CLINIC PLAN OFFERS HOPE FOR WORLD’S LEAST UNDERSTOOD SICK PEOPLE
by Carlton Brown
TO MANY AMERICANS, the alcoholic is a comic character. They call him souse, stewbum, lush, and dipso; they say he is tight, plastered, stewed, fried, or sauced. In recent years, Americans have been exposed to a great deal of writing about the problem of alcoholism, and to a serious novel and movie, The Lost Weekend. Still, many share the reaction of the man who left the theater and said to his companion:
“I’m swearing off right now! You’ll never catch me going to another movie.”
To many other Americans, the alcoholic is a subject for moral censure. They class him as a sinner, a social delinquent, a person of weak moral character. They feel that only pure cussedness keeps him from “handling his liquor.” There are even many alcoholics who do not recognize that they are alcoholics, and feel privileged to look scornfully upon the people they consider alcoholics.
Sample studies recently conducted by Rutgers University at New Brunswick, N.J., indicate that 50 per cent of the American public erroneously believe that an alcoholic can stop drinking if he wants to; that only one in five properly views the alcoholic as a sick person.
This lack of public understanding is the chief obstacle in the way of an effective attack on alcoholism, which Dr. Lawrence Kolb, medical director of the U.S. Public Health Service, has ranked as America’s fourth greatest public health problem.
This is not to say that science has found a miraculous new cure for alcoholism and that only prejudice and indifference keep it from being applied. There is no one new finding, or group of findings, which promises an easy solution. But there do exist today, as never before, plans of attack which utilize all that science knows about alcoholism in medicine, psychiatry, sociology, and allied fields. Comprehensive programs of treatment, prevention, and rehabilitation have been worked out and tested in clinical practice, which can reduce the casualties of alcoholism by one half or more wherever they are thoroughly applied. But these plans will not work anywhere unless groups of individuals in states, cities, and communities become aware of the seriousness of alcoholism, and raise funds and plan programs to deal with it as a major public health problem.
How Many Alcoholics?
The facts about alcoholism concern everyone as intimately as the facts about heart disease, cancer, tuberculosis, infantile paralysis. The number of persons in this country medically classified as chronic alcoholics, who have developed physical or mental disorders as a consequence of prolonged heavy drinking, is 50 per cent higher than the number of known sufferers from tuberculosis. And it is a fact of central importance that no one, whether at present a teetotaler, a moderate, or a “social” drinker, can be positive of a lifelong personal immunity to alcoholism.
Of 100,000,00 Americans of drinking age (15 years and older), an estimated 58,250,000 use some form of alcoholic beverage, to some extent. The great majority of these, some 54,500,000 keep themselves mainly within the category of safe and moderate drinkers, and as such are no part of the public health program. But a minority of all drinking Americans, about 3,750,000, are classified as excessive drinkers, or inebriates, and within this group 750,000 or 800,000 are known, on the basis of hospital and court records, to be chronic alcoholics. Of all excessive drinkers, one in six is a woman.
Alcoholism is also a social problem of incalculable magnitude. Experienced Salvation Army Workers estimate that 90 percent of the down-and-outers who come to them for help have been brought there by excessive drinking. In New York City, one third of the men and one tenth of the women who take their marital difficulties to Domestic Relations Court are alcoholics; so are 95 per cent of all those committed to the Workhouse and 15 percent of those given penitentiary sentences. Officials of an Industrial Conference on Alcoholism held in Chicago this March estimated that alcoholic employees cost industry $1,000,000,000 in pro-duction and 24,000,000 man-hours of work per year. Boards of education find that parental alcoholism is a frequent factor in absences and behavior problems of school children, as it is in juvenile delinquency. Estimates of traffic accidents involving drinking by drivers and pedestrians vary from 10 to 50 per cent of the total, cannot be summarized in nation-wide terms because of local variations and inaccuracies in the reporting of accidents.
