INTRODUCTION

In the twentieth century, with its high-pressure demands on nervous systems which have not yet become adapted to big business, mass production, telephones, automobiles, high economic standards -- in fact, bigger, faster, and noisier living conditions -- alcohol has come to play an ever-increasing part as a narcotic, rather than a mere social stimulant. Because so many can use it in moderation, and because of its social aspect, alcohol is seldom thought of as a drug -- not, at least, until it has done its ruinous work on certain organisms that have proved unable to resist it.

I propose in this book to define the alcoholic, to show how he arrived at this condition, and by what method he may rid himself of his habit once and for all. While aimed primarily at the chronic inebriate, the subject will, I think, be of interest to all who drink, more especially as it may show them where they stand on the line that separates moderation from excess.

Several years' experience in treating chronic alcoholism has shown me that it is perfectly possible to cultivate abstinence under certain conditions. It is a far easier task than the alcoholic has any idea of, provided that a scientific approach is made to the problem. Vague theories based on undirected will power are ineffective in the long run. Above all it must be remembered that eradication of the habit and temporary abstinence represent two totally different states of mind.

This book is in no way concerned with the arguments for and against Prohibition, which roar louder and louder throughout the land. Needless to say, after ten years of the Volstead Act there still seem to be a great many men who are unable to regulate properly their consumption of the liquor they so easily obtain.

Drinking is a manifestation of the wish to escape from reality. The illusory charm of drink comes from the fact that the mental reactions to alcohol are extremely satisfying to certain basic psychological urges. Let any man reflect on his sensations subsequent to taking a drink and I think he will agree that the resultant feelings consist (1) of calmness, poise, and relaxation; (2) of self-satisfaction, self-confidence, and self-importance.

While the satisfaction of the demands for peace of mind and ego-maximation by alcohol may be legitimate for the average man who can control the use of it, certain individuals, normal in other ways, have an abnormal reaction to drinking. It is too fascinating to them. It poisons their nervous systems. Those who react in this manner must eliminate drink from their lives or suffer very serious consequences. If they are willing, these people can be shown how to train their minds so that they no longer wish to drink. They can learn to relax and to satisfy their egos in a manner that is constructive and permanent.

I have taken care to omit from my discussion all moralizing, knowing full well that the uncontrolled drinker is surfeited with it already, however true and justified it may be. He must be aware of all the reasons that his well-meaning friends and relatives have given him in regard to the harm that he is doing himself, to say nothing of his neglected obligations toward others.

Neither is the subject approached from the physiological side. Much authoritative information has already been written upon the destructive effects of alcohol on the bodily tissues. If these books should not be accessible to the individual seeking such information, a short conversation with a physician will shed sufficient light upon this important phase of the subject to leave no doubt in his mind of the harm that results from persistently subjecting the body to large and continuous doses of alcohol.

The explanation of excessive drinking lies in the field of abnormal psychology rather than in that of physiology or ethics. As a background to almost every case of chronic alcoholism there exists an inner nervous condition akin to the "unreasonable" feelings of anxiety and inferiority suffered by the abnormally nervous. It is precisely this condition -- of which moderate drinkers and other so-called normal people are fortunately unaware -- that makes hard and persistent drinking (on the part of those who cannot stand it) so incomprehensible. If friends and relatives wish to be of assistance, they must learn to realize that the nervous person with "imaginary" troubles is just as much in need of help as if he had an acute organic malady. Indeed, those who have experienced both forms of suffering would prefer to repeat the physical rather than the mental if they had to choose between the two evils. It is for the former alone, however, that they customarily receive sympathy.

The more the problem is imaginary, unreasonable, illogical, the harder it is to bear, because the individual suffering from it has neither the respect nor the sympathy of the outside world. What is worse, he has lost caste in his own eyes: he criticizes himself mercilessly, so that the resulting state of mind is one of fear and depression often bordering on terror. While the alcoholic in many cases may not seem to be deserving of pity, he nevertheless to some extent belongs to an unhappy class of neurotics, however much he may keep his mental discomfiture from the outside world or try to pretend to himself that he is free from it. It does him no good to be told that his troubles are his own fault and that all he has to do to get over them is to stop drinking. Though in a sense this may be true, it is of no help, because he is often motivated by inner forces of which he is unaware and over which, without scientific assistance, he has no sustained control.

The world is gradually coming to understand the importance of caring for the mind as intelligently as it does for the body, and that the pain resulting from a broken spirit should no more be faced courageously alone than that resulting from a broken leg. Yet what could be more indicative of a broken spirit than the perpetual attempt to escape from reality through excessive drinking ?

Reality must be faced unaided by alcohol or any other drug. For the more. Responsible concerns of life, a state of mind wherein the individual actually doe; not want to drink must be attained. Such a possibility may seem so remote to a man who has been habitually drinking to excess that its mere suggestion is sufficient to make him shrug his shoulders in contemptuous skepticism, even though he would be free to admit that his present way of life is far from satisfactory. Yet it has been demonstrated over and over again that, in spite of the desires of the moment, sincere men and women anxious to work faithfully toward the goal of not drinking because they do not want to can create this relatively serene attitude of mind with far less hardship than they probably imagine. /font.

I
THE CONDITION

I. THE PERSONAL PROBLEM

Not long ago I interviewed a man who had decided that alcohol as a beverage had reduced him to a condition that lay somewhere between inefficiency and discontent, on the one hand, and potential ruination on the other. He could not confine his drinking to the occasion of which it was supposed to be a part, but continued it for at least one and often more successive days. In other words, he belonged to a class of people known as alcoholics.

Though emotionally out of hand, he was intellectually honest, and therefore he had no delusions as to his ability to confine his indulgence within normal time limits. One drink always led to another, and, what was far more serious, one night almost invariably led to another day. Every so often, medical intervention was necessary. He said to me, " I know I cannot stand alcohol. I must confess that an infrequent and short sojourn on the 'water wagon' is all that my efforts to control my habit amount to. I have been admonished until I am sick of it, although what has been said to me is perfectly true and unquestionably deserved. Much of it has been said by people whose opinions I respect, people who in most instances themselves drink. While I have been severely criticized a few times, to be sure, I have as a rule met with more kindness than I have a right to expect. Furthermore, I have given myself many talks in the same vein which seem to me to be even better than those I have listened to. I have made resolutions not to drink at all as well as to drink with various limitations, but, except for an occasional month or fortnight spent 'on the wagon' in discontented sobriety, I never seem to get anywhere. Once I stayed on for six months, but I have never wanted to try to repeat the experience, if for no other reason than that I don't think I could. Needless to say, I fell off with a crash and started making up for lost time, though it had not been my original intention to do so."

Because he had ability as a salesman, a position which did not require daily attendance at the office, he kept his job. Because he was attractive, made money, and was always kind even under the effects of alcohol, he kept his wife. Because he was endowed with a strong physical constitution, he apparently kept his health. Nevertheless he unquestionably stated the truth when he said, " If I keep this life up much longer, I don't see how I can fail to lose everything."

This individual, while intelligent and educated, is nevertheless a typical drunkard of the somewhat milder variety. He might drink even less and still be classed as a chronic alcoholic, but on the other hand he has by no means reached the lowest depths of disintegration as a result of his habit. While genuinely anxious to allay a condition that has become alarming, he does not in truth understand his present situation or its potentialities for the future, nor is he understood by his fellow beings. By his family, friends, and the public in general he is condemned out of hand as being a moral delinquent who could perfectly well control himself if he wanted to do so. In their criticism moderate drinkers, often show less sympathetic understanding of his condition than teetotalers. This the sufferer from alcoholism puts down as hypocrisy, when in reality it is misunderstanding. His actions are quite naturally considered at their face value without regard to inner impulses and their causes. "Why can't that fellow handle liquor the way I do?" is the comment of the normal drinker. "There is no need for anyone to make a fool of himself once he has had enough," he adds, and forthwith proceeds to instruct the alcoholic in how to drink moderately, not realizing that he is attempting to teach what can never be learned. Ignorance and good intentions often work closely together. The conduct of the alcoholic need not be condoned, but his personality and his problems must be understood if he is to be helped.

2. THE ALCOHOLIC DEFINED

What is a "drunkard," "inebriate," or "alcoholic ?" 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 long 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).

More than one drunkard has told me that the first drink "the morning after"' was by all odds the best of all. They say it makes them feel as if they were coming back to life, as if they were no longer going crazy, and so forth. Such sentiments as these are absolutely incomprehensible to the normal drinker, to whom the idea of an "eye-opener" is almost always repulsive, no matter how much liquor he may have had before going to bed. I recognize, of course, that there is a small group of men who drink slowly and steadily day in and day out without any apparent psychic deterioration. Physically, they almost always break down in the long run, but, as this book does not deal with the physiological side of drinking, we shall disregard them except to say that their drinking is so methodical, their systems are so adapted to it, that as far as pleasure goes it does little more than bring them up to "par," actually a state somewhat below that in which they would be if they did not drink at all. If by chance they want to get a real "kick," they have to drink a prodigious quantity. Then there is a very much larger group than the one just referred to, who from time to time go on a premeditated spree, such as a class reunion or a New Year's week-end, and yet who by no stretch of the imagination can be considered alcoholics.

Lastly, there are a very few exceptions to the general rule who do take a drink the next morning to lessen the punishment resulting from a hard night, but who do not increase the dosage as time goes on. In spite of these exceptions, however, I think we may be justified in making the statement that those who can use alcohol successfully generally terminate the drinking of any particular occasion when they go to bed at night. On awakening, such sickness as alcohol may have caused them is of the body; their unimpaired nervous system sets up no cry for more. They are content to pay the price of their "good time" because the price is not unendurable; it has not changed much, if any, from their early drinking days.

