Psychotherapeutic Procedure in the Treatment of Chronic Alcoholism
RICHARD R. PEABODY
BOSTON, April 18, 1928
In the use of alcohol as a beverage there is a descending scale of mental as well as physical reaction, increasingly pathological, beginning with almost total abstinence and ending with delirium tremens, alcoholic dementia, and death. Just where on this scale chronic alcoholism begins is open to a variety of opinion, but for practical working purposes I draw the dividing line between those to whom a night’s sleep habitually represents the end of an alcoholic occasion and those to whom it is only an unusually bag period of abstention. The former class, which will be referred to as normal, includes the man who limits himself to a casual glass of beer, as well as the man who is intoxicated every evening. But at worst they are hard drinkers, going soberly about their business in the daytime, seeking escape from social rather than subjective suppressions, and to be definitely distinguished from the morning drinkers who are, to all intents and purposes, chronic alcoholics, inebriates, or drunkards. There are normal men who occasionally indulge in a premeditated debauch, and who sometimes start the next day with a drink; but by and large, the men who can drink and remain psychologically integrated avoid it the next day until evening (midday social events excepted).
At first glance such a division would seem to be a quantitative one, but I believe this would be a superficial judgement. In reality there is a clearly defined qualitative mental reaction in chronic alcoholism, more closely associated with narcotics than with the normal use of alcohol.
It does not appear that the original impulse to drink is much, if any, stronger in the chronic alcoholic than it is in the hard drinker, and I believe that the latter would have almost as much difficulty in giving up his habit in spite of his boasting to the contrary; but when it comes to stopping temporarily, the situation is entirely different. once he has entered into it the drunkard has a pathological dread of leaving the alcoholic state.
A man said to me the other day, "That first drink in the morning is the best of all. It makes you feel as if you were coming back to sanity." Normal drinkers know nothing of such an experience as that.
So it is with the individual to whom alcohol has become a narcotic that this article is concerned.
Of course people are not born drunkards, except potentially. Havelock Ellis states that it is no easy matter to make a drunkard out of the average man. This transition is often subtle and slow. It may take place within a year of the initial indulgence or it may be postponed for twenty years. The first definite and generally fatal step is taken when the discovery is made that the mind rather than the body is suffering from alcoholic excess, and that a drink is good medicine for this mental suffering. A man then conceives the idea that he can avoid a nervous depression which he has become too cowardly to face. If he originally felt the necessity to escape from reality by getting intoxicated, reality plus a "hangover" must be avoided at all costs. I do not believe that the average alcoholic wants to remain in a state of intoxication, in the same sense, at any rate, that he wanted to drink in the beginning. He is constantly rationalizing that he is "tapering off" and is seldom enjoying his spree after the first or second day; but he cannot, stand the nervousness and depression that set in when the narcotic is stopped or even cut down. He talks of "needing" a drink rather than of "wanting" one, and when a man "needs" alcohol, he has definitely reached a pathological stage of drinking.
The behavior of the alcoholic is, I believe, better explained as an abnormal search for ego maximation or self-preservation than in terms of repressed libido - using libido in the Freudian sense. There is invariably an inordinate craving for power in an organism that has proved’ totally incapable of realizing its cravings. The alcoholic state takes on the aspect of a simple wish-fulfillment dream. For the time being - i.e., while drinking - the individual has caught up with his imagination. In fact, much can be learned about him by asking him to describe what constitutes to his mind an ideal debauch. On the other hand, mental analyses have rarely disclosed anything abnormal or suppressed in the conscious sex lives of the patients, though I realize that psychoanalysis has uncovered strong evidence of latent homosexuality in the, unconscious minds of alcoholics. There is almost always, however, some degree of inferiority feeling and often it is extreme. It is a separate and more fundamental inadequacy than that which alcoholic misconduct itself creates, through dissipation and shame form such an exceedingly vicious circle that the whole problem on the surface seems confined to the symptom itself. The alcoholic is often unconsciously glad of what he considers a manly excuse to escape his responsibilities and conceal his weakness. A sober ineffective personality is unbearable, but there is something heroic about a drunkard. So he regresses to an infantile state of irresponsibility in which he imagines himself to be safe, and it is this regressive factor that accounts, I think, for much of the childish behavior in those under the influence of liquor.
Originally I tried to explain alcoholism in terms of extroversion and introversion — i.e., as a disease of introversion. There were enough alcoholic extroverts, however, to make such a position untenable, further than to say that alcoholics who are predominantly introverted outnumber the extroverted by three or four to one.
