully in a program that they most desperately need. These unquestionably alcohol-addicted people, who for real or unreal reasons do not have the capacity to participate, are exactly the alcoholics for whom these kinds of medication are in order. The ready availability of a very large number of very effective chemicals is not peculiar to the alcohol population, although it is statistically more significant than in the general population.
Medicare patients are almost identical in this regard to the chronic alcoholic, for they both have a high incidence of medical disability. There are many excellent chemicals available for their use. They are so improved, so chemically refined, that they are referred to as metabolic bullets. As their specific effectiveness increases, their use also becomes more dangerous. Drug interaction has become a very large and a very real problem in our culture today.
It is interesting that the original metabolic bullet is ethyl alcohol itself. It is a chemical that is handled by a very specific metabolic pathway, primarily in the liver. It is in fact completely metabolized. It has very specific modes of action on the various cell systems of the body. Its effect can be predicted by the size and frequency of the dose administered, and the toxic manifestations of the same doses are becoming just as readily predictable.
It is the number one problem chemical today in this whole larger problem of drug interaction. Even the environmental pollutants we hear so much about today play a significant role in this same metabolic competitive mess. It is understandable why it's safer to be an alcoholic in a prairie town rather than a large urban city situation. I have said nothing that would encourage you to lower your defenses against the use of drug substitutes for alcohol except this word of caution that a good many recovering alcoholics are in need of some medication or other. Take some caution in being too quickly judgmental. Take, if you will, a more careful look at where the drugs came from, and maybe take more caution in whom you refer your alcoholic patients to.
A referral to a physician or to a medical institution is a serious consideration. You're asking the sick person to accept the decisions and recommendations of this physician or institution. If he does not do so, it could quite possibly have unfortunate and even serious consequences. I also think if you're responsible for the referral, you are entitled to an explanation. The psychological treatment modalities of the 50s and 70s are almost identical.
Psychotherapy, group therapy, role-playing, psychodrama, family therapy, behavior modification, biofeedback, transactional analysis, transidential meditation. We're doing many of these procedures with a great deal more skill because of long experience. We made a decision in the 50s that if this kind of treatment was going to be available for the alcohol population, we would have to develop our own therapists, and this has most certainly proved to be so.
The professional behavior therapists are still as busy and wrapped up in their own fields of endeavor and as unavailable as they ever were. It is still observable that being an excellent therapist does not automatically qualify a person as an alcohol therapist, and yet as they become comfortable and effective through experience with the addict, they do not really seem to have modified the basic tenets of their training or skill, and it was always so. The great interest in energy and transactional analysis or TA groups has been a matter of some concern. Many of these groups lack the inherent control, the discipline, and tradition of a well-functioning AA group, and they certainly are no more effective.
to have with Pat C. in the early fifties was his great emphasis on the value of meditation. At a professional presentation of this media in Philadelphia a few years back,
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I was impressed because his very learned physician's definition and explanation of transcendental meditation and Pat C.'s effort to define meditation were both equally bad. They both, however, shared the same conclusion. We may not know why, but it does work for some people and a higher percentage for alcoholics than for non-alcoholics. Pat's technique was simple. He asked each of his clients to roll by himself in a boat out into the middle of Medicine Lake, preferably just about sunup. Whatever experience they had out there by themselves was his explanation and his definition of meditation.
A family of ducks going by in the mist or the great quiet of sunup being interrupted by a blue heron was a type of skill that could not be programmed. There are many studies now questioning the role of knowledge or skill in treatment methods. They assess either the skill of the therapist or the program or both. There's one common denominator, and this is not peculiar to the alcohol field, that there are real differences between a therapist who seems unable to help and a therapist who seems to have the unique capacity to help. This applies to programs as well. The significant difference in results between poor programs, ordinary programs, and very successful programs does not turn out to be as much the type of treatment offered or even the length of the treatment process. The magic word seems to be not skill but cognitive care, social pressure, and teamwork. Cognitive care and social pressure are the great assets of the successful industrial-based program. If job pressure and continuous supervision can be married to a program and attitude of understanding and concern for the alcoholic employee, the results are very rewarding. Way back in the early 50s, we referred to cognitive care, social pressure, and teamwork as old-fashioned AA. The kind of social pressure that the 12 steps and 12 traditions Al-Anon is able to apply to the alcoholic patient is really social pressure at its very best. The individual trying to help the alcoholic or intervene in the process still, however, seems to be the most significant factor.
The search for this kind of therapeutic person, again, is not peculiar to the field of alcohol. Almost all of the teaching or behavior modification disciplines have searched and come up with some common denominators. We think of these factors in the alcohol field as being most significantly present in a person who is able to help. In contrast, they are usually lacking in a person who is unable to help. Genuineness, empathy, honesty, action, optimism, and spirituality. Genuineness must have the element of concern. It must have an element of love. The polished professional, the busy, dedicated nurses, prim and proper sisters, rough and ready longshoremen, have all qualified, but they have to be for real.