The problem of alcoholism looms large not only in terms of the number of people it affects, but also because it is such a complicated matter, having so many intangible and unsolved elements. To scientists concerned with the problem, the alcoholic is a sick person, no more deserving of moral blame or ridicule than sufferers from any illness. But alcoholism is not a separate, clearly defined disease entity. No single cause or group of causes can be assigned to it. It is confined to no one group of people within our population. No single course of therapy can be applied universally to all alcoholics. Science is still unable to point with certainty to those individual traits of physical and psychological make-up, which combine to make a small percentage of all drinkers peculiarly susceptible to alcoholism.
Until quite recently, those concerned with the various aspects of alcoholism-sociologists, physiologists, psychiatrists, educators, religious leaders-tended to approach the problem as specialist in their separate fields. Within the past few years, a new point of view has been emerging among these people. It is that alcoholism is a medical, psychological, social, legal, and moral problem, but that it is none of these alone.
A dozen years ago, there was no important national organization that was utilizing the tools of science in a concerted attack on alcoholism. Today, there are two central agencies, the Yale Plan on Alcoholism, and the Research Council on Problems of Alcohol, which are carrying out intensive studies, clinical work, and campaigns of public education in all phases of problem drinking. In addition, there is the now well known “voluntary fellowship” of alcoholics Anonymous, which in its 12 years of existence has gathered a membership of 60,000 rehabilitated alcoholics and contributed to the understanding of excessive drinking.
The Scientific Approach
Scientific work in this field is divided into two main approaches. One is concerned with finding factors in the biological and psychological make-up of individuals which may give them a predisposition toward alcoholism. The second approach is that of working out methods of treating alcoholism in clinics which will utilize all the knowledge of scientific research. In the practical work of the two main groups in the field, these approaches are combined.
The Research Council, which is affiliated with the American Association for the Advancement of Science, is currently carrying on a campaign to raise $200,000 a year to set up a series of combined research and treatment centers in alcoholism in leading medical schools throughout the country. One such center, at New York Hospital-Cornell Medical College, has completed the first year of a five-year plan financed by a $150,000 grant from the council. Some of these funds have been contributed by the liquor industry. This project, under the direction of Dr. Oskar Diethelm, co-ordinates research in the varied fields of psychiatry, internal medicine, physiology, pharmacology, biochemistry, psychology, and anthropology.
In the first year, the staff worked with a selected test group of 25 patients whose normal productive way of life had been seriously disrupted by the use of alcohol. All were people who wanted to be helped and none was of the “derelict” type. Each spent an initial period of from a few weeks to several months in the hospital, undergoing thorough physical, psychiatric, and psychological studies, and following supervised programs of diet, rest, and occupational therapy. Most of the patients willingly kept to the prescribed course and graduated to a transitional stage, of from four to six weeks during which they spent nights and weekends in the hospital and resumed work outside.
After leaving the hospital, patients enter a follow-up period of three to five years, returning for check-ups at first weekly, and eventually monthly. Social workers help the patient find suitable work and recreation, and family and friends are instructed to respect the patient’s “right not to drink.”
Dr. Diethelm’s primary aim is research. He has released no estimate of the success of his project in rehabilitating the first year’s test group, and an estimate based on such a limited group and period of time would have little scientific standing. Clinicians in this field are reluctant to say that alcoholism has been arrested in any patient until he has gone without alcohol for a period of several years and gives evidence of having undergone a basic re-education that eliminates his need for alcohol. But Diethelm’s staff has announced one promising finding: that certain unidentified substances in the blood are apparently associated with the craving for alcohol, as well as with the emotional states of tension, anxiety, and resentment.
Some other clues in the psychological field were reported at the most recent annual meeting of the Research Council, in Chicago last December. From the University of Texas, Dr. Roger J. Williams of the Biochemical Institute, announced that because of individual differences in body chemistry, a low concentration of alcohol in the blood is enough to produce signs of intoxication in many people, while others may have several times as high a percentage without becoming drunk.
