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We Can Lick Alcoholism
CLINIC
PLAN OFFERS HOPE FOR WORLD'S LEAST UNDERSTOOD SICK PEOPLE
by Carlton Brown
TO
MANY AMERICANS, the alcoholic is a comic character. They
call him souse, stewbum, lush, and dipso; they say he is
tight, plastered, stewed, fried, or sauced. In recent years,
Americans have been exposed to a great deal of writing about
the problem of alcoholism, and to a serious novel and movie,
The Lost Weekend. Still, many share the reaction of the
man who left the theater and said to his companion:
“I’m
swearing off right now! You’ll never catch me going
to another movie.”
To many other Americans, the alcoholic is a subject for
moral censure. They class him as a sinner, a social delinquent,
a person of weak moral character. They feel that only pure
cussedness keeps him from “handling his liquor.”
There are even many alcoholics who do not recognize that
they are alcoholics, and feel privileged to look scornfully
upon the people they consider alcoholics.
Sample studies recently conducted by Rutgers University
at New Brunswick, N.J., indicate that 50 per cent of the
American public erroneously believe that an alcoholic can
stop drinking if he wants to; that only one in five properly
views the alcoholic as a sick person.
This lack of public understanding is the chief obstacle
in the way of an effective attack on alcoholism, which Dr.
Lawrence Kolb, medical director of the U.S. Public Health
Service, has ranked as America’s fourth greatest public
health problem.
This is not to say that science has found a miraculous new
cure for alcoholism and that only prejudice and indifference
keep it from being applied. There is no one new finding,
or group of findings, which promises an easy solution. But
there do exist today, as never before, plans of attack which
utilize all that science knows about alcoholism in medicine,
psychiatry, sociology, and allied fields. Comprehensive
programs of treatment, prevention, and rehabilitation have
been worked out and tested in clinical practice, which can
reduce the casualties of alcoholism by one half or more
wherever they are thoroughly applied. But these plans will
not work anywhere unless groups of individuals in states,
cities, and communities become aware of the seriousness
of alcoholism, and raise funds and plan programs to deal
with it as a major public health problem.
How
Many Alcoholics?
The
facts about alcoholism concern everyone as intimately as
the facts about heart disease, cancer, tuberculosis, infantile
paralysis. The number of persons in this country medically
classified as chronic alcoholics, who have developed physical
or mental disorders as a consequence of prolonged heavy
drinking, is 50 per cent higher than the number of known
sufferers from tuberculosis. And it is a fact of central
importance that no one, whether at present a teetotaler,
a moderate, or a “social” drinker, can be positive
of a lifelong personal immunity to alcoholism.
Of 100,000,00 Americans of drinking age (15 years and older),
an estimated 58,250,000 use some form of alcoholic beverage,
to some extent. The great majority of these, some 54,500,000
keep themselves mainly within the category of safe and moderate
drinkers, and as such are no part of the public health program.
But a minority of all drinking Americans, about 3,750,000,
are classified as excessive drinkers, or inebriates, and
within this group 750,000 or 800,000 are known, on the basis
of hospital and court records, to be chronic alcoholics.
Of all excessive drinkers, one in six is a woman.
Alcoholism is also a social problem of incalculable magnitude.
Experienced Salvation Army Workers estimate that 90 percent
of the down-and-outers who come to them for help have been
brought there by excessive drinking. In New York City, one
third of the men and one tenth of the women who take their
marital difficulties to Domestic Relations Court are alcoholics;
so are 95 per cent of all those committed to the Workhouse
and 15 percent of those given penitentiary sentences. Officials
of an Industrial Conference on Alcoholism held in Chicago
this March estimated that alcoholic employees cost industry
$1,000,000,000 in pro-duction and 24,000,000 man-hours of
work per year. Boards of education find that parental alcoholism
is a frequent factor in absences and behavior problems of
school children, as it is in juvenile delinquency. Estimates
of traffic accidents involving drinking by drivers and pedestrians
vary from 10 to 50 per cent of the total, cannot be summarized
in nation-wide terms because of local variations and inaccuracies
in the reporting of accidents.
