A New Approach to Psychotherapy in Chronic Alcoholism
Silkworth, W.D., New York, N.Y.
JOURNAL-LANCET, Vol.46, July, 1939
The beginning and subsequent development of a new approach to the problem of permanent recovery for the chronic alcoholic has already produced remarkable results and promises much for the future this statement is based upon four years of close observation. As this development is one, which has sprung up among alcoholic patients themselves and has been largely conceived and promoted by them, it is felt that this new treatment can be reported freely and objectively.
The central idea is that of a fellowship of ex-alcoholic men and women banded together for mutual help. Each member feels duty bound to assist alcoholic newcomers to get upon their feet. These in turn work with still others, in an endless chain. Hence there is a large growth possibility. In one locality, for example, the fellowship had but three members in September, 1935, eighteen months later the three had succeeded with seven more These ten have since expanded to ninety.
It is much more than a sense of duty, however, which provides the requisite driving power and harmony so necessary for success. One powerful factor is that of self-preservation. These ex-alcoholics frequently find that unless they spend time helping others to health they cannot stay sober themselves. Strenuous, almost sacrificial work for other sufferers is often imperative in the early days of their recovery. This effort proceeds entirely on a good will basis It is an avocation. There are no fees or dues of any kind, nor do these people organize in the ordinary sense of the word.
These ex-alcoholic men and women number about one hundred and fifty. One group is scattered along the Atlantic seaboard with New York as a center. Another, and somewhat larger body, is locate in the Middle West. Many walks of life are represented, though business and professional types predominate. The unselfishness, the extremes to which these men and women go to help each other, the spirit of democracy, tolerance and sanity which prevails, are astonishing to those who know something of the alcoholic personality. But these observations do not adequately explain why so many gravely involved people are able to remain sober and face life again.
The principle answer is each ex-alcoholic has had, and is able to maintain, a vital spiritual or "religious" experience. This so-called "experience" is accompanied, by marked changes in personality. There is always, in a successful case, a radical change in outlook, attitude and habits of thought, which sometimes occur with amazing rapidity, and in nearly all cases these changes are evident within a few months, often less.
That the chronic alcoholic has sometimes recovered by religious means is a fact centuries old. But these recoveries have been sporadic, insufficient in numbers or impressiveness to make headway with the alcoholic problem as a whole.
The conscious search of these ex-alcoholics for the right answer has enabled them to find an approach, which has been effectual in something like half of all the cases upon which it has been tried. This is a truly remarkable record when it is remembered that most of them were undoubtedly beyond the reach of other remedial measures.
The essential features of this new approach, without psychological embellishment are:
1. The ex-alcoholics capitalize upon a fact, which they have so well demonstrated, namely: that one alcoholic can secure the confidence of another in a way and to a degree almost impossible of attainment by a non-alcoholic outsider.
2. After having fully identified themselves with their "prospect" by a recital of symptoms, behavior, anecdotes, etc., these men allow the patient to draw the inference that if he is seriously alcoholic, there may be no hope for him save a spiritual experience. They cite their own cases and quote medical opinion to prove their point. If the patient insists he is not alcoholic to that degree, they recommend he try to stay sober in his own way. Usually, however, the patient agrees at once. If he does not, a few more painful relapses often convince him.
3. Once the patient agrees that he is powerless, he finds himself in a serious dilemma. He sees clearly that he must have a spiritual experience or be destroyed by alcohol.
4. This dilemma brings about a crisis in the patient's life. He finds himself in a position, which, he believes, cannot be untangled by human means. He has been placed in this position by another alcoholic who has recovered through a spiritual experience. This peculiar ability, which an alcoholic who has recovered exercises upon one who has not recovered, is the main secret of the unprecedented success, which these men and women are having. They can penetrate and carry conviction where the physician or the clergyman cannot. Under these conditions, the patient turns to religion with an entire willingness and readily accepts, without reservation, a simple religious proposal. He is then able to acquire much more than a set of religious beliefs; he undergoes the profound mental and emotional change common to religious "experience" (See William James' Varieties of Religious Experience). Then too, the patient's hope is renewed and his imagination is fired by the idea of membership in a group of ex-alcoholics where he will be enabled to save the lives and homes of those who have suffered as he has suffered.
