Chapter 2: What Are the Causes of Alcoholism?
Both the ethical and the therapeutic approaches to the problem of alcoholism must be based on an understanding of alcohol, drinking, and the physiology and psychology of the human being. Many of those who attempt to control alcoholism are like those who attempted to control lightning without knowledge of electricity.
-- Selden D. Bacon, lecturing at the Yale Summer School of Alcohol Studies, 1948
An acquaintance with the facts concerning the causes of alcoholism is a prerequisite to any effective preventive or therapeutic action. Careful examination of the findings of the sciences is important in dealing with any social problem. It is especially so in an area so befogged by misinformation as the one under consideration.
What are the causes of alcoholism? Nobody knows in any complete or final sense. Alcoholism is, at least to a degree, a "cryptogenic" disease -- a disease of which the basic roots or cause are hidden. A great deal is known, however. It behooves us to take advantage of the available knowledge to form a working hypothesis for dealing realistically with the problem. At the same time, a spirit of tentativeness is indicated since tomorrow’s findings may easily render today’s conceptions obsolete.
At the present stage of research it is impossible to point to any single or simple cause of alcoholism. On the contrary, the research findings indicate forcefully that alcoholism is a complex disease in which a variety of factors play a role. The late Carney Landis, from the perspective of a research psychologist, wrote: "If there is any human disorder which can be truly said to be of multiple etiology, it is alcoholism in all its diverse forms." 1. The following types of causative factors seem to be involved in alcoholism: physiological, psychological, cultural, philosophical, and religious. While all of these factors will not operate equally on every level, a combination of one or more will be found at work on each of three levels: (1) factors which make one vulnerable to alcoholism; (2) factors which determine the selection of alcoholism as a symptom, as over against all the other types of psychopathological symptoms; and (3) factors which cause alcoholism to be self-perpetuating once it has reached a certain point. The last of these levels is particularly important because it will deal with the problem of why the alcoholic is usually unable to accept help early in the development of his sickness.
Level One: The "Soil of Addiction"
Fundamentally, the alcoholic is not sick because he drinks but . . . he drinks because he is sick, and then becomes doubly sick. -- Carroll A. Wise 2.
Why is it that of the eighty million people in our country who use alcohol, at least seventy-four million do not become alcoholics? This question leads inevitably to the search for some Achilles’ heel which renders 6 percent of drinkers vulnerable to alcoholism. Inasmuch as 94 percent do not become addicted, alcoholism cannot be considered simply a property of alcohol. There must, therefore, be some "soil of addiction" which is receptive to the seeds of the problem.
There are those who would deny that any special soil of addiction is necessary. One writer quotes Robert Fleming as saying, "Any normal human being can get caught in the vicious downward spiral of alcohol addiction, if he drinks enough liquor over a long enough period of time." 3. This point of view, which regards alcohol as the basic cause of alcoholism, was reflected in the thinking of the alcoholic who said, "The only reason I know why I became an alcoholic was that I drank too damn much whiskey." It should be empha sized that this view is shared by only a small minority.
According to this school of thought the process by which one becomes an alcoholic is simple and direct. A person begins to drink in compliance with social pressures. One drink leads to two, two to three, etc. Each occasion leads to another of increasing intensity as one comes under the sway of the "habit-forming properties" of alcohol. The reason why the 94 percent of drinkers have not become alcoholics is that they haven’t been at it long enough.
This conception of the etiology of alcoholism is descriptive of what happens in the case of some drinkers, namely alcoholics. It is descriptive, but not explanatory. It falls into an oversimplification which leads to the fallacious identification of one factor as the sole cause of alcoholism. It does not answer the question posed by this illustration, given by Dwight Anderson. Stephen Foster died, as we have described, at the age of thirty-eight. His appearance was that of an old man. His life was burned out by alcoholism. In contrast, his contemporary, Dan Emmett, author of "Dixie," drank a limited amount
nearly every day of his adult life and lived, still drinking, to the age of eighty. four. Both musicians were amply exposed to the "habit forming properties" of alcohol. Why is it that Emmett drank all his life without becoming addicted, whereas alcoholism had ravaged Foster’s life at thirty-eight?