But the drunkard with his nerves on edge is in a different plight. Once he has taken a drink he is quite rightly said to be "off again." When his friends are going to their offices, enduring such hangovers as they may have, he is back at the "speakeasy." If he appears at his work at all, it is only after he has been heavily "braced" to avoid the nervousness and depression of a "morning after," which he has become too cowardly to face. At lunch time he imbibes again to avoid the hardships of the afternoon. At five o'clock he can hardly wait to shake up his cocktails, and by late evening he is drunk again. Sooner or later, depending upon his particular stage of disintegration, he is unable to carry on his business at all until he has passed through a somewhat painful period of "drying out." Shortly after such a recovery the cycle recommences, with the alcoholic periods becoming longer and more intense. The resulting worry and feeling of guilt give the mind no rest when sober, in consequence of which these intervals become shorter and the nervous system receives no chance at all for recuperation. The victim is caught in an increasingly vicious circle. Drunkenness, acute nervous hangover, remorse, feelings of inferiority; then drunkenness again. A sanitarium may check temporarily the outward expression of this state of mind, but the inner urge continues to exist.

3. TYPES OF DRINKERS

What sort of people reach this unfortunate condition and by what route? It is interesting -- if somewhat disheartening for the purposes of determining causes -- to note that the group which may be designated as "pathologically alcoholic " comprises persons from all walks of life, reared under the most varied conditions and undergoing the most diverse experiences. Racially, we might say that the Slavs, Teutons, and Anglo-Saxons are less able to control their consumption of alcohol than the Latins and Orientals, even though we should of course expect individual exceptions to the rule. Geographically, those living in the cooler climates seem more disposed to abuse liquor than those situated nearer the equator, though for some peculiar reason northerners who move south are apt to drink more than anybody else. The idea suggests itself that, inasmuch as drinking can be reduced to terms of nervous instability, it tends to be predominant among those who have a larger surplus of easily stimulated nervous energy and hence feel the need of something that in the last analysis soothes far more than it elates.

When we investigate any particular group, we find the most strikingly contrasted persons succumbing to excessive drinking. The rich and the poor, the highly intellectual and the ignorant, the frail and the robust, the shy and the apparently bold, the worried and the seemingly carefree, all furnish their quota of inebriates. We find that this unhappy group includes people of accomplishment as well as those who achieve nothing, the religious and the unbeliever, those with an interest in life and those without one, those who love and are loved, and those who are alone in the world. Among all these opposites and the many that come between we find a relatively small percentage, but a large actual number, whose nervous system cannot withstand alcohol in any quantity whatsoever.

While there are enough apparently confident and successful individuals who succumb to alcoholism to make impossible any hard and fast limitations to a particular type of personality, still the large majority of cases are found among those who are shy, egocentric, and shut in. Jung has designated these people as introverts. They are ably described by Dr. Abraham Myerson in his book, The Foundations of Personality: "There are relatively normal types of the heavy drinker -- the socially minded and the hard manual worker. But there is a large group of those who find in alcohol a relief from the burden of their moods, who find in its real effect the release from inhibitions, a reason for drinking beyond the reach of reason."

"And so men with certain types of temperament, or with unhappy experiences, form the alcoholic habit because it gives them surcease from pain; it deals out to them, temporarily, a new world with happier mood, lessened tension, and greater success."

"Seeking relief from distressing thoughts and moods is perhaps one of the main causes of the narcotic habit. The feeling of inferiority, one of the most painful of mental conditions, is responsible for the use not only of alcohol but also of other drugs, such as cocaine, heroin, morphine, etc."

4. THE EFFECT OF INHERITANCE

Unfortunately we can give no scientific explanation for the creation of alcoholics.

Exceptions to any closed system of causal relationship would stare us in the face at every turn. The study of many inebriates, however, has given definite clues to certain features which have a distinct bearing on the majority of situations, so that within limits we can recognize the forces that have an influence on the shaping of an alcoholic career.

The first question to be considered is inheritance. To what extent are parents responsible for the development of this trait in their offspring through the transmission of the germ plasm? Without going into statistics a cursory examination of this situation shows, first, that among the children of alcoholics there is seldom more than one in a family with this propensity. Secondly, that a much greater number have children who drink normally and in no sense as drunkards. Conversely, a great many alcoholics are born of parents who are temperate in their use of alcohol, in some cases being total abstainers. This would seem to indicate that a man does not acquire chronic alcoholism from his father or mother. Many inebriates use inheritance as an excuse, because it has become a sort of prejudice or credo to do so, but when they are carefully questioned they do not consider that they have any inborn taste or craving for liquor, once they have completely sobered up.

At all events, whatever the validity of inheritance as a cause, it has been definitely proved over and over again that it offers no insurmountable obstacle, or, for that matter, any additional impediment, to the overcoming of the habit once a man has definitely made up his mind to do so. What unquestionably is inherited is a nervous system which proves to be nonresistant to alcohol, though this same nervous system is more often acquired from neurotic parents who have expressed their nervousness in some other manner than that of chronic intoxication. just as a disposition to weak lungs is inherited and not tuberculosis itself, so I believe is a nervous system transmitted which is highly susceptible to alcohol and which may manifest itself in a variety of symptoms regardless of the original manner of expression. An investigation of the inheritance of alcoholics indicates in almost every case a neurotic history at least on one side of the family, and often to an extreme degree. While parents may be exonerated as far as the direct inheritance of alcoholism is concerned, they cannot escape the blame for an injudicious early environment which they themselves have created. For many parents the bringing up of a child should require study and instruction from those who have made a business of treating children from the psychiatric point of view, particularly if the child presents difficult problems at an early age. Because a woman has had six or seven children does not mean that she has been an intelligent mother, as the lives of many members of large families bear witness. Mothers and fathers with the best intentions in the world can ruin a child's future because of a silly superstition that nature endowed all women, and some men, with a superior instinct for performing a very difficult task -- namely, the efficient rearing of children.

I am reminded of Dr. Austin F. Riggs's statement in his book, Intelligent Living: "The relation of grown-ups to children is second to none in importance, whether the grownups be parents, foster parents, or teachers. Obviously the future of civilization depends upon its children. The responsibility which they present to their parents and all other grown-ups is both immediate and absolutely non-transferable."

Certain features in the lives of many patients have stood out so clearly that it is pertinent to set forth what seem to be a few but indisputable instances of bad bringing up. Too much prudishness and restraint either break a child's spirit so that he is never free from parental authority or, as a slightly better choice of two evils, drive him into open revolt. His mind must either become a vassal to that of his more dominating parent, or he must over-assert himself to prevent this surrender. If to preserve his own personality he has been on the defensive with his family, he may in later life become unconsciously hostile to the restrictions of society without being in the least a misanthrope, and may feel that he is satisfying a morbid desire for self-assertion (freedom) by an over-indulgence in alcohol.

The spoiled child, on the other hand, receives no discipline at all, and so is unprepared to meet the world on anything like a give-and-take basis. Confronted with reality and finding it unfriendly compared to the unrestrained solicitude of his doting parents, he has a tendency to seek refuge in a parent substitute, something that will dull his hyper-sensitiveness and make him feel in harmony once more with an unsympathetic environment. It is for this reason that the majority of alcoholics are recruited from the ranks of only children and youngest sons. In his study, The Structure and Meaning of Psycho-analysis, Dr. William Healy makes an interesting observation.

"Rigel," he says, "makes much of a matter which comes frequently to the front in the modem child guidance clinic. He says that all sorts of considerations make it clear that normal psychic development depends upon the gradual emergence from a condition of parental authority. Failure in such a development will result in a relatively feeble adult personality. More dangers lie in the direction of too great rather than too little dependence on the efforts and guidance of the parents or their substitutes. However too sudden or too complete revolt from parental guidance and tradition may be productive of a bias against every kind of authority and convention."

Again, if the parents have been of equal influence and have taken opposite attitudes, or if the more influential has frequently changed his or her attitude, the individual grows up with a twofold ideal of self. He is of unstable temperament because he does not know whether to think of himself as a saint or a sinner, a success or a failure. One minute he has overconfidence and the next none at all. Now he may be elated for no particular reason, and now unduly depressed. These feelings may be semiconscious or they may be entirely unconscious and only demonstrate themselves in behavior.

However, when confronted by situations calling for mature judgment or courage, a person brought up in the manner outlined is unequal to the occasion and, having already tasted alcohol as a matter of social custom, he flies to it as a refuge, knowing that for the time being he can have the courage and poise that he craves and that temporarily he will have compensation for his deficiencies.

Brutality, neglect, and the deliberate teaching of pernicious doctrines are so obviously detrimental to a child's welfare that they do not merit discussion. Rather, I shall conclude this all-important phase of parental influence by summoning to my argument four important quotations, the first two from Dr. Karl A. Menninger's The Human Mind and the latter two from Dr. Alfred Adler's Understanding Human Nature.

"The neurotic personality," says Menninger, "is one whose primitive instincts have been modified to meet social demands only with painful difficulty" This difficulty arises because of the prejudices, misapprehensions, shocks, rebukes, experiences, and parental examples of early childhood. Hence the neurotic personality is very definitely a product of the childhood environment and depends largely on the individual's parents"

"The man was reliving a childhood situation in which fear had been instilled into him by an over-anxious fear-ridden mother, who robbed her son of his self-confidence. Or it may have been a hard-boiled, blustering, storming father, well-meaning perhaps, but intimidating. Some parents intimidate by silent disapproval, others by example, and still others by attack. Fears are educated into us, and can, if we wish, be educated out."

"It will be difficult," says Adler, "to mobilize a child who has grown up in a family where there has never been a proper development of the feeling of tenderness. His whole attitude in life will be a gesture of escape, and evasion of all love and tenderness"

"Education accompanied by too much tenderness is as pernicious as education which proceeds without it. A pampered child, as much as a hated one, labors under great difficulties.

Where it is instituted, a desire for tenderness arises which grows beyond all boundaries; the result is that a petted child binds himself to one or more persons and refuses to allow himself to be detached."

