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September 1956

Why Psychiatrists Fail with Alcoholics

In a frank talk to his professional colleagues, one of the top practitioners in the field of alcoholism gives his answer to a baffling question. It also brings AAers up to date on a professional dilemma.

WHILE NO ONE is more convinced than I am that alcoholism is a disease, no one is more appalled than I am at the blithe manner with which the concept has been received and the easy use to which it has been put. To paraphrase Winston Churchill's famous war statement, I could say, "Never has so much been done on so little with so much hullabaloo."

I can say this quite frankly. I was in on the early hullabaloo and did a certain amount of it myself. I cannot help but feel that the whole field of alcoholism is 'way out on a limb which any minute will crack and drop us all in a frightful mess. I sometimes tremble to think of how little we have to back up our claims.

Yet actually I would not have it otherwise nor do I think it could have happened differently. All movements get under way through some one or some group taking a chance. That has to be. The only danger comes from failure, later on, to see things in perspective. We should never be fooled by our own ballyhoo into any false sense about our accomplishments. The need to do something about alcoholism is admitted; the main question concerns the tools we have available to carve out satisfactory results. To me they still, seem pretty crude and makeshift.

This fact, while it is to be deplored, cannot be used to condemn. It is an outgrowth of forces over which we as a group had little or no control. The field, like Topsy, just "growed." First it was the Research Council, then it was the people at Yale and the mighty impetus of Alcoholics Anonymous. Finally it was the organizational and educational work of the National Committee on Alcoholism. The question now is what do we face,--those of us who are actively engaged in meeting the problem?

Have we not almost promised to do a job with very little real right to say anything more than "we'll try"? Have enough of our energies been devoted to helping us get down off that limb--toward establishing a reliable body of data and experience which will enable us to develop competent practitioners in the field of alcoholism? I very much doubt it.

There are undoubtedly many reasons for this failure to establish reliable information about alcoholism. One, however, strikes me as of great importance because it is subtle and not generally recognized: the fact that persons who enter the field of alcoholism come from other fields. More than they realize, they are bringing something to the field and have little expectation of learning anything from the field, nor do they feel any particular need to do this. They have already been taught; now they will apply what they know. It does not take them long to realize that what they know does not amount to much when it comes to handling alcoholics.

Two reactions are then possible. The individual either changes and begins to function or he remains rigid and becomes discouraged, disillusioned, and skeptical about the prospects of working with the alcoholic. The unfortunate truth is that, as far as psychiatrists are concerned, a sizable majority never quite make the grade. They always seem like fish out of water.

Naturally I have given thought to this new phenomenon. My explanation lies in the point of view they bring with them. They come equipped with training and they busily engage themselves in trying to utilize their equipment. Rarely does it function well in the field of alcoholism. The question is: "Why, when that same equipment serves well in other areas, does it fail them with alcoholics?"

I think this is an important question. One reason for the lack of specific knowledge about alcoholism is the dearth of clinicians who remain in the field long enough to obtain any feel for the condition. They seldom get beyond the dabbling stage and are in no position to add to our knowledge. In the summary of the research meeting held in October 1954, Diethelm[1] stated that most investigators in alcoholism reported once and then quit, confirming my own observations. We must ask the question, "What happens to produce this repeated development?"

This question and its predecessor, "Why does the well-equipped psychiatrist fail with alcoholics?" can, I believe, be answered by the same reply. Before trying to formulate an answer, let me set the stage with some background material. The present day psychiatrist is steeped in the methods of modern medicine. Whenever you encounter illness, you search for the cause, then you treat the cause and cure the illness. That is just as true for psychiatric ailments as it is for physical conditions. Treatment is directed toward etiology.

When a person so oriented hits alcoholism, he is out of luck--only he does not know it. What happens is that he by-passes the disease and looks for causes; he ends up talking about earlier experiences and never gets close to this patient or the illness. His training is a hindrance instead of a help. He must revamp his sights or he is lost.

At a meeting last winter, a psychiatrist thoroughly trained in the modern approach read a paper in which he outlined some of the thinking which he had to scrap before he could operate comfortably with alcoholic patients. He stressed mostly the need to give up history-taking and deep search for causes, particularly at the start of any therapeutic relationship. During the discussion which followed, he was chided by a more orthodox colleague who was a bit horror-struck at the heresy about history taking. The reply of the reader of the paper was in my eyes perfect. He said in part, "I used to think a full history was necessary but I found it didn't work; I had to change my mind." Needless to say this person is continuing in the field of alcoholism and I believe will be heard from again. He did not adhere rigidly to his training precepts; he really accepted reality and to that extent was more effective. Unfortunately, there are not many of his kind.

What happened, of course, was that he shifted his sights and looked at the illness alcoholism, which he was finding could not be treated by the conventional approach he had learned. He had to formulate a new approach. How he did that I cannot tell you. I can tell you, however, about how I have modified my own thinking in the light of experiences similar to those of the man I have been talking about.