The cogency of the belief that alcoholism is the simple result of drinking alcohol is even more seriously challenged by certain sub-cultural studies. In a nationwide survey sponsored by the State University of Iowa 4. it was found that by religious groups abstinence is practiced as follows:
Roman Catholic 11
If alcohol were the primary cause of alcoholism, the Jewish group could be expected to have a high rate, since 90 percent of American Jews drink. The striking fact is that the Jewish rate is much lower than that of any other religious or ethnic group in the country, with the one exception of Americans of Chinese descent. Sociologist Charles R. Snyder summarizes the matter:
In terms of percentages, there are probably more users of alcoholic beverages in the Jewish group than in any other major religio-ethnic group in America. Yet as has been shown repeatedly both in this country and abroad, rates of alcoholism and other drinking pathologies for Jews are very low.5.
Do drinkers become addicted merely by acquiring the habit, with no preliminary pathology (i.e., soil of addiction)? What do the scientists who have studied the problem most intensively have to say? The late E. M. Jellinek, pioneer in alcoholism research at Yale University and later with the World Health Organization, once stated:
Repetition alone won’t produce addiction. It only comes when there is a motive for repeating. Alcohol is not habit-forming in the sense that a drug like morphine is. Rather than calling alcohol a habit-forming drug, it is more accurate
• to say that it is a substance that lends itself to those who form compulsive habits easily. The alcoholic reaction’ is atypical, not universal. It is the reaction of a minority of people, not a property of alcohol. 6.
Jellinek’s observation that alcohol lends itself to those who form compulsive habits easily suggests that alcohol has certain pharmacological properties which render its use hazardous to those with addiction-prone personalities. It is noteworthy that in 1955 the World Health Organization Committee on Alcohol and Alcoholism designated alcohol as a drug intermediate (in kind and degree) between "habit-forming drugs" and "addiction-producing drugs."
In a more recent statement by a WHO committee, the distinction between habituating and addictive drugs was superceded by one term -- "drugs dependence." Alcoholism is one of numerous forms of drug dependence.
Even if we accept the fact that pharmacologically alcohol has certain properties which tend to induce dependence, we must still explain why only certain people become dependent, habituated, or addicted. The weight of evidence, then, seems to he on the side of those who hold to the view expressed by Carroll A. Wise, of Garrett Theological Seminary "The belief that the excessive use of alcohol is simply a matter of habit is no longer scientifically tenable." 7.
Two kinds of cases tend to confuse the issue regarding the existence of a soil of addiction. One is the sudden onset of addictive drinking after years of social drinking. The case of Mary P, cited in Chapter 1, comes to mind. Another is the case of Mrs. Sandra R. For twenty years she drank socially. Alcohol posed no special problem for her. Then the news came that her oldest son had been killed. Immediately her drinking became pathological. Long months after the first awful pain of grief had passed, she continued to shut herself in her room with her bottle. To the casual observer Mrs. R.’s addictive drinking was caused by the trauma. This explanation, however, is incomplete in that it ignores the thousands of other mothers who were social drinkers, lost sons, and did not become alcoholics. In such cases one must always distinguish between the precipitating crisis and the basic cause.
The second type of confusing case is that represented by Oliver M., who in the midst of a successful business career begins to drink addictively. Oliver is known to his friends to be, as one of them put it, "as normal as the next guy." His load of responsibilities and worries is apparently no heavier than that of his nonalcoholic neighbors. Only by looking behind the scenes of Oliver’s life can one make any sense out of his strange behavior. Here one discovers two factors that are important: (1) the ability of the psychic organism to carry a terrific load of inner conflicts over long periods of time and yet to present an adjustment to the world (and even to one’s conscious Self) that hides the inner chaos; (2) the discrepancy between our culture’s definition of "success" and "normal" -- which in our "Babbitt" culture is often a sort of standardized neurosis -- and real integrated emotional health. Henry David Thoreau was probably thinking of the "successful" farmers of Concord when he observed, "The mass of men lead lives of quiet desperation." 8. Often one’s desperation is so quiet that even the person himself is aware of Only a vague, nameless restlessness. If one bears this in mind, then ft is valid to say that "normal" people can become alcoholics. However, it is well to remember the opinion expressed by Giorgio Lolli, former medical director of the Yale Plan Clinic for Alcoholics, who states: "There is practically no case of alcohol addiction isolated from other neurotic disorders and bodily illnesses." 9.