The problem of alcoholism looms large not only in terms
of the number of people it affects, but also because it
is such a complicated matter, having so many intangible
and unsolved elements. To scientists concerned with the
problem, the alcoholic is a sick person, no more deserving
of moral blame or ridicule than sufferers from any illness.
But alcoholism is not a separate, clearly defined disease
entity. No single cause or group of causes can be assigned
to it. It is confined to no one group of people within our
population. No single course of therapy can be applied universally
to all alcoholics. Science is still unable to point with
certainty to those individual traits of physical and psychological
make-up, which combine to make a small percentage of all
drinkers peculiarly susceptible to alcoholism.
Until quite recently, those concerned with the various aspects
of alcoholism-sociologists, physiologists, psychiatrists,
educators, religious leaders-tended to approach the problem
as specialist in their separate fields. Within the past
few years, a new point of view has been emerging among these
people. It is that alcoholism is a medical, psychological,
social, legal, and moral problem, but that it is none of
these alone.
A dozen years ago, there was no important national organization
that was utilizing the tools of science in a concerted attack
on alcoholism. Today, there are two central agencies, the
Yale Plan on Alcoholism, and the Research Council on Problems
of Alcohol, which are carrying out intensive studies, clinical
work, and campaigns of public education in all phases of
problem drinking. In addition, there is the now well known
“voluntary fellowship” of alcoholics Anonymous,
which in its 12 years of existence has gathered a membership
of 60,000 rehabilitated alcoholics and contributed to the
understanding of excessive drinking.
The
Scientific Approach
Scientific
work in this field is divided into two main approaches.
One is concerned with finding factors in the biological
and psychological make-up of individuals which may give
them a predisposition toward alcoholism. The second approach
is that of working out methods of treating alcoholism in
clinics which will utilize all the knowledge of scientific
research. In the practical work of the two main groups in
the field, these approaches are combined.
The Research Council, which is affiliated with the American
Association for the Advancement of Science, is currently
carrying on a campaign to raise $200,000 a year to set up
a series of combined research and treatment centers in alcoholism
in leading medical schools throughout the country. One such
center, at New York Hospital-Cornell Medical College, has
completed the first year of a five-year plan financed by
a $150,000 grant from the council. Some of these funds have
been contributed by the liquor industry. This project, under
the direction of Dr. Oskar Diethelm, co-ordinates research
in the varied fields of psychiatry, internal medicine, physiology,
pharmacology, biochemistry, psychology, and anthropology.
In the first year, the staff worked with a selected test
group of 25 patients whose normal productive way of life
had been seriously disrupted by the use of alcohol. All
were people who wanted to be helped and none was of the
“derelict” type. Each spent an initial period
of from a few weeks to several months in the hospital, undergoing
thorough physical, psychiatric, and psychological studies,
and following supervised programs of diet, rest, and occupational
therapy. Most of the patients willingly kept to the prescribed
course and graduated to a transitional stage, of from four
to six weeks during which they spent nights and weekends
in the hospital and resumed work outside.
After leaving the hospital, patients enter a follow-up period
of three to five years, returning for check-ups at first
weekly, and eventually monthly. Social workers help the
patient find suitable work and recreation, and family and
friends are instructed to respect the patient’s “right
not to drink.”
Dr. Diethelm’s primary aim is research. He has released
no estimate of the success of his project in rehabilitating
the first year’s test group, and an estimate based
on such a limited group and period of time would have little
scientific standing. Clinicians in this field are reluctant
to say that alcoholism has been arrested in any patient
until he has gone without alcohol for a period of several
years and gives evidence of having undergone a basic re-education
that eliminates his need for alcohol. But Diethelm’s
staff has announced one promising finding: that certain
unidentified substances in the blood are apparently associated
with the craving for alcohol, as well as with the emotional
states of tension, anxiety, and resentment.
Some other clues in the psychological field were reported
at the most recent annual meeting of the Research Council,
in Chicago last December. From the University of Texas,
Dr. Roger J. Williams of the Biochemical Institute, announced
that because of individual differences in body chemistry,
a low concentration of alcohol in the blood is enough to
produce signs of intoxication in many people, while others
may have several times as high a percentage without becoming
drunk.
