THE PLACE OF THE LAY THERAPIST IN THE TREATMENT OF ALCOHOLICS
Dwight Anderson, LL.B.
Quarterly Journal of Studies on Alcohol September, 1944*
When the history of the treatment of problem drinking comes at last to be written, the pioneer contributions of the layman will be seen to have been greater than is now generally supposed. It is intended here to indicate in general what this contribution has been, and to inquire why certain laymen as therapists have been able to produce results often denied to professional persons. The treatment and prevention of this ailment, in the future, will benefit by an inquiry regarding the nature of the lay therapists qualifications and techniques. Such an examination begins with the personalities who have already been outstanding in this field of effort.
The late Richard R. Peabody made a notable contribution to therapy. Through his students, many of whom became lay therapists themselves, his techniques have been perpetuated. Most of them are embodied in his book, The Common Sense of Drinking. These techniques functioned to bring about-reactions in the patient which can be classified as surrender, relaxation and catharsis. Peabody did not call them by these names, but an examination of his writings, including the "notes" which he supplied to alcoholics studying with him, shows plainly that these three responses from his subjects were the effects of his instruction. How these three elements are to be found also in the Program of Alcoholics Anonymous, and in the work of other therapists, is described by the author of this article in another place. Peabody and his followers worked out, with their students, nine steps described by Bowman and Jellinek as follows:
1. A mental analysis and removal of doubts, fears, conflicts, created in the past.
2. Permanent removal of tension, which is only temporarily released by alcohol, by formal relaxation and suggestion.
3. Influencing the unconscious mind by suggestion "so that it cooperates with the conscious to bring about a consistent intelligent course of action."
4. control of thoughts and actions.
6. Daily routine of self-imposed schedule to keep the patient occupied, to train his will power and efficiency and to give him the feeling that he is doing something about his problem.
7. warning the patient against unexpected pitfalls.
8. Providing the patient with some means of self—expression.
9. Realization that the same force which drove the patient to disintegration will, under conditions of sobriety, carry him beyond the level of average attainment.
Courtenay Baylor of Boston was specifically credited by Peabody as his preceptor. Peabody stated: "The treatment. . . has been carried on by Courtenay Baylor for seventeen years. I can never sufficiently acknowledge my debts to him for being able to write it." In his book Peabody quotes directly from Baylor;
To substantiate the theory I have described, quotations from Mr. courtenay Baylor’s book, "Remaking a Man," are pertinent. "I recognized," he writes, "that the taking of the tabooed drink was the physical expression of a certain temporary but recurrent mental condition which appeared to be a combination of wrong impulses and a wholly false, though plausible philosophy. Further, I believed that these strange periods were due to a condition of the brain which seemed akin to a physical tension and which set up in the processes a peculiar shifting and distorting and imagining of values; and I have found that with a release of this "tenseness" a normal coordination does come about, bringing proper impulses and rational thinking."
And again,"Underlying and apparently causing this mental state (fear, depression or irritability), I have always found the brain condition which suggests actual physical tenseness. In this condition a brain never senses things as they really are. As the tenseness develops, new and imaginary values arise and existing values change their relative positions of importance and become illogical and irrational. Ideas at other times unnoticed, or even scorned become, under tenseness, so insistent that they become controlling impulses. False values and false thinking run side by side with the normal philosophy for a time; and then with the increasing tenseness the abnormal attitude gradually replaces the normal in control. This is true whether the particular question be one of drinking or of giving way. to some other impulse; the same indecision, changeability, inconsistency, and lack of resistance mark the mental process. In fact, the person will behave like one or the other of two different individuals as he or she is not mentally tense."
Peabody then continues to amplify Baylor’s thought:
"We must not overlook one very important but little-recognized stimulus to drinking. Emotional instability (tension) can be created by legitimate excitement (such as attending a football game where the home team is victorious or, for that matter, by any other form of pleasant emotional stimulation) just as surely as it can by worry and unhappiness. In fact, it would be no exaggeration to say that the alcoholic has to learn to withstand success just as assuredly as he does misfortune, strange as this statement may seem. Many drunkards claim that they do not use alcohol as a refuge but as a means of celebration, and they are probably right as far as their conscious minds are concerned."
