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Procedure in the Treatment of Chronic Alcoholism
RICHARD R. PEABODY
April 18, 1928
the use of alcohol as a beverage there is a descending scale
of mental as well as physical reaction, increasingly pathological,
beginning with almost total abstinence and ending with delirium
tremens, alcoholic dementia, and death. Just where on this
scale chronic alcoholism begins is open to a variety of
opinion, but for practical working purposes I draw the dividing
line between those to whom a night’s sleep habitually
represents the end of an alcoholic occasion and those to
whom it is only an unusually bag period of abstention. The
former class, which will be referred to as normal, includes
the man who limits himself to a casual glass of beer, as
well as the man who is intoxicated every evening. But at
worst they are hard drinkers, going soberly about their
business in the daytime, seeking escape from social rather
than subjective suppressions, and to be definitely distinguished
from the morning drinkers who are, to all intents and purposes,
chronic alcoholics, inebriates, or drunkards. There are
normal men who occasionally indulge in a premeditated debauch,
and who sometimes start the next day with a drink; but by
and large, the men who can drink and remain psychologically
integrated avoid it the next day until evening (midday social
first glance such a division would seem to be a quantitative
one, but I believe this would be a superficial judgement.
In reality there is a clearly defined qualitative mental
reaction in chronic alcoholism, more closely associated
with narcotics than with the normal use of alcohol.
does not appear that the original impulse to drink is much,
if any, stronger in the chronic alcoholic than it is in
the hard drinker, and I believe that the latter would have
almost as much difficulty in giving up his habit in spite
of his boasting to the contrary; but when it comes to stopping
temporarily, the situation is entirely different. once he
has entered into it the drunkard has a pathological dread
of leaving the alcoholic state.
man said to me the other day, "That first drink in
the morning is the best of all. It makes you feel as if
you were coming back to sanity." Normal drinkers know
nothing of such an experience as that.
it is with the individual to whom alcohol has become a narcotic
that this article is concerned.
course people are not born drunkards, except potentially.
Havelock Ellis states that it is no easy matter to make
a drunkard out of the average man. This transition is often
subtle and slow. It may take place within a year of the
initial indulgence or it may be postponed for twenty years.
The first definite and generally fatal step is taken when
the discovery is made that the mind rather than the body
is suffering from alcoholic excess, and that a drink is
good medicine for this mental suffering. A man then conceives
the idea that he can avoid a nervous depression which he
has become too cowardly to face. If he originally felt the
necessity to escape from reality by getting intoxicated,
reality plus a "hangover" must be avoided at all
costs. I do not believe that the average alcoholic wants
to remain in a state of intoxication, in the same sense,
at any rate, that he wanted to drink in the beginning. He
is constantly rationalizing that he is "tapering off"
and is seldom enjoying his spree after the first or second
day; but he cannot, stand the nervousness and depression
that set in when the narcotic is stopped or even cut down.
He talks of "needing" a drink rather than of "wanting"
one, and when a man "needs" alcohol, he has definitely
reached a pathological stage of drinking.
behavior of the alcoholic is, I believe, better explained
as an abnormal search for ego maximation or self-preservation
than in terms of repressed libido - using libido in the
Freudian sense. There is invariably an inordinate craving
for power in an organism that has proved’ totally
incapable of realizing its cravings. The alcoholic state
takes on the aspect of a simple wish-fulfillment dream.
For the time being - i.e., while drinking - the individual
has caught up with his imagination. In fact, much can be
learned about him by asking him to describe what constitutes
to his mind an ideal debauch. On the other hand, mental
analyses have rarely disclosed anything abnormal or suppressed
in the conscious sex lives of the patients, though I realize
that psychoanalysis has uncovered strong evidence of latent
homosexuality in the, unconscious minds of alcoholics. There
is almost always, however, some degree of inferiority feeling
and often it is extreme. It is a separate and more fundamental
inadequacy than that which alcoholic misconduct itself creates,
through dissipation and shame form such an exceedingly vicious
circle that the whole problem on the surface seems confined
to the symptom itself. The alcoholic is often unconsciously
glad of what he considers a manly excuse to escape his responsibilities
and conceal his weakness. A sober ineffective personality
is unbearable, but there is something heroic about a drunkard.
