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PLACE OF THE LAY THERAPIST IN THE TREATMENT OF ALCOHOLICS
Journal of Studies on Alcohol September, 1944*
When the history of the treatment of problem drinking comes
at last to be written, the pioneer contributions of the
layman will be seen to have been greater than is now generally
supposed. It is intended here to indicate in general what
this contribution has been, and to inquire why certain laymen
as therapists have been able to produce results often denied
to professional persons. The treatment and prevention of
this ailment, in the future, will benefit by an inquiry
regarding the nature of the lay therapists qualifications
and techniques. Such an examination begins with the personalities
who have already been outstanding in this field of effort.
late Richard R. Peabody made a notable contribution to therapy.
Through his students, many of whom became lay therapists
themselves, his techniques have been perpetuated. Most of
them are embodied in his book, The Common Sense of Drinking.
These techniques functioned to bring about-reactions in
the patient which can be classified as surrender, relaxation
and catharsis. Peabody did not call them by these names,
but an examination of his writings, including the "notes"
which he supplied to alcoholics studying with him, shows
plainly that these three responses from his subjects were
the effects of his instruction. How these three elements
are to be found also in the Program of Alcoholics Anonymous,
and in the work of other therapists, is described by the
author of this article in another place. Peabody and his
followers worked out, with their students, nine steps described
by Bowman and Jellinek as follows:
A mental analysis and removal of doubts, fears, conflicts,
created in the past.
Permanent removal of tension, which is only temporarily
released by alcohol, by formal relaxation and suggestion.
Influencing the unconscious mind by suggestion "so
that it cooperates with the conscious to bring about a consistent
intelligent course of action."
control of thoughts and actions.
Daily routine of self-imposed schedule to keep the patient
occupied, to train his will power and efficiency and to
give him the feeling that he is doing something about his
warning the patient against unexpected pitfalls.
Providing the patient with some means of self—expression.
Realization that the same force which drove the patient
to disintegration will, under conditions of sobriety, carry
him beyond the level of average attainment.
Baylor of Boston was specifically credited by Peabody as
his preceptor. Peabody stated: "The treatment. . .
has been carried on by Courtenay Baylor for seventeen years.
I can never sufficiently acknowledge my debts to him for
being able to write it." In his book Peabody quotes
directly from Baylor;
substantiate the theory I have described, quotations from
Mr. courtenay Baylor’s book, "Remaking a Man,"
are pertinent. "I recognized," he writes, "that
the taking of the tabooed drink was the physical expression
of a certain temporary but recurrent mental condition which
appeared to be a combination of wrong impulses and a wholly
false, though plausible philosophy. Further, I believed
that these strange periods were due to a condition of the
brain which seemed akin to a physical tension and which
set up in the processes a peculiar shifting and distorting
and imagining of values; and I have found that with a release
of this "tenseness" a normal coordination does
come about, bringing proper impulses and rational thinking."
again,"Underlying and apparently causing this mental
state (fear, depression or irritability), I have always
found the brain condition which suggests actual physical
tenseness. In this condition a brain never senses things
as they really are. As the tenseness develops, new and imaginary
values arise and existing values change their relative positions
of importance and become illogical and irrational. Ideas
at other times unnoticed, or even scorned become, under
tenseness, so insistent that they become controlling impulses.
False values and false thinking run side by side with the
normal philosophy for a time; and then with the increasing
tenseness the abnormal attitude gradually replaces the normal
in control. This is true whether the particular question
be one of drinking or of giving way. to some other impulse;
the same indecision, changeability, inconsistency, and lack
of resistance mark the mental process. In fact, the person
will behave like one or the other of two different individuals
as he or she is not mentally tense."
then continues to amplify Baylor’s thought:
"We must not overlook one very important but little-recognized
stimulus to drinking. Emotional instability (tension) can
be created by legitimate excitement (such as attending a
football game where the home team is victorious or, for
that matter, by any other form of pleasant emotional stimulation)
just as surely as it can by worry and unhappiness. In fact,
it would be no exaggeration to say that the alcoholic has
to learn to withstand success just as assuredly as he does
misfortune, strange as this statement may seem. Many drunkards
claim that they do not use alcohol as a refuge but as a
means of celebration, and they are probably right as far
as their conscious minds are concerned."
a man under pleasant emotional stimulation seeks narcotic
escape from reality in the same manner as he does from unpleasant
emotions is an interesting question but difficult to answer.
