It’s a disease as well as a personal and social catastrophe. That discovery makes the big difference in treatment. Corporate programs can be critical in salvaging executives and workers.
by Herrymon Maurer
During the past year alcoholism has come out of the shadows. Major government reports have dealt with it on an objective basis, and large amounts of federal and state funds have been voted for research and treatment. A decision by the U.S. Courts of Appeals, the rationale of which is under review by the supreme court, changes alcoholism from a crime to a disease, a diagnosis already made by such diverse authorities as the World Health Organization in 1951, the American Medical Association in 1957, the American Psychiatric Association in 1965, the Department of Health, Education and Welfare in 1996, and a national commission in 1967.
The general acceptance of alcoholism as a disease not only reflects a new concept of the illness, but also requires a new public approach to its treatment, postulating as it does that alcoholics be handled in clinics and hospitals instead of in jails. New ward space is being opened and new institutions are being built; medical schools are beginning to add the subject of alcoholism to their curriculums. The federal government is now asking Congress to increase substantially its current $20-million program, of which $13,500,000 is marked for research, training, and education. State expenditures are running about $10 million. There are, in addition, federal plans in the works to treat alcoholics among civil servants, and state plans are being drafted in California and Pennsylvania.
The year 1968 thus becomes the time when alcoholism finally receives recognition as the personal and social catastrophe that a quarter-century of sustained research effort has shown it to be: an illness of the magnitude of heart trouble, cancer, and severe mental disorder. A body of knowledge, remarkable in size for the small amount of research money expended, has been put together on its characteristics, causes, and treatment. No one expects that the incidence of alcoholism will diminish in the foreseeable future. There are no drugs available now or in prospect to work the kind of cure that has all but eradicated polio. Indeed, recovery rates from alcoholism are abysmally low. But the only direction to go is up.
The highest recovery rates, surprisingly, are to be found not in clinics and hospitals, but in offices and factories. By putting the body of knowledge about alcoholism to work in company programs, industry is achieving recovery rates as high as 65 to 70 percent – higher than those for other major diseases and far higher than any imagined only a short time ago. This achievement represents not only a successful use of research, but a major contribution to it as well. Alcoholism is one disease in which laymen, notably men in executive posts in business, play a role as diagnosticians and therapists as well as sufferers. Moreover, the simple fact that business is increasingly willing to admit that its executives can themselves be alcoholic demonstrates an important gain in knowledge about the nature of the disease.
There are some 80 million drinkers in the U.S., and of this number there are five million alcoholics, give or take a million, according to estimates of the Rutgers Center of Alcohol Studies. Such estimates have meaning, however, only if it is agreed that all statistics on alcoholism, are rough – far rougher than statistics on atherosclerosis, cancer or tuberculosis – and that precise definition of the disease is as yet impossible. Unlike other diseases, alcoholism is discovered primarily through study of the behavior of the persons who are attempting to hide their behavior, not primarily through the study of invading organisms or infected organs. For statistical purposes, it can be thought of as a disease, in the words of Rutgers’ Mark Keller, “causing injury to the drinker’s health or to his social and economic functioning.” By that definition, there is one alcoholic for roughly every sixteen persons in the country who ever consumed alcohol. Some years ago men outnumbered women by about five or six to one, but it may be that the ratio is now four to one or even lower.
The sufferers divide into three principal types:
• The loss-of-control alcoholic. In this type preponderant in the U.S., Canada, Great Britain, and Northern Europe, increased tissue tolerance to alcohol and alteration in cell metabolism produce an addiction that makes control over drinking either difficult or impossible. This leads both to compulsion to drink and to harrowing physical symptoms when coming off drink. Typical of the out-of-control drinker is an executive vice president of an industry trade organization who lost family, friends, home, and job, who sobered up in one hospital only to get drunk and land in another, and whose recouping of losses and rise to his present post came only after his recovery. But just as typical is a senior officer of a company with $300 million in sales who hid everything and lost nothing tangible at all (although he figures his drinking cost his company more than a million dollars’ worth of business) and who surprised his colleagues when he told them of his alcoholism a year after his recovery began.