In other words, the evidence seems to point to the fact that alcoholism comes in people, not in bottles. We must look within people for the under lying causes. The scientists who have been doing this may be divided into two schools of thought: those who emphasize the physiological factors in the soil of addiction and those who emphasize the socio-psychological.
Let us examine the evidence for a physiological soil of addiction. The idea that the alcoholic is "allergic" to alcohol was suggested by William Silkworth in 1937 and has since been given wide distribution by the literature and members of AA. E. M. Jellinek stated that a definitive experimental study in 1952 "entirely refuted the allergy hypothesis." 10. Although the alcoholic is not allergic to alcohol in the literal, medical sense (comparable to an allergy to ragweed pollen, for example), he certainly has a "psychological allergy" to alcohol in that he cannot use it without disastrous results. Thus, the figurative use of "alcoholism is an allergy," in counseling and in AA Twelfth Step work, is a useful way of briefing the alcoholic on his condition.
The often-used analogy between diabetes and alcoholism, although useful in counseling, is not based on a strict physiological comparability. In diabetes, pancreatic dysfunction interferes with the metabolism of sugar, producing "a physiologically noxious accumulation of sugar in the organism." 11. According to Jellinek, there is no evidence that the metabolism of alcohol is impaired in the alcoholic, neither the absorption nor the oxidation of alcohol being different in addictive and small users. 12.
Two major physiological hypotheses -- the endocrinological and the nutri tional -- have been advanced by scientists in the alcoholism field. James J. Smith, representing the endocrinological view, reports on research done at Bellevue Medical Center in New York City. "Our laboratory and clinical studies of alcoholics during the past several years have convinced us that alcoholism is a metabolic disease." 13. Studies at Bellevue have shown that disturbances or deficiencies of the pituitary-adrenal-gonadal triad of endocrine glands are present in many alcoholics. Addressing the New York State Medical Society, Smith said: "These observations led us to explore the possibility that the alcoholic’s problem was caused by disturbance of bodily chemistry." 14. This exploration apparently led Smith and his co-workers to the conviction that the alcoholic suffers from an abnormal endocrine system which predisposes him to alcoholism.
Leopold E. Wexberg, director of the Alcoholics Rehabilitation Program, District of Columbia, gives us this critique of Smith’s theory:
Smith emphatically states his conviction that alcoholism is a metabolic disease. No one familiar with the signs and symptoms . . . can challenge this statement. . . It is an entirely different matter, however, to believe -- as Smith apparently does -- that . . . the alcoholic possesses a metabolic individuality which predisposes to addiction. Nowhere in Smith’s article, and nowhere else in the literature, to our knowledge, have facts been brought out to support this theory." 15.
Wexberg goes on to point out that the pathological changes in metabolic and endocrine systems that are fairly common among alcoholics may be the result of years of excess, rather than the cause. This is the point at which the disagreement between the physiological and psychological school focuses.
Closely related to the physiological explanation of alcoholism is the question of heredity. Investigators have long been impressed by the fact that alcoholisni has a much higher incidence in some families than in others. Of the 79 alcoholics interviewed by the author, 50 reported having alcoholics on their family tree. Twenty-seven reported alcoholic parents. Jellinek combined a number of studies embracing a total of 4,372 alcoholics and found that 52 percent had an alcoholic parent. The normal expectancy of alcoholism among children of alcoholics is between 20 and 30 percent as contrasted with an expectancy of approximately 4 percent for the adult population at large.
What is the explanation for this? R. J. Williams’ "genetotrophic" theory of alcoholic etiology holds that certain individuals have inherited metabolic patterns which result in nutritional deficiencies which give rise to a craving for alcohol. Studies with white rats have shown, according to Williams, that some inbred strains have a consistently greater preference for spiked milk than do other strains. Other competent researchers have pointed to certain weak nesses in these experiments. So the question cannot be settled at the present stage of our knowledge.
[Based on his nutritional-deficiency theory, Williams has developed a form of therapy based on a balanced diet plus special high-vitamin supplementary nutrients. No one would question ,the need of many alcoholics for vitamin therapy and good diet. That the Williams' approach constitutes an adequate therapy for most alcoholics, however, is rejected by the vast majority of therapists. (For a critical review of the various physiological theories of alcoholism, see E. M. Jellinek The Disease Concept of Alcoholism, pp. 82-115. A description of Williams’ approach is found in his book, Alcoholism, the Nutritional Approach.] 16.