5. THE EFFECT OF ENVIRONMENT

The temptation to drink, regardless of the parental attitude, does not appear as a problem until late in adolescence. At the earliest it comes up for consideration in the last year or two of school life, more generally upon arrival at college, or, for those who do not continue their education further, at the commencement of work. Obviously the family is still influential throughout the period which separates childhood from maturity, though as the boy grows older it is more and more modified by outside forces, sometimes in one direction and sometimes in another. These forces may be corrective or they may intensify the original trend. For instance, boarding school may give a child the assurance gained through relative independence that he could never have attained at home, or he may be overwhelmed by it through failing to survive among the fittest. For some, probably the large majority, boarding schools are of great benefit if for no other reason than that they remove boys from a too close contact with their families, but for the handicapped child who needs skillful individual attention they are apt to be harmful. Schools differ so much, however, that it would probably be unfair to some to make sweeping statements about them as a class.

Just how much harm these schools can do in the creation of alcoholics is a matter of varying opinion. My own theory is that in some of the most fashionable ones, where the discipline is apt to be of a severe order, a great deal is inadvertently done toward working up a thirst in the minds of the upper school so that, when left to themselves, they are more or less prepared to take up drinking as a serious business. This I think is due to two contributing causes. First, the discipline just mentioned is too confining, particularly as graduation approaches. The upper classes are not allowed much more leeway in choosing for themselves than the youngsters of the lower school. This results in an exaggerated sense of freedom upon arrival at college, a making up for lost time as it were. A super-abundance of energy has resulted from the suppression of liberty with little experience in self-determination to control it. Secondly, there are the school graduates who return from the universities to see their younger brothers and friends in the classes one or two years behind them. From this source the schoolboys hear many lurid tales of dissipation, the suggestion being that the fast life is the one to lead and that anyone who objects to it is a "bluenose" whose opinion is not worth considering. It does not take much to make a boy of sixteen or seventeen feel that drinking is the smart thing to do. When a somewhat natural impression has been reinforced by the thrilling experiences of an "old grad" it is not hard to see what a boy's future aspirations will be when he once gets free from his preparatory-school confinement.

However, while this school life, with the graduate influence, is unquestionably a determinant in making a young man "hit things up" in the beginning, it is at its worst much more conducive to creating drinkers who eventually learn to control themselves than to the actual production of alcoholics. There are many forces working at this time, seemingly remote from alcoholism, which may be much more effective in producing that state than the gaudy tales of graduates. They are a part of growing up, and are independent of any single set of surroundings.

These are the successes and failures, the accomplishments and disappointments, of the young boy and adolescent. Are events shaping themselves in his life so that he becomes self-reliant and confident of his ability to mingle on an equal footing with his friends; or has failure in studies, in athletics, or in achieving reasonable popularity driven his thoughts inward so that he becomes shy, moody, or resentful at life ?

While the major responsibility for an unsatisfactory adjustment lies in the atmosphere of the home during the first ten years, the next ten can do much toward the amelioration or elimination of it. A more careful study of the growing boy as an individual rather than as a relatively insignificant member of a group is almost as important as it was in the case of the child. In other words, if more individual psychology could be brought to bear in the formative years, the neurotic troubles of later life could probably be forestalled, in all but the most extreme cases.

Upon his entrance into the world, which takes place upon graduation from the secondary schools, the boy would find himself prepared to take up his responsibilities with mature judgment rather than with undirected emotions in control. In that provocative volume, Why We Misbehave, Dr. Schmalhausen remarks: On the high authority of Dr. William A. White, we are told that "many mental breakdowns, perhaps the majority of them, occur during adolescence or in early adulthood, and that systematic help extended to the youths in our schools and colleges would be of inestimable value in preventing such breakdowns."

Initial drinking generally takes place upon arrival at college. Now, whatever the prudes may think, a certain amount of drinking and even drunkenness at college is due to nothing more than a normal declaration of independence at coming of age, a youthful desire to be grown up, and an anxiety to be considered one of the boys. Most young men go through this stage none the worse for it, capable of taking up their responsibilities as they appear, with the drink problem well under control for the rest of their lives. In spite of spasmodic excesses they always have been and always will remain social drinkers, using alcohol as a stimulant to make a good time more enjoyable, and for the most part having the quantity consumed suitably adjusted to the occasion. To the truth of this statement the lives of the overwhelming majority of college graduates bear testimony.

On the other hand the individual of strong neurotic tendencies is undoubtedly weakened and prepared for a maladjusted life by a prolonged and intensive period of wild oats, whether the milieu be a college or a fast social set. Though he may show no signs at the time that he is to become a chronic alcoholic, subtle changes are taking place within him which may appear later in life. At an impressionable age he has formed a dangerous connection in his mind between happiness and rum. This criticism sums up the worst that can be said against the colleges; a not very damaging statement, when it is considered to how relatively few individuals it applies.

Most men are going to drink something and many of them a considerable quantity. The amount, so long as it remains within normal limits, may to some extent depend upon the direct alcoholic suggestion received in one form or another. But the point I wish to make clear is this. Whether or not a man becomes an alcoholic as the term is defined in this book depends on character traits deeply rooted in his personality, and not primarily on exposure to an alcoholic environment.

6. THE ATTITUDE OF MIND

Such influences as I have mentioned are usually accompanied by an attitude of mind, which more than any other factor changes the individual from a hard drinker into a true alcoholic. While this transition is often so gradual as to be scarcely noticed, I think, as I have said, that the decisive moment comes when a man finds out that a drink the next morning is soothing nerve medicine for the excesses of the night before.

I recall the case of a man who in his college days was faced with the problem of having to go to a lecture in an extremely nervous condition due to his drinking on many previous evenings. A graduate who happened to be in his club at the time asked him if he had had anything to drink that morning. When told, "No," he evinced surprise that the boy should be willing to suffer "unnecessarily," and suggested to him that what he needed was a stiff drink of brandy to remove any unpleasant feelings of nervousness that he might experience during the lecture. This was a distasteful idea to the younger man, as it had never occurred to him before to drink medicinally. But rather than put up with his nerves any longer he gulped down what was offered to him. In the course of a few minutes alcohol had its narcotic effect and the lecture presented no difficulties whatsoever.

That drink was the beginning of the end for him, although he did not realize it until several years later. As he expressed it to me, "The handwriting was on the wall from that moment on, though of course I didn't realize it at the time." Then and there he conceived the idea that he could drink all he wanted to in the evening and take care of the resulting nervousness with a stiff bracer the next morning. For a year or two he stuck to his one drink in the morning after nights of excessive indulgence. But as he grew older, and his nerves were progressively weakened, additional drinks throughout the day became "necessary," until he was having one every two or three hours. In a few more years he had reached the final stage of disintegration, where he would remain in an intoxicated condition for several days following a "party." He invariably thought that he was tapering off, but in reality he was gathering headway faster and faster, until he was drunk a large part of the time. Respites unfortunately only resulted in a physical recuperation that gave him the needed strength to repeat the performance.

After a period of sobriety the alcoholic wants his first drink for the same reason that his more moderate friends do -- that is, to escape from reality. But in most cases he does not really want to continue drinking for the sole reason that prompted him to start in the beginning. Or perhaps it might be better to say that, while the same reason may be functioning to some extent, it is completely overshadowed by a greater one. He invariably claims that he is "easing" himself out of his condition, until he is entirely under the influence of drink again, and he is speaking the truth as far as his desires are concerned no matter how much his conduct and appearance may belie his statement. But he simply cannot stand the emotional disorganization that even a limited indulgence has created, and, although he realizes in the bottom of his heart that each drink is making matters worse, he postpones the ordeal of a hangover as long as he possibly can.

Are we to conclude from this that there is no such thing as the purely vicious alcoholic, that they one and all sincerely wish to recover from their habit? If we disregard the few moral delinquents whose mentality is practically psychotic, -- that is, insane, -- and those whose failure in life has been so glaring that they are willing slowly to commit suicide, I think we might answer the question in the positive; the reason being that the genuine alcoholic, however he may twist and turn, is undergoing a very unhappy experience most of the time. His ethics may be nil, but he is getting so little out of life except downright suffering that he casts longing looks, not at abstinence to be sure, but at a successful career of hard but controlled drinking. As he can never attain this state again, whatever he may have been able to do in the past and no matter how hard he may try, and as he is unable even to visualize a life free from alcohol, he prefers what in his fatuousness he considers to be the lesser of two evils. To this extent only I think we may say that some drunkards wish to remain in their condition and refuse all offers of assistance which might show them a way out of it.

7. DANGER SIGNALS

From what has been said thus far it might be gathered that prolonged sprees lasting from two days to several weeks are the only form of drinking to be considered pathological and hence in need of formal curative measures. While this type of reaction is the most conspicuous, it is by no means the only manifestation of the fact that alcohol has disintegrated a man psychologically. In the first place there is the partial or potential drunkard who follows out the procedure of the individual outlined above part of the time, and the other part seems to drink in a fairly normal manner. If he is not slowly but surely increasing his dosage, he is at least rather uncertain of the outcome of any given alcoholic occasion, and as a result he keeps those who are dependent on him in a perpetual state of anxiety. His problem, if he wishes to stop his habit, is easier in one way than that of the out-and-out inebriate, because alcohol has not entirely absorbed his attention, but it is more difficult in another, because heroic measures do not seem to him to be so imperative and his tendency to rationalize on his ability to control himself has enough truth in it to prevent him from making a sincere effort. He is a drunkard every so often and a social drinker the rest of the time, but except as an aftermath of a disastrous occasion he bolsters up his self-esteem by thinking of himself as a social drinker, and it sometimes takes a genuine catastrophe to bring him to his senses.