My own theory is that a neurotic is unconsciously, and possibly
consciously, afraid when his emotional equilibrium is disturbed,
no matter what the quality of the disturbance may be. When
he is in a state of euphoria (happiness) he evidently feels
the need of a stabilizer to the same extent as he does in
dysphoria (unhappiness). Just as he is bored when he loooks
inward, so he is frightened when he looks outward, if the
customary scene has changed even a little."
these ideas, first promulgated by Baylor thirty years ago,
have proved their validity down to the present time, is
one of the interesting facts in the history of the lay therapist.
Extensive quotations from ‘Peabody and Baylor appear
in Alcohol, One Man’s Meat, by Edward A. Strecker,
professor of psychiatry at the University of Pennsylvania,
and Francis T. Chambers, Jr., a lay therapist, published
LAYMAN"S SPECIAL QUALIFICATIONS
contributions to theory do not fully explain the layman’s
success in practical application of the principles. Every
recovered alcoholic will acknowledge that the key ideas
caused the revolutionary change in his outlook and behavior
had been presented to him without effect a number of times,
but until he met the right therapist, and perhaps until
he had struck the "rock-bottom" of desperation,
they failed to "click." Since most contemporary
lay therapists are former alcoholics, we do not have far
to seek to learn the reason for the layman’s ability
to get his ideas accepted by the subject. It has been explained
by Foster Kennedy, Director and Chief of the Department
of Neurology and Neuro-Psychiatry, Bellevue Hospital, New
York, in these words:
have no doubt that a man who has cured himself of the lust
for alcohol has a far greater power for curing alcoholism
than has a doctor who has never been afflicted by the same
curse. No matter how sympathetic and patient the, doctor
may be in the approach to his patient, the patient is sure
to feel, or to imagine, either condescension to himself,
or get the notion that he is being hectored by one of the
mere spectator of compulsive drinking can substitute hearsay
knowledge for the conviction born of experience. If a man
has never experienced the joys of alcohol he cannot have
an understanding of its sorrows. Thus, what the lay ex-alcoholic
says to the patient comes with double the force it would
have if said by a psychiatrist, no matter how great his
prestige. In fact, the greater the prestige, perhaps the
greater the resistance of the patient. Rapport can be, and
often is, instantaneous when a former alcoholic acts as
a therapist. What the layman lacks in technique and understanding
can be supplied by training and supported by the continuous
help and supervision of the psychologist, ‘the physician,
and the psychiatrist, what cannot be supplied is his kinship
with the compulsive drinker. He is ideally equipped to break
down the wall of resistance which every alcoholic interposes
to treatment even when he sees it.
James has explained this personality barrier, although in
quite another connection:
"The psychology of individual types of character has
hardly begun even to be sketched as yet — our lectures
may possibly serve as a crumblike contribution to the structure.
The first thing to bear in mind (especially if we ourselves
belong to the clerico—academic—scientific type,
the officially and conventionally "correct" type,
for which to ignore others is a besetting temptation) is
that nothing can be more stupid than to bar out phenomena
from our notice, merely because we are incapable of taking
part in anything like them ourselves."
impulse to heal others is characteristic of almost every
recovered alcoholic by whatever means his abstinence has
been brought about. It would appear that the alcoholic’s
excessive need for importance, praise and attention, described
by Dr. L. S. Sillman of the New York Psychiatric Institute
as a "defiant grandiosity," becomes modified and
converted during and after recovery into a desire to help
those who are suffering as he has suffered. He is further
benefited by learning how to share with others the new and
unexpected values which life now holds for him. This changed
attitude away from egocentricity is reflected in his other
relationships with accompanying benefits which soon become
Kennedy referred to this factor in his comments on the procedures
of Alcoholics Anonymous, previously mentioned. He said:
"The sick man’s association with those who, having
been sick, have become, or are becoming well, is a therapeutic
suggestion of cure and an obliteration of his feeling of
being a pariah; and this tapping of deep internal forces
is shown by the great growth of this sturdy and beneficent
movement. Furthermore, this movement furnishes an objective
of high emotional driving power in making every cured drunkard
a missionary to the sick. These men grow filled with a holy
zeal and their’ very zealousness keeps the missionary
steady while the next man is being cured."
advantage possessed by the recovered alcoholic, which is
of the highest value, is that he will never give up hope.
