A Psychological Approach in Certain Cases of Alcoholism
Francis T. Chambers, Jr.
Mental Hygiene, 21:67-78, 1937
I realize that it would be impossible in the short space available to describe the various subdivisions of the psychotherapeutic treatment advocated by the late Richard Peabody, which I am using in treating abnormal drinkers; at best, I could leave only a vague impression of the treatment as a whole. Therefore, I will limit this paper to the approach that may lead up to a successful termination of a very common and destructive addiction.
My work with abnormal drinkers has been made possible by the generous help and cooperation of the psychiatric group and the general practitioners in Philadelphia and its vicinity, as my layman status makes it impossible for me to treat the condition in any but a non-medical field. This has a psychological advantage in that those who consult me, with the approval of a physician, come with a beginning already made.
First, they have admitted that they are abnormal drinkers, an essential admission before treatment can be given.
Second, the suggestion has been given by a physician whom they respect that there is a way to overcome alcoholism for a group of addicts, who are not psychopathic, but who have sprung from a vast legion of psychoneurotics, those so-called nervous individuals who have found that a perverted indulgence of the intoxication impulse may serve as a temporary compensation for a maladjustment of personality. This type of neurotic alcoholic is unwilling to be considered either insane or stupid; for this reason the best approach to a specialized treatment can be made by the physician, who is usually present at the psychological moment when the patient cries for help.
Once a patient has sought aid, the clinical picture of alcoholism permits little opportunity for a misdiagnosis. You distinguish the neurotic from the normal, though perhaps heavy drinker by his inability to control his drinking and the stupidity of his sacrifice of the most valuable things in life for the state of mind produced by his alcoholic indulgence. Usually we find an uncontrolled drinker utilizing self-deception, one phase of which is his forever blaming his addiction on the conditions of his environment. In so doing he is only following in an exaggerated way the same procedure practiced by his controlled-drinking brothers, whose nervous systems are resistant to alcohol.
The controlled drinker usually wishes to have an excuse for indulging himself. He drinks because it is hot, or because it is cold; he drinks to prolong a pleasant occasion, and hi cheers himself up with a drink when he is unhappy. In fact, to him alcohol is a sort of psychic Aladdin’s lamp, which he uses to alter mentality. There is a vast difference between this type and the uncontrolled drinker. The line separating abnormal drinking from social drinking is a matter of the degree to which the drinker is psychologically dependent on the drink. This in itself is a fairly accurate indication whether the personality has or has not made a good adjustment to reality. We find well-adjusted people using alcohol in its accepted legitimate field, and though they may be far more addicted to it than they wish to admit, they are able to limit their indulgence in it to given occasions, because, having made good adjustments to reality, reality is acceptable to them. They may for a little while put on the mask and costume of a psychic harlequin, but after an hour or two they are quite ready to get back into their own more sober psychic garments, even though they know that this change may be accompanied by headache and frazzled nerves. On the other hand, the alcoholic, with his psychoneurotic maladjustment, is searching for the psycho-medicinal properties of alcohol rather than the pleasurable intoxicating effects.
Physicians who are familiar with the anesthetics, ether and chloroform (the medicinally used narcotic intoxicants), have ample opportunity to observe, in the operating room, the exciting phase followed by complete anesthesia. At cocktail hour in any hotel or club bar, you will see the social use of narcotic intoxicants by an earnest group who are searching for and finding the exciting phase and the relaxing phase in a narcotic intoxicant disguised as a highball or a cocktail, and having found this pleasurable phase, they are satisfied. The abnormal drinker in the same situation is getting drunk quickly because he is searching for the anaesthetic properties or deeper narcotizing effects of alcohol. Hence we observe him hurrying through the exciting pleasurable and relaxing phase brought about by drinking in much the manner of one anaesthetizing himself. When you question the abnormal drinker about this peculiarity, he assures you that he did not mean to get drunk, nor did he want to get drunk; and I believe that consciously he means what he says, not recognizing the tact that unconsciously there is a demand for the oblivion of drunkenness, once the higher nerve centers have been affected by alcohol.