Williams believes that differences in metabolic machinery, the way in which the body turns food into energy, make it possible for some people to drink heavily for many years without ever showing clinical symptoms of alcoholism, and impossible for others to drink even a little without developing an inordinate and disastrous craving for alcohol. He does not contend that the biochemical approach alone can conquer alcoholism; he hopes that it will eventually determine certain definite physiological characteristics which render some people vulnerable to the effects of alcohol.
Such metabolic idiosyncrasies, Williams believes, may be inherited. This does not mean that alcoholism is a hereditary disease – an old- fashioned bugaboo that has been thoroughly scouted by genetic science. The consumption of alcohol, even in excessive quantities over long periods, causes no damage to germ cells, and thus does not effect the genetic make-up of the children of excessive drinkers. Statistics show that only about one third of all alcoholics come from families showing a high incidence of alcoholism and mental illness. The and is emphasized because in an appreciable number of alcoholic patients, alcoholism is merely incidental to their primary ailment. These are “symptomatic” drinkers, who are given to the excessive use of alcohol by a psychosis, serious neurosis, endocrine disturbance, organic illness, or epilepsy. Their drinking is a symptom of their underlying illness.
Small Hereditary Factor
Most authorities consider that there may be some hereditary factor in alcoholism, but that it is a small one and difficult to separate from the greater and less understood picture of heredity in mental illness of all types. They believe that when the children of alcoholics take to drink, the influence of environment is generally a far stronger factor than biological inheritance. What may be inherited is an unstable constitution which, if subjected to adverse influences, is likely to develop alcoholism or mental illness more readily than other not so predisposed.
Williams believes, as do other leading researchers, that both hereditary and environ-mental factors are highly significant and that “a one-sided approach to the problem is doomed to failure.” As a biochemist, his special search is for some biochemical means of identifying potential alcoholics, and from that point, of developing preventive and remedial measures.
The search for a psychological basis for alcoholism is also being carried out in clinical studies at the New York University College of Medicine, under Dr. James J. Smith. He reports that many alcoholics show an insufficiency in the secretions of the adrenal gland (a small ductless gland sitting on the kidney) similar to that found in Addison’s disease. Treatment with adrenal and sex-gland hormones has yielded clinical improvement in NYU ward patients.
From the University of Chicago, Professor Emeritus Anton J. Carlson, president and scientific director of the Research Council, reports that a nitrogen-chlorine gas, previously used to bleach flour for making white bread, has been found to make proteins act as a nerve poison. Animals have developed convulsions as a result of being fed large amounts of white bread containing the chemical. It may be a contributing factor, Carlson believes, in turning potentially unstable persons into alcoholics.
Ranging far beyond this particular theory, Carlson indicates that the will of the alcoholic patient appears to be important to his recovery and rehabilitation. “The hereditary, the biochemical, the nutritional, the neural, the educational and the social factors determining the strength and direction of the will of man are still obscure,” he says, outlining the broad territory which present-day research in alcoholism is setting out to explore.
It is this broad, co-ordinated exploration, rather than individual new findings in separate fields, that constitutes the latest and most promising development in the study of alcoholism. The idea of this co-ordination arose at Yale University, and its practical applications are best seen today in the work of the Yale Plan, a many-faceted operation, which is formally know as the Section of Alcohol Studies of the Laboratory of Applied Physiology, Yale University.
Support from Liquor Industry
Some of the Yale Plan work is done under agreement with the Connecticut Commission on Alcoholism, a state agency of rehabilitation and public education established in 1945, the first of its kind in this country. The Commission currently derives funds of about $200,000 per year from higher licensing fees which representatives of the liquor industry have accepted voluntarily to pay for the program. The Commission is engaged in a broad, long-range program of education, research, treatment in public clinics and hospitals, community services, and, ultimately, prevention. Since 1945, Utah, Wisconsin, Oregon, and the District of Columbia have followed Connecticut’s lead in tackling alcoholism as a specific public health problem, and other states are instituting similar legislation.