The vagaries of the patient’s behavior, which are
often difficult for the physician to cope with, are instantly
understood by the layman who "has been there himself."
He cannot forget ‘the numberless times that his friends
and relatives gave up hope for him, to say nothing of the
occasions, still more numerous, when he had no hope himself.
But when the time was right, and ho himself was ready, he
became accessible, and this memory is an unfailing source
of encouragement as he encounters the inevitable vicissitudes
of his cases. So he never gives up the battle and will stay
with the most difficult cases. longer than any other person.
He insight is derived from seeing in the patient before
him a mirror of his own past. This is no place to delve
into the realm of the mystical, but all who have watched
recoveries from this ailment have observed that the faith
of the therapist is a vital part of the treatment. When
we come to fit lay therapists into a formal, organized scheme
of treatment, there will be no lack of candidates. Up to
now, the successful ones have worked independently of Alcoholics
Anonymous, and whose own recovery was otherwise accomplished,
have developed their clientele in a normal and natural way
by producing results which became talked about. First, their
own success with themselves became known to their friends
who, surprised, asked, "How did you do it?" and
thereafter sent alcoholics to hear the story. Of the many
who were called upon to help others, some failed, and some
succeeded. Those who succeeded found, in time, that they
had gained acceptance from medical men and others; and with
increasing referral of cases to them, they often gradually
came to devote more time to this work. It is doubtful whether
those who failed did any serious harm to the few whom they
tried to help; for if their approach was wrong, it apparently
had little effect on the subject either for good or ill.
No man who continuously fails to accomplish his end continues
long on a course of activity. So there has been a weeding
out of the unfit by the course of events.
ideal arrangement for lay therapy would appear to be the
one existing at the Institute of the Pennsylvania Hospital,
where a layman, Chambers, works with a psychiatrist, Strecker,
and has easy access to him. This does not appear to exist
in just this way anywhere else except at New Haven, Connecticut,
where Mr. Raymond G. McCarthy is a member of the staff of
the recently formed Yale Plan Clinic, with medical and psychiatric
services available. At the latter clinic as well as its
counterpart in Hartford, each patient receives both a medical
and psychiatric examination as early as is possible.
the two Shadel Sanitariums located in Seattle, Washington,
and Portland, Oregon, former patients are used as executives,
employees, and field workers. Laymen conduct the original
interview, and the last one on departure. The conduct of
the establishments is under the constant supervision of
medical men. Psychiatric care can be made available if required,
but cases with pathological conditions are avoided. The
conditioned—reflex or "aversion treatment"
is the basis of the procedures at these establishments,
supported by the psychotherapy of the executives, and of
the field men who call upon patients who have returned to
their homes in, the intervals of a year’s treatment
during which patients come back periodically for reconditioning.
Social workers have not been found to be as effectual for
this purpose as patients who have made recoveries at the
recovering alcoholic needs help with such problems as what
to say to friends who invite him to take a drink, what to
tell employers ,on returning to the job, whether to avoid
previous haunts or go to them from time to time, and as
one man put it to a recovered alcoholic, "what in hell
do you do on pay day?" The problem of going through
the festive Christmas and New Years season is often fraught
with difficulty. One who has had to find answers to these
questions for himself is the best person to advise another.
One lay therapist is responsible for a suggestion which
has proved of great value with patients after a period of
hospitalization; it is to change the furniture around so
that the home looks different. It is found that this device
assists in disrupting some of the associations of the former
way of life.
