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and Comparison of Three Treatments
FOR ALCOHOLISM: ANTABUSE, THE ALCOHOLICS ANONYMOUS APPROACH,
Journal of Addiction, Vol. 50, 1953
FRANCIS T. CHAMBERS, Jr. of the Philadelphia Hospital Institute
1935 I joined the staff of the Institute of the Pennsylvania
Hospital, and with the generous support of the senior staff
members endeavored to work out a treatment plan to be available
for those seeking help for acute problems. This plan had
the then unique characteristic of being a positive, rather
than a negative approach. By and large, at this period,
most treatment consisted of the facilities offered by rest
homes and "cures", where the whole emphasis was
placed on sobering a man up. Temporary sobriety having been
achieved, he was then discharged with little or no understanding
of himself or his problem.
Edward A. Strecker, who held the Chair of Psychiatry at
the University of Pennsylvania, collaborated with me in
writing ALCOHOL: One Man’s Meat, published in 1938.
This book, because it presented a positive treatment plan,
had the effect of stimulating a more optimistic approach
toward the problem, and we were deluged by requests for
help. We did not have the necessary staff, facilities, nor
the economic support that would have made help available
for all. Fortunately, the Alcoholics Anonymous movement
became active at about this time, and has contributed a
great deal of help for many alcoholic addicts who could
not have received it in any other way.
Read before the Society for the Study of Addiction at the
rooms of the Medical Society of London, 11 Chandos Street,
W.l., on Tuesday, 26 August, 1952, the President, Dr. G.
W. Smith, being in the Chair.
1949, Antabuse was introduced in our country for controlled
study, and in 1951 it was released to the medical profession.
This release was introduced in part by the following paragraph:
the drug that builds a ‘chemical fence’ around
the alcoholic, is now available for general prescription
use in the fight against the Nation’s number one emotional
sequence, then, we see three positive approaches, each of
which was met by great optimism on the part of the public.
This optimism has been tempered by the sobering fact that
each one of these approaches had, along with successes,
many failures, and did not live up to the hope engendered
by wishful thinking. This does not mean that Antabuse should
be discarded as a treatment measure because there are failures,
and sometimes fatal failures; nor does it mean that those
who fail to respond to the Alcoholics Anonymous group movement
indicate that the A.A. is not a helpful measure; nor again
does it mean that psychotherapy should be discarded because
it, too, has failures. There is in the United States a number
of treatments other than those we are discussing. Dr. Abraham
Myerson points out: "The treatment of the individual
case has at this time some twenty varieties, ranging from
Alcoholics Anonymous and frank religious exhortation to
spinal fluid drainage, benzedrine sulfate and the conditioned
reflex, not forgetting psychoanalysis, psychotherapeutics,
and shock therapy." Add to this the many advertised
cures in sanitariums and health farms, and one sees how
bewildering the burden of choice can be to the patient or
his family seeking help.
us first analyze Antabuse as a treatment measure. Bear in
mind that it was introduced as "the drug that builds
‘chemical fence’ around the alcoholic."
We must first ask ourselves: what about the individuals
who do not wish a fence built around them, and is it always
wise to do so? In reference to the first group, who do not
wish to be protected, there is in the United States not
a legal statute to enforce this means toward total abstinence.
connection with this point whether or not it is always wise
to build a chemical fence around the alcoholic, my associates,
Dr. Edward A. Strecker and Dr. Vincent T. Lathbury, have
discussed two patients in whom the experimental use of Antabuse
was followed by a psychotic reaction. A like reaction was
discussed by Dr. 0. Martensen—Larsen, and more serious
effects by Dr. Erik Jacobsen of Denmark.
Jacobsen says, in part, that the "effective deprivation
of alcohol without adequate psychotherapy can be just as
dangerous as the untoward effects of disulfiram." In
the same article, Dr. Jacobsen reports that there were 17
fatal cases following treatment with Antabuse among 10,000
patients. Of this total, he cites five cases of death were
due to sudden, unexplained causes. Deaths following the
administration of Antabuse are cited by R. 0. Jones, M.
