INSTITUTE OF PASTORAL PSYCHOLOGY, 1957
A PSYCHIATRIST'S VIEWPOINT
ADELE E. STREESEMAN
My particular relationship to Alcoholics Anonymous is that of a psychiatrist who has seen their miracles at first hand. We psychiatrists are used to miracles. There is, for a doctor, no joy like that of watching the slow growth into health and confidence of a miserably unhappy, confused and panic-ridden patient. As an analyst, I see every year the deep emotional re-education we call psychoanalysis take hold, grow and endure to maturity.
Why cannot we do this with the acute alcoholic? Why can A.A. do it? Why is it so often true that the active, heavy drinking alcoholic - angry, confused, often without money, usually drunk, belligerent, hopeless, hiding a deep conviction of worthlessness behind an offensive arrogance - why is he no candidate for psychotherapy? He needs help. Why does he resist it?
WHAT A-A- DOES FOR THE ALCOHOLIC
It is astonishing to me, now, that we psychiatrists did not see the "why" right away. It is because he cannot trust us - he cannot trust anyone, really. Our first step in any psychotherapy is establishing what we call a transference. The patient transfers to us, for the purpose of a similar emotional education to that of early childhood, an abiding faith in us - so that he takes again the faltering steps of daring to live, of daring to be himself, of daring to make a mistake, or daring to question, of daring to learn, of daring to believe that we will not desert him, and that we will not let him fall as he starts on his journey of growing up all over again.
The alcoholic, as he begins his climb to sobriety, cannot possibly do all this. He trusts, implicitly, no one. It is often even hard for him to trust and love God, his fear of Him is so great. Also, I am reminded of the deep truth of the ancient question: "If a mam love not his brother, whom he hath seen, how can he love God whom he hath not seen?" The alcoholic cannot establish a transference - cannot easily love and trust his brother, and relate, as a child, to the strange doctor, labeled psychiatrist.
But the alcoholic can, even in his despair, open the door of his personality just a little crack, tentatively, to another alcoholic. He does not fear moral condemnation, nor the equally obnoxious saintly, stooping, forgiveness, if it comes from another drinker who has lived in the same hell as himself. He can feel a kinship with another human being, and he has been alone so long. Hence we have the beginning of that valuable thing we psychiatrists (who love to label things) have labelled "interpersonal relationship." This is, to some, the essence and firm foundation of A.A. It establishes and maintains relationships.
The next big step toward health is the gradual loss of that sense of uniqueness most patients have. As you go to A.A. meetings and meet more and more people, suddenly the world is full of problem drinkers, of alcoholics. Among your friends and family you have been a leper, a pariah, an unbelievable catastrophe. But in A.A. meetings, you hear your own story over and over. You begin to feel free to explore this strange phrase "compulsive drinker." Even being called an "addictive personality" by another in the same boat does not make you fighting mad. With lots of company, you dare to take inventory, to explore your own personality, to find out your soft Spots, to read the danger signals and to recognize and accept a limitation in living that you share with all other true alcoholics, that you cannot take the first drink, because you are an addict.
ALCOHOLISM IS AN ADDICTION
A.A. has done a wonderful job in establishing clearly that fact - that alcoholism is an addiction. No doctor, no psychiatrist would tell a heroin or morphine addict that now, since he has been off the drug for four or five years, he can take a little now and then. But I still see patients in my office, alcoholics, who have been told by well meaning psychiatrists that they can become social drinkers after they solve the conflict underlying the drinking problem.
Fortunately, more and more doctors are learning about alcoholism. The New York Medical Society on Alcoholism is both learning and trying to spread learning in this field and fewer patients are chasing the mirage of "social drinking." We have long known "once an addict, always an addict" - and since we now understand alcoholism as an addiction, it follows inevitably that "once an alcoholic, always an alcoholic." Perhaps some day, in the dim and distant future of greater knowledge, this may not be so, but for us now, with our present light, it is clearly established.
This fact - that total abstinence is for always - brings in its wake another need - the need of continued vigilance, of renewed reminders. If the far-away causes of alcoholism in the personality have not been removed (and we certainly do not yet know how to do that), then the danger of those old sleeping conflicts being stirred up and reactivated will always remain. This is true - but this is not frightening. A.A. is ever available and most A.A.'s sense the need for continued fellowship in A.A.