To digress slightly, while I agree with Professor McDougall that the introvert drinks to extrovert himself, I must add that the extrovert drinks for the same reason - that is, further to extrovert himself, but I disagree with McDougall when he says that a person is hard-headed in withstanding the effects of alcohol in proportion as he is introverted. Better, to say that he is light-headed in proportion to his, psychological disintegration.
In searching for causes, it is necessary to distinguish between those that merely influence the individual to take up drinking and those that make him a chronic alcoholic. The former are too obvious and of too little interest to be a part of this article. As for the latter, the question of inheritance naturally arises first. I do not believe and have never seen it stated that the direct craving for alcohol was transmitted from one generation to another. In nearly every case, however, my patients have referred to at least one of their parents as being nervous or temperamental, and often their abnormal behavior seems to have been extreme. Therefore, we can reasonably say, it seems to me, that a nervous system that cannot function properly under alcoholic stimulation is definitely inherited, but that is as far as we can hold the parents responsible, genetically speaking, regardless of their habits.
Much more important is the early home environment. It is difficult to say just what part an alcoholic setting plays in the formation of the child’s character. My own theory is that it is of less importance than one would imagine. It may influence him to drink when he matures, but his tendency to pathological drinking depends on whether he has been taught to believe in and rely on himself or whether he has been frightened, neglected, or pampered, thereby growing up inadequately adjusted to his environment, with attending feelings of inferiority. Cases of chronic alcoholism in which the parental attitude toward the child was intelligent are, rare; more frequently it was decidedly abnormal. Where exceptions to this theory have been noted, I must confess I have been at a loss to explain the etiology of the habit.
The reason we so seldom find alcoholism combined with a pronounced phobia, hysteria, or combination is, I think, because alcoholism has fortuitously occurred as a symptom of an underlying condition which might just as well have been expressed in another kind of neurosis. If, as Freud says, the neurosis is the negative of a perversion, I’ do not see why it would not be equally truthful to say that chronic alcoholism is the negative of a neurosis.
I say fortuitously, but as a matter of fact it is a rather natural method of escape from disturbing conflicts because it is arrived at by a quasi-normal route. An alcoholic is only doing in an exaggerated way what a large portion of the normal male public has done for centuries, and he is not conscious of his pathological condition until its symptomatic expression is fully developed.
While chronic alcoholism is just as definitely a symptom of an abnormal mental condition, as claustrophobia, the analysis of alcoholics as a group brings out different states of mind from those found in more commonly recognized psychoneurotic conditions.
For instance, that exaggerated concentration on self which characterizes most neurotics is much less apparent in alcoholics. They are more interested in life objectively, even though this interest may be of a non-participating nature. A very large majority are intellectually as well as morally honest. (Incidentally, where they are not morally honest when sober, the prognosis is exceedingly unfavorable.) While they are less fearful of their condition, they are far less courageous in their efforts to overcome it. If the average alcoholic had half the bravery and perseverance of the average neurotic,, his problem would soon be a thing of the past. This statement is made because of the apparent ease with which the inebriate indulges himself, once his mind is made up. There seems rarely, if ever, to be that heroic struggle so often found in those suffering from the various psychoneuroses. The point of view is merely changed and action automatically follows. That is why, in the treatment of alcoholism, the mental synthesis must be stressed in contrast to the analysis that has proved so important in the more typical neuroses.
Once a man has become a drunkard, it is no easy matter to rehabilitate him even under the best conditions. It takes at least fifty and generally nearer one hundred hours of work on the part of the instructor and an almost perpetual concentration on the part of the subject. He is taking a course in mental reorganization and he must never forget it. Therefore, certain types can be eliminated as unsuitable for treatment. This includes those who are in any way psychotic, as well as those who wish to recover temporarily for some ulterior motive, as, for instance, the pacification of irate parents by sons eager for an opportunity to renew their excesses, or of discouraged wives by husbands anxious to keep out of the divorce court. Another futile group are those who wish to be taught to "drink like gentlemen," as the saying goes. There is only one thing a drunkard can be taught and that is complete abstention forever, and it is only to those who are sincere and intelligent enough to comprehend this that the treatment is applicable.
