Hope for the Alcoholic
New attitudes, community programs, government action and scientific research promise a more effective attack on alcoholism, a major public health problem.
By Kathryn Close
THE SCENE IS A MUNICIPAL COURTROOM. The setting could be any of thousands of localities throughout the United States. The judge looks wearily down from his bench at a long line of bleary-eyed, disheveled, haggard men. Several of them are as familiar to him as old friends. Time after time their faces have appeared in the morning line-up - downcast, hopeless, ashamed.
Not a man among them puts up a defense. Each pleads guilty to a charge of "drunk and disorderly." With the exception of one or two "new faces" let off with an admonition, each is led back to jail to serve a sentence of ten, thirty, or perhaps ninety days. But they will be back in court soon. The judge knows it; the prisoners know it. For when they are free they will drink again, become drunk and disorderly, be hauled into jail in a stupor, or wildly belligerent, or just plain sick, and they will be thrown into a cell until they are sober enough to appear in court for a new sentence. And the circle will go round and round until they are dead.
For these men are victims of alcoholism, one of the most vicious diseases known to mankind. And neither they nor anyone with whom they come in contact have any hope for them. Coming from almost any walk of life, they have "hit bottom" as a result of a progressive disease from which some 4,000,000 Americans are currently suffering.
Alcoholism is one of those major diseases that have been nourished by ignorance, misunderstanding and stigma - long the protectors of venereal disease, cancer, and tuberculosis. If it is to be effectively attacked in the communities where alcoholics undergo their rounds of binges, terror, and agonized awakening, the stigma and misunderstanding surrounding it must be lifted. Only then will the "hidden alcoholics" - family skeletons in the closet - come forward and ask for help or be brought forward by their relatives, and only then will community leaders take an active interest in seeing that the proper facilities are available to them.
Happily some dramatic developments within the past fifteen years indicate that the negative attitudes which have long blacked out hope for the alcoholic may gradually be eliminated. Happily, too, these developments augur well for a shift in interest from an emotional controversy over liquor control to a concern for the alcoholic as a suffering human being.
Down through the centuries people have taken sides for or against drinking with a frenzy equaled only by their reactions to politics or religion. But the alcoholic was lost in the turmoil. Those against drinking saw the tragedies of alcoholism and wanted to abolish alcohol. It was a though persons with a knowledge of the discomforts of diabetes were to start a movement to abolish sugar. Those who believed in the freedom to drink fought hard for their freedom and looked down on the man without "self-control." And in "wet" periods or "dry" periods the alcoholic drank and suffered.
Shortly following repeal of the Prohibition Amendment, the air began to clear. A recognition dawned that alcoholism or addictive drinking, is not synonymous with drinking or even drunkenness; that only a fraction of those who drink become alcoholics; but that this fraction is large enough to represent one of the major public health problems in the United States; and that something must be done about it. For the first time attention began to be diverted from alcohol to the alcoholic. Today voluntary groups, states and municipalities throughout the country are working out programs to help the alcoholic get out of his vicious circle of drunkenness, aching sobriety, and drunkenness, into satisfactory, useful living.
WHILE THE MAJORITY of our 4,000,000 alcoholics still swim in a sea of hopelessness, more and more ropes are being thrown them by groups with a conscientious awareness of their responsibility to help. Among these are self-help groups of former alcoholics; community committees which are setting up information centers, clinics and hospital facilities for alcoholics; research scientists doubling their efforts to learn more about this disease; and enlightened government agencies which are beginning to recognize its public health aspects.
The question of whether or not alcoholism is a disease is till in dispute among some of the groups doing most to combat it, but the dispute boils down to one of semantics, for all are agreed on a single concept: that alcoholism - chronic excessive drinking, characterized by distinctive behavior patterns - is not caused by alcohol alone, but by more or less mysterious psychological disturbances incompatible with the presence of alcohol. The end result is an intolerance toward alcohol as permanent and incurable as the diabetic's intolerance toward sugar. Just as the diabetic must abjure sweets, the alcohol must abstain from alcohol. One drink will lead him to a disaster.
The basic cause is unknown. There may be one or many, and scientists are searching vigorously for clues. Their researches have brought forth the fact that there are many types of alcoholics, variously amenable to treatment. The most reliable statistics indicate that of 65,000,000 drinkers in the United States, 4,000,000 are chronic excessive drinkers - borderline or actual alcoholics. These have been broken down into problem drinkers, compulsive drinkers of primary and secondary types, social misfits and psychotic drinkers. Of these 4,000,000 inebriates, 750,000 are chronic alcoholics or persons whose drinking has resulted in diagnosable physical or psychological deterioration.