Williams believes that differences in metabolic machinery,
the way in which the body turns food into energy, make it
possible for some people to drink heavily for many years
without ever showing clinical symptoms of alcoholism, and
impossible for others to drink even a little without developing
an inordinate and disastrous craving for alcohol. He does
not contend that the biochemical approach alone can conquer
alcoholism; he hopes that it will eventually determine certain
definite physiological characteristics which render some
people vulnerable to the effects of alcohol.
Such metabolic idiosyncrasies, Williams believes, may be
inherited. This does not mean that alcoholism is a hereditary
disease – an old- fashioned bugaboo that has been
thoroughly scouted by genetic science. The consumption of
alcohol, even in excessive quantities over long periods,
causes no damage to germ cells, and thus does not effect
the genetic make-up of the children of excessive drinkers.
Statistics show that only about one third of all alcoholics
come from families showing a high incidence of alcoholism
and mental illness. The and is emphasized because in an
appreciable number of alcoholic patients, alcoholism is
merely incidental to their primary ailment. These are “symptomatic”
drinkers, who are given to the excessive use of alcohol
by a psychosis, serious neurosis, endocrine disturbance,
organic illness, or epilepsy. Their drinking is a symptom
of their underlying illness.
Small
Hereditary Factor
Most
authorities consider that there may be some hereditary factor
in alcoholism, but that it is a small one and difficult
to separate from the greater and less understood picture
of heredity in mental illness of all types. They believe
that when the children of alcoholics take to drink, the
influence of environment is generally a far stronger factor
than biological inheritance. What may be inherited is an
unstable constitution which, if subjected to adverse influences,
is likely to develop alcoholism or mental illness more readily
than other not so predisposed.
Williams believes, as do other leading researchers, that
both hereditary and environ-mental factors are highly significant
and that “a one-sided approach to the problem is doomed
to failure.” As a biochemist, his special search is
for some biochemical means of identifying potential alcoholics,
and from that point, of developing preventive and remedial
measures.
The search for a psychological basis for alcoholism is also
being carried out in clinical studies at the New York University
College of Medicine, under Dr. James J. Smith. He reports
that many alcoholics show an insufficiency in the secretions
of the adrenal gland (a small ductless gland sitting on
the kidney) similar to that found in Addison’s disease.
Treatment with adrenal and sex-gland hormones has yielded
clinical improvement in NYU ward patients.
From the University of Chicago, Professor Emeritus Anton
J. Carlson, president and scientific director of the Research
Council, reports that a nitrogen-chlorine gas, previously
used to bleach flour for making white bread, has been found
to make proteins act as a nerve poison. Animals have developed
convulsions as a result of being fed large amounts of white
bread containing the chemical. It may be a contributing
factor, Carlson believes, in turning potentially unstable
persons into alcoholics.
Ranging far beyond this particular theory, Carlson indicates
that the will of the alcoholic patient appears to be important
to his recovery and rehabilitation. “The hereditary,
the biochemical, the nutritional, the neural, the educational
and the social factors determining the strength and direction
of the will of man are still obscure,” he says, outlining
the broad territory which present-day research in alcoholism
is setting out to explore.
It is this broad, co-ordinated exploration, rather than
individual new findings in separate fields, that constitutes
the latest and most promising development in the study of
alcoholism. The idea of this co-ordination arose at Yale
University, and its practical applications are best seen
today in the work of the Yale Plan, a many-faceted operation,
which is formally know as the Section of Alcohol Studies
of the Laboratory of Applied Physiology, Yale University.
Support
from Liquor Industry
Some
of the Yale Plan work is done under agreement with the Connecticut
Commission on Alcoholism, a state agency of rehabilitation
and public education established in 1945, the first of its
kind in this country. The Commission currently derives funds
of about $200,000 per year from higher licensing fees which
representatives of the liquor industry have accepted voluntarily
to pay for the program. The Commission is engaged in a broad,
long-range program of education, research, treatment in
public clinics and hospitals, community services, and, ultimately,
prevention. Since 1945, Utah, Wisconsin, Oregon, and the
District of Columbia have followed Connecticut’s lead
in tackling alcoholism as a specific public health problem,
and other states are instituting similar legislation.