Between the sane, sincere group and that just referred to there exists a rather large number of people for whom the prognosis is most uncertain, further than to say that a cure will be effected only after a very long and discouraging course of treatment, if at all. This group I can only designate by those vague terms "constitutional inferior," psychopathic personality," and "peculiar personality." These people are obviously sane and in their own way sincere, but they never have been well integrated even before they indulged in alcohol. They seem to lack sufficient driving force (libido as the word is used by Jung) to sustain any plan of constructive thought or action long enough to have it crystallize into permanently fixed habits. even though rarely cured in the strictest sense of the word, the alcoholic outbreaks of these individuals are often restricted to relative infrequency if they are kept under more or less permanent supervision.
Before describing what the treatment is, mention should be made of one thing that it is not, and that is ethical exhortation. patients have invariably been surfeited with preaching, and they must, be reached by some new approach if their attention is to be gained and held. Appeals to their self-respect, warnings as to future mental and physical disasters seldom do any good. Nor are patients encouraged to give up their habit for the benefit of anybody else. It may, strike a romantic note in the beginning, but sooner or later the person for whom it is given up does something or is imagined to have done something which gives unconsciously the longed for excuse to drink. The patient’s problem is to overcome his habit because he himself believes it to be the expedient thing to do.
There have been cases where the individual has been persuaded that he wanted to stop drinking as well as shown how to do it, but it is more satisfactory to deal with people whose moral problems have been previously settled.
The treatment may be subdivided as follows:(1) analysis; (2) relaxation and suggestion; auto—relaxation andauto-suggestion; (4) general discussion, which might be called persuasion in the manner of Dubois or readjustment after McDougall; (5) outside reading; (6) development where possible of one or more interests or hobbies; (7) exercise; (8) operating on a daily schedule; (9) thought direction and thought control in the conscious mind.
On the first interview I try to gain the confidence of the patient by showing him that his pathological drinking is thoroughly understoo4 and that he is not going to be treated by prayer or abuse.
The patient is encouraged to give a full account of his past history and present situation. I try to make the analysis as thorough as possible, but ‘do not go into the unconscious. There are cases of compulsive periodic dipsomania, which would unquestionably require a psychoanalysis, but I have not met one of them yet. Stekel, I believe, is authority for the statement that psychoanalysis should be used only when other methods have failed. As many worries as can be are removed by helping the patient’ to come to definite decisions, or at least partially relieved by making as concrete plans as possible. Some conflicts tend to disappear under confession, discussions and explanation, and many more are considerably diminished. This is a most necessary preliminary, but only a preliminary to the work.
The second phase of treatment, relaxation and suggestion, is, as far as I can determine, what Boris Sidis has called hypnoidal suggestion, and has been referred to as being particularly effective in the treatment of alcoholism. The patient is put into a state of abstraction. He is asked to close his eyes, breathe slowly, and think of the more prominent muscles when they are mentioned as becoming relaxed. The cadence of the voice is made increasingly monotonous, ending with the suggestion that the patient is drowsier and sleepier. This lasts for five minutes, and then an equal amount of time is spent in giving simple constructive ideas.
More important also is the application of the same measures by the individual himself before going to sleep at night. Ideas that occupy the mind at that time have a particularly effective influence on the thoughts and actions of the succeeding day.
The importance of this part of the treatment is all out of proportion in its effect to the time that it takes. Not only does it have a direct bearing on alcoholism, but it gives the patient a method of control that is extremely helpful in creating other changes in his personality, once his habit has been conquered. In other words, the alcoholic habit being only a symptom, its removal is only a part of the work. Treatment of the underlying conditions reorganizes the entire character, ‘with benefits extending far beyond the negative one of alcoholic abstention.
While on the subject of relaxation, which has been considered in its application for the purpose of influencing the unconscious mind - that is, in a special sense - I might add that it has a general bearing on the immediate causes of drinking. Courtenay Baylor in an excellent little book called Remaking a Man, now unhappily out of print, sets forth as his central theme the idea that drinking before all else gives an artificial release from a tense state of mind, and when this mental tenseness is removed, the apparent necessity for drinking disappears.