THE SPIRITUAL ELEMENT IN A.A.
Moreover, something else - something big and wonderful and unbelievable happens as one goes along in A.A. The fight gets easier as the fighter gets stronger. An imperceptible change is seen in the alcoholic. No one is trying to convert him to anything, but he is changing, spiritually. The A.A. program has no credal affiliation, but it insists that you call upon your God, as you know Him, to help you in your struggle for significance and dignity.
In my opinion, not only as a believer in a living God - but as a psychiatrist, there is no significance or dignity for man in a materialistic, godless world. In my experience as a psychiatrist, a patient must always come to grips with his own deepest personal philosophy of life - its ultimate meaning and significance, before he is whole. What that philosophy is, be he Jew or Gentile or what-have-you, is none of my business. But find it for himself he must. I have had patients of all faiths, as A.A. has members members of all faiths. I must not determine the goal, but I must help him to find his own goal, however he spells it.
Learning how to live seems very unimportant if there is no meaning in living, nothing to live for but the little immediate material joys - no bigness, no significance. If man is just a little blob of protoplasm, mushrooming up to full size and then fading out, wallowing meanwhile in a sea of self-made miseries and fighting the elements, it all doesn't seem worth a long psychotherapy program, or even a striving to sober up. It must be remembered that science and psychiatry concerns itself with method, with "How to," never with objectives to be reached, never with "Why." This is the business of the patient himself - but we psychiatrists have been too slow in saying that the last touch of synthesis after analysis, that last job of spelling it all out in terms of meanings - is imperative. I always like to pay tribute to one psychiatrist, Smiley Blanton, who dared spell it out - who did content himself with just teaching a patient how to love, maturely - but gave mature loving its inescapable alternative in the superb title of his book Love or Perish (Blanton, 1956).
The glory of A.A. and, to me, the deepest and strongest reason for its success, lies in its insistence on the spiritual growth of the alcoholic. Like the psychiatrist, it does not chart creeds - but it suggests, over and over, that you find your own chart, your own pathway, to what you call God.
I heard a distinguished teacher of psychiatry, in a lecture on alcoholism, say that the addictive personality is a pigmy at heart - who uses alcohol over and over, to turn himself into a giant, and who needed ever more and more of the stuff in order to accomplish that feat. He gave no formula for cure, for the reversal of trend. I ask, in rebuttal, what turns all of us pigmies into giants, automatically? The answer is simple, the fatherhood of a living God - living today and loving us.
I think often of the alcoholic when I remember Paul saying - as says the alcoholic in his despairing heart "of myself I am nothing" - but then goes on to say with a leap into the grandiose "but I can do all things (all mind you) through Christ who strengtheneth me." This is to me the secret of A.A.'s steady growth - whether you worship the God of Paul, or the God of Moses and Abraham, or whether you call him Allah. You achieve dignity and significance and you hold on to it and grow quietly because you are rooted in a firm, no-longer-debatable conviction of your own worth and your own potential.
In summary, I would recapitulate. To a psychiatrist who has had close contact with A.A., and we have had many alcoholics as patients, A.A. appears theoretically sound and impressively successful in achieving and maintaining true sobriety. It attacks the drinking problem directly, head on. No therapy of any kind is possible while the patient is in an alcoholic fog. It offers the alcoholic a desperately-needed opportunity to relate to other human beings on a more-or-less equal basis. It continues to provide the means of maintaining sobriety, after achieving it. Finally, it insists on the importance of spiritual growth and spiritual health as the sine qua non of any true health at all. It is not a religion, but it values the objectives of religion - that is, it sets its sights far higher than just keeping one sober and alive and functioning. It aims at helping others through twelve step work and thus gives altruism and dignity to all of its effort. It lifts the work of A.A. beyond self-preservation into nobility.
Truly I believe "God works in mysterious ways - His wonders to perform" and truly I believe A.A. is one of His modern miracles, worked, as so many miracles were, through his favorite medium, mankind.