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A
NEW APPROACH TO PSYCHOTHERAPY IN
CHRONIC ALCOHOLISM
W.
D. Silkworth, M.D.+
New
York, New York
Reprinted from The Journal-Lancet, Minneapolis
July, 1939, Vol. LIX, No. 7, page 312
____________________________________
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 on five 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 over three
hundred.*
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 in 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.
+
Physician in charge, Chas. B. Town’s Hospital, 293
Central Park West, New York City.
* Dr. Silkworth’s
article was published July, 1939. We have taken the liberty
of bringing his figures on our growth up to the present
date. (April 1940).
These
ex-alcoholic men and women number about five hundred. One
group is scattered along the Atlantic seaboard with New
York as a center. Another, and somewhat larger body, is
located 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 principal 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 occurs 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 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 at 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 their own 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 situation 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 particular 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 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 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 what ever 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, 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 seen
the work and must have known these patients before and after
the 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-alcoholic frequently insists, 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, the 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-alcoholic
group. By this time the prospect has self-control, can think
straight, and the approach to him is made casually, with
no intervention by his family or friends. More than half
of this fellowship have 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 some similarity to these outlined above.
An effort is 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 co-operation 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 for the
following reasons:
1. Because
of their alcoholic experiences and successful recoveries
they secure a high degree of confidence from their 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 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 these 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”
five 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 sever hangovers.
But from the moment of my first 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 four years
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 four 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 guest house 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
even when the thought of taking a drink does come, they
react sanely and vigorously.
The 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 effect
his own recovery. He then finds full directions for approaching
and working with other alcoholics. Two chapters are devoted
to 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 many 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.
_________________________________
Houston Press Index
Story of a “Way
Out” for Hopeless Drinkers
Seemingly Allergic
to Drink: Alcoholic's Burden
How it Started
and Gained Speed
Spiritual Aspect
Most Important
Twelve Stages
to Overcome Alcoholism
High Percentage
of Recovery
A New Approach to Psychotherapy in Chronic Alcoholism
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