"When a man under pleasant emotional stimulation seeks narcotic escape from reality in the same manner as he does from unpleasant emotions is an interesting question but difficult to answer. My own theory is that a neurotic is unconsciously, and possibly consciously, afraid when his emotional equilibrium is disturbed, no matter what the quality of the disturbance may be. When he is in a state of euphoria (happiness) he evidently feels the need of a stabilizer to the same extent as he does in dysphoria (unhappiness). Just as he is bored when he loooks inward, so he is frightened when he looks outward, if the customary scene has changed even a little."
That these ideas, first promulgated by Baylor thirty years ago, have proved their validity down to the present time, is one of the interesting facts in the history of the lay therapist. Extensive quotations from ‘Peabody and Baylor appear in Alcohol, One Man’s Meat, by Edward A. Strecker, professor of psychiatry at the University of Pennsylvania, and Francis T. Chambers, Jr., a lay therapist, published in 1941.
THE LAYMAN"S SPECIAL QUALIFICATIONS
These contributions to theory do not fully explain the layman’s success in practical application of the principles. Every recovered alcoholic will acknowledge that the key ideas
which caused the revolutionary change in his outlook and behavior had been presented to him without effect a number of times, but until he met the right therapist, and perhaps until he had struck the "rock-bottom" of desperation, they failed to "click." Since most contemporary lay therapists are former alcoholics, we do not have far to seek to learn the reason for the layman’s ability to get his ideas accepted by the subject. It has been explained by Foster Kennedy, Director and Chief of the Department of Neurology and Neuro-Psychiatry, Bellevue Hospital, New York, in these words:
"I have no doubt that a man who has cured himself of the lust for alcohol has a far greater power for curing alcoholism than has a doctor who has never been afflicted by the same curse. No matter how sympathetic and patient the, doctor may be in the approach to his patient, the patient is sure to feel, or to imagine, either condescension to himself, or get the notion that he is being hectored by one of the minor prophets."
No mere spectator of compulsive drinking can substitute hearsay knowledge for the conviction born of experience. If a man has never experienced the joys of alcohol he cannot have an understanding of its sorrows. Thus, what the lay ex-alcoholic says to the patient comes with double the force it would have if said by a psychiatrist, no matter how great his prestige. In fact, the greater the prestige, perhaps the greater the resistance of the patient. Rapport can be, and often is, instantaneous when a former alcoholic acts as a therapist. What the layman lacks in technique and understanding can be supplied by training and supported by the continuous help and supervision of the psychologist, ‘the physician, and the psychiatrist, what cannot be supplied is his kinship with the compulsive drinker. He is ideally equipped to break down the wall of resistance which every alcoholic interposes to treatment even when he sees it.
William James has explained this personality barrier, although in quite another connection:
"The psychology of individual types of character has hardly begun even to be sketched as yet — our lectures may possibly serve as a crumblike contribution to the structure. The first thing to bear in mind (especially if we ourselves belong to the clerico—academic—scientific type, the officially and conventionally "correct" type, for which to ignore others is a besetting temptation) is that nothing can be more stupid than to bar out phenomena from our notice, merely because we are incapable of taking part in anything like them ourselves."
An impulse to heal others is characteristic of almost every recovered alcoholic by whatever means his abstinence has been brought about. It would appear that the alcoholic’s excessive need for importance, praise and attention, described by Dr. L. S. Sillman of the New York Psychiatric Institute as a "defiant grandiosity," becomes modified and converted during and after recovery into a desire to help those who are suffering as he has suffered. He is further benefited by learning how to share with others the new and unexpected values which life now holds for him. This changed attitude away from egocentricity is reflected in his other relationships with accompanying benefits which soon become apparent.