THE MOVEMENT TO EXTEND PRACTICAL help to alcoholics sprouts from several seeds, all planted at about the same time. The two with the most dramatic growth were sown independently in different places in the same year. That year, a red letter one for alcoholics, was 1935.
One seed was planted in Akron, Ohio by two habitual drunks. One was a doctor, the other a broker, both of some distinction before alcohol addiction began to ruin their careers and threaten to break up their homes. Intelligent men, they fought hard, but without much success, until they managed to get together in a sober interval. Then they decided that one drunk might help another. Out of this idea grew the now famous Alcoholics Anonymous. In a year's time these two former inebriates had not only achieved continuous sobriety for themselves, but had helped others to the same goal. Today the organization they started has some 85,000 members in 2,400 chapters throughout the country.
The entire membership is composed of alcoholics fighting desperately to help each other stay away from the substance that is poison to them. Many of the members have not touched a drop since they became A.A.' s Others have slipped from time to time, but have returned to the organization to keep up the fight. Some former members have sunk back into the mire of perpetual drunkenness. But Alcoholics Anonymous, which maintains that 75 percent of its members have achieved sobriety, is generally conceded to present the most widely successful attempt at alcoholic rehabilitation in this country's history. Statistics on "success" are unreliable, for a man who is sober today may be drunk tomorrow - even though his sobriety has lasted over a number of years. Nevertheless, doctors, scientists, social workers, clergymen, public health experts, suffering relatives, and others who have had to deal with alcoholics, have watched the A.A.'s achievements with amazement.
The other seed was planted in New Haven, Connecticut, by two scientists, Dr. Howard Haggard and Dr. Leon A. Greenberg. Director and associate respectively, of the Yale University Laboratory of Applied Physiology, they were carrying on research in the effects of alcohol on the human body. This led them into an awareness of alcoholism as a phenomenon distinct from normal drinking or occasional drunkenness. As they continued their studies they realized that alcoholism could not be studied in a test tube, that too many factors involving disciplines other than physiology were concerned. Accordingly they raised the money to enlarge their staff to include sociologists, psychiatrists, psychologists, economists, and medical men. Today the laboratory's section on alcohol is larger than all the rest of its sections combined and heads up the program of research, education, and treatment that has come to be known the country over as the Yale Plan on Alcoholism.
From these two seeds have emerged the present sturdy sprouts of public and community concern. The A.A. experience has created a growing awareness of the fact that alcoholics are not "weak-willed" or "immoral," but people who need and can respond to the proper kind of help. In a twelve-point program chiefly emphasizing insight, fellowship, work for others, and spiritual faith, A.A. has wrought miracles that no amount of pleading, threats, shame, cajolery or punishment has ever been able to effect. Simultaneously, the Yale Plan has brought to light scientific facts about a problem formerly regarded only with emotion, indifference, or disgust. Largely because the scientists at Yale have insisted upon putting their knowledge to use, communities and government agencies throughout the country are beginning to stir from their lethargic indifference to do something realistic about their alcoholics.
Already thirteen states have initiated programs concerned with alcoholism, while in fifty cities throughout the country voluntary committees are surveying the local problem and taking action to meet it. In addition, a number of municipalities, notably, New York, Washington, D.C., and Oakland, California, are beginning to recognize the fact that the jails are no answer to a public health problem and are experimenting with more effective types of treatment programs.
IN ITS FOURTEEN YEARS OF existence the Yale Plan has gradually enlarged its original test tube focus to embrace six main divisions: Research; Publications; the Yale Summer School on Alcoholic Studies; the Yale Plan Clinic; the National Committee for Education on Alcoholism; and the recently inaugurated Yale Institute of Alcoholic Studies in the Southwest. Each has a reach far beyond the academic setting where the Plan originated.
The Research Division conducts studies on the effects of alcohol on humans - moderate drinkers as well as inebriates. Currently it is attempting to find the physiological disturbances that scientists feel must accompany the psychological factors in alcoholism - a theory based on the observation that though the alcoholic can be converted to a total abstainer, he can never hope to be a moderate drinker no matter how well adjusted he becomes through psychiatric treatment or other means. Such knowledge, if attained, might not only bring about a revolution in treatment methods, but also a hope of prevention by making it possible to spot a potential alcoholic before he has ever taken a drink.
The Publications Division brings together the findings of scientific research on alcoholism and of medical psychiatric, social, and legal experience with alcoholics. Chief among its publication is The Quarterly Journal of Studies in Alcohol, the bible of the field.