So he regresses to an infantile state of irresponsibility
in which he imagines himself to be safe, and it is this
regressive factor that accounts, I think, for much of the
childish behavior in those under the influence of liquor.
I tried to explain alcoholism in terms of extroversion and
introversion — i.e., as a disease of introversion.
There were enough alcoholic extroverts, however, to make
such a position untenable, further than to say that alcoholics
who are predominantly introverted outnumber the extroverted
by three or four to one.
digress slightly, while I agree with Professor McDougall
that the introvert drinks to extrovert himself, I must add
that the extrovert drinks for the same reason - that is,
further to extrovert himself, but I disagree with McDougall
when he says that a person is hard-headed in withstanding
the effects of alcohol in proportion as he is introverted.
Better, to say that he is light-headed in proportion to
his, psychological disintegration.
searching for causes, it is necessary to distinguish between
those that merely influence the individual to take up drinking
and those that make him a chronic alcoholic. The former
are too obvious and of too little interest to be a part
of this article. As for the latter, the question of inheritance
naturally arises first. I do not believe and have never
seen it stated that the direct craving for alcohol was transmitted
from one generation to another. In nearly every case, however,
my patients have referred to at least one of their parents
as being nervous or temperamental, and often their abnormal
behavior seems to have been extreme. Therefore, we can reasonably
say, it seems to me, that a nervous system that cannot function
properly under alcoholic stimulation is definitely inherited,
but that is as far as we can hold the parents responsible,
genetically speaking, regardless of their habits.
more important is the early home environment. It is difficult
to say just what part an alcoholic setting plays in the
formation of the child’s character. My own theory
is that it is of less importance than one would imagine.
It may influence him to drink when he matures, but his tendency
to pathological drinking depends on whether he has been
taught to believe in and rely on himself or whether he has
been frightened, neglected, or pampered, thereby growing
up inadequately adjusted to his environment, with attending
feelings of inferiority. Cases of chronic alcoholism in
which the parental attitude toward the child was intelligent
are, rare; more frequently it was decidedly abnormal. Where
exceptions to this theory have been noted, I must confess
I have been at a loss to explain the etiology of the habit.
reason we so seldom find alcoholism combined with a pronounced
phobia, hysteria, or combination is, I think, because alcoholism
has fortuitously occurred as a symptom of an underlying
condition which might just as well have been expressed in
another kind of neurosis. If, as Freud says, the neurosis
is the negative of a perversion, I’ do not see why
it would not be equally truthful to say that chronic alcoholism
is the negative of a neurosis.
say fortuitously, but as a matter of fact it is a rather
natural method of escape from disturbing conflicts because
it is arrived at by a quasi-normal route. An alcoholic is
only doing in an exaggerated way what a large portion of
the normal male public has done for centuries, and he is
not conscious of his pathological condition until its symptomatic
expression is fully developed.
chronic alcoholism is just as definitely a symptom of an
abnormal mental condition, as claustrophobia, the analysis
of alcoholics as a group brings out different states of
mind from those found in more commonly recognized psychoneurotic
instance, that exaggerated concentration on self which characterizes
most neurotics is much less apparent in alcoholics. They
are more interested in life objectively, even though this
interest may be of a non-participating nature. A very large
majority are intellectually as well as morally honest. (Incidentally,
where they are not morally honest when sober, the prognosis
is exceedingly unfavorable.) While they are less fearful
of their condition, they are far less courageous in their
efforts to overcome it. If the average alcoholic had half
the bravery and perseverance of the average neurotic,, his
problem would soon be a thing of the past. This statement
is made because of the apparent ease with which the inebriate
indulges himself, once his mind is made up. There seems
rarely, if ever, to be that heroic struggle so often found
in those suffering from the various psychoneuroses. The
point of view is merely changed and action automatically
follows. That is why, in the treatment of alcoholism, the
mental synthesis must be stressed in contrast to the analysis
that has proved so important in the more typical neuroses.