The other day one of my friends who was consulting me about his abnormal drinking said, "If you would only say that you could teach the abnormal drinker how to drink in moderation, you would have thousands flocking to your door." This is undoubtedly true, but if I made any such claims, I should be the most unmitigated liar, and those who consulted me would be doing so with no chance of success, for the simple reason that normal intoxication is not what the alcoholic is after, nor is he ever satisfied with it. The proof of this statement is obvious. No one makes these people seek drunkenness, and yet that is the state in which they inevitably arrive, if they use alcohol in any form whatsoever.
It is difficult to give a textbook definition of the underlying neurotic condition that makes alcoholism possible in certain individuals. It is perhaps most nearly covered by the definition of "compulsion neurosis" as given by Professor Horace B.English:
"Group of mental disorders characterized by an irresistible impulse to perform some apparently unreasonable act or to cherish an unreasonable idea or emotion. Generally the patient is not deluded and frankly admits the unreasonableness of his attitude."
This definition would, of course, apply to the alcoholic only when he has been sobered up, as the effects of alcohol may create a delusional state.
The causes of an alcoholic compulsion neurosis are soon apparent in a cooperative patient anxious to aid therapy by unburdening himself of his innermost thoughts and reaction. Usually we find a marked lack of mental hygiene in the early parental environment. Often one or both parents have failed to make adequate adjustments to reality and they pass on to their offspring, by suggestion and tactless handling, a predisposition to maladjustment in maturity.
Citing from cases which I believe I have analyzed correctly, I find overprotection in childhood is often projected into adolescence and maturity as an abnormal dependence on the state of mind produced by alcohol. For instance a mother consulted me about her grown son. She was active in the prohibition movement and a strict disciplinarian in the home, over which she domineered in a tyrannical manner, utilizing her fanatical interpretation of right and wrong to justify her every intolerant attitude. At thirty-one, her son was ruled by, and depended on, his forceful mother. He was still waiting for her to manipulate the puppet strings. At the same time he resented this forced dependence, and so he rebelled and hurt her in her tender spot-prohibition - by seeking escape in chronic alcoholism, ironically enough still depending on her in a way that she decidedly did not like.
Not infrequently the overprotection resulting from inherited wealth seems to turn out ill-equipped personalities that find an escape solution in alcohol. Man rich men, free from the necessity of earning their bread in a business or a profession, seek to suppress their creative urge by substituting alcoholic phantasies. Such men find in alcohol a synthetic existence which apes the give and take of normal life (emphasis always being on the take). This type might be described as perpetual euphoria seekers. They usually must endure a severe alcoholic breakdown before they learn the primary equation of life - that "you can’t get something for nothing."
Among the neurotics who become alcoholic we occasionally find an initial adjustment to a smooth, uneventful environment, with no abnormal dependence on alcohol until an emotional shock is experienced. Then they start searching for a stabilizer and often find it and utilize it with little realization that they have developed a psychopathological addiction; War experiences and business failures have produced a group of these men who might under other circumstances have gone through life as normal drinkers. Occasionally a gonorrhea infection and the mental reaction to it have seemed to herald an abnormal addiction to alcohol. One man traced his narcotic use of alcohol to the fact that, after a severe infection, the doctor who was treating him said that if he started to drink and there was no return of his symptoms, it would be a proof that the condition was cured. He went on a drinking spree and though he had been a controlled drinker up to the time of this incident, he found, after his humiliating experience, that alcohol offered him a solace for the shame and feelings of inferiority which the disease had caused. From this time on, he said, he used alcohol more and more as a psychic cure-all.
Marital discord is often used as a reason for drinking, but this is usually a cart-before-the-horse explanation whose falsity is evident as soon as the patient gains real insight into his personality maladjustment. The truth is that marriage enlarges the field of reality and increases responsibility, the very thing the alcoholic was seeking to. avoid by his narcotic use of alcohol. Hence the conspicuous failures of those women who marry in order to reform their inebriate lovers.