• The unable-to-abstain alcoholic. Physical addiction also characterizes this type, which predominates in France and other wine-producing countries where heavy drinking throughout the day is socially acceptable. Addiction leads, however, not to the uncontrolled-spree behavior typical of American alcoholics, but to an inability to get off drink for even a day or two.
Social protection for such alcoholism is common in France but rare in the U.S. The president of a small business organization in New Jersey built his own kind of social protection around his drinking. He had secretaries, subordinates, bartenders, and family trained to help him keep a relatively constant volume of liquor in his system. But when he was suddenly separated from his family he quickly began spree drinking and ended by touring hospitals and jails. Dr. George N. Thompson of the University of Southern California reports another case: “A patient who had continued a desk job fairly successfully for twenty years while he drank two fifths of bourbon daily. He finally succumbed to hepatic cirrhoses but never seemed to suffer from toxic effects to his nervous system.”
• The dependent-but-unaddicted alcoholic. This type does not drink compulsively, but heavily enough to cause eventual damage to his family and work relationships, and sometimes to his health. Often he progresses into out-of-control alcoholism. What happens to him depends less on the quantity he drinks than on his drinking behavior. He can cut down if he is aware that he is heading for trouble. It is not always easy to spot this type of drinker, and the difficulties are increased because so many alcoholics delude themselves into believing that they are heavy drinking nonalcoholics.
Executive suite and skid row
The alcoholic reinforces his delusion that he is some other sort of drinker by adhering to the popular notion that alcoholism has a definite location – skid row. But, in fact, only about 3 percent of all the alcoholics in the country are to be found there. Only recently has the general public been willing to acknowledge that alcoholics are also to be found in the bosoms of their families, the arms of their churches, and the management rosters of their corporations. In fact, alcoholism has been found to be more of a problem in the executive suite, in professional offices, and in workshops than on skid row. Generally speaking, the more educated, the more urban, and the better salaried Americans are, the more likely to drink.
The skid-row myth, says Dr. Selden D. Bacon, director of the Rutgers Center of Alcohol Studies, grew out of the old controversy between the wets and the drys. Many persons escaped both camps by avoiding the problems of alcoholism altogether; they came to believe that such problems simply did not exist in nice families or in good neighborhoods, but only in out-of-sight areas where they could be handled by the police, the courts, the jails, and the state mental institutions. Dr. Morris E. Chafetz of Massachusetts General Hospital has shown statistically that admitting physicians in hospitals tend to diagnose alcoholism as if it were a disease confined to the unwashed and the ill clad. When a disease is socially unmentionable, medical research in that disease is stymied by want of support. The new recognition that alcoholism is also found among respectable people is a fact possibly more important for research than was the similar recognition of cancer about a generation ago.
In short, social considerations are as much a factor in alcoholism research as are the physical and psychological characteristics of its victims. A concatenation of sociological, biochemical, and psychiatric happenings, alcoholism has to be studied by specialists in many fields. Moreover, it is an illness whose patients band together in great numbers – 400,000 of them in 14,154 groups throughout the world – as Alcoholics Anonymous to treat one another. Multiple approaches to the problem often commingle but sometimes conflict. The fact, for instance, that alcoholism is far less prevalent among Jews than among the Irish is explained in terms of cultural or psychodynamic conditions, but some physiologists explain it as the consequence of genetically determined body chemistry. Such diversity of approach is actually an important research aid, and it has already produced a very considerable body of knowledge about the nature of the illness, a good deal of information about its treatment, and plenty of speculation about its causes.
The observable symptoms of the disease, its course from early manifestation all the way to recovery or death, together with its incidence and characteristics in various segments of the population, can now be defined roughly. There is, for instance, ample working data on alcoholism among factory and white collar workers with reasonably precise studies on work performance, absenteeism, accidents, and the like. There is also an increasing body of data about alcoholism among executives, a topic not generally discussed only a few years ago.