More important for our purposes is a study by Anne Roe of a group of 36 children of alcoholic parents who were separated from their parents and reared by nonalcoholic foster parents. At the time of the study they had reached the age of 21 or over. A control group of children born of normal parents but also raised in foster homes was used for comparison. Roe summarizes her findings:
As regards their present adjustment, there are no significant differences be tween the groups, and there are as many seriously maladjusted among the normal parentage group as there are among the alcoholic-parentage group.. . . The children of alcoholic parentage. . . cannot be said to have turned out as expected on the basis of any hypothesis of hereditary taint. 17. "
She points out that none of the children of alcoholic parents is alcoholic and that only three use alcohol regularly. The fact that so few use alcohol now and, more important, that most of them have established adequate personal lives would seem to give good reason to expect that few, if any, would become alcoholics.
In the light of this study, it is simply not justified to consign the problem of alcoholism to the category of heredity, with somber implications of hopelessness. The transmission of alcoholism from parents to child would seem to be a question of social rather than biological heredity. In fact, the emotionally insecure atmosphere of an alcoholic home tends to produce a high rate of all forms of social pathology. In the case of the approximately 8 per cent of inebriates who are mental defectives, heredity plays an important role. Its role is not in the transmission of inebriate tendencies, but of the mental inadequacy of which the drinking is purely symptomatic.
Having granted that the existence of a physiological soil of addiction is still a moot question, let us turn to the evidence for a psychosocial vulnerability to alcoholism. This view holds that the alcoholic is emotionally sick even be fore he begins to drink; he is vulnerable because he possesses a damaged personality. To use Carroll Wise’s words again, "He drinks because he is sick and then becomes doubly sick." His drinking is a symptom of his inner problems.
What evidence is there that alcoholics were psychologically inadequate before they began to use alcohol? Here the author’s interview material will be useful. This material throws light on the characteristics of the parents and the childhood of the alcoholics, thus allowing us to delve back into the period before they began to drink.
Let us begin with the recognition that children have certain basic psycho logical needs or hungers analogous to their nutritional needs. To the extent that these needs are satisfied in the home, the child’s personality grows strong and healthy in its ability to live a satisfying life in relation to others. To the extent that emotional. malnutrition exists, personality stunting, immaturity, and interpersonal inadequacy result.
As is true in the case of physical nutrition, deprivation of adequate emo tional food is the most damaging in the earliest years of life, when growth is the most rapid and personality the most plastic. Many psychologists believe that the foundations of subsequent health or illness are laid during the first few years of life. This general point of view concerning psychic needs of hungers is widely accepted by social scientists. Dorothy Walter Baruch gives us an excellent discussion of the nature of these needs in her outstanding book on rearing emotionally healthy children entitled New Ways in Discipline, You and Your Child Today:
What are the emotional foods that every human being must have regardless of age? What are the basic emotional requirements that must come to every small infant, to every growing child, to every adult?
In the first place, there must be affection and a lot of it. Real down-to-earth, sincere loving. The kind that carries conviction through body-warmth, through touch, through the good, mellow ring of the voice, through the fond look that says as clearly as words, "I love you because you are you."
Closely allied with being loved should come the sure knowledge of belonging, of being wanted, the glow of knowing oneself to be a part of some bigger whole. Our town, our school, our work, our family -- all bring the sound of togetherness, of being united with others, not isolated or alone.
Every human being needs also to have the nourishment of pleasure that comes through the senses. Color, balanced form and beauty to meet the eye, harmonious sounds to meet the ear. The hearty enjoyment of touch and taste and smell. And finally, the realization that the pleasurable sensations of sex can be right and fine and a part of the spirit as well as of the body.
Everyone must feel that he is capable of achievement. He needs to develop the ultimate conviction, strong within him, that he can do things, that he is adequate to meet life’s demands. He needs also the satisfaction of knowing that he can gain from others recognition for what he does.
And most important, each and every one of us must have acceptance and under. standing. We need desperately to be able to share our thoughts and feelings with some one person, or several, who really understands. - . . We yearn for the deep relief of knowing that we can be ourselves with honest freedom, secure in knowledge that says, "This person is with me. He accepts how I feel!" 18.
