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