It is undeniable that two definite states of mind are sought after by the drinker - calmness and happiness. The childish pleasure that the alcoholic attains in the early stages of intoxication can be easily dispensed with when the desire to give up drinking is genuine, but the release from nervous tension is a different matter. When a person has been taught relaxation, he is treating the immediate cause rather than the symptom itself, which is the first step in removing the primary conscious cause —i.e., the feeling of inferiority and fear. The imagined fascination of alcohol lies in the fact that it is a stimulant and a narcotic at the same time, psychologically speaking. In other words, drink soothes as it elates and it elates largely because it soothes - i.e., relaxes. Barbitol will soothe, but in a purely negative manner and without any accompanying idea of elation. Strychnine and coffee will stimulate, but with so much nervous excitation that their stimulation has little relationship to escape from reality. Alcohol in the preliminary stages produces simultaneously the two longed for states of mind in a way that is unfortunately most seductive to those who can the least afford artificial stimulation or relaxation.
It is an interesting point that alcoholics as a class, no matter how cynical they may be, respond to relaxation even more enthusiastically than other neurotics, though it would seem that the latter were more in need of it and therefore would be more impressed by it.
Development of new interests is obviously a most important part of any therapeutic treatment. The only way to remove destructive ideas from a person’s mind is to introduce constructive ones. For a man to occupy himself solely with the thought that he is not going to drink would be such a sterile performance that it would probably not be true, for long at any rate. An alcoholic has one idea of pleasure, and it is of the greatest importance that he discovers as soon as possible that he can enjoy life in many ways outside of intoxication if he will lift himself to a more intelligent plane of thought and action. Furthermore; a drunkard has little by little withdrawn himself from his natural environment, his acquaintance is apt to be the dregs of society, and drunk or sober, his constructive interest in things of any value is nil. He must be made to reach out in many directions to divert himself from his former negative stereotyped habits.
The reason that long periods of being on the conventional "water wagon" have not changed a man’s point of view is because the idea of eventual indulgence has kept the alcoholic conflict alive and thus prevented the creative urge from becoming attached to some worth-while interest. It is essential that this normal urge be given adequate expression. Where it is inhibited through fear or laziness, its force is not extinguished, but turned inward, creating a conflict, which symbolically expresses itself in fear, worry, or boredom. Thus a mental situation is produced that needs to be soothed and forgotten, and it is perfectly obvious how the alcoholic is going to sooth and forget it. Until he rearranges his life so that he no longer perpetually craves to escape from his inner turmoil, he feels that he is up against a temptation which he cannot resist, though he thinks of the temptation as an entity in itself and not as a symbolic defense against an underlying mental condition. The creative urge must be legitimately satisfied. Jung, referring to neurotics in his essay The Ego and the Unconscious, remarks: "As a result of their narrow conscious outlook and their too limited existence, they spend too little energy. The unused surplus gradually accumulates in the unconscious, and finally explodes in the form of a more or less acute neurosis." For "neurosis" I think we should substitute "debauch" without changing the validity of the statement.
While on the subject of interest development, a case recently finished might be mentioned in which the patient was encouraged to develop his literary proclivities. One night, while writing an essay, he became so absorbed in his work that he experienced the same vital intensity that he had found previously only in intoxication, and he stayed awake until four o’clock in the morning to finish it. I felt then for the first time that sooner or later he would be cured. It proved to be true. In a short time he obtained research work in a library and supplemented that by writing book reviews for the newspapers. As he expressed it, "I am enjoying life for the first time without rum."
One method, obviously, of arousing a normal interest is reading. There is a short list of books that patients are asked to read carefully, marking the passages that appeal to them. These passages are later copied into a notebook along with some typewritten sheets that are given them, the most important of which I shall outline when I come to the topic of persuasion. These books are self—help essays of a practical rather than a religious or sentimental nature. Arnold Bennett’s Human Machine, Cosrer’s Psychoanalysis for Normal People, and James’s monograph on habit are typical examples.
The importance of a reasonable amount of exercise each day, as well as obedience to the ordinary rules of hygiene, cannot be overemphasized. A mind can function properly only in a well regulated body, and an alcoholic in process of reorganization needs to have his mind function as near 100 per cent properly as he can all the time.
While on the subject of hygiene, I might add that precautions are taken to find out if the individual is as physically healthy as possible, and if he has not recently been examined, he is urged to get in touch with his physician. At any rate, I disclaim any responsibility on the physical side and never under any circumstances suggest even the simplest medicines.
We now come to the most important phase of the treatment, the central feature to which all others are expected to contribute. That is thought direction and control. A person literally thinks himself out of his alcoholic habit, and his ability permanently to control or direct his thoughts is the determining factor in his success! or failure. A drunkard is invariably lost when he takes his first drink, or perhaps it would be better to say when the determining thought to take the drink becomes crystallized in his mind. Back of this thought are a long series of thoughts leading up to it, which, had they existed in opposite form, would have produced correspondingly different action.