An arrested psychological sexual development is sometimes found at the bottom of discord between wife and alcoholic husband. The husband blames his drinking, of his wife’s lack of affection. The wife, on the other hand, is sexually and growing more so because of the impotency of her husband, which is exaggerated by alcohol. Such a circle becomes ever more vicious, the husband’s sense of inferiority being increased by his wife’s attitude, which further inhibits the possibility of a normal sexual adjustment. To add to the confusion, the husband considers alcohol as an aphrodisiac, not realizing that the drug that narcotizes his inhibitions is equally narcotizing his sexual power, so that metaphorically he is using gasoline to put out a fire. I have recently had the pleasure of seeing a case of this sort gradually work out into a normal adjustment. The insight gained and the readjustment of the personality after reeducation, which was undertaken to overcome the alcoholism, automatically took care of the sexual immaturity. This adjustment could never have been made on any but a non-alcoholic basis.
The double standard of drinking which came about during prohibition has increased the number of feminine inebriates. I have found this condition harder to treat in the limited number of women who consult me. They seem to find it more difficult to be absolutely frank about themselves. However, where they can see the necessity of strict truthfulness and are sincere in their desire to overcome abnormal drinking, they respond to therapy in much the same manner as men. The underlying cause in women and in men is the same - i.e., emotional immaturity, which renders their personalities unequal to the task of facing reality. In their narcotic use of alcohol they find the answer at least temporarily, and to the emotionally immature the temporary solution is sufficient’. This temporary escape from reality is soon extended into days and weeks.
Most of those who wish to take formal steps to overcome their alcoholism are between the ages of thirty and fifty. This is perhaps a psychological time, because under thirty the driving force of youth and a nervous system that can withstand repeated alcohol shocks are reasons for not taking the alcohol problem seriously. After thirty the abnormal drinker gradually becomes aware that his drinking is forcing him to pay an exaggerated price mentally, morally, and physically, and his inability to limit his drinking to even the dissipated variety of indulgence is brought home to him by repeated unsuccessful attempts. By this time the penalty that one must pay for breaking any law of nature has become an obvious fact, no longer to be dismissed with a shrug and a smile as it was in young manhood. In the last analysis, I should say that the instinct of self-preservation is aroused only when the situation is so bad that’ it cannot fail to cause the gravest apprehension and alarm.
Having experienced fifteen years, as a chronic alcoholic, I doubt whether any of us in the alcoholic brotherhood want to get, well without reservations. Alcohol means too much to the man who is using it psycho-medicinally for him to want to give it up in’ its entirety. The best that can be hoped for is that he shall want to get well. Such a state of mind is sufficient at least to get him to consult some one who can show him how to help himself. Whether or not he will undergo treatment is another matter, but usually if he gets as far as this, he is on his way to a more mature handling of his problem. Bringing himself to this point amounts to a formal admission on his part that something definite must be done.
In the first interview with the patient I explain that I have been alcoholic and that I understand and sympathize with what he is going through; after which I ask him to describe his own case in his own way. I take down the history of his case as he gives it. I ask him to state when he realized that his drinking was abnormal. I ask him his reasons for consulting me and get him to describe his early environment and his present environment. This may take several interviews during which I do not commit myself as to whether or not I think he is a fit subject for this type of work. I give him a copy of Richard Peabody’s book, The Common Sense of Drinking, and ask him to mark any passages in it that he thinks are applicable to his case. Though I find that many of these men have read Peabody’s book, they have little more than a superficial understanding of their own problems, probably because, at the time they read it, they were unwilling to project themselves into the position of one in need of treatment. This marking of the book and the subsequent discussions of it put psychotherapeutic treatment on a sound basis from the start. The patient has shouldered the full responsibility of the admission that he is one of those with a nervous system non-resistant to alcohol. It is a form of self-analysis, and the patient usually appreciates, and is impressed by, the fact that he is believed in and to a certain extent is allowed to act as his own analyst.