There is, moreover, a good deal more that is known about alcoholism’s sundry complications. An HEW study of 1,343 patients at alcoholism treatment centers in California reveals that accidents kill seven times as many alcoholics as nonalcoholics, cirrhosis ten times as many, influenza and pneumonia 6.2 times, and suicide (a new research area) 3.5 times. A sampling of 922 drinkers (532 known to be and 390 thought to be alcoholics) and 922 nondrinkers at E.I. du Pont de Nemours indicates that various other degenerative diseases, including some not popularly associated with alcohol, strike drinkers with measurably greater frequency than nondrinkers: e.g., hypertension 2.3 times as frequently, cerebrovascular disease 2 times, stomach ulcer 1.9 times, asthma 1,7 times. “More alcoholics,” declares Dr. Edwin Boyle of the Miami Heart Institute, “die of cardiovascular catastrophe than from all other causes combined.”
Other studies, supported by A.A. experience, yield an equally important and far more heartening discovery: alcoholism can be arrested much earlier in its course than was previously thought possible and with much better likelihood of recovery than in its later stages. It was once believed that only those alcoholics who had gone down through the whole bitter sequence of the early, middle, and late stages would accept therapy. Today an estimated 50 percent of A.A. members join during the early and early-middle stages. “An alcoholic,” explains a vice president of a company headquartered in New York, “Is constantly building up a wall of defenses around his illness. Early in the process when the wall is low, it takes much less suffering to convince him to clamber over it than it takes when the wall is high.”
Physiological research also has been yielding detailed information on the way alcohol acts in the human body, how it is metabolized, how it sedates – producing in the process an initial misleading euphoria, but subsequently depressing and anesthetizing – and how it leaves behind that jittery sense of excitation that often prompts the alcoholic to another drink or another bout. Established are such facts as alcohol’s ability to induce hyperactivity of the brain through its effect on the brain’s reticular activating mechanism. The ancient surmise that alcohol in the bloodstream is the agent of the alcoholic’s compulsion to keep on drinking has been confirmed by a variety of experiments, including a thirty-one day test conducted by Harvard’s Dr. Jack H. Mendelson, in which alcoholic volunteers were subjected to twenty-four days of controlled drinking and seven days of observed withdrawal, in the course of which classic and unmistakable signs of physical addiction were manifest.
Why it comes and how it goes
Certain facts about the treatment of alcoholism are indisputable. As rooted, it has been established as a disease treatable by physical, psychological, and A.A. therapies. Medical authorities have perfected the hospital handling of its agonizing withdrawal symptoms – the physician has a whole battery of variously acting drugs at his command – and withdrawal is now rated no more of a risk than minor surgery. It is universally agreed that the one way to arrest the illness is to get the patient off drink altogether. And it is known that the alcoholic can’t get off drink through his own will power, that he must seek outside help.
At this point, however, the various sociologists, psychologists, physiologists, and the A.A. laity tend to part company. Alcoholics Anonymous is widely conceded to have produced more recoveries than have all other therapists put together, but it suffers in the minds of some professional research men from being insufficiently scientific. A scientist can hardly quarrel with the fact of 400,000 recovered alcoholics, but he can nonetheless feel uneasy about a fellowship whose program begins with an admission of abject surrender of one’s life as unmanageable, follows with belief in “a Power greater than ourselves that can restore us to sanity,” and prescribes constant meetings and labor with other alcoholics. Such propositions, whose principal intellectual ancestor is the pragmatic philosopher William James, are not subject to quantitative measurements and are often troubling to outsiders. What is more, only about one alcoholic in fifteen in the country is a member of A.A. Its one requirement for membership – a desire to stop drinking – is thought by some to limit its therapeutic efforts to a relatively select few.