As one alcoholic expressed it, "Sometimes I actually find myself at the bootlegger’s almost without knowing how I got there, and without, I am sure, intending to go there." When I showed him his habitual thought processes, he readily saw how this apparent somnambulism had taken place.
To be more explicit, patients are advised to divert their minds as much as possible from the whole subject of drinking. When this diversion amounts to downright suppression - when it is impossible of accomplishment, as is always the case in the beginning - then they are most emphatically told to think of the subject in its entirety, as it exists in fact. If they, are reflecting on some "wonderful party" that they have had, then they must pursue it to its conclusion, and recall as vividly as possible the remorse, the sickness, and the trouble that came after it, bringing the question down to the present time. Before leaving the subject, they must have a complete view of the whole dismal picture. Nothing is more harmful than thinking or daydreaming in the past, present or future on the pleasant side of alcoholic excesses. Whereas, if the alcoholic will review the entire scene, he will reject the dangerous suggestion that alcohol produces a truly pleasurable occasion.
Some drinkers give up trying to justify their behavior, but the reasoning processes of the great majority are a series of rationalizations. The excuses range from inheritance to a cold in the head, and they are all equally futile. The alcoholic must understand that there, are no excuses for his taking even one glass of beer. If a man takes a drink, it is because he wants to take it and not because he is impelled to do so by some exterior event.
The following ideas form the substance of what I have designated as discussion or persuasion. These thoughts are repeated over and over again to the patient in one form or another.
The first thing to impress on his mind is the fact that he is a drunkard and as such to be deliberately distinguished from his moderate or hard-drinking friends; furthermore, that he can never successfully drink anything containing alcohol. These points have been already explained, as has thought direction and control.
In spite of much pretense, no work of a serious nature is ever accomplished until the alcoholic surrenders completely to the fact just mentioned in regard to never drinking alcohol in any form or quantity. This surrender to its full depth is apt to be a difficult thing to accomplish because of the interference of a distorted pride. A man who is bold enough to enter a condition that he knows is disgracing him is ashamed to admit to himself and to his friends that he has given up the cause of his disgrace. On three occasions this year I have made inquiry into the sudden favorable change of attitude on the part of the patient, and each time I received the answer, "Well, I really never made up my mind to stop for good before. I never really gave up on the idea that I couldn’t and wouldn’t drink some day in the distant future." My reply to this is ‘that one attitude toward drinking which at first seems reasonable, but which from long experience has proved to be disastrous, is that of stopping for only a limited period of time, no matter how long that period may be. If a person could refrain from drinking for five years while diligently reconstructing his thought processes, it would be sufficient. Unfortunately it has been thoroughly proven that five years can and does become five minutes under emotional excitement in a manner that would seem impossible in moments of calm reasoning.
While the theory of treatment is not predicated on will power except in so far as it applies to carrying out instructions, it is necessary that the will be used in the early stages while the new methods are getting thought power upon its feet. Obviously, new ideas cannot make much headway in a mind that is constantly befuddled’ with alcohol. Because in the long run people tend to do as they wish, will power sooner or later loses in the conflict with desire. Win or lose, a perpetual conflict in the mind is almost as much of a handicap as its outward expression in a habit. The proper control of thinking, therefore, must be established to obviate the necessity for will power by redirecting the psychic processes.
The greatest difficulty in trying to accomplish this is to find enough things for patients to do when they are absent from the office. They should consider that they are taking a course, but because of the simplicity of the work it is difficult for them to keep their mind on the seriousness of what they are doing.
It is impressed upon them that they must play the part of self-instructor as well as of student. It is really this instructor element in them that stimulated their interest in the beginning, and they must continue to cooperate with me and not expect that I can do all the work with them in the role of passive listeners. Regardless of their past record, they must be made to feel as self—reliant as possible, for in. the last analysis it is they who must reorganize themselves while I am only their associate instructor. The reverse of this necessary self—reliant attitude is, of course, the main argument against confining a person to an institution. He is sober there because he cannot be otherwise. His power of choice is removed by compulsion, with attending humiliation. Incarceration should never be employed until everything else has failed and the desperateness of the situation requires that society be considered first and the individual second. A situation in which careful physical supervision is necessary to enable a man to recuperate from long continued excesses would of course constitute an exception to this statement. Where the individual willingly goes to an institution as a means of checking an irresistible compulsion to drink, the effect is entirely different- i.e., beneficial.