C. Becker and G. Sugarman, and D. M. Spain, V.A. Bradess
and A.A. Eggston. I am quoting only in part from the available
literature dealing with such unfavorable reactions.
then, we have three contraindications to the use of Antabuse.
First, there are those who refuse this treatment; second,
those who may develop a psychotic reaction following the
treatment; and third, those to whom the treatment may be
fatal. Let me add a fourth risk, perhaps the most important;
namely that the indiscriminate use of Antabuse on a group
of patients most apt to respond to psychotherapy might interfere
with or even block their potential accessibility to psychotherapy.
Experience with patients who have had previous treatment
with Antabuse shows that they have often resented this treatment
and discontinued it. As one of them expressed his attitude
to me, "I found that my reaction to alcohol after the
Antabuse treatment was terrifying. Therefore I was pretty
sure to take no more Antabuse." Several patients have
told me that while taking Antabuse they found that a very
little alcohol plus the Antabuse reaction gave them a desirable
result of intoxication.
the other hand, medical literature is full of successful
results obtained by the administration of Antabuse. One
patient of mine, a woman of 65, asked for the Antabuse treatment
two years ago. My associates, Dr. Kenneth Appel and Dr.
Alexander Vujan, after careful tests, administered Antabuse,
and this woman has since then made a much better adjustment.
We recommended follow-up psychotherapy, which was not accepted.
Without such follow-up therapy, we can only guess as to
why the Antabuse worked. This woman was highly intelligent,
with a strong indication of psychoneurotic nucleus. She
came from a protected walk of life. Later on she encountered
more than her share of tragedy. The death of two husbands
during her young womanhood probably augmented an already
established unconscious feeling of rejection. The insidious
sway of her addiction held fast through middle life. Now
her grown children were repeating the pattern of rejection
because of her addiction problem. At this psychologically
important moment we supplied, via the Antabuse treatment,
a way to make alcohol actually reject her even more severely
than did reality from her neurotic viewpoint.
1939, the Alcoholics Anonymous group movement published
their book Alcoholics Anonymous. It received a tremendous
amount of publicity because of the enthusiasm of its members,
plus the fact that it had a very understandable popular
appeal. In the forward of this book the writers remark that
they wish to show other alcoholics "precisely how we
have recovered," and they state. "We are not an
organization in the conventional sense of the word. There
are no fees nor dues whatsoever. The only requirement for
membership is an honest desire to stop drinking. We are
not allied with any particular faith, sect, or denomination,
nor do we oppose anyone. We simply wish to be helpful to
those who are afflicted."
this book was written, groups of Alcoholics Anonymous have
formed in all the large cities of the United States, and
in many of the smaller towns. As a movement it has a strong
similarity to religious conversion. They state in their
great fact is just this, and nothing less: that we have
had deep and effective spiritual experiences, which have
revolutionized our whole attitude toward life, toward our
fellows, and toward God’s universe. The central fact
of our lives to-day is the absolute certainty that our Creator
has entered into our hearts and lives in a way which is
indeed miraculous. He has commenced to accomplish those
things for us which we could never do by ourselves."
have gathered from talks with many of the group that the
spiritual experience does not always take place, but that
even without this experience some are successful in refraining
from drinking. With or without the religious experience,
members have a very deep sense of Cause, and each becomes
an Apostle for this Cause. They insist that members attend
weekly or bi-weekly meetings, at which meeting novices hear
ex-alcoholics recount the misery of their drinking history,
and how they had hurt all their loved ones, but how, now,
with the help of the Alcoholics Anonymous group they are
no longer hurting those they love, and are happy and successful
without alcohol. They recommend twelve steps in their program
We admitted we were powerless over alcohol — that
our lives had become unmanageable.