The Yale Plan conducts the Yale Summer School of Alcohol
Studies, now in its sixth year, which gives an intensive
course in all phases of alcoholism to educators, social
workers, and other professionally concerned with the subject.
It is the outgrowth of experiments in the physiology of
alcohol, which Dr. Howard W. Haggard and his associates
in the Laboratory of Applied Physiology began around 1930.
They made important findings about the metabolism of alcohol
and its absorption and oxidation in the body. But Dr. Haggard,
who became director of the Laboratory in 1938, saw the important
need for going beyond these researches and getting at the
fundamental causes and the possible means of prevention
of alcoholism. “We got plenty of leads that suggested
a physiological basis for compulsive drinking,” Haggard
said recently. “But they were just leads. We couldn’t
find a way of applying them to the individual alcoholics.
So we decided to study all aspects of alcoholism and the
problems of alcohol. In addition to our physiologists we
brought in a biometrician, an anthropologist, a psychologist,
a sociologist, an economist, and workers in other fields.”
The Yale biometrician, Dr. E.M. Jellinek, is now director
of the Summer School of Alcohol Studies, associate editor
of the Quarterly Journal of Studies on Alcohol, and an active
collaborator in all of the work of the Yale Plan.
“We
went after the larger questions of why people drink,”
Dr. Haggard said, “why a few become alcoholics while
the great majority does not, what alcohol does to people
psychologically as well as physically. When we started the
summer school, we were a little afraid of attracting special
pleaders for one point of view or another. But we found
that when people of various persuasions got together and
saw each other’s point of view, they got a broader
understanding of the picture. They had discussion sessions
outside of lectures, and discovered just what we had found
out-that the best way of dealing with the problems of alcohol
is to tackle them as a total problem, uniting all approaches.”
For the interested laymen, the most dramatic work being
done by the Yale Plan is in its “pilot clinic”
at New Haven. This clinic and the one at Hartford were set
up in the spring of 1944 with the aid of the Connecticut
Prison Association; the management of the Hartford clinic
has since been taken over by the Connecticut Commission
on Alcoholism. Both clinics were established not only to
cope with the loss of industrial manpower through alcoholism
in Connecticut, but with the longer aim of working out methods
for dealing with two essential problems encountered all
over the country: 1) Where can the individual in the community
go for aid, advice and treatment? 2) By what method can
the community restore the social usefulness of its alcoholically
incapacitated members? By what methods can it best prevent
alcoholism?
The
Qualified Recoveries
“We’re
not concerned here with whether you should drink or not,”
Dr. Haggard says. “We’re concerned with those
people whose drinking interferes with their lives, who become
social problems through excessive drinking. We wanted to
know whether it was feasible to set up a free clinic where,
at a cost to the community of about $100 per patient, we
could get a reasonable recovery. We don’t talk about
curing alcoholics. We call our successful cases qualified
recoveries. The qualification is that the patient will stay
recovered only as long as he doesn’t touch liquor
again.”
The Yale Plan Clinic is housed in an old-fashioned red brick
building which bears no resemblance to a hospital. Patients
are admitted without charge, regardless of their financial
circumstances. Some are brought or sent in by members of
their family, friends, doctors, or employers. Others, by
arrangement with the Connecticut Commission on Alcoholism,
are referred to the clinic by the courts. And a good many
others, who turn out to be the most responsive to treatment,
come in of their own accord, because they are greatly concerned
by the extent to which drinking interferes with their leading
normal lives.
The
Three Categories
The
medical director of the Yale Plan Clinic, Dr. Giorgio Lolli,
heads a staff of ten. Besides himself, there are three other
doctors (on part time), three social workers, a psychotherapist,
a psychologist, and two secretaries. The clinic has no hospital
facilities; all patients are ambulatory cases. The clinic
admits all applicants for a least a preliminary interview,
but because of its limited facilities and staff, because
its function is that of an experimental model rather than
a full-scale rehabilitation project, it cannot undertake
to treat all applicants. For practical purposes, the New
Haven Clinic divides applicants on the basis of diagnosis
into three categories:
1) The symptomatic drinker, whose drinking is incidental
to mental illness, severe endocrine disturbance, or epilepsy.