a man has become a drunkard, it is no easy matter to rehabilitate
him even under the best conditions. It takes at least fifty
and generally nearer one hundred hours of work on the part
of the instructor and an almost perpetual concentration
on the part of the subject. He is taking a course in mental
reorganization and he must never forget it. Therefore, certain
types can be eliminated as unsuitable for treatment. This
includes those who are in any way psychotic, as well as
those who wish to recover temporarily for some ulterior
motive, as, for instance, the pacification of irate parents
by sons eager for an opportunity to renew their excesses,
or of discouraged wives by husbands anxious to keep out
of the divorce court. Another futile group are those who
wish to be taught to "drink like gentlemen," as
the saying goes. There is only one thing a drunkard can
be taught and that is complete abstention forever, and it
is only to those who are sincere and intelligent enough
to comprehend this that the treatment is applicable.
the sane, sincere group and that just referred to there
exists a rather large number of people for whom the prognosis
is most uncertain, further than to say that a cure will
be effected only after a very long and discouraging course
of treatment, if at all. This group I can only designate
by those vague terms "constitutional inferior,"
psychopathic personality," and "peculiar personality."
These people are obviously sane and in their own way sincere,
but they never have been well integrated even before they
indulged in alcohol. They seem to lack sufficient driving
force (libido as the word is used by Jung) to sustain any
plan of constructive thought or action long enough to have
it crystallize into permanently fixed habits. even though
rarely cured in the strictest sense of the word, the alcoholic
outbreaks of these individuals are often restricted to relative
infrequency if they are kept under more or less permanent
describing what the treatment is, mention should be made
of one thing that it is not, and that is ethical exhortation.
patients have invariably been surfeited with preaching,
and they must, be reached by some new approach if their
attention is to be gained and held. Appeals to their self-respect,
warnings as to future mental and physical disasters seldom
do any good. Nor are patients encouraged to give up their
habit for the benefit of anybody else. It may, strike a
romantic note in the beginning, but sooner or later the
person for whom it is given up does something or is imagined
to have done something which gives unconsciously the longed
for excuse to drink. The patient’s problem is to overcome
his habit because he himself believes it to be the expedient
thing to do.
have been cases where the individual has been persuaded
that he wanted to stop drinking as well as shown how to
do it, but it is more satisfactory to deal with people whose
moral problems have been previously settled.
treatment may be subdivided as follows:(1) analysis; (2)
relaxation and suggestion; auto—relaxation andauto-suggestion;
(4) general discussion, which might be called persuasion
in the manner of Dubois or readjustment after McDougall;
(5) outside reading; (6) development where possible of one
or more interests or hobbies; (7) exercise; (8) operating
on a daily schedule; (9) thought direction and thought control
in the conscious mind.
the first interview I try to gain the confidence of the
patient by showing him that his pathological drinking is
thoroughly understoo4 and that he is not going to be treated
by prayer or abuse.
patient is encouraged to give a full account of his past
history and present situation. I try to make the analysis
as thorough as possible, but ‘do not go into the unconscious.
There are cases of compulsive periodic dipsomania, which
would unquestionably require a psychoanalysis, but I have
not met one of them yet. Stekel, I believe, is authority
for the statement that psychoanalysis should be used only
when other methods have failed. As many worries as can be
are removed by helping the patient’ to come to definite
decisions, or at least partially relieved by making as concrete
plans as possible. Some conflicts tend to disappear under
confession, discussions and explanation, and many more are
considerably diminished. This is a most necessary preliminary,
but only a preliminary to the work.
second phase of treatment, relaxation and suggestion, is,
as far as I can determine, what Boris Sidis has called hypnoidal
suggestion, and has been referred to as being particularly
effective in the treatment of alcoholism. The patient is
put into a state of abstraction. He is asked to close his
eyes, breathe slowly, and think of the more prominent muscles
when they are mentioned as becoming relaxed. The cadence
of the voice is made increasingly monotonous, ending with
the suggestion that the patient is drowsier and sleepier.