Came to believe that a power greater than ourselves could
restore us to sanity.
Made a decision to turn our will and our lives over to the
care of God as we understood Him.
Made a searching and fearless inventory of ourselves.
Admitted to God, to ourselves, and to another human being
the exact nature of our wrongs.
Were entirely ready to have God remove all these defects
Humbly asked him to remove our shortcomings.
Made a list of all persons we had harmed, and became willing
to make amends to them all.
Made direct amends to such people wherever possible, except
when to do so would injure them or others.
Continued to take personal inventory and when we were wrong
promptly admitted it.
Sought through prayer and meditation to improve our conscious
contact with God as we understood Him praying only for knowledge
of His will for us and the power to carry that out.
Having had a spiritual experience as the result of these
steps, we tried to carry this message to alcoholics, and
to practice these principles in all our affairs."
understand that you have similar groups in Great Britain.
I believe that they work with the same principles as Alcoholics
Anonymous in the U.S.A. In the States some of its appeal
is because of the go-getter attitude contained in its emotional
approach. It savors of the credo of the American success
story, and it is colored by the aggressive streamlined glamorization
so woven into American custom. My experience with members
of this group has been that the successful men and women
are those who have made A.A. the most important thing in
their lives. They devote a tremendous amount of time to
discussion of Alcoholics Anonymous work, they attend meetings
regularly, and are willing, at great inconvenience to themselves,
to be called out to administer to one of their group who
has fallen, or to call on some drunkard in order to persuade
him to seek their help. Let me briefly try to analyze some
of the aspects of what they have to offer.
of those who become members have gone downhill quite far.
In fact, many A.A. members say you have to "hit bottom"
before you are accessible to their movement. These men and
women, due to their abnormal drinking lives, have by and
large lost their normal friends and their contact with society.
They are lonely, isolated by their addiction problem. To
be welcomed again in an uncritical group, where their past
alcoholic history can be worn as a badge of honor, provided
they recover, must give them a tremendous emotional lift
in re-establishing contact with other human beings.
of us who are interested in the vast problem of mental hygiene
owe a debt of deep gratitude to the circumstances that presented
this movement at this time. The group is keeping many men
and women sober, who otherwise would be cluttering up our
jails and our mental hospitals. They are relieving psychiatrists
of an already intolerable load, and most important, this
approach is keeping many men and women from destroying themselves
and crippling their families irretrievably.
all due credit for A.A.’s valuable work, some of the
more fanatical members bring to mind a sketch written by
the American humorist, James Thurber, entitled, The Bear
Who Let It Alone.
the woods of the Far West there once lived a brown bear
who could take it or leave it alone. He would go into a
bar where they sold mead, a fermented drink made of honey,
and he would have just two drinks. Then he would put some
money on the bar and say, ’See what the bears in the
back room will have,’ and he would go home. But finally
he took to drinking by himself most of the day. He would
reel home at night, kick over the umbrella stand, knock
down the bridge lamps, and ram his elbows through the windows.
Then he would collapse on the floor and lie there until
he went to sleep. His wife was greatly distressed and his
children were very frightened.
length the bear saw the error of his ways and began to reform.
In the end he became a famous teetotaller and a persistent
temperance lecturer. He would tell everybody who came to
his house about the awful effects of drink, and he would
boast about how strong and well he had become since he gave
up touching the stuff. To demonstrate this, he would stand
on his head and on his hands and he would turn cartwheels
in the house, kicking over the umbrella stand, knocking
down the bridge lamps, and ramming his elbows through the
windows. Then he would lie down on the floor, tired by his
healthful exercise, and go to sleep. His wife was greatly
distressed and his children were very frightened."