5. The fellowship is entirely indifferent concerning the individual manner of spiritual approach so long as the patient is willing to turn his life and his problems over to the care and direction of his Creator. The patient may picture the Deity in any way he likes. No effort whatever is made to convert him to some particular faith or creed. Many creeds are represented among the group and the greatest harmony prevails. It is emphasized that the fellowship is non-sectarian and that the patient is entirely free to follow his own inclination. Not a trace of aggressive evangelism is exhibited.
6. If the patient indicates a willingness to go on, a suggestion is made that he do certain things which are obviously good psychology, good morals and good religion, regardless of creed.
a. That he make a moral appraisal of himself, and confidentially discuss his findings with a competent person whom he trusts.
b. That he try to adjust bad personal relationships, setting right, so far as possible, such wrongs as he may have done in the past.
c. That he recommit himself daily, or hourly if need be, to God's care and direction, asking for strength.
d. That, if possible, he attend weekly meetings of the fellowship and actively lend a hand with alcoholic newcomers.
This is the procedure in brief. The manner of presentation may vary considerably, depending upon the individual approached, but the essential ingredients of the process are always much the same. When presented by an ex-alcoholic, the power of this approach is remarkable. For a full appreciation one must have known these patients before and after their change.
Considering the presence of the religious factor, one might expect to find unhealthy emotionalism and prejudice. This is not the case however; on the contrary, there is an instant readiness to discard old methods for new ones, which produce better results. For instance, it was early found that usually the weakest approach to an alcoholic is directly through his family or friends, especially if the patient is drinking heavily at the time. The ex-alcoholics frequently insist, therefore, that a physician first take the patient in hand, placing him in a hospital whenever possible If proper hospitalization and medical care is not carried out, this patient faces the danger of delirium tremens, "wet brain" or other complications After a few days' stay, during which time the patient has been thoroughly detoxicated, the physician brings up the question of permanent sobriety and,' if the patient is interested, tactfully introduces a member of the ex-alcoholics group. By this time the prospect has self-control, can think straight, and the approach to him can be made casually, with no intervention by family or friends. More than half of this fellowship has been so treated. The group is unanimous in its belief that hospitalization is desirable, even imperative, in most cases.
What has happened to these men and women? For years, physicians have pursued methods, which bear same similarity to those outlined above. An effort is being made to procure a frank discussion with the patient, leading to self-understanding. It is indicated that he must make the necessary re-adjustment to his environment. His cooperation and confidence must be secured. The objectives are to bring about extraversion and to provide someone to whom the alcoholic can transfer his dilemma.
In a large number of cases, this alcoholic group is now attaining these very objectives because their simple but powerful devices appear to cut deeper than do other methods of treatment because of the following reasons:
1. Because of their alcoholic experiences and successful recoveries they secure a high degree of confidence from the prospects.
2. Because of this initial confidence, identical experience, and the fact that the discussion is pitched on moral and religious grounds, the patient tells his story and makes his self-appraisal with extreme thoroughness and honesty. He stops living alone and finds himself within reach of a fellowship with whom he can discuss his problems as they arise.
3. Because of the ex-alcoholic brotherhood, the patient, too, is able to save other alcoholics from destruction. At one and the same time, the patient acquires an ideal, a hobby, a strenuous avocation, and a social life, which he enjoys among other ex-alcoholics and their families. These factors make powerfully for his extraversion.
4. Because of objects aplenty in whom to vest his confidence, the patient can turn to the individuals to whom he first gave his confidence, the ex-alcoholic group as a whole, or the Deity. It is paramount to note that the religious factor is all-important even from the beginning. Newcomers have been unable to stay sober when they have tried the program minus the Deity.