The Yale Plan conducts the Yale Summer School of Alcohol Studies, now in its sixth year, which gives an intensive course in all phases of alcoholism to educators, social workers, and other professionally concerned with the subject. It is the outgrowth of experiments in the physiology of alcohol, which Dr. Howard W. Haggard and his associates in the Laboratory of Applied Physiology began around 1930. They made important findings about the metabolism of alcohol and its absorption and oxidation in the body. But Dr. Haggard, who became director of the Laboratory in 1938, saw the important need for going beyond these researches and getting at the fundamental causes and the possible means of prevention of alcoholism. “We got plenty of leads that suggested a physiological basis for compulsive drinking,” Haggard said recently. “But they were just leads. We couldn’t find a way of applying them to the individual alcoholics. So we decided to study all aspects of alcoholism and the problems of alcohol. In addition to our physiologists we brought in a biometrician, an anthropologist, a psychologist, a sociologist, an economist, and workers in other fields.” The Yale biometrician, Dr. E.M. Jellinek, is now director of the Summer School of Alcohol Studies, associate editor of the Quarterly Journal of Studies on Alcohol, and an active collaborator in all of the work of the Yale Plan.
“We went after the larger questions of why people drink,” Dr. Haggard said, “why a few become alcoholics while the great majority does not, what alcohol does to people psychologically as well as physically. When we started the summer school, we were a little afraid of attracting special pleaders for one point of view or another. But we found that when people of various persuasions got together and saw each other’s point of view, they got a broader understanding of the picture. They had discussion sessions outside of lectures, and discovered just what we had found out-that the best way of dealing with the problems of alcohol is to tackle them as a total problem, uniting all approaches.”
For the interested laymen, the most dramatic work being done by the Yale Plan is in its “pilot clinic” at New Haven. This clinic and the one at Hartford were set up in the spring of 1944 with the aid of the Connecticut Prison Association; the management of the Hartford clinic has since been taken over by the Connecticut Commission on Alcoholism. Both clinics were established not only to cope with the loss of industrial manpower through alcoholism in Connecticut, but with the longer aim of working out methods for dealing with two essential problems encountered all over the country: 1) Where can the individual in the community go for aid, advice and treatment? 2) By what method can the community restore the social usefulness of its alcoholically incapacitated members? By what methods can it best prevent alcoholism?
The Qualified Recoveries
“We’re not concerned here with whether you should drink or not,” Dr. Haggard says. “We’re concerned with those people whose drinking interferes with their lives, who become social problems through excessive drinking. We wanted to know whether it was feasible to set up a free clinic where, at a cost to the community of about $100 per patient, we could get a reasonable recovery. We don’t talk about curing alcoholics. We call our successful cases qualified recoveries. The qualification is that the patient will stay recovered only as long as he doesn’t touch liquor again.”
The Yale Plan Clinic is housed in an old-fashioned red brick building which bears no resemblance to a hospital. Patients are admitted without charge, regardless of their financial circumstances. Some are brought or sent in by members of their family, friends, doctors, or employers. Others, by arrangement with the Connecticut Commission on Alcoholism, are referred to the clinic by the courts. And a good many others, who turn out to be the most responsive to treatment, come in of their own accord, because they are greatly concerned by the extent to which drinking interferes with their leading normal lives.