Sociologists come under cross fire from some of the other professionals for focusing on nonmedical aspects of alcoholism. Their basic proposal for treatment is the prevention of alcoholism by social and cultural change, a proposal whose value can be determined only at some time in the future. Moreover, they offer both statistical studies and cogent etiological arguments. “It has been noted,” says sociologist Dr. Seldon Bacon of Rutgers, ”by almost all observers for decades that by and large Americans are anxious, confused, ambivalent, at times guilt-ridden about their attitudes toward drinking.” Sociologists have delineated such uncertainties in detail and have re-created in the process the history of drinking in the U.S., replete with such intriguing facts as nearly identical per capita consumption rates between 1850 and 1968, despite the intervention of the industrial revolution, urbanization, and world wars.
Knowledge through no-knowledge
Physiologists and psychologists, highly vocal about the causes and treatment of alcoholism, have contributed another body of facts, and also have delineated important areas of ignorance. Dr. Peter Stokes, research physician at Payne Whitney Clinic of the New York Hospital and co-discoverer of the effect of alcohol on white-cell mobilization, remarks confidently, “We don’t know anything about the causes of alcoholism; we can’t identify the susceptible individual; we can’t treat specifically or chronically; and we can’t prevent it.” This state of knowing what one does not know, Dr. Stokes emphasizes, is essential for solid future discovery. Medical research in general has to explore areas of ignorance before arriving at areas of new information. Cancer research, more advanced than research in alcoholism, developed its virus theory only after assiduous exploration of the unknown.
Physiologists, of course, examine complex cellular, metabolic, glandular, and like biochemical events, while psychologists and psychiatrists apply a body of concepts ranging from learning theory and conditioned reflex formulations to personality testing and psychodynamics. Almost all researchers in these fields believe it is likely that alcoholism rests on a physical base upon which is built a psychological structure, but research knowledge both of base and structure is as yet not very deep. Alcoholism indeed coexists with various types of mental and emotional illness that require specialized medical attention. Until very recently it was believed that predisposing psychological factors played a causative role of some sort in the development of alcoholism. Alcoholics, after all, are so frequently separated from reality that they can be called schizoid, so regularly low in mood they can be called depressed, so often unsure they can be called dependent, and so obviously devoted to the bottle they can be labeled obsessive-compulsive and orally fixated. But these characteristics did not necessarily pertain to their condition before they became alcoholic, and the same characteristics, moreover, are not uncommon among nonalcoholics. Today there is less enthusiasm over predisposing factors.
Enthusiasm plays a key role in medical research, but in the search for remedies for alcoholism, it is now much more subdued. In the past, various therapeutic devices, based on various etiological theories, were put forward with considerable ardor as the therapies for alcoholism, but they turned out later to be at best adjuncts to standard therapy. Among these are psychodrama, group therapy, and hypnosis as well as individual counseling. The list also includes the barbiturates (useful but themselves addictive), aversion therapy, vitamins and sound diet, Ayerst Laboratories’ Antabuse (still widely used), ACHT, tranquilizers (also useful and also addictive), LSD, Searle & Co., Flagyl, and latest of all, niacin, proposed for use in massive doses as an adjunct to therapy to deal with hypoglycemia and schizoid conditions.
Almost all alcoholics, of course, would welcome any pill or any procedure that would not deprive them of liquor. For fifteen years a New Jersey management consultant read selectively in the professional literature to convince himself that he was a neurotic drinker who would be able to drink normally as soon as his neurosis was resolved. He persuaded his physicians and psychiatrists to let him try out a whole series of new treatments, from barbiturates to LSD. Despite repeated hospitalization, he believed fervently that his emotional health was improving – up to the very moment when desperation eventually convinced him he was a common out-of-control alcoholic. As U.S.C.’s Dr. Thompson says, “It is axiomatic that it is useless to attempt psychotherapy on a patient who is continuing his drinking.”
The new social acceptance of alcoholism as a disease rather than as a stigma of sin, say the professionals, should help break down the massive defenses alcoholics develop against yielding to treatment. Acceptance is providing a cultural climate in which they may be more readily helped and a long needed financial base for an important burst of new research.