The interviews showed that of the seventy-six parental constellations 19 described by the interviewees, seventy-one showed the presence in a marked degree of those attitudes and practices on the part of the parents which tend to deprive children of the adequate satisfaction of these basic emotional needs! Of these seventy-one inadequate homes, forty-four were obviously so; the remaining twenty-seven showed fewer or better disguised inadequacies, and would probably be described by the casual observer as "normal" homes. In five of the seventy-six homes, no apparent inadequacy was found.
Among the inadequate homes were found twenty-seven cases of parental alcoholism, producing twenty-one home situations in which unity was seriously disturbed or nonexistent. Twenty-three other alcoholics reported broken homes -- divorce, "emotional divorce" (i.e., constant strife), or the death of a parent when the child was under eighteen. In other words, 57 percent of the alcoholics came from broken homes. In addition, four alcoholics reported psychotic parents. In one case the father was an alcoholic and the mother a drug addict.
Even if one makes generous allowances, as one must do, for distortions in the data due to emotional blind-spots in the interviewees, the striking impression is still intact: Generally speaking, these alcoholics came from disturbed and inadequate homes! What is important here is not the percentages them selves, but the general evidence which is supported by them that many alcoholics come from such homes.
The homes of the alcoholics showed four main types of parental attitudes and behavior which make for the traumatization and emotional deprivation of a child’s personality: authoritarianism, success-worship, moralism, and overt rejection. As we shall see, the first three types actually amount to covert rejection of the child’s basic needs.
The most frequent parental characteristic was what psychoanalyst Erich Fromm has described as "irrational authoritarianism." This is the kind of authority that is based not on competence but solely on superior power. Fifty-six of the alcoholics, or 72 percent, described this in one or both parents.
In the father this most often took the direct "Papa is all" form. In the mothers it took the more indirect form of dominance through overprotection, the benevolent matriarch type. A frequent pattern was that in which the male child of a stern father formed an unhealthy indentification with an overprotective mother. Authoritarianism denies fulfillment of the child’s need for unqualified love by making acceptance contingent on obedience. It denies the fulfillment of the need for gradually increasing autonomy by making him a puppet of the parents. Severe inferiority feelings are the result.
In some cases the descriptions of parental authoritarianism gave evidence of sadism and emotional rejection. Here are some samples from interviews with male alcoholics:
Tom R. recalled: "Father had a killing temper . . . practically killed me when he got mad. I didn’t know him very well - . . didn’t like him. - . . I lost interest in things early in life."
Frank P. said concerning his father: "My Dad was a big shot in town. I was just someone who happened to come along. There was fear of the head of the house . . - strict discipline . . - he hit us with his big mit."
Just as the authoritarian parent makes love contingent on obedience, the success-worshiping parent makes it contingent on the child’s ability to feed the parental ego by his success. The presence of this factor among the parents of the alcoholics was exceeded in frequency only by authoritarianism. Of the seventy-seven who provided data, thirty-three reported homes in which success-worship was a prominent factor. This took various forms -- excessive ambition for the child in terms of financial success, position, and educational attainment were all common. It is interesting that only four of the thirty-three were females. This points to the fact that the cult of success exerts greater pressure on boys in our culture than on girls. The cultural expectations for girls are in a different direction.
Success-worship deprives the child of his need for self-direction. It saddles him with parent-chosen goals which are usually impossibly perfectionistic (since they are derived from the parents’ own frustrations) and completely out of touch with the realities of the child’s abilities and inclinations. A child soon internalizes his parents’ excessive goals and becomes his own slavedriver.
The case of alcoholic Frederick N., age fifty-four, illustrates the effects of a combination of authoritarian overprotection and success-worship:
Fred describes his parents in glowing terms. "My father was a very successful banker, a Phi Beta Kappa in college. He often called my attention to how successful my grandfather had been. I was closer to him than my mother. She was a very unusual person -- widely traveled and cosmopolitan. She was the family disciplinarian, but there were few spankings because I was a good boy. I was taught that I was better than other folks."
Concerning his childhood he says: "I was an only child and the only link in both sides of the family chain. Consequently I was closely guarded. . . . My parents wanted me to win scholarships and study to become a great doctor. I was the prime disappointment of their lives. Goals and standards were set for me. They made all the decisions. I lost heart very early because I couldn’t measure up. Every thing became distasteful to me. I did only what was necessary."