Foster Kennedy referred to this factor in his comments on the procedures of Alcoholics Anonymous, previously mentioned. He said:
"The sick man’s association with those who, having been sick, have become, or are becoming well, is a therapeutic suggestion of cure and an obliteration of his feeling of being a pariah; and this tapping of deep internal forces is shown by the great growth of this sturdy and beneficent movement. Furthermore, this movement furnishes an objective of high emotional driving power in making every cured drunkard a missionary to the sick. These men grow filled with a holy zeal and their’ very zealousness keeps the missionary steady while the next man is being cured."
Another advantage possessed by the recovered alcoholic, which is of the highest value, is that he will never give up hope. The vagaries of the patient’s behavior, which are often difficult for the physician to cope with, are instantly understood by the layman who "has been there himself." He cannot forget ‘the numberless times that his friends and relatives gave up hope for him, to say nothing of the occasions, still more numerous, when he had no hope himself. But when the time was right, and ho himself was ready, he became accessible, and this memory is an unfailing source of encouragement as he encounters the inevitable vicissitudes of his cases. So he never gives up the battle and will stay with the most difficult cases. longer than any other person. He insight is derived from seeing in the patient before him a mirror of his own past. This is no place to delve into the realm of the mystical, but all who have watched recoveries from this ailment have observed that the faith of the therapist is a vital part of the treatment. When we come to fit lay therapists into a formal, organized scheme of treatment, there will be no lack of candidates. Up to now, the successful ones have worked independently of Alcoholics Anonymous, and whose own recovery was otherwise accomplished, have developed their clientele in a normal and natural way by producing results which became talked about. First, their own success with themselves became known to their friends who, surprised, asked, "How did you do it?" and thereafter sent alcoholics to hear the story. Of the many who were called upon to help others, some failed, and some succeeded. Those who succeeded found, in time, that they had gained acceptance from medical men and others; and with increasing referral of cases to them, they often gradually came to devote more time to this work. It is doubtful whether those who failed did any serious harm to the few whom they tried to help; for if their approach was wrong, it apparently had little effect on the subject either for good or ill. No man who continuously fails to accomplish his end continues long on a course of activity. So there has been a weeding out of the unfit by the course of events.
The, ideal arrangement for lay therapy would appear to be the one existing at the Institute of the Pennsylvania Hospital, where a layman, Chambers, works with a psychiatrist, Strecker, and has easy access to him. This does not appear to exist in just this way anywhere else except at New Haven, Connecticut, where Mr. Raymond G. McCarthy is a member of the staff of the recently formed Yale Plan Clinic, with medical and psychiatric services available. At the latter clinic as well as its counterpart in Hartford, each patient receives both a medical and psychiatric examination as early as is possible.
At the two Shadel Sanitariums located in Seattle, Washington, and Portland, Oregon, former patients are used as executives, employees, and field workers. Laymen conduct the original interview, and the last one on departure. The conduct of the establishments is under the constant supervision of medical men. Psychiatric care can be made available if required, but cases with pathological conditions are avoided. The conditioned—reflex or "aversion treatment" is the basis of the procedures at these establishments, supported by the psychotherapy of the executives, and of the field men who call upon patients who have returned to their homes in, the intervals of a year’s treatment during which patients come back periodically for reconditioning. Social workers have not been found to be as effectual for this purpose as patients who have made recoveries at the Shadel establishments.
Every recovering alcoholic needs help with such problems as what to say to friends who invite him to take a drink, what to tell employers ,on returning to the job, whether to avoid previous haunts or go to them from time to time, and as one man put it to a recovered alcoholic, "what in hell do you do on pay day?" The problem of going through the festive Christmas and New Years season is often fraught with difficulty. One who has had to find answers to these questions for himself is the best person to advise another. One lay therapist is responsible for a suggestion which has proved of great value with patients after a period of hospitalization; it is to change the furniture around so that the home looks different. It is found that this device assists in disrupting some of the associations of the former way of life.