It has been found that a most useful aid to reintegration is to make out a schedule each evening and then follow it faithfully the next day. It prevents idleness, assists in making the work concrete, and, what is most important, trains the individual to execute his own commands. If a person cannot do simple things and in the manner planned, he has little chance of overcoming his major temptation. If, on the other hand, he. forms the habit of carrying out his own instructions, he creates thereby a disciplined will and an executive state of mind, so that when the idea of drinking comes to his attention, there is every chance of it being diverted. An alcoholic is a specialist at avoiding life, but it is as rarely his fundamental philosophy to do so, he is in a constant state of conflict and dissatisfaction; so it is our first duty to build up a moral that will take care of normal responsibilities and give him a legitimate feeling of power. Incidentally, a schedule discloses the limits of laziness and insincerity. When you find a subject who will not and cannot keep a schedule that he makes himself, with the understanding that it can be changed for honest reasons, you can be pretty sure that you are going to be unsuccessful with him until he changes his attitude, and you may be somewhat skeptical that he can change it.
Wise planning is a most important preliminary to a course of conduct, and for most people it is comparatively easy. But the majority of alcoholics, in common with neurotics, find the execution of a plan difficult, even through to a normal person the plan itself may seem short and simple. As William James has stated in his essay on habit, once a course of action has been determined upon, execute it. This applies to the small things of the alcoholic’s life as well as the central theme. Many nervous troubles have a common denominator exaggerated introspection, and the greatest defense against this weakness is sustained action. The alcoholic must be able to observe concrete, positive results of his efforts as a means of maintaining, his interest in the work.
Of the various methods discussed for combating chronic alcoholism, it is impossible as well as unnecessary to say which is the most or the least important. That would vary with the individual. Each element has its place, and it would not be fair to several of the elements if one or two were neglected. The surest way to prolong the work is to avoid the more distasteful part and then become depressed because the rest, of it does not produce better results.
In no case where a relapse has occurred has it been found that a person has been cooperating conscientiously. In fact the usual answer to my query is, "Yes, I must admit that I have only been making about half an effort. I thought I was going ahead all right and didn’t need it." To which I reply that he is getting out of the work just what he put into it, and that the same ratio will continue in the future. Hard, faithful work cannot be avoided, as the habitual thinking of many years is not going to be reversed in a month or two.
After certain progress has been made, there is one bit of sophistry that the alcoholic has to guard against, and that is the idea that he is entitled to a vacation. He knows that he has shown improvement, so he imagines that if he falls temporarily, those who are interested in him will still feel encouraged, and such action will not prove fatal to the eventual cure. There is enough truth to this reasoning to make it a serious impediment to recovery if it is acted upon.
Much of this persuasion obviously aims at prevention through anticipation. Difficulties of which one is forewarned are not apt to be so dangerous where one is sincerely desirous of embarking on a new course of behavior. In this connection there are three points that I wish to bring out.
It is generally understood that the best excuses for drinking are those of an unpleasant emotional nature - anger, worry, and sorrow. It is not so well recognized, but equally true, that the pleasant emotions have just as contagious an effect and in many cases more so. An alcoholic has to learn to face success with the same fortitude, strange as it may seem, as he does disaster. Any emotional stimulation has to be guarded from spreading into, the alcoholic sphere in order to avoid the return to humdrum reality. It is only when reality has been made constructively interesting and the fear of it thereby removed that a patient can stand normal excitement. Just as one drink leads invariably to another, so an emotion seems to take the place of the first drink by producing the same mental condition. This emotional contagion is an exceedingly important point. It is the cause of a great deal of unaccounted for alcoholic behavior, behavior which is often the hardest to control.
Why 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, he evidently feels the need of a stabilizer to the same extent as he does in dysphoria. Just as he is bored when he looks inward, so he is frightened when he looks outward, if the customary scene has changed even a little.
An individual who was prematurely confident of his self control fell from grace at a recent football game. "When your team made its first score, you had your first drink," I said. He started to tell me it was not until the half was over, but saw my point before he had finished. "Yes," he said. "I never thought of it that way before, but it is perfectly true. Between the halves that first actual drink went down with as little compunction as if it had been the third or fourth ordinarily. I lost my emotional balance when the team scored and got into the alcoholic frame of mind before I knew it."