Since these people do not respond to treatment for alcoholism
as such, they are referred to psychiatrists, private physicians,
mental-hygiene clinics, or hospitals, where their underlying
illness can be treated. Perhaps 15 per cent of the total
number of alcoholics are in this group.
2) The social misfit, “derelict” type of alcoholic,
who is disqualified for family life, hasn’t the emotional
stability to hold a good job, is apt to be so physically
deteriorated and psychologically disorganized that only
long institutional care and social rehabilitation could
redeem him. These make up 15-20 per cent of those seen.
For this type, the Yale plan people would like to see custodial
therapeutic institutions established that would utilize
all elements of the co-ordinated approach. The danger in
jails and “inebriate farms” as they have been
constituted, is that they don’t make proper diagnosis,
that they merely keep derelict alcoholics in custody, finally
releasing them without any basic improvement in condition.
3) The true alcoholic, with an impulsive drive to drink.
People in this group show a variety of pattern in their
drinking habits. Some go on periodical binges, every weekend,
or irregularly. Some get drunk every night. Others are always
moderately under the influence, have a constant concentration
of alcohol in the blood but do not necessarily show obvious
signs of drunkenness.
Handling
of Applicants
Yale
Plan doctors do not hold that all alcoholics necessarily
fall into one of these arbitrary categories, which are principally
useful in the handling of applicants. “Our distinction
is made on the basis of whether we think we can or can’t
help,” Dr. Lolli explains. “Our handling of
a patient just coming to the clinic varies greatly according
to his state. If he’s just coming out of a binge,
he may need help in overcoming the effects of his hangover.
In all cases, we make an immediate attempt to give relief.
Sedatives may be used when the patient is jittery and nervous.
In the early days of treatment, we may administer crude
liver plus Vitamin B1. When the physical condition improves,
and Vitamin B1 can help bring this about, the need for alcohol
diminishes, but nothing has been done to clear up the underlying
condition. To tackle this, we use a variety of methods,
depending on the individual.
“At
an early point the patient is usually interviewed by a social
worker with some psychiatric training. Without antagonizing
the patient, we may make a start at getting his case history,
his background, family circumstances, employment record,
and some preliminary notes on his troubles with drinking.
If we can’t get this information at first, we postpone
it to weeks or months later.
A
Patient, Not a Sinner
“There
are usually a lot of difficulties which require immediate
attention-family troubles, loss of job, legal and financial
problems. The social worker starts at once to try to solve
the most pressing of these and relieve the tension they
cause in the patient. We impress upon every applicant the
fact that we consider him a patient, not a sinner. If the
patient doesn’t show an immediate psychosis or serious
neurosis calling for deep therapy, even these preliminary
steps, establishing the fact that he is a patient and that
some relief is in sight, have some therapeutic effect. Our
approach is a very factual one. We don’t promise anything,
and we don’t want patients to promise us anything.
We give them the evidence that we can relieve them of some
pain, by psychological or medical means, and when they get
even this much hope they are off to a good start.”
The next step in the Yale Plan procedure is a thorough physical
examination to find out if any illness is present, due or
not to alcohol. Alcoholics show “organ-neurotic”
symptoms-physical complaints which are apparently of psychological
origin. Some of these can be relieved by medical treatment.
Benzedrine and dexedrin can help to overcome depressed states.
If medical laboratory tests are necessary, they are usually
done elsewhere.
Although the Yale Plan Clinic has no official connection
with Alcoholics Anonymous, it refers some of its applicants
to the local group of that association, and in turn takes
in patients referred to it by AA. Local groups hold regular
meetings at which members tell of their own experiences
as compulsive drinkers, and testify to their recovery through
adherence to the AA plan. This plan consists of twelve formal
steps, which may be reduced to these essentials: a) the
alcoholic must admit that he is powerless over alcohol and
seek help from outside; b) he must attempt to analyze his
personality, acknowledge his wrongs, make amends when possible
to people he has harmed; c) he must place his dependence
upon a higher power, which at first may be merely the AA
organization, but ultimately should be God as he understands
the concept; d) he must work at rehabilitating other alcoholics.