This lasts for five minutes, and then an equal amount of
time is spent in giving simple constructive ideas.
important also is the application of the same measures by
the individual himself before going to sleep at night. Ideas
that occupy the mind at that time have a particularly effective
influence on the thoughts and actions of the succeeding
importance of this part of the treatment is all out of proportion
in its effect to the time that it takes. Not only does it
have a direct bearing on alcoholism, but it gives the patient
a method of control that is extremely helpful in creating
other changes in his personality, once his habit has been
conquered. In other words, the alcoholic habit being only
a symptom, its removal is only a part of the work. Treatment
of the underlying conditions reorganizes the entire character,
‘with benefits extending far beyond the negative one
of alcoholic abstention.
on the subject of relaxation, which has been considered
in its application for the purpose of influencing the unconscious
mind - that is, in a special sense - I might add that it
has a general bearing on the immediate causes of drinking.
Courtenay Baylor in an excellent little book called Remaking
a Man, now unhappily out of print, sets forth as his central
theme the idea that drinking before all else gives an artificial
release from a tense state of mind, and when this mental
tenseness is removed, the apparent necessity for drinking
is undeniable that two definite states of mind are sought
after by the drinker - calmness and happiness. The childish
pleasure that the alcoholic attains in the early stages
of intoxication can be easily dispensed with when the desire
to give up drinking is genuine, but the release from nervous
tension is a different matter. When a person has been taught
relaxation, he is treating the immediate cause rather than
the symptom itself, which is the first step in removing
the primary conscious cause —i.e., the feeling of
inferiority and fear. The imagined fascination of alcohol
lies in the fact that it is a stimulant and a narcotic at
the same time, psychologically speaking. In other words,
drink soothes as it elates and it elates largely because
it soothes - i.e., relaxes. Barbitol will soothe, but in
a purely negative manner and without any accompanying idea
of elation. Strychnine and coffee will stimulate, but with
so much nervous excitation that their stimulation has little
relationship to escape from reality. Alcohol in the preliminary
stages produces simultaneously the two longed for states
of mind in a way that is unfortunately most seductive to
those who can the least afford artificial stimulation or
is an interesting point that alcoholics as a class, no matter
how cynical they may be, respond to relaxation even more
enthusiastically than other neurotics, though it would seem
that the latter were more in need of it and therefore would
be more impressed by it.
of new interests is obviously a most important part of any
therapeutic treatment. The only way to remove destructive
ideas from a person’s mind is to introduce constructive
ones. For a man to occupy himself solely with the thought
that he is not going to drink would be such a sterile performance
that it would probably not be true, for long at any rate.
An alcoholic has one idea of pleasure, and it is of the
greatest importance that he discovers as soon as possible
that he can enjoy life in many ways outside of intoxication
if he will lift himself to a more intelligent plane of thought
and action. Furthermore; a drunkard has little by little
withdrawn himself from his natural environment, his acquaintance
is apt to be the dregs of society, and drunk or sober, his
constructive interest in things of any value is nil. He
must be made to reach out in many directions to divert himself
from his former negative stereotyped habits.
reason that long periods of being on the conventional "water
wagon" have not changed a man’s point of view
is because the idea of eventual indulgence has kept the
alcoholic conflict alive and thus prevented the creative
urge from becoming attached to some worth-while interest.
It is essential that this normal urge be given adequate
expression. Where it is inhibited through fear or laziness,
its force is not extinguished, but turned inward, creating
a conflict, which symbolically expresses itself in fear,
worry, or boredom. Thus a mental situation is produced that
needs to be soothed and forgotten, and it is perfectly obvious
how the alcoholic is going to sooth and forget it. Until
he rearranges his life so that he no longer perpetually
craves to escape from his inner turmoil, he feels that he
is up against a temptation which he cannot resist, though
he thinks of the temptation as an entity in itself and not
as a symbolic defense against an underlying mental condition.
