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THE BEGINNING OF WISDOM ABOUT ALCOHOLISM
It’s
a disease as well as a personal and social catastrophe.
That discovery makes the big difference in treatment. Corporate
programs can be critical in salvaging executives and workers.
by
Herrymon Maurer
During
the past year alcoholism has come out of the shadows. Major
government reports have dealt with it on an objective basis,
and large amounts of federal and state funds have been voted
for research and treatment. A decision by the U.S. Courts
of Appeals, the rationale of which is under review by the
supreme court, changes alcoholism from a crime to a disease,
a diagnosis already made by such diverse authorities as
the World Health Organization in 1951, the American Medical
Association in 1957, the American Psychiatric Association
in 1965, the Department of Health, Education and Welfare
in 1996, and a national commission in 1967.
The general acceptance of alcoholism as a disease not only
reflects a new concept of the illness, but also requires
a new public approach to its treatment, postulating as it
does that alcoholics be handled in clinics and hospitals
instead of in jails. New ward space is being opened and
new institutions are being built; medical schools are beginning
to add the subject of alcoholism to their curriculums. The
federal government is now asking Congress to increase substantially
its current $20-million program, of which $13,500,000 is
marked for research, training, and education. State expenditures
are running about $10 million. There are, in addition, federal
plans in the works to treat alcoholics among civil servants,
and state plans are being drafted in California and Pennsylvania.
The year 1968 thus becomes the time when alcoholism finally
receives recognition as the personal and social catastrophe
that a quarter-century of sustained research effort has
shown it to be: an illness of the magnitude of heart trouble,
cancer, and severe mental disorder. A body of knowledge,
remarkable in size for the small amount of research money
expended, has been put together on its characteristics,
causes, and treatment. No one expects that the incidence
of alcoholism will diminish in the foreseeable future. There
are no drugs available now or in prospect to work the kind
of cure that has all but eradicated polio. Indeed, recovery
rates from alcoholism are abysmally low. But the only direction
to go is up.
The highest recovery rates, surprisingly, are to be found
not in clinics and hospitals, but in offices and factories.
By putting the body of knowledge about alcoholism to work
in company programs, industry is achieving recovery rates
as high as 65 to 70 percent - higher than those for other
major diseases and far higher than any imagined only a short
time ago. This achievement represents not only a successful
use of research, but a major contribution to it as well.
Alcoholism is one disease in which laymen, notably men in
executive posts in business, play a role as diagnosticians
and therapists as well as sufferers. Moreover, the simple
fact that business is increasingly willing to admit that
its executives can themselves be alcoholic demonstrates
an important gain in knowledge about the nature of the disease.
There are some 80 million drinkers in the U.S., and of this
number there are five million alcoholics, give or take a
million, according to estimates of the Rutgers Center of
Alcohol Studies. Such estimates have meaning, however, only
if it is agreed that all statistics on alcoholism, are rough
– far rougher than statistics on atherosclerosis,
cancer or tuberculosis – and that precise definition
of the disease is as yet impossible. Unlike other diseases,
alcoholism is discovered primarily through study of the
behavior of the persons who are attempting to hide their
behavior, not primarily through the study of invading organisms
or infected organs. For statistical purposes, it can be
thought of as a disease, in the words of Rutgers’
Mark Keller, “causing injury to the drinker’s
health or to his social and economic functioning.”
By that definition, there is one alcoholic for roughly every
sixteen persons in the country who ever consumed alcohol.
Some years ago men outnumbered women by about five or six
to one, but it may be that the ratio is now four to one
or even lower.
The sufferers divide into three principal types:
• The
loss-of-control alcoholic. In this type preponderant in
the U.S., Canada, Great Britain, and Northern Europe, increased
tissue tolerance to alcohol and alteration in cell metabolism
produce an addiction that makes control over drinking either
difficult or impossible. This leads both to compulsion to
drink and to harrowing physical symptoms when coming off
drink. Typical of the out-of-control drinker is an executive
vice president of an industry trade organization who lost
family, friends, home, and job, who sobered up in one hospital
only to get drunk and land in another, and whose recouping
of losses and rise to his present post came only after his
recovery. But just as typical is a senior officer of a company
with $300 million in sales who hid everything and lost nothing
tangible at all (although he figures his drinking cost his
company more than a million dollars’ worth of business)
and who surprised his colleagues when he told them of his
alcoholism a year after his recovery began.