NATURE OF TRAINING
As Mr. Chambers connection with the Pennsylvania Hospital as lay therapist was formed in the year 1935, his opinion was sought on the preparation of this article. In a letter dated May 31,1944, he writes:
"The intelligent lay therapist should have gained deep insight because of his own alcoholic dependency and recovery. The therapist who has overcome his drinking problem acts as a constructive suggestion element. The reeducational treatment plan that he uses, if it is sound, should afford insight and stimulation toward readjustment."
"The lay therapist working withou’ medical support exposes himself to risks that might make him directly or indirectly responsible for tragic consequences. From a commonsense angle, he should not attempt unsupported therapy."
"As a associate in therapy, he can greatly relieve the heavy caseload of the already overworked physician in clinic and hospital."
"His qualification should be a two-year period of abstinence, during which time he has adjusted satisfactorily, in his social life and vocational field. If after a two-year period of abstinence, he wishes to become an associate in therapy, he should have at least a year’s special training. This training should include courses in a reeducational treatment plan. He should attend lectures on psychiatry, such as are given to third year students of medicine at the University of Pennsylvania by Dr. Strecker. He should attend lectures given by psychologists so that he would have an appreciation and understanding of psychometric testing. A period of nursing would be an invaluable experience in order to familiarize him with the difficulties of alcohol withdrawal symptoms. He should attend selected medical lectures so that he would have an appreciation of the medical aspects of the problem. If he progresses satisfactorily, he should be permitted to work with a certain number of alcoholic patients under the supervision of an experienced therapist. When undertaking a reeducational treatment plan he should consider himself as an assistant to the psychiatrist in charge, and make use of the psychologist’s reports. He should also be familiar with the facilities offered by the laboratory."
"The graduate would have benefited himself in many ways. He would have had experience under the discipline of science, and learned to respect and depend on the scientific procedure. He would learn to work with others, both depending on them and contributing to their effort. More than this, he would personally benefit by subduing his often exaggerated craving for importance to a more healthy level."
"It is obvious that choosing the right caliber person is important. Emphasis should be laid on quality rather than quantity."
In line with Chambers’ suggestions, additional attention may be paid to educational qualifications. As a candidate for training, a lay therapist would have an advantage if he possessed at least an academic bachelor’s degree. This requirement could be relaxed in instances where high intelligence, combined with a pronounced record of success in helping to bring about recoveries, clearly demonstrates fitness."
It will be excellent if work with alcoholics, or at least observation of them, continues during the period of instruction, so that the words and definitions which he is taught in the classroom will have meaning to him in their manifestations in human beings.
Students can learn how to take case histories by actual contact with patients. Lectures may be accompanied by seminars, and discussions of these case histories. A social worker will have placed at the disposal of the therapist studies of the environment and family relationships. The physician’s findings, as well as the psychiatrist’s, will be interpreted to the student at the time they are made available to the therapist in charge of the patient, and they are made to mean more to the student if he is allowed to come in contact with the patient. The teaching should be done as much as possible with the participation of the student, giving him little of theory, but reiterating that little, time after time, by group discussion and contact with individual patients.
An invaluable part of the therapist’s education will be to bring home to him a realization of how little he knows of the subject matter he has studied. A little knowledge is not a dangerous thing, if it is known to be little, with this will come to him also an appreciation of how little anybody knows, or can ever know, of the psychic mysteries of the wellsprings of human behavior. He will respect himself and his colleagues when he finds that those who know the most make the least claims for what they can do in the treatment of the psyche. For what is not known is vastly greater than what is known, and the most experienced psychiatrists often do not understand just how they produced a favorable result in one case, or why they failed in another. There is no machine that will give us an X-ray of the soul. No intelligence test can tell us what use a person’s emotions will make of his intelligence. This may be approached some day when we have a means of determining an emotional quotient comparable to the intelligence quotient. The Rorschach Test is a step in this direction for the few who have the education, training and experience to apply it.