The creative urge must be legitimately satisfied. Jung,
referring to neurotics in his essay The Ego and the Unconscious,
remarks: "As a result of their narrow conscious outlook
and their too limited existence, they spend too little energy.
The unused surplus gradually accumulates in the unconscious,
and finally explodes in the form of a more or less acute
neurosis." For "neurosis" I think we should
substitute "debauch" without changing the validity
of the statement.
on the subject of interest development, a case recently
finished might be mentioned in which the patient was encouraged
to develop his literary proclivities. One night, while writing
an essay, he became so absorbed in his work that he experienced
the same vital intensity that he had found previously only
in intoxication, and he stayed awake until four o’clock
in the morning to finish it. I felt then for the first time
that sooner or later he would be cured. It proved to be
true. In a short time he obtained research work in a library
and supplemented that by writing book reviews for the newspapers.
As he expressed it, "I am enjoying life for the first
time without rum."
method, obviously, of arousing a normal interest is reading.
There is a short list of books that patients are asked to
read carefully, marking the passages that appeal to them.
These passages are later copied into a notebook along with
some typewritten sheets that are given them, the most important
of which I shall outline when I come to the topic of persuasion.
These books are self—help essays of a practical rather
than a religious or sentimental nature. Arnold Bennett’s
Human Machine, Cosrer’s Psychoanalysis for Normal
People, and James’s monograph on habit are typical
importance of a reasonable amount of exercise each day,
as well as obedience to the ordinary rules of hygiene, cannot
be overemphasized. A mind can function properly only in
a well regulated body, and an alcoholic in process of reorganization
needs to have his mind function as near 100 per cent properly
as he can all the time.
on the subject of hygiene, I might add that precautions
are taken to find out if the individual is as physically
healthy as possible, and if he has not recently been examined,
he is urged to get in touch with his physician. At any rate,
I disclaim any responsibility on the physical side and never
under any circumstances suggest even the simplest medicines.
now come to the most important phase of the treatment, the
central feature to which all others are expected to contribute.
That is thought direction and control. A person literally
thinks himself out of his alcoholic habit, and his ability
permanently to control or direct his thoughts is the determining
factor in his success! or failure. A drunkard is invariably
lost when he takes his first drink, or perhaps it would
be better to say when the determining thought to take the
drink becomes crystallized in his mind. Back of this thought
are a long series of thoughts leading up to it, which, had
they existed in opposite form, would have produced correspondingly
one alcoholic expressed it, "Sometimes I actually find
myself at the bootlegger’s almost without knowing
how I got there, and without, I am sure, intending to go
there." When I showed him his habitual thought processes,
he readily saw how this apparent somnambulism had taken
be more explicit, patients are advised to divert their minds
as much as possible from the whole subject of drinking.
When this diversion amounts to downright suppression - when
it is impossible of accomplishment, as is always the case
in the beginning - then they are most emphatically told
to think of the subject in its entirety, as it exists in
fact. If they, are reflecting on some "wonderful party"
that they have had, then they must pursue it to its conclusion,
and recall as vividly as possible the remorse, the sickness,
and the trouble that came after it, bringing the question
down to the present time. Before leaving the subject, they
must have a complete view of the whole dismal picture. Nothing
is more harmful than thinking or daydreaming in the past,
present or future on the pleasant side of alcoholic excesses.
Whereas, if the alcoholic will review the entire scene,
he will reject the dangerous suggestion that alcohol produces
a truly pleasurable occasion.
drinkers give up trying to justify their behavior, but the
reasoning processes of the great majority are a series of
rationalizations. The excuses range from inheritance to
a cold in the head, and they are all equally futile. The
alcoholic must understand that there, are no excuses for
his taking even one glass of beer. If a man takes a drink,
it is because he wants to take it and not because he is
impelled to do so by some exterior event.
following ideas form the substance of what I have designated
as discussion or persuasion. These thoughts are repeated
over and over again to the patient in one form or another.