Fred began to drink at the age of twelve with a group of boys. His parents got him out of repeated jams in college resulting from his drinking. Finally he dropped out of college because of his drinking and got a job in a mill. This was a crushing blow to his parents’ dreams. Twenty years of periodic binges followed. Of his drinking he says, "My deep inadequacy was lost in alcohol. I could feel I was any body when I was drinking."
In retrospect, as a result of insight gained from psychiatric help, Fred says, "Had I grown up differently and had been allowed to find my own level, I wouldn’t have had the terrific sense of disappointment as early as twenty-one. No matter what I did it was so far short of what they had in mind for me, it didn’t seem like an achievement."
Moralism is the word used to describe the behavior of the parent who Unwittingly projects puritanical attitudes onto the child. Moralism results in strong feelings of guilt and inhibition concerning bodily drives and hostile feelings. As a result the chi]d grows up emotionally handicapped in the areas of sex and normal aggression. A parent who is compulsively "moral" because of guilt feelings will project impossibly perfectionistic standards on the child. The child will feel that he must earn the all-important love of the parent by being a "good" child. Since the standards of parental expectation are perfectionistic, the child can never really feel accepted. He can, therefore, never accept such vital areas of himself as his bodily drives and normal negative feelings.
Twenty-nine of the seventy-seven alcoholics mentioned strong traits of puritanism in describing their parents. Roger L., age thirty-eight, one year of college, illustrates the destructive effects of puritanism, success-worship, and overt authoritarianism:
Roger says: "My father was very stern. I was deathly afraid of him. If I did something that was wrong, he wouldn’t talk to me, just beat me. My mother was very much like my father -- I never got much love from her. She had a feeling that she shouldn’t get too close to me. She was a very righteous person, very moral. My terrific standards come from this, I think."
Concerning his childhood, Roger recalls: "I was shy and aloof, never comfortable with people. I was very weak and never wanted to fight with other boys. My father beat me for walking away from fights. He beat me for petty stealing. Never praised me. Would say, ‘Why can’t you be like other boys?’ I had three sisters and one brother. I was the black sheep -- very dull in school -- deathly afraid of reciting. I was beaten for not being a good student. I took a business course in college because my father wanted me to follow him; I really wanted to be a surgeon -- a great sur geon. Always wanted to be something great."
Both Roger’s parents were adamantly against alcohol. He began to drink at eighteen and got drunk the first time he drank. He dropped out of college because of drinking. He says, "I had no period of social drinking. It was no fun. I used it to escape from my problems from the beginning." Roger worked for a time as a salesman. "I drank to sell. Couldn’t sell anything without alcohol in me -- afraid of people in general -- never able to hold a job for long because of my drinking." After a discharge without honor from the army because of drinking, Roger lived on various Skid Rows for several years. Just prior to his discharge he had married a woman seven years older than himself. He says, "I was looking for the maternal care I had missed." Roger’s guilt about sexual matters proved too strong, and they were divorced after six months. Although he has been sober for three years in AA, Roger still can’t forgive himself for sexual deviations during his drinking. The suc cess worship and puritanism of his parents are still reflected in statements such as:
"I push myself entirely too much -- makes me unhappy. I condemn myself when I do wrong, feel I’m cutting myself off from God. My standards are too high. Always concerned about whether I’m doing right. If I can’t be almost perfect I don’t expect anything good to happen to me."
Roger’s parents rejected him by their crude authoritarianism, moralism, and success-worship. In many of the cases of those interviewed, the parental errors were not so obvious. In others, the rejection was even more overt.
Up to this point we have been discussing inadequacies in the parents of the alcoholics. Is there concrete evidence that these inadequacies actually affected the alcoholics adversely? Is there evidence of serious maladjustment in the childhood and adolescence of the alcoholics, even before they began drinking? Here again, the impression is striking. Of the seventy-seven cases in which this kind of data was available, only ten were lacking in evidence of a disturbed childhood. Behavior difficulties, evidences of low self-esteem, and unhappy memories of childhood were a constant refrain in the interviews. Here are some sample recollections from the interviews with five different male Alcoholics: "I was three years behind in school -- life a hell on earth, no kid’s life." "I had few playmates. There was no love in our home. My big desire was to get away." "I lived in a shell as a kid, felt different and confused." "I was alone as a boy. I was left-handed, and my father forced me to use my right. I stuttered terribly, and the nuns made fun of me." "I never got along with people."