The Three Categories
The medical director of the Yale Plan Clinic, Dr. Giorgio Lolli, heads a staff of ten. Besides himself, there are three other doctors (on part time), three social workers, a psychotherapist, a psychologist, and two secretaries. The clinic has no hospital facilities; all patients are ambulatory cases. The clinic admits all applicants for a least a preliminary interview, but because of its limited facilities and staff, because its function is that of an experimental model rather than a full-scale rehabilitation project, it cannot undertake to treat all applicants. For practical purposes, the New Haven Clinic divides applicants on the basis of diagnosis into three categories:
1) The symptomatic drinker, whose drinking is incidental to mental illness, severe endocrine disturbance, or epilepsy. Since these people do not respond to treatment for alcoholism as such, they are referred to psychiatrists, private physicians, mental-hygiene clinics, or hospitals, where their underlying illness can be treated. Perhaps 15 per cent of the total number of alcoholics are in this group.
2) The social misfit, “derelict” type of alcoholic, who is disqualified for family life, hasn’t the emotional stability to hold a good job, is apt to be so physically deteriorated and psychologically disorganized that only long institutional care and social rehabilitation could redeem him. These make up 15-20 per cent of those seen. For this type, the Yale plan people would like to see custodial therapeutic institutions established that would utilize all elements of the co-ordinated approach. The danger in jails and “inebriate farms” as they have been constituted, is that they don’t make proper diagnosis, that they merely keep derelict alcoholics in custody, finally releasing them without any basic improvement in condition.
3) The true alcoholic, with an impulsive drive to drink. People in this group show a variety of pattern in their drinking habits. Some go on periodical binges, every weekend, or irregularly. Some get drunk every night. Others are always moderately under the influence, have a constant concentration of alcohol in the blood but do not necessarily show obvious signs of drunkenness.
Handling of Applicants
Yale Plan doctors do not hold that all alcoholics necessarily fall into one of these arbitrary categories, which are principally useful in the handling of applicants. “Our distinction is made on the basis of whether we think we can or can’t help,” Dr. Lolli explains. “Our handling of a patient just coming to the clinic varies greatly according to his state. If he’s just coming out of a binge, he may need help in overcoming the effects of his hangover. In all cases, we make an immediate attempt to give relief. Sedatives may be used when the patient is jittery and nervous. In the early days of treatment, we may administer crude liver plus Vitamin B1. When the physical condition improves, and Vitamin B1 can help bring this about, the need for alcohol diminishes, but nothing has been done to clear up the underlying condition. To tackle this, we use a variety of methods, depending on the individual.
“At an early point the patient is usually interviewed by a social worker with some psychiatric training. Without antagonizing the patient, we may make a start at getting his case history, his background, family circumstances, employment record, and some preliminary notes on his troubles with drinking. If we can’t get this information at first, we postpone it to weeks or months later.
A Patient, Not a Sinner
“There are usually a lot of difficulties which require immediate attention-family troubles, loss of job, legal and financial problems. The social worker starts at once to try to solve the most pressing of these and relieve the tension they cause in the patient. We impress upon every applicant the fact that we consider him a patient, not a sinner. If the patient doesn’t show an immediate psychosis or serious neurosis calling for deep therapy, even these preliminary steps, establishing the fact that he is a patient and that some relief is in sight, have some therapeutic effect. Our approach is a very factual one. We don’t promise anything, and we don’t want patients to promise us anything. We give them the evidence that we can relieve them of some pain, by psychological or medical means, and when they get even this much hope they are off to a good start.”
The next step in the Yale Plan procedure is a thorough physical examination to find out if any illness is present, due or not to alcohol. Alcoholics show “organ-neurotic” symptoms-physical complaints which are apparently of psychological origin. Some of these can be relieved by medical treatment. Benzedrine and dexedrin can help to overcome depressed states. If medical laboratory tests are necessary, they are usually done elsewhere.
Although the Yale Plan Clinic has no official connection with Alcoholics Anonymous, it refers some of its applicants to the local group of that association, and in turn takes in patients referred to it by AA. Local groups hold regular meetings at which members tell of their own experiences as compulsive drinkers, and testify to their recovery through adherence to the AA plan. This plan consists of twelve formal steps, which may be reduced to these essentials: a) the alcoholic must admit that he is powerless over alcohol and seek help from outside; b) he must attempt to analyze his personality, acknowledge his wrongs, make amends when possible to people he has harmed; c) he must place his dependence upon a higher power, which at first may be merely the AA organization, but ultimately should be God as he understands the concept; d) he must work at rehabilitating other alcoholics.