SCOPE OF THE LAYMAN'S ACTIVITIES
Few psychiatrists are sympathetic to the need for treating people whose behavior is within what is considered to be the normal range, insofar as psychoneurosis or psychosis is concerned, but who spend much of their time either getting into or out of trouble with alcohol. These persons are ready made material for the lay therapist, and they form a considerable portion of all the cases of problem drinking. The layman will fail, doubtless, with many patients who are definitely psychopathic, just as the psychiatrist frequently fails. Hervey Cleckley, of the University of Georgia School of Medicine, has provided a series of fifteen case histories diagnosed as "psychopathic personalities, without psychosis" and mostly complicated by excessive drinking. He devotes chapters to the psychopath as a business man, as a man of the world, as a gentleman, as a scientist, as a physician, and as a psychiatrist. Repeated hospitalization accomplished little with these persons. The lay therapist cannot hope to succeed with many of these.
What the competent lay therapist does is to make an analysis after his own fashion, following a series of interviews and a study of the history of the case. These judgements have little in them of formal science, but much of the intuitive art of influencing human behavior. The competent therapist looks for the areas of emotional structure in which the alcoholic’s responses are impaired, confused, or even wholly absent. To use a homely comparison, the patient is like a jangling piano. The case, the outer appearance, the apparent behavior, often appears fine and competent.
But touch the keys of C and E. No sound comes forth, part of the personality, gives no response whatsoever, although all the keys are there and most of the strings respond with notes of good quality, when the lay therapist finds that a patient lacks certain "strings"— due to a congenital defect or to disease, trauma or degeneration he promptly sends that patient to a psychiatrist. Perhaps the psychiatrist can stop the deterioration or repair the damage. This is a last hope. If he does nothing more, the psychiatrist may organize a non-taxing environment, write a simple score for the patient to play.
If, on the other hand, and as so often happens, the lay therapist gets a response too faint or too loud from the disordered alcoholic, or the one that is sharp or flat, he knows that the fundamental mechanism is still intact, and that eventually he can repair the instrument. Perhaps the hammers need new felt, or the damper pedals should be regulated, or a string here or there needs to be adjusted.
To continue the analogy, pianos are made to stand great stress; the tension of the strings exerts between 15 and 20 tons of pressure upon their frames. People in the world today are subjected to severe and continuous tensions and shocks. Many merely get out of tune. They use alcohol to create a feeling of inner harmony. But the alcohol causes more discord. They are the very ones whom the lay therapist can most readily tune up so that they are again acceptable for the orchestra of society and may play well for the great dance of life.
At the Yale Plan Clinics it has been found that a number of inquiries have come from persons who are not alcoholics, but who have reason to think alcohol is having an increasing serious effect upon them, and are worried. Groups of Alcoholics Anonymous also are often called upon to answer the question, "Am I in danger of becoming an alcoholic?" A lay therapist is as well qualified to answer such questions, for all practical purposes, as a psychiatrist, and he can be used in this way to economize the time of the latter. Common sense, practical suggestions are often all that are needed to help the baffled patient over what seem to him insuperable hurdles; often a quiet talk with the wife, mother or mother-in—law helps tremendously. The intervention’ here of a social worker is often useless; her suggestions are not so acceptable as those which come from a person who tears a leaf out of his own diary and says, "well, here is what was done in my case." To marshal to the resolution of these problems the powers of the psychiatrist would be like bringing up a pile—driver or a steam hammer to drive a nail. While these difficulties are simple, they are also crucial, and successful therapy often begins, and sometimes ends, with their happy solution.
1. Lay therapists have made a significant contribution to the treatment of compulsive drinking.
2. Their chief qualification derives from the fact that they themselves have made a recovery from this ailment.
3. They can be made increasingly of use in the future if we learn how to select them, how to train them, and, recognizing the scope of their function, learn how to use them in cooperation with the social worker, the psychologist, the physician and the psychiatrist.