There is already enough knowledge for dealing effectively with the problems of alcoholics on the job. An HEW study estimates that 70 percent of them, indeed, are still on the job and have been there for fifteen to twenty-five or more years. An alcoholic’s job, in fact, is the last great bulwark of his defense against admitting his illness; the threat of its loss can often produce the inward crisis that is required before he will submit to treatment. Well-conceived company programs, moreover, can speed up the precipitation of such a crisis, in the process rescuing men from unnecessarily long suffering at a cost to the company that is far less than the amount it is already losing through poor productivity, absenteeism, severance or retirement payments.
Successful company programs – programs that succeed with two out of three alcoholics, as they do at Equitable Life, Eastman Kodak, Consolidated Edison, Allis-Chalmers, and du Pont – are still rare, although more than 200 companies have some sort of program or some statement of policy. Because alcoholics are so skilled in avoiding anything that looks like a trap, some programs are little better than no programs at all.
Good basic company procedure is relatively simple. It depends on early recognition of the alcoholic, employee or executive, by his immediate supervisor on the basis of his work performance and on his referral by the supervisor to the company physician. The physician has to be – or has to become – one of the small and select group of specialists in alcoholism, though he does not usually treat the man himself. He refers him after diagnosis to Alcoholics Anonymous, to a psychiatrist, a hosp-ital, or a rehabilitation center. Follow-up is in the hands of the company physician. And in all cases, willingness to accept treatment is a criterion for determining whether an employee continues to hold his job.
The mechanics of this operation are straightforward. It is not difficult to spot alcoholics on the job; usually they are recognized long before they think they are. Most of them can be identified simply by running through work records on absenteeism and performance. But getting a supervisor to refer a man to the medical department is a different matter. It is almost impossible if the program is not well conceived, difficult when even a good program is new, though relatively easy when the program is widely understood.
When the medical director of a billion-dollar company was summoned one day to his company’s executive offices, he found himself in the presence of two senior officers. He was told by one of them that the other was beginning to get into such trouble with drinking that he would have to report him to the board of directors unless he accepted medical help. The medical director simply said, “Since this is a health matter, we will treat this conversation as if it never happened.” He then took the sick executive back to his office, talked with him, got him into the hospital for a two-day checkup, dispatched him to a rehabilitation center for a four-week “vacation,” and on his return introduced him personally to members of an A.A. group. A few weeks before, the physician had handled a case involving a maintenance man employee in precisely the same way.
Implementing a program based on crisis precipitation requires a marked amount of organized wisdom, experience, and good sense in dealing with the tortured complexities and resistance’s of the alcoholic mind. For example, it is essential that the confidential relationship between doctor and patient remain inviolate; otherwise the whole program will be bypassed by the alcoholic. It is not necessary for the word alcoholism to appear in company records. Equitable Life’s Dr. Luther A. Cloud finds it wise even to avoid using the word in his conversation with a patient until the patient himself does so. At Eastman Kodak, executives not infrequently refer themselves to Dr. John L. Norris, associate medical director, who is also the nonalcoholic chairman of A.A.’s general service board. Among all employees about two out of ten are self-referrals.
One pitfall to avoid, warns Dr. Harrison M. Trice of Cornell’s School of Industrial and Labor Relations, is a company plan that is designed to take care of alcoholism only among wage and salary workers. Alcoholics are so notably thin-skinned, whatever their level of employment, that it is advisable to handle all of them as if they were executives. If a plan works smoothly with executives, it will work smoothly with others down the line.
Atmospherics and the chief executive
Obviously a company plan cannot be rigid-Practicing alcoholics respond far better to a general atmosphere than to an inflexible system. At Equitable, atmospheric considerations include easy and unobserved access corridors to Dr. Cloud’s office. Although Eastman Kodak is a pioneer in company alcohol problems, Dr. Norris and the company management still feel no urge to commit all of the program to paper; it is simply discussed between Dr. Norris and the top executives who frequently drop into one another’s offices to talk informally about a wide range of company and community health matters. Olin Mathieson’s Dr. J. Ray Chittum holds that his program should not even be called an alcoholism program, maintaining that alcoholism should simply be considered one of the various illnesses that his company helps treat.