• The
unable-to-abstain alcoholic. Physical addiction also characterizes
this type, which predominates in France and other wine-producing
countries where heavy drinking throughout the day is socially
acceptable. Addiction leads, however, not to the uncontrolled-spree
behavior typical of American alcoholics, but to an inability
to get off drink for even a day or two.
Social
protection for such alcoholism is common in France but rare
in the U.S. The president of a small business organization
in New Jersey built his own kind of social protection around
his drinking. He had secretaries, subordinates, bartenders,
and family trained to help him keep a relatively constant
volume of liquor in his system. But when he was suddenly
separated from his family he quickly began spree drinking
and ended by touring hospitals and jails. Dr. George N.
Thompson of the University of Southern California reports
another case: “A patient who had continued a desk
job fairly successfully for twenty years while he drank
two fifths of bourbon daily. He finally succumbed to hepatic
cirrhoses but never seemed to suffer from toxic effects
to his nervous system.”
• The
dependent-but-unaddicted alcoholic. This type does not drink
compulsively, but heavily enough to cause eventual damage
to his family and work relationships, and sometimes to his
health. Often he progresses into out-of-control alcoholism.
What happens to him depends less on the quantity he drinks
than on his drinking behavior. He can cut down if he is
aware that he is heading for trouble. It is not always easy
to spot this type of drinker, and the difficulties are increased
because so many alcoholics delude themselves into believing
that they are heavy drinking nonalcoholics.
Executive
suite and skid row
The
alcoholic reinforces his delusion that he is some other
sort of drinker by adhering to the popular notion that alcoholism
has a definite location – skid row. But, in fact,
only about 3 percent of all the alcoholics in the country
are to be found there. Only recently has the general public
been willing to acknowledge that alcoholics are also to
be found in the bosoms of their families, the arms of their
churches, and the management rosters of their corporations.
In fact, alcoholism has been found to be more of a problem
in the executive suite, in professional offices, and in
workshops than on skid row. Generally speaking, the more
educated, the more urban, and the better salaried Americans
are, the more likely to drink.
The skid-row myth, says Dr. Selden D. Bacon, director of
the Rutgers Center of Alcohol Studies, grew out of the old
controversy between the wets and the drys. Many persons
escaped both camps by avoiding the problems of alcoholism
altogether; they came to believe that such problems simply
did not exist in nice families or in good neighborhoods,
but only in out-of-sight areas where they could be handled
by the police, the courts, the jails, and the state mental
institutions. Dr. Morris E. Chafetz of Massachusetts General
Hospital has shown statistically that admitting physicians
in hospitals tend to diagnose alcoholism as if it were a
disease confined to the unwashed and the ill clad. When
a disease is socially unmentionable, medical research in
that disease is stymied by want of support. The new recognition
that alcoholism is also found among respectable people is
a fact possibly more important for research than was the
similar recognition of cancer about a generation ago.
In short, social considerations are as much a factor in
alcoholism research as are the physical and psychological
characteristics of its victims. A concatenation of sociological,
biochemical, and psychiatric happenings, alcoholism has
to be studied by specialists in many fields. Moreover, it
is an illness whose patients band together in great numbers
– 400,000 of them in 14,154 groups throughout the
world – as Alcoholics Anonymous to treat one another.
Multiple approaches to the problem often commingle but sometimes
conflict. The fact, for instance, that alcoholism is far
less prevalent among Jews than among the Irish is explained
in terms of cultural or psychodynamic conditions, but some
physiologists explain it as the consequence of genetically
determined body chemistry. Such diversity of approach is
actually an important research aid, and it has already produced
a very considerable body of knowledge about the nature of
the illness, a good deal of information about its treatment,
and plenty of speculation about its causes.
The observable symptoms of the disease, its course from
early manifestation all the way to recovery or death, together
with its incidence and characteristics in various segments
of the population, can now be defined roughly. There is,
for instance, ample working data on alcoholism among factory
and white collar workers with reasonably precise studies
on work performance, absenteeism, accidents, and the like.