Effective
Rehabilitation
Alcoholics
Anonymous claims a recovery rate of from 50 to 75 per cent
of those who give its methods a sincere trial, and the majority
of scientific researchers agree that it is the most effective
single course of rehabilitation. Dr. Howard Haggard attributes
the success of AA in part to the need of the alcoholic for
treatment that is understanding, tolerant, patient, and
serious.
“Recriminations
are useless, for the alcoholic has deep within him the strongest
feelings of guilt and responds to them with hostility,”
Haggard says. “They are only further proof that no
one understands him. A high moral tone, preaching, drives
him away. The gift of really understanding the alcoholic,
winning his confidence and co-operation, is often held in
high degree by ex-alcoholics who act as lay therapists or
group therapists as in Alcoholics Anonymous. They have been
through the same experience themselves; they know the feeling
of tension, of discontent, of omnipotence, of guilt, and
of resentment. They know, and forgive, the inevitable ‘slips’;
after the sprees, they are able to maintain their fully
understanding attitude and an unabated confidence.”
Religious
Elements
But
some problem drinkers, particularly those who are unable
to accept the religious elements of the AA plan, prove unresponsive
to it. With a small percentage of these, the Yale Plan Clinic
uses the aversion therapy or conditioned reflex method as
an initial step. This consists of giving the patient a drink
in combination with a medicine which produces nausea; after
several such treatments an association is built up which
makes alcoholic beverages distasteful. The method is useful
as a means of keeping a patient away from liquor for a period
of weeks or months, when it may be renewed, but it does
not clear up the basic maladjustment.
It is this basic maladjustment, a highly individual matter
in each case, which the Yale Group attempts to cope with
as soon as possible through a variety of psychotherapeutic
approaches. After the diagnostic study has been carried
out, the staff tries to fit the therapist to the individual.
If he doesn’t click with one person, he is shifted
to another, for a favorable reaction to the therapist’s
personality is considered highly important in holding the
patient’s faith in a course of treatment. A social
worker may be able to deal with some of the most troublesome
phases of the case; a doctor will be needed for others-difficulties
in the sexual sphere, for example. The sex therapist, Mr.
Raymond G. McCarthy, executive director of the Yale Plan
Clinic, takes on patients who seem likely to respond well
to a series of daily interviews over a period of three months,
through which the patient develops insight into his problem
and is re-educated into a satisfactory pattern of living
which excludes the use of alcohol.
Exact
Figures Unknown
So
far some 1,000 patients have been seen by the two Yale Plan
clinics at New Haven and Hartford. This figure includes
symptomatic drinkers who have been referred elsewhere, and
those who have kept no more than one appointment. About
100 of them were referred to the clinics by the courts,
and of these, not more that ten per cent came back for further
interviews. The Yale group are reluctant to give figures
relating to success. They prefer to talk of the “percentage
in which the drinking pattern has been favorably affected.”
“Of
those who kept coming after the second or third month,”
says Dr. Lolli, “about 70 per cent have been favorably
affected. We can’t even guess how many have stayed
entirely off liquor. We had one patient who went for 18
months without a drink, then went on a binge, and came back.
Was he a failure? No. His drinking pattern had been favorably
affected. He had learned during those 18 months that he
got more enjoyment out of life without drinking than with
it. We can’t consider that one relapse makes a patient
a failure.”
The
Time Will Come
“We
don’t have all the answers yet, by any means,”
Lolli sums up. “But we do feel that we are demonstrating
that the specialized clinic for alcoholics is the most effective
way of meeting the problem. And the best approach is a combined
one-medical, psychological, religious, social. The time
will come when the psychological basis of alcoholism will
be found. Then we will be able to put a finger on predisposing
conditions, perhaps correct them medically or at least convince
people with these conditions that alcohol is poison for
them.”
(Source:
Science Illustrated, June 1948)
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