Low self-esteem during childhood was indicated by the following: A total of fifty-four of the interviewees said, in effect, that they had "inferiority complexes," were "very shy," or felt "lonely." This is approximately 70 percent of the total number interviewed. These samples give the tone of the recollections. One said, "I was shy, fearful -- had nightmares of a big snake." Another recalled, "I was timid as far back as I can remember -- thought of myself as ‘nasty self.’ Always expected to fail." A third put it this way, "I had no close friends -- felt alone and inferior. Never had any self-confidence."
The weight of evidence seems to be that a high percentage of alcoholics are emotionally disturbed even before they begin drinking. The soil of addiction is prepared by the inadequacies of their lives. Numerous psychological tests have shown that, although many alcoholics are able to function with remarkable social adequacy when they are not drinking, they make their social adjustment in spite of their inner conflicts. In the case of those who do not adjust well, the effect of the inner conflicts is quite obvious. These inner conflicts, which are a carry-over from unsatisfactory childhoods, constitute an essential part of the soil of addiction.
A knowledge of the psychological problems and attributes which are typical of many alcoholics can be of tremendous practical importance to anyone who wishes to help them. The following have been mentioned repeatedly in reports of psychological studies of alcoholics: (1) a high level of anxiety in inter personal relationships, (2) emotional immaturity, (3) ambivalence toward authority, (4) low frustration tolerance, (5) grandiosity, (6) low self-esteem, (7) feelings of isolation, (8) perfectionism, (9) guilt, (10) compulsiveness. These psychological attributes are often present in enlarged proportions when the person is in the nightmare of active alcoholism. That they are not entirely the result of prolonged excessive drinking is indicated by the fact that the attributes are present in many alcoholics before they begin excessive drinking and persist in diminished form long after sobriety has been achieved.
Many of the alcoholics interviewed gave evidence of continuing inner conflict and anxiety. About half mentioned depression and mood swings as being Severe enough to bother them. Thirty-five described themselves as "the nervous type" (or some equivalent term). Twenty-six complained of chronic insomnia and fatigue. Twenty spoke of "nervous stomach," including nine cases of ulcers, several of which had developed since they had been sober. Referring to his anxiety, one male alcoholic said, "I feel like there’s a rattlesnake in me breeding venom." What do the psychological tests show? Bühler and Lefever, in "A Rorschach Study on the Psychological Characteristics of Alcoholics," report the "presence of high anxiety and apprehension." 20. Florence Halpern 21. mentions uncertainty, irritability, depression, and tension as evidence that her subjects experience considerable anxiety.
We have seen ample evidence of conditions in the emotional climate of the early lives of the alcoholics which give rise to inner conflicts. For example, authoritarianism does so by forcing the child to choose between security and autonomy, both of which he needs. Emotional immaturity, a phrase one hears in many an AA meeting, is the result of this conflict. The individual’s emo tional or interpersonal development is stunted on a level incommensurate with his chronological age. He continues to respond in childish fashion long after he has left the age when such was appropriate.
One symptom of this failure to grow up emotionally is the continuance of childhood or adolescent ambivalence toward authority. As Giorgio Lolli has pointed out, the conflict between dependence and independence is almost universal among alcoholics. An alcoholic will often form a very dependent relationship (in counseling, for example) and then keenly resent his own dependency. This conflict often operates in the alcoholic’s marital relationship, where he will marry a dominant, mothering woman (who protects him to an absurd degree) and then so resent the dependency as to turn the marriage into a civil war.
Low frustration tolerance is another characteristic of many alcoholics which makes counseling difficult. The alcoholic tends to escape from any frustration or tension into the world of alcohol. Reporting on their Rorschach study, Buhler and Lefever say: "Statistically, the most significant and most consistent trait is the alcoholic’s incapacity to stand strain or tension." 22. Inability to tolerate frustration is normal in children. Anything that impairs a child’s security can render him hypersensitive to frustration throughout his life.