Effective Rehabilitation
Alcoholics Anonymous claims a recovery rate of from 50 to 75 per cent of those who give its methods a sincere trial, and the majority of scientific researchers agree that it is the most effective single course of rehabilitation. Dr. Howard Haggard attributes the success of AA in part to the need of the alcoholic for treatment that is understanding, tolerant, patient, and serious.
“Recriminations are useless, for the alcoholic has deep within him the strongest feelings of guilt and responds to them with hostility,” Haggard says. “They are only further proof that no one understands him. A high moral tone, preaching, drives him away. The gift of really understanding the alcoholic, winning his confidence and co-operation, is often held in high degree by ex-alcoholics who act as lay therapists or group therapists as in Alcoholics Anonymous. They have been through the same experience themselves; they know the feeling of tension, of discontent, of omnipotence, of guilt, and of resentment. They know, and forgive, the inevitable ‘slips’; after the sprees, they are able to maintain their fully understanding attitude and an unabated confidence.”
Religious Elements
But some problem drinkers, particularly those who are unable to accept the religious elements of the AA plan, prove unresponsive to it. With a small percentage of these, the Yale Plan Clinic uses the aversion therapy or conditioned reflex method as an initial step. This consists of giving the patient a drink in combination with a medicine which produces nausea; after several such treatments an association is built up which makes alcoholic beverages distasteful. The method is useful as a means of keeping a patient away from liquor for a period of weeks or months, when it may be renewed, but it does not clear up the basic maladjustment.
It is this basic maladjustment, a highly individual matter in each case, which the Yale Group attempts to cope with as soon as possible through a variety of psychotherapeutic approaches. After the diagnostic study has been carried out, the staff tries to fit the therapist to the individual. If he doesn’t click with one person, he is shifted to another, for a favorable reaction to the therapist’s personality is considered highly important in holding the patient’s faith in a course of treatment. A social worker may be able to deal with some of the most troublesome phases of the case; a doctor will be needed for others-difficulties in the sexual sphere, for example. The sex therapist, Mr. Raymond G. McCarthy, executive director of the Yale Plan Clinic, takes on patients who seem likely to respond well to a series of daily interviews over a period of three months, through which the patient develops insight into his problem and is re-educated into a satisfactory pattern of living which excludes the use of alcohol.
Exact Figures Unknown
So far some 1,000 patients have been seen by the two Yale Plan clinics at New Haven and Hartford. This figure includes symptomatic drinkers who have been referred elsewhere, and those who have kept no more than one appointment. About 100 of them were referred to the clinics by the courts, and of these, not more that ten per cent came back for further interviews. The Yale group are reluctant to give figures relating to success. They prefer to talk of the “percentage in which the drinking pattern has been favorably affected.”
“Of those who kept coming after the second or third month,” says Dr. Lolli, “about 70 per cent have been favorably affected. We can’t even guess how many have stayed entirely off liquor. We had one patient who went for 18 months without a drink, then went on a binge, and came back. Was he a failure? No. His drinking pattern had been favorably affected. He had learned during those 18 months that he got more enjoyment out of life without drinking than with it. We can’t consider that one relapse makes a patient a failure.”
The Time Will Come
“We don’t have all the answers yet, by any means,” Lolli sums up. “But we do feel that we are demonstrating that the specialized clinic for alcoholics is the most effective way of meeting the problem. And the best approach is a combined one-medical, psychological, religious, social. The time will come when the psychological basis of alcoholism will be found. Then we will be able to put a finger on predisposing conditions, perhaps correct them medically or at least convince people with these conditions that alcohol is poison for them.”
(Source: Science Illustrated, June 1948)