first thing to impress on his mind is the fact that he is
a drunkard and as such to be deliberately distinguished
from his moderate or hard-drinking friends; furthermore,
that he can never successfully drink anything containing
alcohol. These points have been already explained, as has
thought direction and control.
spite of much pretense, no work of a serious nature is ever
accomplished until the alcoholic surrenders completely to
the fact just mentioned in regard to never drinking alcohol
in any form or quantity. This surrender to its full depth
is apt to be a difficult thing to accomplish because of
the interference of a distorted pride. A man who is bold
enough to enter a condition that he knows is disgracing
him is ashamed to admit to himself and to his friends that
he has given up the cause of his disgrace. On three occasions
this year I have made inquiry into the sudden favorable
change of attitude on the part of the patient, and each
time I received the answer, "Well, I really never made
up my mind to stop for good before. I never really gave
up on the idea that I couldn’t and wouldn’t
drink some day in the distant future." My reply to
this is ‘that one attitude toward drinking which at
first seems reasonable, but which from long experience has
proved to be disastrous, is that of stopping for only a
limited period of time, no matter how long that period may
be. If a person could refrain from drinking for five years
while diligently reconstructing his thought processes, it
would be sufficient. Unfortunately it has been thoroughly
proven that five years can and does become five minutes
under emotional excitement in a manner that would seem impossible
in moments of calm reasoning.
the theory of treatment is not predicated on will power
except in so far as it applies to carrying out instructions,
it is necessary that the will be used in the early stages
while the new methods are getting thought power upon its
feet. Obviously, new ideas cannot make much headway in a
mind that is constantly befuddled’ with alcohol. Because
in the long run people tend to do as they wish, will power
sooner or later loses in the conflict with desire. Win or
lose, a perpetual conflict in the mind is almost as much
of a handicap as its outward expression in a habit. The
proper control of thinking, therefore, must be established
to obviate the necessity for will power by redirecting the
greatest difficulty in trying to accomplish this is to find
enough things for patients to do when they are absent from
the office. They should consider that they are taking a
course, but because of the simplicity of the work it is
difficult for them to keep their mind on the seriousness
of what they are doing.
is impressed upon them that they must play the part of self-instructor
as well as of student. It is really this instructor element
in them that stimulated their interest in the beginning,
and they must continue to cooperate with me and not expect
that I can do all the work with them in the role of passive
listeners. Regardless of their past record, they must be
made to feel as self—reliant as possible, for in.
the last analysis it is they who must reorganize themselves
while I am only their associate instructor. The reverse
of this necessary self—reliant attitude is, of course,
the main argument against confining a person to an institution.
He is sober there because he cannot be otherwise. His power
of choice is removed by compulsion, with attending humiliation.
Incarceration should never be employed until everything
else has failed and the desperateness of the situation requires
that society be considered first and the individual second.
A situation in which careful physical supervision is necessary
to enable a man to recuperate from long continued excesses
would of course constitute an exception to this statement.
Where the individual willingly goes to an institution as
a means of checking an irresistible compulsion to drink,
the effect is entirely different- i.e., beneficial.
has been found that a most useful aid to reintegration is
to make out a schedule each evening and then follow it faithfully
the next day. It prevents idleness, assists in making the
work concrete, and, what is most important, trains the individual
to execute his own commands. If a person cannot do simple
things and in the manner planned, he has little chance of
overcoming his major temptation. If, on the other hand,
he. forms the habit of carrying out his own instructions,
he creates thereby a disciplined will and an executive state
of mind, so that when the idea of drinking comes to his
attention, there is every chance of it being diverted. An
alcoholic is a specialist at avoiding life, but it is as
rarely his fundamental philosophy to do so, he is in a constant
state of conflict and dissatisfaction; so it is our first
duty to build up a moral that will take care of normal responsibilities
and give him a legitimate feeling of power. Incidentally,
a schedule discloses the limits of laziness and insincerity.