Then there is the man who restricts his indulgence to the social event where it started, but who, during this time, runs amuck either habitually or at unexpected intervals. He may develop a maniacal viciousness which seriously menaces all who cross his path, or he may, with the best intentions in the world, perform insane acts which endanger himself and those about him. It is indeed far from unknown for an apparently mild person to commit a murder in a drunken rage without the slightest provocation, without, needless to say, premeditation, and without any remembrance of what he has done after he sobers up.

I knew a man who for no apparent reason developed a streak of madness while under the influence of alcohol which led him to run his horse full gallop at an eight-foot stone wall, killing the animal and all but killing himself. This extreme sort of behavior in certain individuals may occur regularly until death or the law intervenes, or it may come infrequently "out of the blue" as it were; in which case a certain amount of luck may permit the offender "to get away with it" for some time. As a matter of fact this horseman acted normally under the influence of drink a large proportion of the time, but occasionally he became temporarily insane, and at those times nobody knew what he would do -- least of all himself. Alcoholic indulgence for this type of person is a more dangerous activity than it is for many out-and-out inebriates.

Of a similar nature, but to a modified degree, are the people who, while not actually dangerous, are morose, disagreeable, or disgusting, so that they make enemies, while drinking, through their slanderous remarks or vulgarity. As often as not these people are perfectly pleasant and gentlemanly when sober, though it is hard not to believe that there is a strong antisocial sentiment within them which comes to the surface when alcohol has removed the inhibitions. It behooves them not to irritate this abnormal streak, especially in a manner that makes them irresponsible when they are doing it. Many, though not all, of these obnoxious drinkers have considerable remorse when they sober up, particularly if they are confronted with and are about to suffer in some concrete manner from the harm that they have done. This naturally leads to brooding, an unhealthy activity for any mind, and such an unpleasant one that sooner or later alcohol in larger quantities is resorted to as a means of forgetting it.

While some degree of alcoholic depression following even a successful "party" is natural, a few carry it to an unwarranted extreme. These people are probably predisposed to a morbid state of mind in sobriety, and are living temporarily and in miniature what they may come to live permanently even to the point of a pernicious depression if they do not mend their ways. Their reaction to alcohol is a danger signal which should not go unheeded. Unfortunately these various manifestations of drinking may be combined in the same man. At any rate those missing are in many instances latent and will probably develop under sufficient provocation. I knew an inebriate, whose conduct was for a long time condoned because of his humor and amiability, suddenly to become rude, obscene, and sometimes actively hostile. Another man with these unpleasant qualities to begin with always prided himself upon his ability to be at his office early the next morning in a state of sober efficiency. In the course of time he became a continuous drinker; he lost his habit of quick recovery, but he did not lose any of his disagreeable traits. Once the nervous system has begun to react pathologically to liquor we can be sure of one thing only -- it is going to maintain this form of action, but in what way, and to what degree of intensity, time alone will tell.

Certain forms of conduct, as we have seen, are latent in the alcoholic, and we might suggest that they are latent in any more people than is realized. Whether such a manifestation actually appears or not may be entirely fortuitous, depending upon the nervous strains to which the persons are subjected. The strongest systems have a limit to what they can withstand. A certain number, if hard enough pressed, will take refuge in excessive alcoholic indulgence, though they had for years thought of themselves as immune to abnormal drinking. Nor is it always disaster that produces the crisis. Success, particularly when it is financial, and thus permits a life of luxurious leisure, has been frequently known to create the same slavery to alcohol that is so often attributed to misfortune alone.

By this statement, however, I by no means imply that alcoholism is a probable or even possible outcome of the moderate drinking of the large majority. Far from it, as the life histories of an overwhelming number of men show. What I do mean is this -- there are enough alcoholic breakdowns late in life to show us that there is a considerable group who only need a strong and easily accessible stimulation to force them from moderate drinking into chronic alcoholism.

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II
DIAGNOSIS

1. A TYPICAL CASE

Bearing fully in mind the somewhat restricted picture that any particular case history can give of the whole problem, let us at this point sketch a typical alcoholic personality. This man, after thirty-six years of living and approximately sixteen of drinking, has definitely proved to his own conviction that he cannot use alcohol without abusing it, and that by his own efforts he is equally powerless to stop his indulgence.

While we need not discuss the characteristics of the grandparents, a short description of the father and mother will not be out of place. The father is a reserved sort of person with a keen mind, though shy, and given to mild periods of despondency due to a lack of success in a business to which he was never suited. His mother is domineering and prudish. He describes her as somewhat suspicious and fearful of the future, and he believes that she was mildly resentful of the quiet life which her marriage compelled her to lead, though she would never admit this and always referred to her husband in the highest terms. The family life centered about her. Our patient, in speaking of her attitude, says that she spoiled him in a negative sort of way -- nagging him and making him think a great deal too much about himself. Everything seemed to be reduced to terms of right or wrong. Furthermore, he was made to feel in one way or another that the world was a difficult place to live in, and that nervousness was the rule rather than the exception. He thinks that the death of his older brother at an early age was partly responsible for her peculiar states of mind. Sometimes she had temper tantrums, which were apt to be directed at him if he were present. These were followed by remorse and a desire to compensate by being temporarily over-solicitous. He never felt quite sure what her attitude was going to be, and, as his father considered it much easier to agree with whatever she said than to dispute it, he often felt very much misunderstood and friendless. However, he wishes me to understand that on the whole he received kind and generous treatment, and, while he does not look back on his childhood as something he would like to repeat, he does not feel that it was so very difficult. Alcoholic drinks were served at the house as a matter of course, without any particular attitude being taken toward the subject. He does not consider that such drinking as he saw in his home has any bearing at all on his present problem.

His elementary schooling was completed without any occurrences worthy of comment having taken place. He went to boarding school, where he mixed well with the other boys, though he had a distinct feeling of inferiority which he thinks now came from being less mature as well as from a lack of ability in athletics. As he was small and not very strong, the others did not hold this against him, but nevertheless he was envious and admired greatly those who were more successful than he. There was little difficulty if any with the faculty, as his work was above the minimum required for passing and his conduct was somewhat better than the average, though he assures me that he was by no means a goody-goody.

Them was no particular temptation to drink while at school. Three or four of his friends did so during the vacations, but it was so obviously done in an effort to be smart that he did not feel the least urge to imitate them.

In college his first two years were moderate in all directions, in spite of the freedom that he felt in getting away from school. His puritanical prejudices did not yield immediately to his newly acquired liberty. Furthermore he was not overburdened with money, and as a result he associated primarily with one or two rather conservative individuals who had been his intimates at school. He made friends easily despite his shyness. Eventually he joined a fraternity, and it was this influence more than any other that started him drinking. However, he does not hold his fraternity or the club system in general responsible, as them was no drinking allowed in the house and them were a few members at least who were total abstainers and more who drank in moderation. Nevertheless the friendships that he made at this time resulted in many trips to a neighboring small city, which invariably ended in drinking to excess.

At this point it might be well to state that he is not conscious of ever having had any trouble with his sex life. To be sure, the information he received on the subject from his family was scanty, but his friends supplied this deficiency rather adequately and in plenty of time to prevent any morbid introspection.

Of course at this period drinking did not seem to be any problem to him whatsoever. Custom soon adapted his physical system to it, and he had few hangovers. He maintained his ability to enjoy non-alcoholic occasions, though he noted a slightly progressive decline in this respect during his senior year. It was then, too, that he first began to experience nervousness, though on only one occasion did he notice the sedative effects of alcohol. This was inadvertent, a prolonged spree having been planned in advance to celebrate the end of examinations. It made a distinct impression on him, however ("that wonderful feeling," as he expressed it, "of being picked out of the depths so quickly in the morning"), but he did not deliberately use alcohol as medicine until some months later. He was in no sense an alcoholic at any time during his college career, nor was there any reason to believe from his conduct or from his mental attitude that he would ever become one. He said there were several boys who gave more evidence of becoming drunkards than he did, though as far as he knows only one lived up to expectations.

Upon graduation he enlisted in the aviation corps. He did not go overseas, but as he chose a particularly dangerous branch of the service he quite naturally had no feeling of inferiority in regard to his war record. He enjoyed flying and does not remember that he was ever particularly frightened by it. After fatal accidents, which happened often enough at the flying field, he became temporarily nervous and apprehensive, but to no greater extent than his brother officers. He thinks that his nerves suffered relatively little from his war-time experiences, but, as his excessive drinking began shortly after his discharge from the army, he is perfectly willing to admit that this may not be so. During this period he drank all that he could get his hands on, but except on one or two occasions this was never very much.

While in the service he married a girl to whom he had long been attached and who has since made him a very good wife, the only source of friction being his abnormal drinking. Even here he feels that she has been, to use his own words, "a damn good sport." An analysis of his married life seems to disclose nothing to excuse his exaggerated indulgence in alcohol. He thinks if he were single it would be worse, if that were possible.

After the war he moved to another city to enter a business that was soon to prove extremely successful. This gave him a superficial self-assurance which he unfortunately misused. Almost immediately he became associated with a "country club" crowd who spent most of their spare time drinking. While in the beginning he "carried" what he drank pretty well, he became increasingly nervous on the "morning after," and within a year of his discharge from the army he was bracing himself by pouring two fingers of gin into his coffee at breakfast. Furthermore he was sneaking additional drinks at the weekend parties -- a totally unnecessary performance, as almost all his friends were drinking openly a great deal more than they could hold. Sunday afternoons he generally became intoxicated again, and it was not long before he was decidedly under the influence of liquor from Friday night until Monday morning. This naturally required an additional dose of "medicine" to get him back to the office.

Soon he found that, if a drink at breakfast helped out the morning, another one at lunch saved the afternoon. So, slowly but surely, with infrequent periods on the wagon which were invariably terminated prematurely, he arrived at a state where one drink meant a two or three-day debauch. This would have cost him his job but for the leniency of his employer and his own ability as a salesman during his sober periods. I say "sober periods" because he felt that, while some business success could be attributed to artificial conviviality, he would have accomplished a great deal more in the long run if he had let the other fellow do all the drinking.