There is also an increasing body of data about alcoholism
among executives, a topic not generally discussed only a
few years ago.
There is, moreover, a good deal more that is known about
alcoholism’s sundry complications. An HEW study of
1,343 patients at alcoholism treatment centers in California
reveals that accidents kill seven times as many alcoholics
as nonalcoholics, cirrhosis ten times as many, influenza
and pneumonia 6.2 times, and suicide (a new research area)
3.5 times. A sampling of 922 drinkers (532 known to be and
390 thought to be alcoholics) and 922 nondrinkers at E.I.
du Pont de Nemours indicates that various other degenerative
diseases, including some not popularly associated with alcohol,
strike drinkers with measurably greater frequency than nondrinkers:
e.g., hypertension 2.3 times as frequently, cerebrovascular
disease 2 times, stomach ulcer 1.9 times, asthma 1,7 times.
“More alcoholics,” declares Dr. Edwin Boyle
of the Miami Heart Institute, “die of cardiovascular
catastrophe than from all other causes combined.”
Other studies, supported by A.A. experience, yield an equally
important and far more heartening discovery: alcoholism
can be arrested much earlier in its course than was previously
thought possible and with much better likelihood of recovery
than in its later stages. It was once believed that only
those alcoholics who had gone down through the whole bitter
sequence of the early, middle, and late stages would accept
therapy. Today an estimated 50 percent of A.A. members join
during the early and early-middle stages. “An alcoholic,”
explains a vice president of a company headquartered in
New York, “Is constantly building up a wall of defenses
around his illness. Early in the process when the wall is
low, it takes much less suffering to convince him to clamber
over it than it takes when the wall is high.”
Physiological research also has been yielding detailed information
on the way alcohol acts in the human body, how it is metabolized,
how it sedates – producing in the process an initial
misleading euphoria, but subsequently depressing and anesthetizing
– and how it leaves behind that jittery sense of excitation
that often prompts the alcoholic to another drink or another
bout. Established are such facts as alcohol’s ability
to induce hyperactivity of the brain through its effect
on the brain’s reticular activating mechanism. The
ancient surmise that alcohol in the bloodstream is the agent
of the alcoholic’s compulsion to keep on drinking
has been confirmed by a variety of experiments, including
a thirty-one day test conducted by Harvard’s Dr. Jack
H. Mendelson, in which alcoholic volunteers were subjected
to twenty-four days of controlled drinking and seven days
of observed withdrawal, in the course of which classic and
unmistakable signs of physical addiction were manifest.
Why
it comes and how it goes
Certain
facts about the treatment of alcoholism are indisputable.
As rooted, it has been established as a disease treatable
by physical, psychological, and A.A. therapies. Medical
authorities have perfected the hospital handling of its
agonizing withdrawal symptoms – the physician has
a whole battery of variously acting drugs at his command
– and withdrawal is now rated no more of a risk than
minor surgery. It is universally agreed that the one way
to arrest the illness is to get the patient off drink altogether.
And it is known that the alcoholic can’t get off drink
through his own will power, that he must seek outside help.
At this point, however, the various sociologists, psychologists,
physiologists, and the A.A. laity tend to part company.
Alcoholics Anonymous is widely conceded to have produced
more recoveries than have all other therapists put together,
but it suffers in the minds of some professional research
men from being insufficiently scientific. A scientist can
hardly quarrel with the fact of 400,000 recovered alcoholics,
but he can nonetheless feel uneasy about a fellowship whose
program begins with an admission of abject surrender of
one’s life as unmanageable, follows with belief in
“a Power greater than ourselves that can restore us
to sanity,” and prescribes constant meetings and labor
with other alcoholics. Such propositions, whose principal
intellectual ancestor is the pragmatic philosopher William
James, are not subject to quantitative measurements and
are often troubling to outsiders. What is more, only about
one alcoholic in fifteen in the country is a member of A.A.
Its one requirement for membership – a desire to stop
drinking – is thought by some to limit its therapeutic
efforts to a relatively select few.
Sociologists come under cross fire from some of the other
professionals for focusing on nonmedical aspects of alcoholism.
Their basic proposal for treatment is the prevention of
alcoholism by social and cultural change, a proposal whose
value can be determined only at some time in the future.