ten years ago, I was asked to read a short paper, "Emotional
Immaturity in Alcoholics," at the Philadelphia General
Hospital. This was followed by a talk given by one of the
key men in Alcoholics Anonymous. He began his talk by saying
that he agreed with me that all alcoholics were emotionally
immature; hence they needed Alcoholics Anonymous to compensate
for the deficiency of emotional maturity. This pointed out
to me the outstanding difference between their approach
and a psychotherapeutic approach; namely, that they accept
the emotional immaturity, and supplied a crutch for it,
where psychotherapy attempts to supply insight into the
emotional immaturity, and helps the patient toward emotional
growth and maturity as a necessary adjunct to abstinence.
of the earliest papers on the subject of alcoholism that
I have come upon was by Dr. Benjamin Rush, written in the
early eighteen hundreds. He cites religious conversion as
the only effective means of bringing about abstinence among
his alcoholic patients. This phenomenon, I think, is explained
in part by the extraordinary egocentricity we find in alcoholics,
and this in turn leads us to uncover the omnipotent infant
hidden behind the iron curtain of the unconscious, who is
still dictating the personality, policy, and behavior of
the patient. We see that these patients are in a way playing
God. This highly disguised phenomenon was beautifully revealed
in the William Saroyan play, The Time of Your Life. In religious
conversion, one admits to an all-powerful God. Therefore
the convert is forced to abdicate the throne, but in turn
becomes God’s lieutenant. This is an emotional growth
step not always possible, not always wise, but where it
works effectively and suffices to give a fractional degree
of stability to the addicted personality, we should thank
God for its occurrence wherever we encounter it.
may include a great many different approaches and various
disciplines and techniques. Alcoholics Anonymous might be
described as a simple form of psychotherapy. Freudian psychoanalysis
is considered by some as the only thorough approach to a
non-addicted readjustment. This could be described as a
very complicated and time—consuming psychotherapy.
Because of the variant concepts of psychotherapy, I would
like to outline briefly the type that we have found practical
and effective with a certain group of patients.
first and often neglected step in the treatment of pathological
drinking is a personality diagnosis. This diagnosis should
be avoided during the intoxication symptoms and withdrawal
symptoms. Even after a state of sobriety has been reached,
the physician should delay opinion as to the best method
of treatment until he has had ample opportunity to study
the personality of his patient.
following classification can be employed advantageously
in the clinic devoted to abnormal drinking if it is used
in the spirit that Thompson suggests when he says: ‘We
have revised this classification to some extent, but we
have altered still more extensively our application of it.
Many individuals who are examined in this clinic we now
regard as normal or average individuals with an exaggeration
of some particular personality characteristic, rather than
as psychopathic personalities or deviates.’ Even a
glance at this classification makes clear how wide is the
range of alcoholism. The classification is as follows:
Normal individuals with predominant personality characteristics:
sly, wily type professional gambler or ‘con
professional criminal of the planning, careful type. I
think you have a slang word "Spiv" that describes
Adolescent immature type,
Adolescent adventurous type.
and selfish type.
lazy, uninhibited, pleasure-loving type.
to lower economic level.
adjusted to ordinary, average life."
have found that the germ of alcoholism reaches far back
into childhood and that most patients are suffering from
unconscious feeling of guilt and rejection coming, usually,
from these childhood experiences. We are beginning to see
more clearly that drinking alcohol in itself did not create
their problem. Rather it was their neurotic insecurity which
created their addiction. We see in the paranoid patient
a tendency to project his personality discomfort outward,
in the psycho—neurotic a tendency to project personality
discomfort inward, and in the alcoholic a tendency to reach
for a drug to anesthetize his personality discomfort.
have found in the study of the personalities of those who
consulted us that emotional immaturity manifests itself
prior to drinking, and certainly we have found that emotional
immaturity is ever-present in the emotional life of the
abnormal drinker. "Man is but a child-born," and
I doubt that in our civilization emotional maturity is a
completely obtainable goal. When we talk of maturity, we
talk of degree. In the abnormal drinker, emotional immaturity
plus the addiction problem precludes emotional growth. We
see a like reaction in the psychoneurotic, and we see, perhaps,
in the psychotic a terrifying regression to the infantile
level. Maturity, if we must attempt to analyze it, could
be described as an individual’s ability to deal with,
compromise with, and sublimate the primitive infantile tendencies
that exist in all of us. The alcoholic, when intoxicated,
is on an infantile level. When sober, he is a very uncomfortable
child in an adult body in an adult world.