2. SELF-ANALYSIS

Having ascertained in a preliminary interview that this man sincerely wanted to stop drinking once and for all, and would work seriously to that end, I asked him to set forth in writing his reasons for drinking.

Not being a student of abnormal psychology, he was not expected to unearth any hidden causes behind his reasons unless they came freely into his mind. His account of himself is interesting, however, as he was an intelligent person and, like the great majority of alcoholics, an honest thinker when sober. He was cautioned to avoid the petty excuses that all drinkers are wont to make in order to give themselves some flimsy moral justification. His short thesis on "The Causes, Reasons, and Excuses for My Drinking," as he entitled it, is quoted in full: -- "When I think of what liquor does to me and how much it makes me suffer, I sometimes feel as if I didn't know why I drank, as if any reason sounded too foolish to bother with. Then again when I concentrate on the problem it seems as if there were reasons or impulses, some of which are obvious, and some of which are vague and hence hard to explain.

"In the first place my environment is a distinctly alcoholic one; even business seems to demand a certain amount of drinking, either to land a sale or to be congenial with the men in the office after hours. The country dub where my wife and I spend most of our spare time is of course wringing wet, and it seems as if I were forever expected to shake up a drink for someone else or that one was being shaken up for me. Of course I don't want to make a goat out of my environment. Only one of my intimate friends drinks as hard as I do and he is a rich bachelor, and many of them do not drink hard at all. When it comes right down to it I have reached such a state now that I would probably try to drink all I could get in any environment.

"When I start to sober up the next day I feel nervous and depressed, and I can't get it out of my head that one good drink won't set me up for the day the way it used to. So I take it and of course it doesn't, then I take another and the game starts A over again. I really don't want to stay drunk, whatever people may think; in fact I don't even feel that I am drinking in the same manner or for the same purpose that I do at the beginning of a party.

"After I have been sober, say, for a week, a part of me seems to be trying to fool the other part, and I begin to think that the next time things am going to be different. Though I really know in my heart that this is not so, still I am fool enough to think that it is. If by any chance I do make a success of it, which is very rare, I use it as an excuse for the next three months, forgetting the hundreds of other times where my schemes and resolutions for "drinking like a gentleman" have come to naught. When I do stay off it, I become envious of those who are drinking, and that makes me cross. I don't say much of anything to them, because I wouldn't get away with it, but every so often I take it out on my wife, which makes me ashamed of myself.

"I hate to admit that I can't handle liquor the way my friends do and the way I used to be able to, and at times I will think up the queerest systems of reasoning rather than admit that I am licked.

"Then my wife likes to go out or entertain at home, and I like it myself as long as I can drink. She doesn't ask why I can't drink moderately and always suggests that I have a cocktail or two and stop there, which of course I never can do because all one drink does is to make me want another.

"Furthermore there are the celebrations which have to be taken care of, such as football games, weddings, ushers' dinners, class reunions, and so forth. Sometimes it seems as if every Saturday and holiday came under this head.

"More and more lately I have been using it as a sort of refuge from worry and troubles in general. If the market goes down, or if I have to entertain someone who bores me, I take a few drinks to forget it. As a matter of fact I get bored more and more easily, whereas after a drink or two I enjoy everything and everybody.

"I have no real interest outside of business and drinking. I don't mean by that that I don't like my home, because I do and I would feel like hell if anything happened to my wife. Also I like golf, and fishing, and shooting, but when it comes right down to it I would rather sit around and drink with a congenial companion or two than anything I know.

"While I have never tried to get away from a wet environment, still I feel sure if I did stop drinking and went anywhere else I would find practically no one my own age who wasn't drinking something, generally enough to make him feel pretty good, even though he might not be actually drunk. It's hard when you are bored without it, and you see everyone else doing it, not to say to yourself that you will just take one and that won't do you any harm, even though you secretly know it is a lie. As far as the next day goes that is different, nobody is doing it then and I get no support or sympathy, but I can't help going on.

"Another reason that goes with my grouchiness, when I am sober and see others drinking, is that I feel sort of out of place, tongue-tied, too tired at times to compete with their alcoholic wit. I guess you would call it an inferiority complex, though perhaps I am not using those words correctly.

"That seems to be about all the reasons I can think of now, though perhaps some others will come into my head later."

3. THE ROOTS OF THE TROUBLE

The individual described here is a fairly typical example of a man who, by his own admission. has passed through the different stages from normal drinking to habitual drunkenness, although he has not vet reached a state of complete demoralization, nor has he committed any act or reached a frame of mind which makes the prognosis for a cure unfavorable. He has already found out that he cannot learn to drink normally, because he has exhausted all known methods in an effort to control his habit, nor has he even been successful in keeping it within limits satisfactory to an extremely liberal, if not actually dissipated, social group. While he feels that no irreparable harm has been done so far, he is convinced that his habit is progressive, and that if he keeps it up he will be down and out within a very few years.

What does an examination of this man's history disclose? What does an analysis of the past show as a cause for his inability to drink as his friends (to, and what prognosis may be made for the future? (Incidentally I should like to state that it is very unwise to make any prognosis whatsoever until at least two or three months of consultation have elapsed. "Hopeless cases" sometimes show remarkable aptitude in rehabilitating themselves. and "excellent prospects" fail to measure up to what is expected of them.)

The most marked feature of this situation is the comparative normalcy of this man's life. There have been no obvious reasons why he should be unable to control his drinking within reasonable social limitations. He has not had a hard time in the world, nor has he experienced any severe shocks; in fact there was almost nothing until the end of the war that might give an inkling of the deterioration that he was to undergo. However, bearing in mind what has already been said in regard to inheritance and early environment, an analysis of his family relationship may not leave us so much in the dark.

His father, it will be recalled. was a reserved type of man afflicted with moods of mild despondency. His mother was prudish domineering, and subject to tantrums -- symptoms of an attempt to cover tap her pronounced fear of the world. The characteristics of both parents inclined the child toward self-consciousness, for children unwittingly absorb and reflect the attitudes of those who bring them up. How much of this parental influence was imparted through inheritance and how much through precept and suggestion we will leave to the "Inheritance School" and the "Environmentalists" to decide. An any rate a hypersensitive nervous constitution was inherited, and an unfavorable Home atmosphere in the early years of the child's life combined to create a personality ill-adapted to facing life with stability. Of the two influences I believe that the environment plays a more important part; but, from whichever angle the subject is approached, the resulting character is the fault of the parents, though in our use of the word "fault" we do not wish to conjure up an ethical concept so much as one of ignorance and lack of self-control -- an ignorance which would be less excusable nowadays, in the light of modern knowledge, than it was at the time of this man's childhood.

Our patient does not seem to recall very clearly his youthful mental reactions save a fear of his mother -- not of being abused. but rather of being interfered with and misunderstood. Also he was in a continuous state of uncertainty as to what her attitude was going to he on any given question, and how soon it would change to the opposite for no apparent reason. He made a particular point of avoiding her whenever he had something that he especially wanted to do, for fear of being thwarted, though very often his desires were perfectly harmless and natural. He would sneak down the back stairs and hide in the cellar until she went out, so that she would not have an opportunity to spoil his plans, a performance in which it seemed to him she specialized. At other times he would run from the house yelling at the top of his lungs to drown out the sound of her voice should she attempt to recall him.

This man as a child was unquestionably stubborn, and his mother was not always at fault except in so far as her lack of tact and control was originally responsible for creating stubbornness in her offspring. Our patient had unconsciously to choose between becoming a timid mother's darling, completely surrendering his own personality, or putting up an exaggerated opposition. Of the two he unquestionably chose the wiser course, though as a result he has had an antagonistic attitude toward life in general. Our patient does not seem to recall very clearly his youthful mental reactions save a fear of his mother -- not of being abused, but rather of being interfered with and misunderstood. Also he was in a continuous state of uncertainty ever since.

In fact, a neurotic, whether his neurosis takes the form of alcoholism or not, is generally reacting to life as he formerly did to his immediate family when it comprised his entire world. Where this child-world was consistent, poised, and mature, where it demanded a system of conduct which was justified by its own example, we expect to find resulting personalities who can adjust themselves to an ever-changing environment without remaining fixated in or regressing to an infantile state the minute they are confronted with the complexities of life. Where we have a different kind of child-world we must be on the lookout for individuals who have never matured and who will be tempted to adapt themselves through a stimulant-depressant medium, or take refuge in some other form of neurotic behavior.

It was pointed out to this man that he probably grew up with a two-fold conception of self, largely unconscious, to be sure, but which gave him a feeling of insecurity because of the changing mental states of superiority-inferiority which his mother's attitude had produced in him.

What else can we find in this life history that has contributed to an emotionally unstable condition? I say contributed, because we have already had the seeds of the trouble sown in childhood, and they only needed the benefit of certain experiences in college and the war to make them sprout and flourish. But I want to emphasize that unless the seed had been there, and by seed I mean a disposition to react neurotically to life, the condition would never have developed, as the overwhelming number of normal college graduates and war veterans bear witness.

It should be noted, parenthetically, that the attitude toward drinking in some of our colleges does not help matters for the nervously inclined individual. This attitude, though seldom openly expressed, seems to be that drinking should consist of a "party." In other words, if you drink at all, you are supposed to become intoxicated. One of my patients, a man who had graduated from one of our largest and most celebrated universities, told me that it was considered almost degenerate to take one or two drinks unless they consisted of beer. You were supposed to leave it alone entirely or make a thorough job of it. This point of view, it goes without saying, was as unsuited to an unstable personality as it was nonsensical from the point of view of logic. Had this boy grown up under Continental influences, his reaction to alcohol might have been very different; drink would probably have been an accessory to other interests and not an end in itself.