When you find a subject who will not and cannot keep a schedule
that he makes himself, with the understanding that it can
be changed for honest reasons, you can be pretty sure that
you are going to be unsuccessful with him until he changes
his attitude, and you may be somewhat skeptical that he
can change it.
planning is a most important preliminary to a course of
conduct, and for most people it is comparatively easy. But
the majority of alcoholics, in common with neurotics, find
the execution of a plan difficult, even through to a normal
person the plan itself may seem short and simple. As William
James has stated in his essay on habit, once a course of
action has been determined upon, execute it. This applies
to the small things of the alcoholic’s life as well
as the central theme. Many nervous troubles have a common
denominator exaggerated introspection, and the greatest
defense against this weakness is sustained action. The alcoholic
must be able to observe concrete, positive results of his
efforts as a means of maintaining, his interest in the work.
the various methods discussed for combating chronic alcoholism,
it is impossible as well as unnecessary to say which is
the most or the least important. That would vary with the
individual. Each element has its place, and it would not
be fair to several of the elements if one or two were neglected.
The surest way to prolong the work is to avoid the more
distasteful part and then become depressed because the rest,
of it does not produce better results.
no case where a relapse has occurred has it been found that
a person has been cooperating conscientiously. In fact the
usual answer to my query is, "Yes, I must admit that
I have only been making about half an effort. I thought
I was going ahead all right and didn’t need it."
To which I reply that he is getting out of the work just
what he put into it, and that the same ratio will continue
in the future. Hard, faithful work cannot be avoided, as
the habitual thinking of many years is not going to be reversed
in a month or two.
certain progress has been made, there is one bit of sophistry
that the alcoholic has to guard against, and that is the
idea that he is entitled to a vacation. He knows that he
has shown improvement, so he imagines that if he falls temporarily,
those who are interested in him will still feel encouraged,
and such action will not prove fatal to the eventual cure.
There is enough truth to this reasoning to make it a serious
impediment to recovery if it is acted upon.
of this persuasion obviously aims at prevention through
anticipation. Difficulties of which one is forewarned are
not apt to be so dangerous where one is sincerely desirous
of embarking on a new course of behavior. In this connection
there are three points that I wish to bring out.
is generally understood that the best excuses for drinking
are those of an unpleasant emotional nature - anger, worry,
and sorrow. It is not so well recognized, but equally true,
that the pleasant emotions have just as contagious an effect
and in many cases more so. An alcoholic has to learn to
face success with the same fortitude, strange as it may
seem, as he does disaster. Any emotional stimulation has
to be guarded from spreading into, the alcoholic sphere
in order to avoid the return to humdrum reality. It is only
when reality has been made constructively interesting and
the fear of it thereby removed that a patient can stand
normal excitement. Just as one drink leads invariably to
another, so an emotion seems to take the place of the first
drink by producing the same mental condition. This emotional
contagion is an exceedingly important point. It is the cause
of a great deal of unaccounted for alcoholic behavior, behavior
which is often the hardest to control.
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, he evidently feels the need
of a stabilizer to the same extent as he does in dysphoria.
Just as he is bored when he looks inward, so he is frightened
when he looks outward, if the customary scene has changed
even a little.
individual who was prematurely confident of his self control
fell from grace at a recent football game. "When your
team made its first score, you had your first drink,"
I said. He started to tell me it was not until the half
was over, but saw my point before he had finished. "Yes,"
he said. "I never thought of it that way before, but
it is perfectly true. Between the halves that first actual
drink went down with as little compunction as if it had
been the third or fourth ordinarily. I lost my emotional
balance when the team scored and got into the alcoholic
frame of mind before I knew it."
trouble is caused by men trying to force themselves into
an uncongenial environment on the plea that they like it
when intoxicated. As a matter of fact, they like almost
any thing when intoxicated, and nothing when sober. Somewhere
in them is a supposedly genuine discrimination. When a natural
interest is unearthed or a new one acquired, they find that
it is not necessary to enjoy everything, or even many things,
if they will soberly and sincerely expend their energy on
the, few things that catch their imagination and hold their
attention. Where there is no real interest and none can
be created, the difficulty of the problem is tremendously
increased. These obvious truths are mentioned because it
seems to be a part of the treatment to drive home platitudes
as if they were profundities.