In the realization that knowledge in an ivory tower can be of little help to the sinking alcoholic, his harried wife, or terrified children, the instigators of the Yale Plan determined to spread what they learned as quickly as possible to persons who could put the facts to most effective use. Accordingly in 1943 they inaugurated the Yale Summer School of Alcohol Studies, a four week course for persons professionally concerned with alcoholics or education on alcoholism - doctors, ministers, social workers, police chiefs, judges, teachers. The curriculum, which covers almost everything, that is known about alcohol and alcoholism, focuses on alcoholism as a disease and the alcoholic as a sick person who should be treated with kindness, sympathy, and firmness and without resentment or moral judgment. The role of education in prevention is equally stressed, with the emphasis on supplanting "folklore" with true facts - for example the common belief that alcohol is a stimulant with the fact that alcohol is a depressant, or the not unpopular assumption that drinking inevitably leads to alcoholism, with a clear definition between the moderate drinker and the addict.
Some 200 persons have registered at the summer school each year since its opening. In addition, so many others have indicated interest in the course that this year a similar summer school will be held at Trinity University, San Antonio, Texas, under the auspices of a newly organized Yale Institute of Alcoholic Studies in the Southwest jointly sponsored by Yale and Texas Christian University. The new project includes plans for research, a summer school and clinical facilities similar to the parent program at New Haven. It is under the direction of Dr. E.M. Jellinek, biometrician with the Yale Plan since the first expansion from its physiological beginning.
SCIENTIFIC FINDINGS ARE OF little use to the sick unless translated into treatment. The Yale Plan Clinic, with a staff of two psychiatrists, a physician, a psychologist, and two psychiatric caseworkers, opened in 1944 as a demonstration of an integrated approach to the rehabilitation of alcoholics. Far from an attempt to compete with New Haven's flourishing A.A. chapter, the clinic is an effective complement to the group.
In spite of the relative success of Alcoholics Anonymous a group fellowship program does not answer the needs of all alcoholics - nor even of all who want to be cured. In many persons alcoholism is merely a symptom of some deep disturbance of either a psychological or physical nature. Thus a brain tumor may have its first manifestations in excessive drinking; a psychotic of the manic depressive type may go on bouts in his depressed periods; a person with deep neurotic conflicts may find in alcohol his only release; or an "uncomplicated alcoholic" may cringe from the testimonial or religious facets of the A.A. program.
All these persons need diagnosis and individualized treatment. Only an operation will help the man with the brain tumor. The psychotic will need care in a mental hospital; the neurotic, deep psychotherapy; while the uncomplicated alcoholic may need less intensive psychiatric help in gaining insight into the nature of his affliction, along with some counseling and guidance in regard to employment, domestic troubles, or social interests.
Diagnosis was from the first a major concern of the Yale Plan Clinic, but experience soon demonstrated that if diagnosis was to have any meaning it would have to followed by therapy and guidance in cases needing treatment not provided by other community services. Since its opening the clinic has received 1,100 alcoholics, 60 per cent of whom have achieved either complete sobriety or markedly lengthened spacing between their drinking bouts. Referrals between the clinic and Alcoholics Anonymous are a commonplace, the clinic getting patients from A.A. and in turn recommending A.A. to persons who seem able to benefit from the fellowship program. Many persons are clinic patients and active A.A. members at the same time.
The Yale Plan Clinic was developed as a model for other communities as well as for experimental purposes. But neither Yale nor Alcoholics Anonymous pretended to be able to tackle the whole cast problem of alcoholism alone. No real dent is ever made in a public health problem until widespread understanding of its true nature develops.
For four years the National Committee for education on Alcoholism, an affiliate of the Yale Plan, has been trying to break down community ignorance and indifference, through field trips, consultation services, the provision of literature, and the promotion of institutes. The fifty communities which have setup local committees for education on alcoholism provide a measure of its success.
These committees are usually composed of persons of some influence in the community because of their social or professional standing, as well as of persons whose work brings them in close contact with alcoholics or their families - social workers, doctors, clergymen, judges, teachers, and members of Alcoholics Anonymous. As a rule, they begin shooting at three main goals: general public education on the problem and nature of alcoholism; the establishment of an information center where alcoholics, their relatives, and other interested persons can find out more about the disease and where to go for effective treatment; promotion or establishment of specialized clinics, hospital beds, and convalescent homes for alcoholics.
The local committees are in various stages of development. Though the oldest was created in Boston early in 1945, many of them only came into being in recent months, and are still in the organizational stage. Nineteen, however, are far enough along to be operating information centers as well as community education programs; and a few are offering direct rehabilitation services.