To revert, however, to the case before us, we should observe the part played by aviation in the further weakening of our patient's nervous system. The war seems to have had a marked effect on the nerves of many men, including some who never saw the front-line trenches. "Shell-shock" often began its work on some organisms the minute they donned a uniform five thousand miles and many months away from the front. There were nervous breakdowns, in some cases reaching the point of suicide, on the part of men to whom the question, "Shall I be brave when the time comes?" occurred with morbid intensity even though it was doubtful if they would ever be put to the test.

When this war state of mind was attained through aviation, it was increased a hundredfold, for an aviator did not have to go to the front to have his life in jeopardy a good proportion of the time. Few failed during their training course to see at least one, and sometimes many more, of their friends crash to the ground. Whether this fear of not being brave was conscious or whether it was largely repressed seems to have made little difference as regards its effect on the nervous system. In the case of our patient, while it cannot be considered as a fundamental cause of his intemperate conduct after the war, it most certainly precipitated matters. He undoubtedly would have been an unsuccessful drinker in the long run, but his army experience reduced the time limit by a considerable amount.

Another feature of military life that tended to make the soldier -- and even a junior officer -- irresponsible was the lack of initiative required in his daily life. The government told him what to wear, what to eat, and where and when to move about; in fact, his whole life was passed in carrying out carefully prescribed instructions. Superimposed upon this irresponsibility was an annoying confinement, so that when at last he was discharged it was not unlike being released from an honorable jail. The boarding-school-to-college change was in a sense repeated without the youthful nerves to withstand the shock, and, for an unfortunate few, without any increased maturity.

So, with his nerves frayed by aviation, with a feeling of escape from an absolute discipline, with a justified sense of having done his duty (and hence being entitled to allowances), and with a young wife anxious to have a good time. our patient found himself in a large city among strangers. There followed a period of business success, partly due to the intrinsic ability of the individual, partly due to post-war prosperity, and partly due to luck. The list of friends grew and the social demands kept pace; but the nervous system began to crack, and in order to keep it going, drink was used in larger and larger quantities as medicine.

It was a social stimulant in the beginning, but, as hangovers could no longer be faced philosophically, a sedative was required to steady the jangling nerves. One had to work, one had to eat, and one had to sleep, drink unfortunately gave temporarily the strength on the one hand, and the relaxation on the other, to accomplish all these things. This man had in reality become a species of drug addict by carrying to excess a normal social custom. He would have been horrified at the idea of a hypodermic, yet alcohol had become a powerful narcotic for him without his having the slightest idea that he was an addict to any form of dope whatsoever.

4. WINE, WOMEN, AND INFERIOR1TY

In view of what has been said it is clear, I think, that the real causative factors are those which induce a nervous condition first, and that this condition in turn induces alcoholism. In other words, alcoholism does not directly result from an event or a series of events in the manner that fever results from am infection. Drinking, or an isolated debauch, may follow a specific stimulation, but chronic alcoholism is a pathological method of life and not a mode of revenge, diversion, or even of suicide. The majority of men -- and this must necessarily include a goodly number who are none too brave -- simply do not choose that means of faring their troubles or of ending their life.

Says Dr. Myerson in his Foundations of Personality "Not all persons have a liability to the alcoholic habit. For most people, lack of real desire or pleasure prevented alcoholism. The majority of those who drank little or not at all were not in the least tempted by the drug. 'Will power' rarely had anything to do with their abstinence, and the complacency with which they held themselves up as an example to the drunken had all the flavor of Pharisecism. To some the taste is not pleasing, to others the immediate effects are so terrifying as automatically to shut off excess. Many people become dizzy or nauseated almost at once and even lose the power of locomotion or speech."

Anything that creates fear in a person creates uncertainty, timidity, inferiority; and so I firmly believe that the inferiority complex of the Adlerian School of abnormal psychology goes much further in explaining the origin of alcoholism than the pansexualism of Freud.

I agree with Dr. Schmalhausen when he says: "The ego is more pervasive as a human reality than sex. Human natures that harmonize on the ego level can contrive to put up with sex disharmony; but sex harmony cannot cope with the problem of disharmony rooted in a maladjustment of egos. The Adlerian theme runs deeper in human life than the Freudian, though the latter, because of its dramatic and sensational components, gives the impression of being more fundamental."

Inasmuch as Dr. Schmalhausen's book, Why We Misbehave, is very far from being hostile to much that has been written by Freud, this remark is quite significant. At any rate I have yet to find a case of alcoholism which seemed to rest on suppressed sexual desires either normal or abnormal, unless all uncalled-for violence is to be interpreted as Sadism and all exaggerated friendliness is reduced to terms of homosexuality which does not seem reasonable to me. Nor does this opinion arise from any prejudice against Freud in favor of Adler or from any a priori reasoning. As a matter of fact, it came somewhat as a surprise in my experience that alcoholics should be so free from sexual disturbances past and present.

As I do not explore the unconscious by psychoanalysis or hypnotism, I cannot make an unqualified statement that there is not a deep-seated relationship that can be discovered by these methods. It has, however, seemed unnecessary to go to such lengths to procure satisfactory results.

On the other hand, sex can function as a conscious or semiconscious stimulation to drink under certain conditions as contrasted with a fundamental instinctive urge. Men who are self-conscious in the presence of women find it easier to accomplish their purpose if their timidity is removed by alcohol (though "satyrs" never allow any blunting of their sensibilities to interfere with their pleasure). Furthermore, many men have more of a conscience than they realize. Alcohol will suppress this inhibiting force during the event and give them an excuse ("I wouldn't have done it if I hadn't been drunk") to dispel remorse after it is over. Thirdly, the crudities, of coarse, inferior women are obliterated if men of sensibility drink a sufficient amount. Thus for many a bachelor, unable to find a woman of his own class, the old association of "wine, women, and song" consciously or unconsciously recommends itself.

For the man who is going to stop drinking this association must be broken up. There is no biological urge for drink such as there is for sex, and only vicious custom has given them a connection. If this break cannot be made, then "women" must be avoided until the alcoholic habit has been definitely overcome. An inebriate's entire life depends on the successful outcome of the treatment; so it will not do him any harm if he finds he has to do without women until this has taken place.

In contrast to the sexual theme, them always appears inferiority in some form or another, often to a marked degree and most cases fully admitted, although sometimes a compensatory mechanism is at work. (disguised under a bold front. Alcohol, with the "Dutch courage" that it temporarily supplies, is a logical antidote for inferiority. Some of the causes of this inferiority, in addition to the early environment already referred to. are shocks, humiliations, accidents, failures in athletics and scholarships as well as in business, disappointments in love, inability to make friends, and the doing of some act which, even if unknown to the outside world, degrades the individual in his own eyes. According to Dr. Myerson, " 'Dutch courage' drove from many a man the inferiority and fear that plagued his soul. True, it drove him into a worse situation, but for a few moments he tasted something of the life that heroes and the great have. If we can ever find something that does not degrade as it exalts, all the world will rush to use it."

A case might be mentioned of a man becoming a drunkard as a result, so he thought, of having his Heart broken in a love affair. This individual had always been lacking in self-confidence, but his girl had temporarily given him the feeling of power that he had abnormally craved. When she terminated their relationship he collapsed. A short analysis soon showed him that it was his ego that was broken and not his heart. Sad he was, without question, but it was humiliation and not sorrow that "drove" him to excessive, drinking.

Just as we speak of a vicious circle of cause and effect which moves faster and faster as drinking continues, so we can with equal validity refer, in the case of inebriates, to the cessation of drinking as a benign circle where confidence and poise follow sobriety, inferiority disappears, and so sobriety itself is made easier. Self-respect is substituted for degradation.

While the eliminating of drink itself has been the factor in determining this restored state of mind, still there may be other forces at work which will determine whether or not the alcoholic is going to be able to complete satisfactorily his treatment. If he is leading, apart from his drinking, a life which causes him to lose caste in his own eyes, it is almost certain that he will conceive of himself as too weak or vicious to give up the drink habit, though this low opinion of himself may be partly repressed into the unconscious.

The most ready illustrations of the above condition are the sexual irregularities on the part of married men. Many men, as has been mentioned before, have more of a sex conscience than they realize. Some, of course, though they would collapse under the remorse following a petty theft and are in many other directions anything but conscienceless, have no immorality conscience at all. On the other hand, there are a great many men who pretend to this irresponsibility, whereas in reality they are unable to escape the traditions of their inheritance and bringing up. I have had two cases which have involved extramarital sexual relationships. In each case I replied that, as long as it did not lead to drinking directly through emotional contagion or indirectly through a feeling of guilt which produced inferiority, it was their own problem to decide. However, these men voluntarily came to the conclusion that, inasmuch as their wives were doing all that they could to make the home a happy one, they would make a clean sweep of their entire irregular life. They found that fundamentally they did feel conscience stricken, and that in addition the fear of being caught had a demoralizing effect upon them.

I have known of other men in this predicament who, because of the difference of their natures, did not require the adjustment of this factor in their treatment and cure.

But sex is by no means the only cause for an enervating and demoralized self-ideal, nor is it necessarily the most important one. It was merely used as a convenient illustration. Any form of behavior which lowers a man in his own eyes, whether the outside world knows about it or not, will obviously prevent the vigorous, sustained, and un-diverted concentration on the giving up of the alcoholic habit. Lying furnishes another excellent illustration of destructive conduct. A man who lies to those who have a right by nature of their position to know of his affairs is soon motivated by the feeling that if he is not man enough to tell the truth to those who are endeavoring to help him, he is not man enough to give up drinking. While he may not consciously formulate this relationship in so many words, the effects- that is, his actions -- soon testify to its validity. A man quite naturally has feelings of inferiority at the beginning of his treatment because of the effect that alcohol has had upon him. and so he should do all in his power to eliminate anything that fosters a lack of self respect, whether it appears on the surface to pertain directly to the question of drinking or not.