Much trouble is caused by men trying to force themselves into an uncongenial environment on the plea that they like it when intoxicated. As a matter of fact, they like almost any thing when intoxicated, and nothing when sober. Somewhere in them is a supposedly genuine discrimination. When a natural interest is unearthed or a new one acquired, they find that it is not necessary to enjoy everything, or even many things, if they will soberly and sincerely expend their energy on the, few things that catch their imagination and hold their attention. Where there is no real interest and none can be created, the difficulty of the problem is tremendously increased. These obvious truths are mentioned because it seems to be a part of the treatment to drive home platitudes as if they were profundities.
Moral victories, strange to relate, have to be watched carefully or they turn into defeats. Apparently the resistance of the individual is exhausted by the struggle, and he falls prey to the suggestion absorbed during it, though the provocative situation is over. Often a patient bravely resists the "occasion" itself only to yield a day or two afterwards in a most unexpected manner. If he does not actually give in to the temptation, he is more apt to be depressed than elated in spite of his triumph -that is, of course, temporarily. In the long run these moral victories are not only helpful, they are the stepping stones to final success.
Last year a man asked my opinion about going to a class reunion. I had misgivings, but I thought I might as well test his resistance, so it was suggested that of course he could go. The results were unfortunate, but interesting. The first two days he drank nothing and was scarcely tempted. The third day, as he expressed it, "I was taken suddenly drunk before lunch almost without realizing that I was doing anything wrong."
What attitude should the family take while the treatment is going on, is a question that is invariably asked. The answer is that friends and relatives should cooperate with the patient in his own way. If he wants to tell of his work, then show an interest in it, but if he keeps it to himself, then let him alone. Avoid all dramatic gestures such as pouring away the liquor in the house. If it has been his custom in the past, he should continue to offer drinks in moderation to his friends as a means of keeping up his self—esteem, until it is definitely proven that he cannot stand the temptation. The environment should be made as helpful to the patient as is practical, but he need not be spoiled or coddled.
Of course disturbances in the external life that would depress or worry the normal man have in some cases a decisive influence on the alcoholic situation and must always be carefully considered. The environment, however, is not stressed as much as might be expected because many men show a surprising ability to cope with unpleasant conditions while completing the work, and as many others seem incapable of appreciating an admittedly satisfactory external situation.
How does the work proceed? As may have been gathered from what has been said, very far from smoothly in the beginning, even with the most intelligent and ambitious subject. It is essential to caution those immediately concerned that the friend or relative undergoing treatment will probably slip several times, and that the size of the slip does not matter in point of view of time or quantity of liquor consumed. In fact, if the patient is going to drink at all, he had much better make a thorough job of it. Anything is preferable to a "successful one-night stand" from which he derives the idea that perhaps after all he can drink and get away with it, or at least learn to drink. As long as this idea is in his head, the reeducation is brought to a standstill. I had a patient last year who continued to get intoxicated at least once a week for two months. This exaggerated situation was due to the youthfulness of the subject, and to the fact that he really did not want to stop when he first undertook the work. But the same thing to a less degree is liable to happen to any patient in the beginning, and it does not necessarily mean that the case is hopeless, if the patient evidences a sincere desire to continue the work. This discouraging prognosis must on no account be made to the patient, as he would then be absolutely certain to live up to what was expected of him. Everything must be done to make him think that his recent indulgence was actually the last one.
In other words, the alcoholic craving is modified gradually rather than stopped instantly. This is depressing to all concerned and particularly to those who have no basis for comparison and thus hoped that a complete conversion would take place on the first interview. However, a man who is willing to make a sincere effort over a sufficient period of time, even though he cannot be called a very strong character, seems to develop resistance to alcoholic temptation by eliminating his tense state of mind and permitting the dissolution of the temptation in other interests. If, however, he is unwilling or unable to help himself, then there is nothing that I can do for him. So it is to the sincere and intelligent, though not necessarily highly educated, individual that I am anxious to give my attention.
Read before the Boston Society of Psychiatry and Neurology, April 18, 1928, and before the Harvard Psychological Clinic, December 14, 1928. The treatment outlined in this article has been carried on by Courtenay Baylor for seventeen years. I can never sufficiently acknowledge my debt to him for my ability to write it. In rewriting the paper helpful suggestions were received from Dr.G.C.Caner, Dr. H.A. Murray, Dr. Martin W. Peck, and Dr. Morton Prince.