The mental attitude of the people toward alcohol is interesting. Most of them report that they are seldom tempted to drink. If tempted, their defense against the first drink is emphatic and adequate. To quote from one of their number, once a serious case at this hospital, but who has had no relapse since his "experience" four and one-half years ago:
"Soon after I had my experience, I realized I had the answer to my problem. For about three years prior to December 1934 I had been taking two and sometimes three bottles of gin a day. Even in my brief periods of sobriety, my mind was much on liquor, especially if my thoughts turned toward home, where I had bottles hidden on every floor of the house. Soon after leaving the hospital, I commenced to work with other alcoholics. With reference to them, I thought much about alcohol, even to the point of carrying a bottle in my pocket to help them through the severe hangovers. But from the first moment of my experience, the thought of taking a drink myself hardly ever occurred. I had the feeling of being in a position of neutrality. I was not fighting to stay on the water wagon. The problem was removed; it simply ceased to exist for me. This new state of mind came about in my case at once and automatically. About six weeks after leaving the hospital my wife asked me to fetch a small utensil, which stood on a shelf in our kitchen. As I fumbled for it, my hand grasped a bottle, still partly full. With a start of surprise and gratitude, it flashed upon me that not once during the past weeks had the thought of liquor being in my home occurred to me. Considering the extent to which alcohol had dominated my thinking, I call this no less than a miracle. During the past your pears of sobriety I have seriously considered drinking only a few times. On each occasion, my reaction was one of fear, followed by the reassurance, which came with my new found ability to think the matter through, to work with another alcoholic, or to enter upon a brief period of prayer and meditation. I now have a defense against alcoholism which is positive so long as I keep myself spiritually fit and active, which I am only too glad to do."
Another interesting example of reaction to temptation comes from a former patient; now sober three and one-half years. Like most of these people, he was beyond the reach of psychiatric methods. He relates the following incident:
"Though sober now for several years, I am still bothered by periods of deep depression and resentment. I live on a farm, and weeks sometimes pass in which I have no contact with the ex-alcoholic group. During one of my spells I became violently angry over a trifling domestic matter. I deliberately decided to get drunk, going so far as to stock my guesthouse with food, thinking to lock myself in when I had returned from town with a case of liquor. I got in my car and started down the drive; still furious. As I reached the gate I stopped the car, suddenly feeling unable to carry out my plan. I said to myself, at least I have to be honest with my wife. I returned to the house and announced I was on my way to town to get drunk. She looked at me calmly, never saying a word. The absurdity of the whole thing burst upon me and I laughed and so the matter passed. Yes, I now have a defense that works. Prior to my spiritual experience I would never have reacted that way."
The testimony of the membership as a whole sums up to this: For the most part, these men and women are now indifferent to alcohol, but when the thought of taking a drink does come, they react sanely and vigorously.
This alcoholic fellowship hopes to extend its work to all parts of the country and to make its methods and answers known to every alcoholic who wishes to recover as a first step, they have prepared a book called Alcoholics Anonymous*. A large volume of 400 pages, it sets forth their methods and experience exhaustively, and with much clarity and force. The first half of the book is a text aimed to show an alcoholic the attitude he ought to take and precisely the steps he may follow to affect his own recovery. He then finds full directions for approaching and working with other alcoholics. Two chapters are devoted to working with family relations and one to employers for the guidance of those who surround the sick man. There is a powerful chapter addressed to the agnostic, as the majority of the present members were of that description. Of particular interest to the physician is the chapter on alcoholism dealing mostly with its mental phenomena, as these men see it.
By contacting personally those who are getting results from the book, these ex-alcoholics expect to establish new centers. Experience has shown that as soon as any community contains three or four active members, growth is inevitable, for the good reason that each member feels he must work with other alcoholics or perhaps perish himself.
Will the movement spread? Will all of these recoveries be permanent? No one can say. Yet, we at this hospital, from our observation of many cases, are willing to record our present opinion as a strong "Yes" to both questions.
*EDITOR'S NOTE. The book, Alcoholics Anonymous ($3.50) may be secured from The Alcoholic foundation, Post Box 658, Church Street Annex, New York City.
JOURNAL-LANCET, Vol.46, July, 1939