"If," writes Professor McDougall in his Outline of Abnormal Psychology, "a unitary personality is to be achieved, the various sentiments must be brought into one system within which their impulses must be harmonized, each duly subordinate to the higher integration of which it becomes a member. This higher integration is what we call 'character'; it is achieved by the development of a master sentiment which dominates the whole system of sentiments, subordinating their impulses to its own . . . . The only sentiment which can adequately fulfill the function of dominating and harmonizing all other sentiments is the sentiment of self-regard, taking the form of a self-conscious devotion to an ideal of character. . . .

"A firm or strong or well-knit character, one that can resist all disintegrating influences, is one that can face all problems, all critical alternatives, and can make a decision, can choose one of the alternatives and give that line of action an assured predominance over all others; and this capacity depends upon the organization of the sentiments in an ordered system dominated by a master sentiment; and of all possible master sentiments the most effective is a sentiment for an ideal of character, an autonomous self, a reflective self that can control, in the light of reason and moral principles, all the promptings of other sentiments as well as the crude urgings of instinct and appetite."

Another factor in the background of alcoholism, which is common to all neurotics, but which might escape those uninitiated to abnormal psychology, is the fact that by his conduct the alcoholic is making himself important in his own eves. Prevented by his habit from living a constructive life, he is unconsciously anxious to make a stir in the world, even though this stir is of a purely destructive nature. Anything is better than oblivion, and so all the fuss that is made about him, as well as the fact that he is a "serious problem," is not as distasteful to him as he may imagine. In fact, he often considers himself a heroic villain or martyr. Those who have had dealings with drunkards have noticed the phase of self-pity wherein they expatiate at length about the curse that is laid upon them. They delight in relating how they are drinking themselves to death; it seems that they cannot help this unfortunate procedure, since, owing to inheritance or some other bugaboo, they are in the clutches of a " vice" which is more powerful than they are. Often this discourse is accompanied by drunken temperance lectures. In a weepy manner they implore their audience not to follow in their footsteps, and state with great emphasis that, had they their lives to lead over again, they would never touch a drop. This is, of course, 100 per cent hocus-pocus, and nobody realizes it more than the man who has given up the habit "he couldn't help" and has learned to satisfy his craving for attention in a legitimate manner.

5. PSYCHOANALYSIS

In the foregoing I have had occasion to refer to psychoanalysis. Owing to the profound influence that Freud and his followers have had on abnormal psychology and the justified interest that the public has taken in the popularization of his works, the relationship between this most important study of the human mind and alcoholism should be made clear.

When the large number of inebriates seeking help is contrasted with the relatively small amount of space that the psychoanalysts have devoted in their works to this phase of abnormal psychology, the thought occurs that possibly psychoanalytic procedure in this direction has not been as productive as it has been with hysteria, anxiety, and obsessional neuroses. In Dr. William Healy's recent publication, The Structure and Meaning of Psychoanalysis, which Dr. Wittels of Vienna has referred to as a "Bible of Psychoanalysis," less than two pages out of 480 are devoted to alcoholism.

Nevertheless since psychoanalysis has done more than anything else to illuminate for me the abnormal processes of the human mind, this form of treatment at the hands of an expert is most sincerely recommended when stringent methods seem necessary. I do not question the fact that the fundamental motivating cause of alcoholism may often be a conflict buried in the unconscious, but experience has shown in others besides myself that methods more or less similar to those set forth in this book are in general adequate for cure without more intricate psychoanalytical investigation.

Of course I do not mean in the least to imply that exploration is neglected. The patient, as I have described, is encouraged to talk at length on every conceivable topic that interests him from his earliest childhood to the present time, and past as well as present problems are given special attention from the point of view of "confession" or catharsis. This, to many psychiatrists who are by no means inimical to psychoanalysis, constitutes sufficient analysis. Let me here refer to The Human Mind.

"One very useful method," (of treating nervous disorders) says Dr. Menninger, "is a combination of expression (analysis) and suppression (persuasion). Sometimes it is called reeducation. It amounts to this. The physician learns as much as he can about his patient, in all the ways he can, but chiefly by as much mental catharsis and as much environmental investigation as possible. These he puts together, consults his knowledge of the principles of mental functioning and mental disease, and his experience with other cases, and on this basis he gives advice, adjuration, enlightenment, encouragement."

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III
FIRST STEPS

l. SURRENDER

The first essential requirement for successful treatment is the sincere desire to be helped on the part of the alcoholic himself. Nothing constructive has ever been accomplished or ever will be with men who are dragged or pushed toward curative measures by friends or relatives. In fact, sometimes actual harm is done by such a procedure. A man will often reject premature persuasion, and, once having rejected it, may maintain his attitude for all time. He should be informed that professional assistance is available and then left undisturbed to seek it on his own initiative.

I can well understand from the point of view of the family that "premature" may hardly seem a suitable word to apply to a person who has been drinking to excess for many months and possibly years, but in spite of this fact, I repeat, he should be given the idea as a suggestion and then left alone to think it over. Nothing may ever come of it, to be sure, but on the other hand he may be much more concerned with the matter than appears on the surface. No action may result until some particularly depressing Series of events has brought vividly home to him the futility of trying to continue drinking and the apparent impossibility of giving it up unaided. If he should have a friend who has been successfully treated and in whom he has confidence some pressure may be applied by this friend, but even here tact and suggestion should be relied on more than persuasion or exhortation. Alcoholics are apt to be extremely stubborn people; in fact, it might be said with much truth that the therapeutic problem consists in redirecting this stubbornness from destructive to constructive ends.

One man, who now no longer drinks anything, when first informed by an ex-alcoholic that there was a systematic method for treating inebriety, did nothing about it for a year, although it had long been obvious to even his most dissipated friends that he simply could not withstand alcohol. Matters naturally went from bad to worse, but this seemed to be necessary in order to convince him that his habit had definitely gotten the upper hand. When at last he awoke to his condition, he allowed his friend to bring him in for an interview. Before very long he was a successful case himself, though both he and the friend who introduced him had looked upon the situation as hopeless before the treatment. However, he did want to stop, or, to use his own phraseology, he "wanted to want to stop," which is all that can be desired in the uninitiated.

The surrender to the fact that alcohol can no longer be indulged in without bringing disastrous results is of such importance that it requires extremely thoughtful consideration. This surrender is an absolute starting point as far as the conscious mind is concerned. Experience has shown, however, that an intellectual surrender by no means settles the question, because there are unconscious motivations working in opposition which the patient must be made aware of and upon which he must devote considerable reflection in order that a distorted pride may be expelled from the deepest recesses of the mind.

The alcoholic, in company with all other drinkers, started his habit with the idea of being smart or manly as one of the main impulses. Although this idea is supposed to pass away with the coming of maturity, in reality it does not do so. It still lingers in the unconscious as a sort of credo and accounts for much of the driving force which operates against a graceful surrender to the inevitable. In some cases it is fully conscious, and the individual frankly admits that he hates to say "no forever" for reasons which are hard for him to explain because they seem to be apart from an actual desire to drink. When he is confronted with the "manly" or "freshman" complex, as I often call it, a certain illumination is shed on the question, though often it takes a little analysis and "explanation for the idea to become a conviction. If he will face this problem and bring to bear on it the counter idea (which is, of course, only too obvious) that it is the manly thing to give up drinking because weaklings cannot do it, he will accomplish a great deal in the correcting of a very deep-seated obstruction to the cure. It is driving home platitudes as if they were profundities over and over again that actually unifies the emotional system with the intellect so that the latter has complete and permanent domination.

Another reason for not wanting to surrender is that the patient visualizes such a step in the light of an irrevocable pledge which he might some day want to retract. The sooner he takes this "pledge" by himself, the better off he will be, but he is not asked to do so, and a little reflection should show him that as long as he remains in a civilized community there is nothing to prevent a retraction if he really wants to make it.

A third way of expressing this will-not-to-surrender is in terms of bogus freedom. The alcoholic wishes to feel "free" to do as he likes; he does not want to bow to the will of his family, his friends, the prohibitionists, or his own better self. This demand for free self-expression may be logical for the man who has drink under control. He may be justified in resenting the interference of those who wish by legislation to interfere with customs which are as old as civilization. But the drunkard should realize that he is in search of a larger freedom which rises far above the influence of man-made law. He has become a slave to something which can in the long run only be used by those who remain masters of it. In reality he has not known what freedom was since the first trial to limit his drinking and found himself unable to do so. The only freedom he can enjoy is that derived from an abstinence which gives him assurance and self-respect in his own eyes. When he knows each day what he has done, what he wants to do, and when he feels within himself the power to do it, then and then only can he understand the true meaning of the word "freedom," as well as the absolute bondage that he was in when he tried to express himself "freely" by drinking all the alcohol that he could lay his hands on.

These various theories for not surrendering are often supported by actions clearly showing unconscious motivation: such, for instance, as persistent attendance at very wet parties (though the patient was "absolutely sure of Himself" before he went to them), quarrels with relatives and friends inducing self-pity, the distortion of theories designed for the elimination of drinking so that they come to permit of light drinking once in a while. This unconscious resistance against surrendering -- that is, being cured is nowhere better demonstrated than by avoiding work and being late for or breaking appointments, apparently always with the best of reasons. There is a telling paragraph in Dr. Sigmund Freud's Introduction to Psychoanalysis: "If you were to come in contact with neurotics as a physician, you will soon cease to expect that those who complain most woefully of their illness are the ones who will oppose its therapy with the least resistance or who will welcome any help. On the contrary, you will readily understand that everything contributing to the advantage derived from the disease will strengthen the resistance to the suppression and heighten the difficulty of the therapy. We must also add another and later advantage to the gain of illness which is born with the symptom. If a psychic organization, such as this illness, has persisted for a long time, it finally behaves as an independent unit, it expresses something like self-preservation, attains a kind of modus vivendi between itself and other parts of psychic life, even those that are fundamentally hostile to it."