Perhaps the first thing to impress me with the need to change my approach was the routine complaint from patients that their talks with psychiatrists were almost uniformly unhelpful. This was in the earlier days. The complaint was that the psychiatrists never talked about the drinking and seemed to minimize its importance, which was duck soup for the alcoholic, but, in the long run, not very effective. The routine history-taking approach seemed to have many strikes against it.

Then secondly, AA came along with a program to stop drinking; causation was ignored, the focus was all on treatment. Medicine's insistence on treating causes was disregarded, not wittingly to be sure, but the emphasis was on stopping the drinking and helping the individual to achieve and maintain that end. Like the treatment by surgery, the causes were irrelevant in meeting the immediate issues. Instead of the scalpel, there was the AA program. Instead of the infected appendix being removed, the individual was told to stop drinking, or stated in another way, liquor was removed from his life.

In the old days, patients were given remedies such as digitalis to help correct or overcome the symptom, namely, the weakened heart muscle. Remedial treatment nowadays tends to be downgraded as temporizing and superficial. It lacks precision and seems a blunderbuss method. Yet no one is willing to discard digitalis and no one that I know of is going to urge the scrapping of AA. They both work, they both preserve life, and though neither cures, both provide for the prolongation of life and thus add years of satisfying existence. For people so benefited, interest in causation is academic. The clinician may wish he knew more about causes but he is grateful for the fact that he has a remedy. And almost always he wishes he had more of them.

Similarly, any treatment of the alcoholic must be remedial. There is no present value in getting at the causes and correcting them because the net result of such an endeavor would be to enable the person to drink normally. While such a goal may be achieved in some far off millennium, its attainment in the immediate future is absolutely unlikely. Any therapy devoted to such a goal is admittedly unrealistic; everyone acknowledges that there is no present cure, that the only remedy is total sobriety. The person does not learn how to handle liquor, he stops using it.

The goal of therapy is, therefore, to get the patient to stop taking the first drink. I have found it fruitful to work along the line of why the patient will not or cannot stop taking that first drink. It has led to the concepts of hitting bottom, (adopted, of course, from AA) surrender, compliance, and recognition of an intractable ego which will not stop for anyone or anything. And strangely enough, in trying to apply the remedy of stopping drinking, I have learned morn about the alcoholic and his problem than I ever did when I was concentrating on causes and minimizing all remedial efforts.

Once I concentrated on trying to stop the drinking, I began to focus on the illness itself which took on more and more stature as a disease. Finally, I was willing to set aside my previous experience and center attention upon what was going on that was ill or sick. The clinical situation held my nose to the grindstone and it was from the clinical situation I learned about alcoholism. And I know that as soon as I divorce myself from the clinical situation my source of learning will be gone.

Now is not the time to talk about the remedies we have available. You know them as well as I do. The real problem is to get the individual to take those remedies. Unless one is practiced in handling the various dodges or stratagems of the alcoholic, one gets nowhere. Defense reactions are found in every psychological illness. The alcoholic has the same defenses as others plus a sturdy crop of his own, arising from the special nature of his ailment. Until the practitioner develops some dexterity in penetrating the wall surrounding the alcoholic, he can anticipate little progress.

Articles on how to establish contact with the alcoholic in order to get him to accept possible remedies are scarcer than hen's teeth. Should there be pressure or not is an everyday issue. Do we have any consensus of opinion? What has experience taught? Too often the voice of the clinician is muted because all he can offer is his own experience which seems pretty feeble compared with the authoritative voice of statistics. Yet all the statistics in the world will never provide one with clinical judgment nor aid one in the practice of one's trade or profession.

In the field of alcoholism, we need more people who will report their experiences as practitioners so that gradually a body of accepted practice can slowly be acquired. The knowledge of that practice and the ability to apply it will enable the individual to be expert in the field. Not until he has that knowledge can he be called expert, no matter how thoroughly trained he may be in the same allied field.

We can now answer the question raised previously, namely, "Why do psychiatrists fail so frequently with alcoholics?" The answer is that they fail to adopt a remedial approach and consequently are pretty much strangled as therapists. Not until they know that they are tackling a disease which must be treated for itself can they hope to be effective.

My plea, of course, is for more serious study of the illness alcoholism. My interest is not so much in causation as in the recognition of a disease which must be treated by remedial measures. My hope is that as the focus is kept on the disease, the practice of handling the disease will receive even greater study and consideration. I believe that only in that way will the field be able to climb off the limb it now occupies and reach solid ground where it can meet its obligations with some degree of consistency.

We must stop borrowing from other disciplines and develop our own body of knowledge and experience.

1*DIETHELM, OSKAR, M.D.: Current Research on Problems of Alcoholism. 6. Report of the Section on Psychiatric Research. Quart. J. Stud. Alcohol 16: 574, 1955.

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