Moreover, they offer both statistical studies and cogent
etiological arguments. “It has been noted,”
says sociologist Dr. Seldon Bacon of Rutgers, ”by
almost all observers for decades that by and large Americans
are anxious, confused, ambivalent, at times guilt-ridden
about their attitudes toward drinking.” Sociologists
have delineated such uncertainties in detail and have re-created
in the process the history of drinking in the U.S., replete
with such intriguing facts as nearly identical per capita
consumption rates between 1850 and 1968, despite the intervention
of the industrial revolution, urbanization, and world wars.
Knowledge
through no-knowledge
Physiologists
and psychologists, highly vocal about the causes and treatment
of alcoholism, have contributed another body of facts, and
also have delineated important areas of ignorance. Dr. Peter
Stokes, research physician at Payne Whitney Clinic of the
New York Hospital and co-discoverer of the effect of alcohol
on white-cell mobilization, remarks confidently, “We
don’t know anything about the causes of alcoholism;
we can’t identify the susceptible individual; we can’t
treat specifically or chronically; and we can’t prevent
it.” This state of knowing what one does not know,
Dr. Stokes emphasizes, is essential for solid future discovery.
Medical research in general has to explore areas of ignorance
before arriving at areas of new information. Cancer research,
more advanced than research in alcoholism, developed its
virus theory only after assiduous exploration of the unknown.
Physiologists, of course, examine complex cellular, metabolic,
glandular, and like biochemical events, while psychologists
and psychiatrists apply a body of concepts ranging from
learning theory and conditioned reflex formulations to personality
testing and psychodynamics. Almost all researchers in these
fields believe it is likely that alcoholism rests on a physical
base upon which is built a psychological structure, but
research knowledge both of base and structure is as yet
not very deep. Alcoholism indeed coexists with various types
of mental and emotional illness that require specialized
medical attention. Until very recently it was believed that
predisposing psychological factors played a causative role
of some sort in the development of alcoholism. Alcoholics,
after all, are so frequently separated from reality that
they can be called schizoid, so regularly low in mood they
can be called depressed, so often unsure they can be called
dependent, and so obviously devoted to the bottle they can
be labeled obsessive-compulsive and orally fixated. But
these characteristics did not necessarily pertain to their
condition before they became alcoholic, and the same characteristics,
moreover, are not uncommon among nonalcoholics. Today there
is less enthusiasm over predisposing factors.
Enthusiasm plays a key role in medical research, but in
the search for remedies for alcoholism, it is now much more
subdued. In the past, various therapeutic devices, based
on various etiological theories, were put forward with considerable
ardor as the therapies for alcoholism, but they turned out
later to be at best adjuncts to standard therapy. Among
these are psychodrama, group therapy, and hypnosis as well
as individual counseling. The list also includes the barbiturates
(useful but themselves addictive), aversion therapy, vitamins
and sound diet, Ayerst Laboratories’ Antabuse (still
widely used), ACHT, tranquilizers (also useful and also
addictive), LSD, Searle & Co., Flagyl, and latest of
all, niacin, proposed for use in massive doses as an adjunct
to therapy to deal with hypoglycemia and schizoid conditions.
Almost all alcoholics, of course, would welcome any pill
or any procedure that would not deprive them of liquor.
For fifteen years a New Jersey management consultant read
selectively in the professional literature to convince himself
that he was a neurotic drinker who would be able to drink
normally as soon as his neurosis was resolved. He persuaded
his physicians and psychiatrists to let him try out a whole
series of new treatments, from barbiturates to LSD. Despite
repeated hospitalization, he believed fervently that his
emotional health was improving – up to the very moment
when desperation eventually convinced him he was a common
out-of-control alcoholic. As U.S.C.’s Dr. Thompson
says, “It is axiomatic that it is useless to attempt
psychotherapy on a patient who is continuing his drinking.”
The new social acceptance of alcoholism as a disease rather
than as a stigma of sin, say the professionals, should help
break down the massive defenses alcoholics develop against
yielding to treatment. Acceptance is providing a cultural
climate in which they may be more readily helped and a long
needed financial base for an important burst of new research.
Crisis
precipitation
There
is already enough knowledge for dealing effectively with
the problems of alcoholics on the job. An HEW study estimates
that 70 percent of them, indeed, are still on the job and
have been there for fifteen to twenty-five or more years.