victories, strange to relate, have to be watched carefully
or they turn into defeats. Apparently the resistance of
the individual is exhausted by the struggle, and he falls
prey to the suggestion absorbed during it, though the provocative
situation is over. Often a patient bravely resists the "occasion"
itself only to yield a day or two afterwards in a most unexpected
manner. If he does not actually give in to the temptation,
he is more apt to be depressed than elated in spite of his
triumph -that is, of course, temporarily. In the long run
these moral victories are not only helpful, they are the
stepping stones to final success.
year a man asked my opinion about going to a class reunion.
I had misgivings, but I thought I might as well test his
resistance, so it was suggested that of course he could
go. The results were unfortunate, but interesting. The first
two days he drank nothing and was scarcely tempted. The
third day, as he expressed it, "I was taken suddenly
drunk before lunch almost without realizing that I was doing
attitude should the family take while the treatment is going
on, is a question that is invariably asked. The answer is
that friends and relatives should cooperate with the patient
in his own way. If he wants to tell of his work, then show
an interest in it, but if he keeps it to himself, then let
him alone. Avoid all dramatic gestures such as pouring away
the liquor in the house. If it has been his custom in the
past, he should continue to offer drinks in moderation to
his friends as a means of keeping up his self—esteem,
until it is definitely proven that he cannot stand the temptation.
The environment should be made as helpful to the patient
as is practical, but he need not be spoiled or coddled.
course disturbances in the external life that would depress
or worry the normal man have in some cases a decisive influence
on the alcoholic situation and must always be carefully
considered. The environment, however, is not stressed as
much as might be expected because many men show a surprising
ability to cope with unpleasant conditions while completing
the work, and as many others seem incapable of appreciating
an admittedly satisfactory external situation.
does the work proceed? As may have been gathered from what
has been said, very far from smoothly in the beginning,
even with the most intelligent and ambitious subject. It
is essential to caution those immediately concerned that
the friend or relative undergoing treatment will probably
slip several times, and that the size of the slip does not
matter in point of view of time or quantity of liquor consumed.
In fact, if the patient is going to drink at all, he had
much better make a thorough job of it. Anything is preferable
to a "successful one-night stand" from which he
derives the idea that perhaps after all he can drink and
get away with it, or at least learn to drink. As long as
this idea is in his head, the reeducation is brought to
a standstill. I had a patient last year who continued to
get intoxicated at least once a week for two months. This
exaggerated situation was due to the youthfulness of the
subject, and to the fact that he really did not want to
stop when he first undertook the work. But the same thing
to a less degree is liable to happen to any patient in the
beginning, and it does not necessarily mean that the case
is hopeless, if the patient evidences a sincere desire to
continue the work. This discouraging prognosis must on no
account be made to the patient, as he would then be absolutely
certain to live up to what was expected of him. Everything
must be done to make him think that his recent indulgence
was actually the last one.
other words, the alcoholic craving is modified gradually
rather than stopped instantly. This is depressing to all
concerned and particularly to those who have no basis for
comparison and thus hoped that a complete conversion would
take place on the first interview. However, a man who is
willing to make a sincere effort over a sufficient period
of time, even though he cannot be called a very strong character,
seems to develop resistance to alcoholic temptation by eliminating
his tense state of mind and permitting the dissolution of
the temptation in other interests. If, however, he is unwilling
or unable to help himself, then there is nothing that I
can do for him. So it is to the sincere and intelligent,
though not necessarily highly educated, individual that
I am anxious to give my attention.
before the Boston Society of Psychiatry and Neurology, April
18, 1928, and before the Harvard Psychological Clinic, December
14, 1928. The treatment outlined in this article has been
carried on by Courtenay Baylor for seventeen years. I can
never sufficiently acknowledge my debt to him for my ability
to write it. In rewriting the paper helpful suggestions
were received from Dr.G.C.Caner, Dr. H.A. Murray, Dr. Martin
W. Peck, and Dr. Morton Prince.