Of course a man cannot be expected to agree to do something until he knows of what it consists. Therefore one who has not been entirely convinced that he needs or wants help might be interested in a preliminary interview so that he can have first-hand information that may be of use to him some day, or that might entertain him as pure theory.

The attitude taken with such an individual is simply to answer his questions as fully as possible, discussing drink from any angle that he may wish. The accounts of changes in the lives of others more or less similarly situated may catch his attention and it may be possible thus inadvertently to "convert" him as to the advisability of seeking a cure. He is definitely informed that he is not interviewing an evangelist, so that whether he wants to stop drinking or not is most decidedly his own business. There is not the slightest desire or even willingness on my part to settle anybody's moral problems for them. If a person thinks he can drink, let him continue to (1o so. He may be right, and at any rate it is his own concern. whether he is or not. If his condition is extreme, not from the point of view of prudes, but from that of his drinking friends, and he does not wish to correct it, then he is either insane or a moral delinquent, in which case his problem belongs in another field.

When, however, a man is doing something that his more intelligent self (which he would like to have as a permanently directing force) knows to be the height of inexpediency, and when he admits, furthermore, that he can do relatively little about checking this something in spite of his desire to do so, then and then only is the prospect favorable. A person in the beginning cannot be expected to say that he wants to give up drinking in the broadest sense of the word, because if this were true he would promptly give it up without any difficulty and without any assistance, as obviously nobody compels him to drink. But on the other hand he can say that he would like to be shown how to reconstruct his mental processes so that in due time he will no longer want to drink. This is what I mean by the necessary "surrender."

2. FUTURE DRINKING

The patient's point of view in regard to future drinking is a second essential for successful treatment. He must have as his goal, no matter how fantastic the idea may seem in the beginning, the complete renunciation of the use of alcohol as a beverage in any quantity however small for all time. No man who has ever passed from normal or hard drinking to chronic alcoholism, or who has shown persistently a disposition to act in an antisocial manner when under the influence of intoxicating beverages, can ever expect to be shown how to drink in a controlled manner, or to learn how by himself even after long periods of abstention. The very concept of eventual drinking, however remote, seems to be fatal to satisfactory results. The going-on-the-wagon point of view and the giving-it-up-forever point of view have little or no relationship. The first is only a stop-gap. Sober conduct, to be sure, may temporarily result from it, but the alcoholic conflict continues in the mind and sooner or later results in action.

Dr. Elwood Worcester, a pioneer in the psychological treatment of inebriates, tried in the early days of his work to teach drunkards to drink "like gentlemen." He told me that in spite of his best efforts was 100 per cent unsuccessful. Because of Dr. Worcester's skill and experience this would seem to be convincing testimony of the futility of trying to teach the art of drinking to one who has ever reached the point where it has become a pathological problem. Mr. Courtenay Baylor, after seventeen years' successful work with alcoholics, is most emphatically of the same opinion.

Why it is that certain persons have a morbid reaction to alcohol after a period of fairly normal indulgence has been indicated in the first part of this book. Whether some day the microscope will disclose psychological deteriorations now unknown is a matter of mere conjecture. Nevertheless, lack of specific knowledge on this interesting point, however helpful it might be, does not seem to stand in the way of successful treatment. Once the mental conflicts, at least those within reach of the conscious mind, have been broken up, the outlook is forward rather than back. Suffice it to say, once a drunkard always a drunkard, or a teetotaler! A fairly exhaustive inquiry has elicited no exceptions to this rule.

Of course a man who has had long periods of abstinence may on a few occasions be able to manage things pretty well when he resumes drinking, but sooner or later, depending somewhat on outside conditions, but still more on the stage of psychological deterioration that he has reached, he will crash harder thin ever.

One of the reasons that may make it difficult for an inebriate to reform permanently is an idealization of the past, which he futilely believes he can revive, a belief often unexpressed with which he fools himself over and over again. "This time it is going to be different," you may hear him say, but if you know him well you will smile. There are plans made to drink slowly, to take small drinks, to stick to beer (the most futile of all), to prime first with olive oil, and not to drink before or after certain hours; all in the long run are of no avail.

Then there are the occasions; at first only the big ones will cause the vows to be broken, but before long the little ones are getting their full share of alcoholic attention, and eventually they are deliberately invented. Just as the glow of the first cocktail cannot be repeated on any given party no matter how many may be imbibed, so the carefree days when the nerves were strong are gone forever for the man who has abused his nervous system through long periods of excessive indulgence. He has exhausted all but the most fleeting pleasures that can be derived from drinking, and he must understand that he can never recall them.

3. ECONOMIC FREEDOM

Some degree of economic freedom is necessary to assist in carrying out the cure. It is futile to attempt a systematic character reorganization with a man who does not know where the next meal is coming from, or whether he is going to have a bed to sleep an that night. The idea of reform is obviously appropriate, but the development of the idea so that it becomes expressed in sustained action requires sufficient freedom from the basic demands of self-preservation to allow the drink problem, intrinsically so important in itself, not to appear to be relatively insignificant before the larger quest. It would seem as if destitution would act as a powerful deterrent to alcoholism, but, as is well known, the reverse is only too often the case when unstable personalities are involved. For this reason, among the poor only those who are at least assured of room and board while they are seeking employment are suitable subjects for reeducation.

However, the rich and poor alike cannot await the ideal moment for taking up treatment, since it would doubtless never come. Many of the reasons why the present is unbearable for the alcoholic are derived directly from his drinking and will only be intensified by its continuance. Putting off treatment until this or that trouble disappears is just another way of saying one intends to continue.

Experience has shown that the habit has been gotten rid of by many people whose lives were by no means a bed of roses at the time they started to work, but tended toward that ideal state in some degree when they took a mature attitude toward their self-improvement. If drink could permanently remove worry, most of the world would probably be more or less drunk a fair share of the time. But liquor as a diversion is definitely a two-edged sword, as the temporary oblivion gained from its use is unfortunately overcompensated for by an intensified and morbid remembrance when a state of sobriety is regained.

Incidentally, if a person is going to drink to any extent he should do so when he is in a happy frame of mind. The men who "get away with it" use alcohol in this manner because it does not require an increasing amount to make an environmental adjustment that is becoming more and more difficult. Some may claim that they know drunkards who only drink, or at least start drinking, in this manner, -- to celebrate rather than to seek refuge, -- and have the testimony of the drunkards themselves in support of their statement.

It seems hard to believe, however, that an otherwise sane person will deliberately ruin his life against his own best judgment for the sake of a most immature form of enjoyment unless he is motivated by a strong compelling force of which he is unaware and from which he is at times trying to escape. Because he picks his time for escaping at moments when his friends are celebrating, he is led to believe that he is doing as they are; but, with the full knowledge of his unfortunate reaction to alcohol, he would not attend these celebrations at all, or would not indulge if he did, if he were not motivated by an abnormal mental condition.

4. THE FAMILY

Unless a prospective patient is entirely on his own, a preliminary interview with his family or most intimate friend is most important. Much instructive material may be obtained from them which the patient cannot give, no matter how willing and honest he may be. Frequently what he says and does when drinking is a valuable source of information. The inhibitions are lowered and the resulting speech and action may show clearly the repressions, somewhat in the manner of a dream but without its symbolization.

Inasmuch as the family interview often takes place after the patient has been treated several times, it must be stated plainly that the latter's private affairs can be told to nobody without his express permission and that he is only being discussed for his own good. If this were not clearly understood, most people would disclose nothing of an intimate nature, and as a result the work would have to consist of persuasion devoid of analysis, with rather doubtful prospects of success.

Of even more importance than the information received are the suggestions which should be given the family to enable them to cooperate with the patient to the best advantage.

Another serious concern is the readjustment of the patient to his surroundings, of which the family is obviously the focal point. Where this is impossible, the surroundings themselves must be changed - a more difficult and less constructive performance, as it is often synonymous with hospitalization or permanent rustication in some remote spot. I am using the word "changed" in its most comprehensive sense minor changes in the environment are nearly always necessary, and generally the most important of these is the facing of the problem by the individual's family and intimate friends in an intelligent and cooperative manner.

In the first place, it must be understood that the immediate results of the treatment are far from satisfactory to the layman. There may be relapses throughout the first six months and sometimes these discouraging episodes are numerous and extreme. I say "discouraging" because that is the logical reaction of the uninitiated, but for those who have had experience with alcoholics these falls from grace are discounted in advance as being part of the normal procedure. In nearly every case the individual is slowly weaned from his habit. He is not instantly checked. During this weaning process the change in the fundamental attitude toward drink is often further advanced than would appear in actual conduct, though it is of course recognized that conduct in the long run is the only criterion.

In two extreme instances which I can recall no sustained progress was made during the first year of effort. Then suddenly both individuals completely eliminated their habit. As there was no sudden shock in either situation, the complete change of heart can only be explained on the grounds that the effects of the persuasion and the suggestion were accumulating in a mind that had been opened up by analysis, and when these suggestions became sufficiently strong the old habits yielded to them.

The first stage in the cure is reached when the patient abandons alcohol as a way of life, so that his upsets are actually life mistakes and not a continuation of his former method of environmental adaptation. In the beginning the conduct itself may often be indistinguishable, but unless the patient is a liar (this trait is rare among alcoholics when they are sober, and when it exists the prognosis is very bad) it is easy enough to find out his fundamental attitude by asking him.

Relapses may continue after this important change has been made, but on recovery the patient reaches a different point of view: he has a sincere disgust at having been so stupid as to drink, a realization that the best part of his mind at least did not intend to do so, and a feeling that he got little or no satisfaction out of his "party" save in the early stages. Moreover, if with this new suite of mind goes a recog