Mr. Chambers connection with the Pennsylvania Hospital as
lay therapist was formed in the year 1935, his opinion was
sought on the preparation of this article. In a letter dated
May 31,1944, he writes:
intelligent lay therapist should have gained deep insight
because of his own alcoholic dependency and recovery. The
therapist who has overcome his drinking problem acts as
a constructive suggestion element. The reeducational treatment
plan that he uses, if it is sound, should afford insight
and stimulation toward readjustment."
lay therapist working withou’ medical support exposes
himself to risks that might make him directly or indirectly
responsible for tragic consequences. From a commonsense
angle, he should not attempt unsupported therapy."
a associate in therapy, he can greatly relieve the heavy
caseload of the already overworked physician in clinic and
qualification should be a two-year period of abstinence,
during which time he has adjusted satisfactorily, in his
social life and vocational field. If after a two-year period
of abstinence, he wishes to become an associate in therapy,
he should have at least a year’s special training.
This training should include courses in a reeducational
treatment plan. He should attend lectures on psychiatry,
such as are given to third year students of medicine at
the University of Pennsylvania by Dr. Strecker. He should
attend lectures given by psychologists so that he would
have an appreciation and understanding of psychometric testing.
A period of nursing would be an invaluable experience in
order to familiarize him with the difficulties of alcohol
withdrawal symptoms. He should attend selected medical lectures
so that he would have an appreciation of the medical aspects
of the problem. If he progresses satisfactorily, he should
be permitted to work with a certain number of alcoholic
patients under the supervision of an experienced therapist.
When undertaking a reeducational treatment plan he should
consider himself as an assistant to the psychiatrist in
charge, and make use of the psychologist’s reports.
He should also be familiar with the facilities offered by
graduate would have benefited himself in many ways. He would
have had experience under the discipline of science, and
learned to respect and depend on the scientific procedure.
He would learn to work with others, both depending on them
and contributing to their effort. More than this, he would
personally benefit by subduing his often exaggerated craving
for importance to a more healthy level."
is obvious that choosing the right caliber person is important.
Emphasis should be laid on quality rather than quantity."
line with Chambers’ suggestions, additional attention
may be paid to educational qualifications. As a candidate
for training, a lay therapist would have an advantage if
he possessed at least an academic bachelor’s degree.
This requirement could be relaxed in instances where high
intelligence, combined with a pronounced record of success
in helping to bring about recoveries, clearly demonstrates
will be excellent if work with alcoholics, or at least observation
of them, continues during the period of instruction, so
that the words and definitions which he is taught in the
classroom will have meaning to him in their manifestations
in human beings.
can learn how to take case histories by actual contact with
patients. Lectures may be accompanied by seminars, and discussions
of these case histories. A social worker will have placed
at the disposal of the therapist studies of the environment
and family relationships. The physician’s findings,
as well as the psychiatrist’s, will be interpreted
to the student at the time they are made available to the
therapist in charge of the patient, and they are made to
mean more to the student if he is allowed to come in contact
with the patient. The teaching should be done as much as
possible with the participation of the student, giving him
little of theory, but reiterating that little, time after
time, by group discussion and contact with individual patients.
invaluable part of the therapist’s education will
be to bring home to him a realization of how little he knows
of the subject matter he has studied. A little knowledge
is not a dangerous thing, if it is known to be little, with
this will come to him also an appreciation of how little
anybody knows, or can ever know, of the psychic mysteries
of the wellsprings of human behavior. He will respect himself
and his colleagues when he finds that those who know the
most make the least claims for what they can do in the treatment
of the psyche. For what is not known is vastly greater than
what is known, and the most experienced psychiatrists often
do not understand just how they produced a favorable result
in one case, or why they failed in another. There is no
machine that will give us an X-ray of the soul. No intelligence
test can tell us what use a person’s emotions will
make of his intelligence. This may be approached some day
when we have a means of determining an emotional quotient
comparable to the intelligence quotient. The Rorschach Test
is a step in this direction for the few who have the education,
training and experience to apply it.