An alcoholic’s job, in fact, is the last great bulwark
of his defense against admitting his illness; the threat
of its loss can often produce the inward crisis that is
required before he will submit to treatment. Well-conceived
company programs, moreover, can speed up the precipitation
of such a crisis, in the process rescuing men from unnecessarily
long suffering at a cost to the company that is far less
than the amount it is already losing through poor productivity,
absenteeism, severance or retirement payments.
Successful company programs – programs that succeed
with two out of three alcoholics, as they do at Equitable
Life, Eastman Kodak, Consolidated Edison, Allis-Chalmers,
and du Pont – are still rare, although more than 200
companies have some sort of program or some statement of
policy. Because alcoholics are so skilled in avoiding anything
that looks like a trap, some programs are little better
than no programs at all.
Good basic company procedure is relatively simple. It depends
on early recognition of the alcoholic, employee or executive,
by his immediate supervisor on the basis of his work performance
and on his referral by the supervisor to the company physician.
The physician has to be – or has to become –
one of the small and select group of specialists in alcoholism,
though he does not usually treat the man himself. He refers
him after diagnosis to Alcoholics Anonymous, to a psychiatrist,
a hosp-ital, or a rehabilitation center. Follow-up is in
the hands of the company physician. And in all cases, willingness
to accept treatment is a criterion for determining whether
an employee continues to hold his job.
The mechanics of this operation are straightforward. It
is not difficult to spot alcoholics on the job; usually
they are recognized long before they think they are. Most
of them can be identified simply by running through work
records on absenteeism and performance. But getting a supervisor
to refer a man to the medical department is a different
matter. It is almost impossible if the program is not well
conceived, difficult when even a good program is new, though
relatively easy when the program is widely understood.
Removing
resistance
When
the medical director of a billion-dollar company was summoned
one day to his company’s executive offices, he found
himself in the presence of two senior officers. He was told
by one of them that the other was beginning to get into
such trouble with drinking that he would have to report
him to the board of directors unless he accepted medical
help. The medical director simply said, “Since this
is a health matter, we will treat this conversation as if
it never happened.” He then took the sick executive
back to his office, talked with him, got him into the hospital
for a two-day checkup, dispatched him to a rehabilitation
center for a four-week “vacation,” and on his
return introduced him personally to members of an A.A. group.
A few weeks before, the physician had handled a case involving
a maintenance man employee in precisely the same way.
Implementing a program based on crisis precipitation requires
a marked amount of organized wisdom, experience, and good
sense in dealing with the tortured complexities and resistance’s
of the alcoholic mind. For example, it is essential that
the confidential relationship between doctor and patient
remain inviolate; otherwise the whole program will be bypassed
by the alcoholic. It is not necessary for the word alcoholism
to appear in company records. Equitable Life’s Dr.
Luther A. Cloud finds it wise even to avoid using the word
in his conversation with a patient until the patient himself
does so. At Eastman Kodak, executives not infrequently refer
themselves to Dr. John L. Norris, associate medical director,
who is also the nonalcoholic chairman of A.A.’s general
service board. Among all employees about two out of ten
are self-referrals.
One pitfall to avoid, warns Dr. Harrison M. Trice of Cornell’s
School of Industrial and Labor Relations, is a company plan
that is designed to take care of alcoholism only among wage
and salary workers. Alcoholics are so notably thin-skinned,
whatever their level of employment, that it is advisable
to handle all of them as if they were executives. If a plan
works smoothly with executives, it will work smoothly with
others down the line.
Atmospherics
and the chief executive
Obviously
a company plan cannot be rigid-Practicing alcoholics respond
far better to a general atmosphere than to an inflexible
system. At Equitable, atmospheric considerations include
easy and unobserved access corridors to Dr. Cloud’s
office. Although Eastman Kodak is a pioneer in company alcohol
problems, Dr. Norris and the company management still feel
no urge to commit all of the program to paper; it is simply
discussed between Dr. Norris and the top executives who
frequently drop into one another's offices to talk informally
about a wide range of company and community health matters.