It has been my experience in this type of treatment that it is best never to attempt to convince a man that he is an abnormal drinker; rather I put it to him that he must convince me, and incidentally himself; that he is in need, of instruction in methods of helping himself. I take my cue from Peabody with this approach, and I remember my own shocked amazement in one of our early talks when he said somewhat as follows: "If you have any, idea that you can still drink in moderation, there is absolutely no use in your consulting me. If you really believe that you can drink in a controlled manner despite what you have been through, the best thing for you to do is to go out and try. Then if you fail, come back to me and I will be glad to go into the matter further." This approach is a shock to most men who have spent many years as abnormal drinkers. Heretofore they have been surfeited with advice as to what they can and what they cannot do. They have been told that they must never have liquor in the house, they must avoid associating with their friends who drink, their wives must under no consideration take anything to drink. Very often they have been advised to leave their environment and attempt to make a new start in a community in which there is no drinking. In the first place, I don’t know of any such community, and in the second place, such advice amounts to telling a man that he is a weakling and advising him to escape reality, which is the very thing he has been attempting to do by his abnormal use of alcohol. The psychological approach which I have found effective is that of accepting the prospective patient as an individual who is perfectly able to stand on his own two feet, provided he will apply himself to the work that is outlined for him in a conscientious manner. It is up to him to prove whether or not he is in need of hospitalization. Many men come to me in bad shape nervously, despite which they say that they can pull themselves up in their own homes. My reply to this is, "Fine, I hope you can. But, if you find you cannot, it is then up to you to admit it, and we will make arrangements for you to go somewhere and get physically and nervously in shape." The purpose of this is twofold - to get the patient to act entirely on his own, and to allow him to determine his own degree of stability or instability. The man who can not pull himself out of an alcoholic rut in his own environment, and who admits it, is in a position to benefit by institutional treatment without the resentment that usually results when outsiders frighten or overpersuade one to go to an institution.
As I wish to keep my contact with the patient on a basis of friendship and mutual trust, I try to be entirely frank and honest in my approach. For instance, I tell him that I am going to instruct his wife, with his full consent, to let me know if he has a relapse. I explain to him that this is not done because I feel that he will not be perfectly honest with me, but because a man who has started to drink and is in the throes of an alcoholic breakdown is not capable of acting in a mature or reasoning manner. I always try to keep the patient informed of the reasons for everything that has to do with treatment. In fact, I consider him more of a student than a patient - a student who his failed to pass the final entrance examination into a mature existence. It is up to him to gain insight as to why he failed and how he can succeed. There is only one thing that will prevent his passing this examination, and that is retaining the state of mind that sought an escape from reality in the use of alcohol. This is the reason why this psychotherapy has been an effective treatment in a great many cases of chronic alcoholism. It is well called reeducation, which is a word implying the possibility of a new and successful adaptation to life. For this reason, the insane and the imbecile must be excluded from the group who may be said to have a favorable prognosis.
If we accept alcoholism as a compulsion neurosis, psychotherapeutic measures at once suggest themselves, and we see that insight, reeducation, and readaption of the personality must be brought about before the condition can be cleared up. This, I think, is the correct approach and one more hopeful and helpful than the defeatist stand so often taken, or the limited objective of keeping a man sober by any means that occur to an adroit mind.