One of the more highly developed is the Western Pennsylvania Committee for education on Alcoholism, in Pittsburgh. Organized in 1945, this committee carries on a continuous educational program through a speaker's bureau, institutes, and the dissemination of literature, emphasizing the three points stressed by the national committee; alcoholism is a disease; the alcoholic can be helped; alcoholism is a public health problem. In addition, the committee operated an information center and diagnostic clinic, staffed by a psychiatrically oriented physician and the executive secretary, who is a trained social worker. The center cooperates closely not only with the A.A.'s, but with other community agencies serving alcoholics, particularly Morals Court. The committee has fortunately been spared a problem which looms heavily in other areas, the securing of hospital facilities for alcoholics, for Pittsburgh is one of the few communities where hospital beds are available to alcoholic patients.
How to get a person suffering from acute alcoholism into hospitals is an urgent problem in most communities. Acute alcoholism is often an extremely dangerous state which can be fatal if emergency medical treatment is not provided. The number of alcoholics found dead in their cells after being callously tossed into jail to "sleep it off" probably never will be tabulated, but anyone who has been around jails knows that this occurrence is not uncommon. Good hospital care in the sobering up period may also be crucial to rehabilitative efforts, since the mental and physical pain of the hangover is what frequently drives the alcoholic back to drink.
Few communities, however, have sufficient, if any, hospital beds available for alcoholics, a situation mainly due to the general hospital's disinterest in the alcoholic as a patient. While some municipally owned hospitals operate alcoholic wards, general hospitals more often than not refuse to have anything to do with the alcoholic patient except in extreme emergencies.
Because the lack of hospital facilities has long handicapped their work, many A.A. groups have exerted special efforts to persuade general hospitals to provide beds for such patients, but without much success. A notable exception is in New York City where the Knickerbocker Hospital has given over an entire wing to alcoholics and put admission into the hands of the A.A.'s. Every person admitted to Knickerbocker's wing for alcoholics is assigned an A.A. sponsor, who visits the patient every day during his five-day stay and is the only visitor allowed. Doctors, nurses, and the A.A. visitors urge the patient to a realization that hospital treatment is only the beginning of rehabilitation and must be followed through by the patient's own efforts if real recovery is to be achieved.
Generally frustrated in their attempts to secure hospital beds, A.A. chapters are welcoming such efforts on the part of local committees for education on alcoholism, in the hopes that these representative community groups may be able to achieve through prestige what the A.A. 's with no pressure group value, have found extremely difficult. A number of local committees already have experienced some success in this direction. Only one, however, the Youngstown (Ohio) Committee for Education on Alcoholism, has managed to secure an entire hospital for alcoholics, which it owns and operates itself. As in the case of the A.A. association with New York's Knickerbocker Hospital, this system makes it possible to screen patients carefully at the point of admission so that the beds are made available to those most in need of them. It also makes it possible to offer rehabilitative service at the time of convalescence when the patient is more apt to be in a receptive mood.
ALCOHOLISM IS CALLED THE FOURTH public health problem in the United States. As such it warrants attention from the public authorities as well as from voluntary groups. Recent actions of thirteen state legislatures in authorizing programs on alcoholism indicate that such attention may at last be forthcoming.
Most of the state programs are headed by legislatively created commissions with varying degrees of responsibility. Some commissions are charged only with providing educational programs. Others, responsible also for surveying the problem and establishing facilities to meet needs, are hamstrung by inadequate appropriations. However, a few have drawn up comprehensive plans for education, rehabilitation, and prevention.
Among the most ambitious state programs is that of the Connecticut Commission on Alcoholism, set up by the state legislature in 1945. With an income of about $200,000 a year, representing 9 percent of the state's revenues from liquor licenses, the commission plans to operate a network of out-patient clinics modeled on the Yale Plan Clinic, as well as hospitals and possibly convalescent hones for alcoholics. Already three of the clinics are in operation, and plans for opening a fifty-bed hospital in Hartford are nearly completed. The commission benefits considerably from consultation with the Yale Plan staff and has its chairman, Selden D, Bacon, staff sociologist at the Yale Laboratory of Applied Physiology. A joint undertaking with the Yale Plan Clinic involves special services and research among women alcoholics at the State Reformatory for Women.
Oregon is unique in having developed a rehabilitation program under the auspices of an advisory committee to the State Liquor Control Commission. Here, too, the funds come from liquor licenses, and bring $115,000 biennially to the state's outpatient alcoholic clinic located in Portland. Plans for expanding the clinic's services to other areas in the state are currently under consideration.
