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Rehabilitation of Alcoholics
William D. Silkworth, M.D.
Medical Record, July 19, 1939
is an expanded letter from Silky, parts of which can be
found in the Big Book pages xxiii to xxx called "The Doctor's
a study of carefully recorded histories of alcoholics in
our hospital, two important facts appear to be outstanding.
Expressed briefly, they are:
A majority or our patients do not wish to have an alcoholic
problem. They lead busy lives & would like to enjoy the
fruits of their efforts, but they cannot stop the use
These patients cannot use alcohol in moderation.
allergic nature of true alcoholism was postulated in a previous
paper. We then endeavored to show that alcohol does not
become a problem to every person who uses it, & that the
use of alcohol in itself does not produce a chronic alcoholic.
phenomenon of craving must be present as a manifestation
of an allergy. Once established in an individual, one drink
creates a desire for more. It sets this person aside as
a separate entity. It creates a conflict that ends in a
form of neurosis.
further at the record of these unfortunates, we find that
the majority could not drink in moderation from the very
beginning. Whether 20, 30, or 50 years of age, they soon
become a problem to themselves & to their friends.
in analyzing these alcoholic-minded persons, there is no
one physical or psychical fact that is sufficiently constant
to justify its use as the basis of an accepted theory. Such
phrases as "escape from reality" & "inferiority complex"
hold true for some, but not all, while heredity, only son,
& implied spoiling in childhood, account for a few more.
They all lead to confusion & have no answer.
the constitutional psychopaths, the moral & mental defectives,
& there remains a large class, neurotic in type, for whom
something is worth doing. Remember we are discussing the
chronic alcoholic, not the man who drinks more than is good
for him but has no resulting problem.
all these people - good, bad & indifferent - have one thing
in common: they cannot drink in moderation. We believe they
show manifestations of an allergy to alcohol. They may abstain
from use of alcohol for a month or a year, but on taking
it again in any form, they at once establish the phenomenon
of craving. This fact is well known to all alcoholics &
creates their major problems in the early stages of their
drinking habits. They complain about it, too.
we naturally ask, in the early years of drinking, while
they still have the ability to choose, do these people not
solve this problem by the complete discontinuance of alcohol?
Some do, but many are like the rest of us who do things
we know we should not, but like to do them anyway. Many
really believe they can drink as they see others doing,
& enjoy themselves. For many reasons, most of which are
social or even physical, the idea of drinking is developed
gradually. As this idea advances, daily life becomes more
secure, but these men are unwilling to accept the facts
as presented to them. The act of drinking (in the end damaging)
is followed by certain comfortable emotional states that
make it a pleasure. They prove to themselves that they can
stop drinking by going on the wagon for varying periods,
but even as life becomes more complicated, they still persist
in that old, original idea. Up to this time, in what one
might call the first period of alcoholism there are methods
employed to help these persons return to a normal life &
accept the fact that their old idea of drinking must be
discarded forever. We ourselves have treated some of them
with permanent results, but the majority continues along
the primrose path. The history of these people & their families
present from now on, one of the real tragedies of human
life & is too well known to comment on further here.
begins the second stage. Understood by no one & not understanding
themselves, they enter an ever-widening circle, remorse,
penance, new transgressions, new penance, until they lose
all capacity for spontaneous action. They sacrifice themselves
for a perversive idea & defying the law of nature (allergy)
operating in their case, pay the penalty. They have lost
all pleasure in normal life. Based on their underlying neurotic
nature, they develop a compulsion type of thinking, and,
although not a true compulsion neurosis, it is surely a
borderline type. The patient now acts under what has been
called by Wechsler a psychic imperative, the dreaded terminal
state of paralysis of the will. The predisposing factor
in bringing about this definite state of insecurity is the
conflict brought about by alcoholism.
is not within the scope of this paper to discuss the complications
of the obsessional neurosis, which are, in fact, the most
elastic of all the neuroses, but in this particular type
it seems to permit a retreat from the ever-increasing anxieties
induced by the advancing chronic alcoholism. This compulsive
thinking is apparently a purely intellectual process occurring
more frequently among persons of relatively higher intellectual
attainment, from which class, by the way, comes the average
of all compulsion types of thinking is the relatively good
insight that accompanies them. The victim knows his impulse
to drink is wrong but he is helpless before it. Wives may
plead, friends argue, & employers threaten, but he is no
longer amenable to impression. He is unable to resolve between
opposing impulses. He cries out in agony, "I must stop,
I cannot be like this; but I cannot stop; someone must help
he has sufficient means, he has by now been treated by psychiatrists,
good men, who fully realize the unfavorable prognosis, but
who, often without remuneration, give freely of their time
to help the victim. I have often seen psychoanalysis of
an alcoholic, instead of breaking up the compulsive thinking;
start the person further theorizing on his own illness.
know that, as a rule, the only relief from psychoanalysis
is in making the so-called transfer, & experience has taught
us that this is gratifyingly successful if accomplished.