think we often see in the abnormal drinker an actor living
a role of pretence that is fooling him far more than the
audience. This actor has a complete misconception of the
reality of himself. All he knows is that this reality is
painful. He does not see that reality is painful because
of his maladjustment to it. Having found that alcohol will
induce a brief pleasurable fantasy of self, the abnormal
drinker seeks more and more the escape mechanism of alcohol.
Because such a patient appears to be normal to his family
and the public when he is not drinking, the degree of his
emotional maladjustment is not recognized by society, nor
is it recognized by the patient. In the mind of the public
and the patient the problem seems simple, i.e., if alcohol
is destroying this man or woman’s potentiality to
live a normal, constructive life, then the answer is to
give up alcohol. I think we can say that the majority of
non—deteriorated and non-psychotic alcoholics want
to get well. Despite the contradiction of oft repeated drunken
behavior, there is little doubt that somewhere within the
mental recesses of the abnormal drinker there lies the desire
to rid himself of his addiction. He wants to be normal,
but he does not know how to start. To bridge the gap of
understanding between the patient and those who want to
help him we must first recognize and understand his conception
of what constitutes normality. What does he mean when he
says; "I want to get well?"
exploration uncovers an apparent contradiction of sane thinking;
i.e., normality is synonymous in the mind of the alcoholic
with only one thing - drinking normally. He really believes
he wants to drink in a normal way. Most patients give a
history of repeated determination to drink in moderation,
which attempt eventually ends in acute alcoholic episodes.
This self deception on the patient’s part, of wanting
to be temperate in the use of alcohol, should be discarded
with the insight gained in psychotherapy. It is not easy
for the patient to see that the one or two cocktails he
thinks would suffice actually would be as unsatisfactory
to him as one or two aspirin tablets would be to the morphinist
awaiting his customary dose of morphine.
in dealing with patients, we must realize that a mental
condition exists which renders a normal response impossible.
We do not tell our patients that they are normal and that
all that is wrong with them is that they drink too much.
If this were only true, everything would be so beautifully
simple. We would only have to say, "Please stop drinking,
and everything will be all right." Obviously if they
stop drinking they will be more acceptable to society, but
otherwise nothing has been accomplished toward curing the
state of mind that originally sought escape from their personality
discomfort by blunting this discomfort with alcohol. When
the stream of alcohol is dammed but nothing else is done
then there is merely produced a condition of suppressed
alcoholism that could be rightly described as an alcoholic
complex, or a partially repressed but imperative urge, that
becomes endowed with a super—emotional content. In
all probability this is the condition of many successful
non-drinking alcoholics, wherein hate and fear have supplanted
the love of and depending on alcohol. The partially repressed
but imperative urge becomes endowed with a superemotional
redirection. The truth is that abstinence frequently means
the discarding of an all important crutch by a sick personality.
This may be the right moment for psychotherapy to be substituted
for the crutch, not as something to lean on, but as a means
of gaining insight into the little boy or girl who never
grew up emotionally.
is obvious to anyone who ever studied the problem of addiction
that the abnormal drinker is playing a very passive role
no matter how well he may disguise it by over—compensating
action. The very role of drinking is passive. Without being
conscious of it, he is asking a drug to change his ways
of thinking and being and feeling. The addict carries the
passive role to its extreme in deep intoxication. He is
this hidden passivity in mind I endeavor to lead a patient
into an active role toward treatment. I ask him to read
and analyze the book, Alcohol: One Man’s Meat, underscoring
any passages that he thinks might give us insight into his
own problem. By the very act of doing this he is taking
an active rather than a passive role toward his recovery.
inform the patient at the first contact that he and he alone
will effect his recovery, that I can only help him to gain
understanding of himself and his problem. If a good rapport
is established I find it is helpful to anticipate with the
patient the emotional growing pains that he will encounter
during the beginning of his non-alcoholic readjustment.