The following quotation from Dr. Abraham Myerson, in his book, The Psychology of Mental Disorders is of interest. He says:
"The alcoholic’s mental disease disappears with abstinence and there is nothing to distinguish him from other people except his reaction to alcohol." I beg to disagree. There are many things, besides his reaction to alcohol, by which he may be distinguished from other people. That reaction is definitely and recognizably abnormal, but so is the state of mind back of that reaction. Peabody referred to the alcoholic’s conflict in sobriety and pointed out that until this conflict - whether or not to drink again - is settled on a lasting basis, nothing of a permanent curative nature has taken place. Settling this conflict once and for all time is not the simple proposition that many non-addicted seem to think. The man who has not experienced the state of mind of alcoholism usually has little realization of the bombardment of alcoholic impulses that besiege such a mind in periods of sobriety. Nearly, every association of life has an alcoholic tie- up. Without alcohol the mental process is a painful one which the addict knows can be temporarily relieved by a reversion to his habit. The state of, mind denied alcohol could be compared to a dull perpetual ache rather than an agony. I asked one man who had been off alcohol for three weeks before he consulted me how often the thought of drinking came up in his mind. "It is much less now," he said, "I only average an alcoholic thought about every fifteen minutes."
The gesture of making a formal effort to give up alcohol creates an added mental conflict. Baudouin, in describing the difficulties of a patient overcoming a neurosis, used a very apt simile which I think is particularly applicable to the man undertaking treatment for alcoholism. He compared the neurotic to one who is learning to ride a bicycle. Ahead of him looms a large dangerous rock and, despite himself, he seems drawn towards it and usually comes a cropper on it. Probably we have all experience this in learning to ride a bicycle, and we know that confidence and technique soon enable us to avoid the rock. To the alcoholic the rock signifies drinking: He wishes to avoid it, yet seems irresistibly drawn toward it. Psychologically the job is to teach him how to ride the bicycle and to show him how to avoid the rock, so that with a new technique he may learn to travel the pleasant road of reality that lies on the farther side.
To sum up the psychological approach to certain cases of alcoholism, the following methods of treating these cases have been of the greatest help to me:
1. Letting the patient convince me, and incidentally himself, that he is an abnormal drinker.
2. Allowing him to pick out his own characteristics in Peabody’s book, The Common Sense of Drinking.
3. Always taking the scientific psychological approach to the problem, which is usually welcomed as a relief from admonitions and emotional approaches.
4. Helping him to gain a psychological insight into his alcoholic problem and discussing his other problems with him during frequent appointments.
5. Instructing him how to relax physically, and mentally and following this with suggestion while he is in a relaxed state.
6. Discussing alcoholic dreams. It is significant that every cooperative patient who has worked with me has, after a period of abstinence, experienced dreams of an alcoholic wishfulfillment nature.
7. Giving the patient for exhaustive study some 80 notes by Richard Peabody which he kindly allowed to use in my work. These notes are of particular interest in that they cover and redirect certain trends of mind that inevitably occur to the man undergoing treatment. The vivid imagination of some of my patients has enabled me to add to these notes from time to time.
8. Mapping out a course of outside study so that it is interesting to the individual case.
9. Systematizing a daily routine, which includes the keeping of a schedule, exercise, recreation, study, business, and hobbies.
The length of time necessary for adequate treatment is usually from 80 to 100 hours over a period of a year. With the beginning of treatment, two or three "hourly appointments a week are necessary. Where patients are in hospital, daily appointments for several weeks, in conjunction with medical care, physio and occupational therapy, and a scheduled existence, constitute an ideal beginning for treatment.
The major advantage of this form of therapy, however, is that it is carried on after the patient has returned to his environment. Here he has a chance to apply his newly learned’ psychological reapproach on the actual battle front, where the real test must take place. It is the adjustment in his environment with a sympathetic instructor that is the most important phase of readjusting the point of view of the chronic alcoholic. The battle front is life, his life, with its sorrows and joys, perhaps complicated by a nagging ,or flirtatious wife, or domineering parents, a vicious business partner, or personal failures and successes, or just monotony and boredom. These are the offensive and defensive engagements that the partially rehabilitated personality must face. It seems reasonable that this best be done with some one who understands the condition and who can discuss the problems of adjustments as they occur, in conjunction with the opening of the mind and reeducation along modern scientific methods.
The successful patient is one who realizes that alcohol is a mental poison for him, and who has learned, by repeated actual experiments over a long period of time, that the technique of, facing reality is a far more pleasant and dividend-paying proposition than finding a miserable escape in alcohol.