OF THE LAYMAN'S ACTIVITIES
psychiatrists are sympathetic to the need for treating people
whose behavior is within what is considered to be the normal
range, insofar as psychoneurosis or psychosis is concerned,
but who spend much of their time either getting into or
out of trouble with alcohol. These persons are ready made
material for the lay therapist, and they form a considerable
portion of all the cases of problem drinking. The layman
will fail, doubtless, with many patients who are definitely
psychopathic, just as the psychiatrist frequently fails.
Hervey Cleckley, of the University of Georgia School of
Medicine, has provided a series of fifteen case histories
diagnosed as "psychopathic personalities, without psychosis"
and mostly complicated by excessive drinking. He devotes
chapters to the psychopath as a business man, as a man of
the world, as a gentleman, as a scientist, as a physician,
and as a psychiatrist. Repeated hospitalization accomplished
little with these persons. The lay therapist cannot hope
to succeed with many of these.
the competent lay therapist does is to make an analysis
after his own fashion, following a series of interviews
and a study of the history of the case. These judgements
have little in them of formal science, but much of the intuitive
art of influencing human behavior. The competent therapist
looks for the areas of emotional structure in which the
alcoholic’s responses are impaired, confused, or even
wholly absent. To use a homely comparison, the patient is
like a jangling piano. The case, the outer appearance, the
apparent behavior, often appears fine and competent.
touch the keys of C and E. No sound comes forth, part of
the personality, gives no response whatsoever, although
all the keys are there and most of the strings respond with
notes of good quality, when the lay therapist finds that
a patient lacks certain "strings"— due to
a congenital defect or to disease, trauma or degeneration
he promptly sends that patient to a psychiatrist. Perhaps
the psychiatrist can stop the deterioration or repair the
damage. This is a last hope. If he does nothing more, the
psychiatrist may organize a non-taxing environment, write
a simple score for the patient to play.
on the other hand, and as so often happens, the lay therapist
gets a response too faint or too loud from the disordered
alcoholic, or the one that is sharp or flat, he knows that
the fundamental mechanism is still intact, and that eventually
he can repair the instrument. Perhaps the hammers need new
felt, or the damper pedals should be regulated, or a string
here or there needs to be adjusted.
continue the analogy, pianos are made to stand great stress;
the tension of the strings exerts between 15 and 20 tons
of pressure upon their frames. People in the world today
are subjected to severe and continuous tensions and shocks.
Many merely get out of tune. They use alcohol to create
a feeling of inner harmony. But the alcohol causes more
discord. They are the very ones whom the lay therapist can
most readily tune up so that they are again acceptable for
the orchestra of society and may play well for the great
dance of life.
the Yale Plan Clinics it has been found that a number of
inquiries have come from persons who are not alcoholics,
but who have reason to think alcohol is having an increasing
serious effect upon them, and are worried. Groups of Alcoholics
Anonymous also are often called upon to answer the question,
"Am I in danger of becoming an alcoholic?" A lay
therapist is as well qualified to answer such questions,
for all practical purposes, as a psychiatrist, and he can
be used in this way to economize the time of the latter.
Common sense, practical suggestions are often all that are
needed to help the baffled patient over what seem to him
insuperable hurdles; often a quiet talk with the wife, mother
or mother-in—law helps tremendously. The intervention’
here of a social worker is often useless; her suggestions
are not so acceptable as those which come from a person
who tears a leaf out of his own diary and says, "well,
here is what was done in my case." To marshal to the
resolution of these problems the powers of the psychiatrist
would be like bringing up a pile—driver or a steam
hammer to drive a nail. While these difficulties are simple,
they are also crucial, and successful therapy often begins,
and sometimes ends, with their happy solution.
Lay therapists have made a significant contribution to the
treatment of compulsive drinking.
Their chief qualification derives from the fact that they
themselves have made a recovery from this ailment.
They can be made increasingly of use in the future if we
learn how to select them, how to train them, and, recognizing
the scope of their function, learn how to use them in cooperation
with the social worker, the psychologist, the physician
and the psychiatrist.
with permission from Alcohol Research Documentation,
Inc., publisher of the Quarterly Journal of Studies
on Alcohol (now the Journal of Studies on Alcohol and