Washington, D.C., has two clinics operating under the Bureau of Mental Hygiene of the District's Health Department, and a third in the offing. The latter, authorized by a special act of congress in 1947, and to be financed by liquor license revenues, will cooperate closely with the District Courts. Under the proposed plan the courts will send men and women to the clinic on probation.
Most clinics for alcoholics have a voluntary arrangement with the courts in their communities. Apparently the judges, weary of sentencing endless lines of familiar drunks to ineffectual jail terms, welcome the opportunity to break the vicious cycle. Usually, however, they refer only those alcoholics who would seem amenable to treatment - newcomers to their courts or persons in whom the repeating pattern has not been long established. The 69-year-old woman who had 124 jail sentences in New Jersey would probably not be considered a good treatment prospect.
In Oakland, California, a court-devised plan for breaking the circle of spree-jail-spree leans heavily on the authority of the court. Its instigators were two probation officers - one a "graduate" of the Yale Summer School of Alcoholic Studies - who persuaded the county judge to let them take a try at rehabilitating police court alcoholics. Accordingly, the judge, who used to sentence the day's line-up of 60 to 100 drunks en masse, views each inebriate as an individual person and fits the "punishment" not to the crime, but to the man's or woman's potentialities for rehabilitation. Those he regards as capable of straightening out without benefit of institutional care he puts on probation, leaving to the probation officer the job of painstaking guidance or referral to other services. Others who obviously need the protection of an institutional setting he sends to the county farm.
The question of the compulsory treatment of alcoholics is still under debate, but opinion seems to be growing that the protection of society as well as of the victims of also holism demands a move in this direction. In New York State a bill drawn up by the State Bar Association, and already introduced in the legislature, would authorize a proposed Bureau for Alcoholics to establish state farms for alcoholics to which persons needing long term institutional treatment could be committed by the courts, either after arrest or at their own relatives request. The bill would not only provide needed treatment facilities, far superior to jails, but would make commitment long enough for rehabilitation to get a good start.
ONE OF THE MOST VIGOROUS opponents of compulsory treatment is a man who through his own experience has devised a unique method of rehabilitation which he tried out on others with considerable success. Edward J. McGoldrick, Jr., director of New York City's Bureau of Alcoholic Therapy, established within the Department of Welfare in 1943, is an individualist among alcoholic therapists for he also holds out against the theory that alcoholism is a disease. The method which he uses at Bridge House, the bureau's convalescent home for selected male alcoholics, is based on theories of will and thought control. Agreeing with the scientists that alcoholism has a "psychic" basis, Mr. McGoldrick has developed a system of personal interviews and group lectures intended to convert the alcoholic from a sense of defeat to a sense of power over himself.
All therapists at Bridge House are former alcoholics who have been rehabilitated through the McGoldrick method. Though the method differs from procedures of Alcoholics Anonymous, the director goes along with them in the theory that persons who have "hit bottom" as alcoholics themselves can more easily help other alcoholics.
Mr. McGoldrick objects to calling alcoholism a disease on the grounds that it adds to the alcoholic's sense of weakness and helplessness, thus giving him an excuse to go on drinking. He opposes compulsory treatment as useless, for it ignores the ingredient of positive willingness which he feels is necessary to reform.
Bridge House, with only twenty beds, serves about 350 alcoholics a year, both on a resident and a non-resident basis. Its record of success, using Mr. McGoldrick's measurement of one year of complete sobriety, is 66 percent - a good record but one not affecting some 200,000 alcoholics in New York City who do not reach Bridge House, nor any of the city's alcoholic women. It is, however, a project being watched throughout the country.
Industry as well as the public has a real stake in combating alcoholism, for alcoholic workers cause a tremendous waste. It has been estimated that the 1,370,000 alcoholic males employed in heavy industry lose an average of 22 days each year from the acute effects of alcohol. Moreover, the alcoholic has an accident rate twice as high as the non-alcoholic. On the basis of such statistics, the Yale Plan Clinic is offering industrial plants a service to help take up the fight against this menace. This involves a survey of the extent of the plant's problem, help in developing constructive personnel policies affecting the alcoholic, the introduction of an educational program and an information service for workers, and help in establishing rehabilitation facilities.
All the efforts so far initiated to help the alcoholic seem infinitesimal when viewed against the size of the problem. But it is encouraging to remember that fifteen years ago practically nothing at all effective was being done in this direction. The developments which have come in that short time mark an auspicious awakening to a long neglected responsibility.
Source: THE SURVEY©, Vol. 85, April 1949.