Olin Mathieson’s Dr. J. Ray Chittum holds that his
program should not even be called an alcoholism program,
maintaining that alcoholism should simply be considered
one of the various illnesses that his company helps treat.
One manufacturing company with a number of scattered plants
in the Midwest has no organized plan at all and uses outside
physicians instead of company doctors. But it is known confidentially
to a good many men both at headquarters and down the line
that both the president and their personnel head are recovered
alcoholics active in A.A., and as such the company’s
authorities on alcoholism. This company has probably one
of the lowest rates of active alcoholism in the country.
Most of the information required as the basis of sound and
successful company programs can be found at four institutions
where the problems of alcoholism in industry have been under
scientific and professional study for many years. Dr. Milton
A. Maxwell, of the Rutgers Center of Alcohol Studies, is
an expert on problems of accidents and absenteeism. At Cornell,
Dr. Trice is knowledgeable about problems of early identification
and crisis precipitation. At the National Council on Alcoholism,
Lewis F. Presnall has installed practical programs in a
number of specific companies. And at the Christopher D.
Smithers Foundation of New York, the organization that has
given research in alcoholism most of its private financial
support, R. Brinkley Smithers pays special attention to
company programs. Smithers is the foundation’s president
and president also of the National Council on Alcoholism.
Obviously, the experience of particular men or particular
companies cannot be overlaid on the organizational pattern
of other companies. Such patterns typically represent a
company’s unique way of doing business, and any change
in them is a matter for the chief executive officer. The
chief executive, indeed, is the one person in any company
who must take responsibility for an alcoholism program,
not simply because it is advisable to have top backing for
good ideas, but because it is essential for him to do the
actual tailoring of any system to the company cloth.
On the chief executive falls further responsibility for
the alcoholics the program does not help. To be sure, two
men in three can Recover and often achieve levels of performance
not previously reached, but there remain the men who refuse
therapy or abandon it. Some of them pass on to other companies,
end up on early retirement, relief, or skid row. Moreover,
it has now become known that an alarming percentage of alcoholics
commit suicide upon losing a job or separating from family.
Such negative consequences of crisis precipitation can be
mitigated in some part, however, by the chief executive
taking two steps: first, making it clear to employees that
acceptance of treatment for alcoholism is a defense against
loss of job, and, second, separating alcoholics when necessary
from the company on an on-leave basis, it being understood
that they will be taken back whenever they accept therapy.
Pragmatic
synthesis
For
its successful crisis-precipitation approach to the problem
of alcoholism, industry clearly owes a debt to research.
Scholarship, however, owes a debt to industry programs,
not simply for the statistical, psychological, or medical
data they yield, but also for showing the way to the pragmatic
achievement of the higher recover rates known. These results
suggest that the synthesis of research findings with working
industrial programs may be more significant than either
the research or the programs alone.
Important in this synthesis is industry’s use of Alcoholics
Anonymous as the chief therapeutic agent of company programs.
Business proved a new challenge to A.A. through its methods
of crisis precipitation that sent men and women for therapeutic
help long before they might otherwise have gone, and thus
provoked a new response. Now that the dimensions of the
disease of alcoholism are becoming widely known, it may
well be that many physicians and psychiatrists, psychologists
and social workers, together with their hospitals and clinics,
will develop new forms of crisis precipitation and share
their therapeutic load more widely with A.A. Today there
simply are not enough professionals in the country to handle
the number of alcoholics needing treatment, and there are
350,000 members of A.A. available anywhere and at any hour
in the U.S. and Canada.
Whatever else A.A. may be, it is a successful method of
treating a disease, and a study of methods of recovery can
lead to important facts about the nature of the disease
itself. A.A. recovery for one man, the executive vice president
of a research and development corporation in the South,
included listening to more than 1,000 case histories during
the first two
years of his membership, getting to know intimately the
life histories of more than fifty persons, introducing fifteen
newcomers directly to A.A. and twenty-five more in partnership
with others, and discussing the problems of alcoholism with
more than a hundred nonalcoholic friends, scientific colleagues,
and business associates. A.A.’s response to the challenge
of still-suffering alcoholics is the combined response of
cohorts of such men striving to maintain their own recovery
through helping the recovery of others. Working with A.A.,
business has worked wonders.
END
(Source:
Fortune, May 1968)
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