Empathy is not the model and do-gooder kind of sympathy, but a real knowledge and a gut feeling of how this person is and how he feels at this point in time. The alcoholic nature presents in so many different conditions and in so many different situations. A cardinal rule in a treatment program must be that you treat what presents. In an acutely distressed admission to the emergency room, you are not empathically relating to him if you are going to insist on his social security number or his home address. Next morning, you have a different kind of person with a new set of fears, a new set of pains, and a new set of defenses. Very easy to understand why the first successful group of therapeutic persons were from among the alcoholics themselves.
Just admitting to be an alcoholic meant becoming a genuine entity to many a nameless alcoholic.
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Most certainly someone who had walk the walk and talk the talk had a well-informed capacity to empathize. The Founding Fathers were aware of how difficult an assignment it was to be really honest, so this abstract capacity of self-honesty was structured into the total program as the fourth and fifth steps. AA has always been a great enemy of vacillation. They meet situations as they arrive. Solve the little problems and the big ones will look after themselves. Or if the big problem is what is presented, let's attack that and the little ones will look after themselves.
The magic thinking that all problems are one problem and that one problem is just the need to stay sober meant this one problem could then be attacked with great energy and dispatch. Being optimistic is so natural and logical in the arrested alcoholic, and it transcends optimism when the arrested alcoholic has the capacity and the grace to attribute this joy and peace of mind not to his own poor skills, but a great gift of a power greater than himself.
This quality of spirituality has been the most coveted commodity of the AA way, and also the most formidable for the professionals to acknowledge, and the most difficult for him to define and to utilize. The old AA concept that the alcoholic himself has got to accept the program is, of course, basically true. The alcohol victims have to accept themselves as genuine and as they really are. This means they too have to get honest with themselves, and with this honesty maybe will come some empathy, some understanding, and less useless self-judgment and immobilizing condemnation.
The same therapeutic standards can be applied to a medical institution, to an industry, to a law. They must have the same capacity to be what they present themselves to be, to be concerned, involved, non-judgmental, optimistic, something beyond a technical skill, something beyond a proven method or a traditional policy. There's one real problem with the therapeutic personality concept. It's an all-or-none kind of proposition, and again it applies whether you're talking about an alcoholic accepting these values in himself or a therapist trying to sell or convey these values to the alcoholic patient. Exploiting or being dependent on any one or less than all of these values nearly always ends in discouragement, if not failure. A recovered alcoholic becomes so intrigued with this phenomena of accepting himself as he is, and the serenity that rewards this kind of acceptance, that he becomes obsessed with selling it. This is exciting and ideal, but much to his chagrin, even this so invaluable a product is not necessarily accepted even by those who are in the most desperate need of it. We refer to the action-obsessed AA as the first and 12-stepper, the doer and the organizer, the serenity prayer grouper, the perennial optimist. All of these are invaluable additions to a club, but as individuals, as therapeutic personalities, their impact invariably fades and they become ineffective. The all-or-none kind of concept is not a difficult one for anyone experienced with trying to work the 12 steps. The skilled physician or the psychiatrist who may well have a great insight into the tortured psyche of an alcohol victim, the well-meaning priest, the charitable organization, the conscientious law enforcer, police or judge, the patient and forgiving spouse, too frequently find these enlightened attitudes are therapeutically ineffective and initial enthusiasm and concern end up as cynicism and neglect.
In reality, any person who feels he has all of the therapeutic qualities is in grave danger
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of being the person AA refers to as being proud of their humility. Even a person even if a person does seem to have all these attributes and has even demonstrated so, to claim that this happy combination is always available in every situation that presents is verging on a sense of omnipotence, the degree of which we usually see in the alcohol victims themselves. A good, well-balanced team, however, should have combined somewhere within their group all of these qualities and capacities and surely someone in the group at whatever time or condition the alcoholic chooses to present himself will be in readiness to share them. The capacity to function as a member of a team is not peculiar, in fact, not even inherent in professional training, if even in human nature. The successful professional must have or come to experience this capacity to accept the limitations of his own training, his own great capabilities. He has to accept the limitations inherent in any single individual, any single skill, any single discipline, in the same way as the alcoholic victims have to learn to accept that they, in fact, had problems not only over alcohol but as it affected their whole being and as an individual they were powerless.
The joy, the peace and serenity that the simple but timeless truth of strength through surrender that is so available to the arrested alcoholic is still a powerful message that it is our hope that the professional is able to accept and the AA will never cease to try and sell in the 70s as they did so well in the late 40s and early 50s. Thank you. Thank you very much Dr. Bradley. We will have time before this session ends for some questions for Dr. Kam and for Dr. Bradley.