If successful, it must be based on respect & confidence
on the part of the patient. It can seldom be accomplished
in this class of patients, except by one who has suffered
in the same manner & has recovered. In other words, to accomplish
the transfer of this compulsive idea by the plan we have
seen developed, an ex-alcoholic who has recovered by the
same means be the medium employed. Such a medium can explain
convincingly, not only that the transfer of the compulsive
thinking can be made, but also he can prove how he did it
physicians have realized for a long time that some form
of moral psychology was of urgent importance to alcoholics,
but its application presented difficulties beyond our conception.
What with our ultramodern standards, our scientific approach
to everything, we are perhaps not well equipped to apply
the powers of good lying outside our synthetic knowledge.
four years ago, we hospitalized a young man for severe chronic
alcoholism, &, while under our care he developed a plan
that seemed to me to be a combination of psychology & religion.
He never drank any form of alcohol again.
he requested the privilege of being allowed to tell his
story to other patients &, perhaps with some misgiving,
we consented. The cases we have followed through have been
most interesting: in fact many of them are amazing. The
unselfishness of these men as we have come to know them,
the entire absence of profit motive & their community spirit,
are indeed inspiring to one who has labored long & wearily
in the field of alcoholism. They believe in themselves,
& still more in the Power which pulls chronic alcoholics
back from the gates of death.
course, prior to & in preparation for the application of
this plan, it is, in my opinion, essential to detoxicate
the alcoholics by hospitalization. You then have a subject
whose brain is clear & whose mind is receptive & temporarily
free from his craving. I hesitate here to attempt even an
outline of the plan as employed by these men. Sufficient
to say, perhaps, that following many failures, they gradually
devised a plan or procedure that led them to make this so-called
transfer to one greater than themselves, to God.
whole story is admirably told in a book written by them
entitled "Alcoholics Anonymous". It would seem to me that
they have wrung from the Eternal a new application of an
old truth that is sufficient equipment to restore the patient
in his fight for sobriety. The results seem to flow naturally
from a follow-up of honest effort.
make any such plan practical they have also projected this
transfer beyond the individual to the group. The information
of these men into groups, each one with the hand of fellowship
passing on his experiences to others, helping those who
have newly joined to adjust themselves, actively engaged
in gathering in new members, seems to me the most practical
application of their moral psychology, to assure their "transfer"
of being permanent. (Although I have met some 30 or more
of these ex-alcoholics. I relate my experience with two
one year prior to this experience a man was brought in to
be treated for chronic alcoholism. He had but partially
recovered from a gastric hemorrhage & seemed to be a case
of pathological mental deterioration. He had lost everything
worthwhile in life, & was only living, one might say, to
drink. He frankly admitted & believed that for him there
was no hope. Following the elimination of alcohol there
was found to be no permanent brain injury. He accepted the
plan outlined in the book. One year later he called to see
me, & I experienced a very strange sensation. I knew the
man by name & partly recognized his features, but there
all resemblance ended. From a trembling, despairing, nervous
wreck, had emerged a man brimming over with self-reliance
& contentment. I talked with him for some time, but was
not able to bring myself to feel that I had known him before.
To me he was a stranger, & so he left me. More than three
years have now passed with no return to alcohol.
I need a mental uplift, I often think of another case brought
in by a physician, prominent in New York City. The patient
made his own diagnosis, & deciding that his condition was
hopeless, had hidden in a deserted barn, determined to die.
He was rescued by a searching party, & in desperate condition
brought to me. Following his physical rehabilitation, he
had a talk with me in which he frankly stated he thought
the treatment a waste of time & effort, unless I could assure
him, which no one ever had, that in the future he could
have the will power to resist the impulse to drink. His
alcoholic problem was so complex, & his depression so great,
that we felt his only hope would be through what we then
called "moral psychology," & we doubted if even that would
have any effect. However, he did adopt the ideas contained
in this book. He has not had a drink for more than three
years. I see him now & then, & he is as fine a specimen
as one could wish to meet.
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