The patient puts much emphasis on the immediate withdrawal
symptoms from alcohol. He has experienced these and knows
how dreadful they are. He has no understanding of or preparation
for the secondary emotional withdrawal symptoms that he
will encounter during the first year or two of abstinence.
These secondary withdrawal symptoms seem to take place in
insidiously disguised protests against reality and in bombardments
of rationalization urging him to return to alcohol. The
late Richard Peabody contributed great insight into this
phase of readjustment. In his book, The Common Sense of
Drinking, he supplies this insight to the patient, as well
as forearming him against the extraordinary rationalizing
technique that he will uncover from time to time during
his struggle to make readjustment without alcohol.
encounter in alcoholism an age—old phenomenon of politics;
the political psychology of the dictator. Dictator ideology
survives only by creating and then enlarging the enemy without,
in order to take the focus off the real enemy within -i.e.,
the dictator. With this technique whole populations are
seduced into relinquishing their freedom. They become willing
slaves to their State, hypnotized through propaganda by
the imagined enemy without. In the addicted personality,
alcohol is the dictator and here, too, the enemy without
is created and becomes part of the rationalizing process
of alcoholism. The typical alcoholic drinks because his
wife nags him, or because he does not get the promotion
he thinks he deserves, or because his friends let him down
or shun him. In effect each aspect of reality soon becomes
the threatening enemy without and the patient relinquishes
his freedom to the alcoholic dictator in order to save himself
from his own misconception of a hostile reality. There is
always a paranoid-like rationalizing system in alcoholism.
Understanding the abnormal psychology of addiction, one
sees that rationalization is a necessary support to the
alcoholic disease that has taken over the personality. Outside
of delirium tremens, alcoholic psychosis and the occasional
psychotic reactions following the administration of Antabuse,
it does not reveal itself overtly, but it is there nonetheless,
and it is very important that the patient gain insight into
its abnormal mechanisms.
therapy the patient will under our guidance gain insight
into his unconscious feelings of rejection and guilt. If
he is successful he learns to deal with these feelings instead
of running away from them, and if acquired his insight into
their source may help to allay a great deal of his personality
hope it will be seen from my very brief description of a
treatment approach that I attempt to deal with a patient’s
personality problem as well as his alcoholic problem. Personality
problems presented by patients vary enormously, as do the
underlying causes for their addiction. They have, however,
an extraordinarily similar system of irrational thoughts
about drinking which will apply to all of them. Just as
the understanding of the warped thought process in the paranoid
schizophrenic will help to make the diagnosis and indicate
the type of treatment, so also will the understanding of
the warped thought process in the alcoholic help us to treat
criticism of this type of psychotherapy is that it is limited
to a group who can afford the expense involved in such a
treatment. Many of our patients are out—patients,
and do well on an out-patient status. In this way, the expense
can be kept down so that it is within the reach of nearly
everyone. However many of our patients need psychotherapy
and would not respond to it without an initial and sometimes
prolonged hospital stay, and this is, of course, expensive.
order to make a treatment plan available to a greater number
of people it has been suggested that group therapy might
be instigated. Unhappily group treatment precludes the rapport
which has been shown to be so necessary. It has been tried
by some of my associates, but the results have not been
my attempt to analyze and compare three treatment measures,
I have clarified for myself, and I hope for you, the fallacy
of finding the treatment for alcoholics. Far better, and
much more rewarding in results, is to find the form of treatment
best suited to each type of personality afflicted with alcoholism.
Francis T. Chambers, Jr. was a lay—therapist and was
trained by Richard R. Peabody.