One manufacturing company with a number of scattered plants in the Midwest has no organized plan at all and uses outside physicians instead of company doctors. But it is known confidentially to a good many men both at headquarters and down the line that both the president and their personnel head are recovered alcoholics active in A.A., and as such the company’s authorities on alcoholism. This company has probably one of the lowest rates of active alcoholism in the country.
Most of the information required as the basis of sound and successful company programs can be found at four institutions where the problems of alcoholism in industry have been under scientific and professional study for many years. Dr. Milton A. Maxwell, of the Rutgers Center of Alcohol Studies, is an expert on problems of accidents and absenteeism. At Cornell, Dr. Trice is knowledgeable about problems of early identification and crisis precipitation. At the National Council on Alcoholism, Lewis F. Presnall has installed practical programs in a number of specific companies. And at the Christopher D. Smithers Foundation of New York, the organization that has given research in alcoholism most of its private financial support, R. Brinkley Smithers pays special attention to company programs. Smithers is the foundation’s president and president also of the National Council on Alcoholism.
Obviously, the experience of particular men or particular companies cannot be overlaid on the organizational pattern of other companies. Such patterns typically represent a company’s unique way of doing business, and any change in them is a matter for the chief executive officer. The chief executive, indeed, is the one person in any company who must take responsibility for an alcoholism program, not simply because it is advisable to have top backing for good ideas, but because it is essential for him to do the actual tailoring of any system to the company cloth.
On the chief executive falls further responsibility for the alcoholics the program does not help. To be sure, two men in three can Recover and often achieve levels of performance not previously reached, but there remain the men who refuse therapy or abandon it. Some of them pass on to other companies, end up on early retirement, relief, or skid row. Moreover, it has now become known that an alarming percentage of alcoholics commit suicide upon losing a job or separating from family. Such negative consequences of crisis precipitation can be mitigated in some part, however, by the chief executive taking two steps: first, making it clear to employees that acceptance of treatment for alcoholism is a defense against loss of job, and, second, separating alcoholics when necessary from the company on an on-leave basis, it being understood that they will be taken back whenever they accept therapy.
For its successful crisis-precipitation approach to the problem of alcoholism, industry clearly owes a debt to research. Scholarship, however, owes a debt to industry programs, not simply for the statistical, psychological, or medical data they yield, but also for showing the way to the pragmatic achievement of the higher recover rates known. These results suggest that the synthesis of research findings with working industrial programs may be more significant than either the research or the programs alone.
Important in this synthesis is industry’s use of Alcoholics Anonymous as the chief therapeutic agent of company programs. Business proved a new challenge to A.A. through its methods of crisis precipitation that sent men and women for therapeutic help long before they might otherwise have gone, and thus provoked a new response. Now that the dimensions of the disease of alcoholism are becoming widely known, it may well be that many physicians and psychiatrists, psychologists and social workers, together with their hospitals and clinics, will develop new forms of crisis precipitation and share their therapeutic load more widely with A.A. Today there simply are not enough professionals in the country to handle the number of alcoholics needing treatment, and there are 350,000 members of A.A. available anywhere and at any hour in the U.S. and Canada.
Whatever else A.A. may be, it is a successful method of treating a disease, and a study of methods of recovery can lead to important facts about the nature of the disease itself. A.A. recovery for one man, the executive vice president of a research and development corporation in the South, included listening to more than 1,000 case histories during the first two years of his membership, getting to know intimately the life histories of more than fifty persons, introducing fifteen newcomers directly to A.A. and twenty-five more in partnership with others, and discussing the problems of alcoholism with more than a hundred nonalcoholic friends, scientific colleagues, and business associates. A.A.’s response to the challenge of still-suffering alcoholics is the combined response of cohorts of such men striving to maintain their own recovery through helping the recovery of others. Working with A.A., business has worked wonders.
(Source: Fortune, May 1968)