Grandiosity, another common alcoholic trait, is especially evident in the defiant, self-inflating behavior during active alcoholism, when the alcoholic seems to "organize the universe around the perpendicular pronoun," as one of them put it. Harry Tiebout (now deceased), a psychiatrist who studied this attribute, referred to the "king complex." A king is a special kind of person who can’t be frustrated. The alcoholic’s grandiosity is a mechanism for defend ing, in an immature way, his hypersensitive ego. Grandiosity, again, is a symp tom of emotional stunting or immaturity. In order to maintain his grandiose image of himself, the person must shut himself off from interpersonal reality by what Tiebout called the "alcoholic shell." This shell makes the establishment of a real therapeutic relationship in counseling a difficult matter. To relax his defensive shell and fully accept help would be the equivalent of surrendering his "idealized image" (to use Karen Horney’s phrase) of himself. The image cannot be surrendered because it reflects the person’s feelings of what he must be in order to be worthwhile. Perfectionism, a common com plaint of alcoholics, is dynamically related to the maintenance of the grandiose ego image. It is important to remember that this process is not amenable to conscious control.
That the ego defenses of the alcoholic are not an effective psychological solution is clear. Take the problem of alcoholic depression. It was Augustine, a man of immense introspective insight, who said, "Pride is known by its despondency as well as its arrogance." The shell of an unrealistic image of self may protect one from some of the discomforts of interpersonal life, but it also cuts one off from vital satisfactions. One alcoholic, viewing in retrospect his grandiose isolation, said, "I felt so far removed from common garden-variety people that there wasn’t any place for me." Thirty-four of the interviewees (44 percent) reported feelings of isolation and loneliness, a majority tracing their feelings throughout their lives. A typical comment was, "I can’t feel warm toward people."
Perfectionism is actually a form of self-punishment. Inevitable failure, resulting from perfectionistic goals, is followed by extreme guilt. For many alcoholics guilt is a persistent problem. As one put it, "There’s some kind of guilt complex with most of us alcoholics." A very articulate alcoholic wrote: "I was crucified on the bitter angle guilt cuts across the rigid upright of every Ameri can’s puritanism." 23 We have already seen the roots of this guilt.
When discussing the subject of guilt, it is well to bear in mind that an appreciable percentage of alcoholics comes from the clinical group known as "psychopathic personalities," who are unable to experience either guilt or responsibility. In AA these are known as "phonies." These unfortunate persons can give any counselor gray hair unless he is alert to the situation.
The grandiosity of the alcoholic is a defense against his own real feelings of low self-esteem, The alcoholic’s outwardly self-enamored behavior is a mask for his shaky self-regard. This fact can be all-important in counseling procedures. Because of his low self-esteem the alcoholic is hypersensitive to Criticism and will often misinterpret the behavior of others as rejection. Low self-esteem gives rise to anxiety in interpersonal relationships.
Insecurity and low self-esteem are two of the effects of parental alcoholism. A female alcoholic said: "My father was a periodic alcoholic. This was a disgrace in our little town... . He felt he was lord and master. We were all afraid of him. - . . Mother thought sex was a terrible thing." The community’s ostracism, the father’s authoritarianism, and the mother’s puritanism combined in this case to produce a child who grew up feeling "self-conscious and inferior. I was different. I lived in a shell."
The general psychological maladjustment suffered by alcoholics is reflected, in many cases, in their sexual maladjustment. For example, a study of seventy-nine alcoholics by Jacob Levine showed that a decided majority had either diminished or nonexistent interest in heterosexual relationships. 24 The orthodox psychoanalytic hypothesis regarding alcoholism is that the alcoholic has a basic homosexual problem, usually unconscious, of which the alcoholism is an expression. Although many alcoholics are sexually maladjusted and some homosexual, it seems likely that these sexual problems are more adequately understood as symptoms, like the person’s alcoholism, of underlying personality problems. However, one who is counseling alcoholics should bear in mind that their sexual problems may complicate and aggravate their alcoholic problems, and vice versa.
A significant longitudinal (before-and-after) study of alcoholics was made by sociologists William and Joan McCord, and reported in Origins of Alco holism. 25 For ten years, beginning in 1935, records were kept on the family relationships of 650 boys as a part of the Cambridge-Somerville delinquency prevention project. A follow-up study of 510 of these, in 1956, revealed that approximately 10 percent of the group, now in their early thirties, had become alcoholics. The differences in the family backgrounds of those who did and those who did not become alcoholics were then compared by the McCords. They conclude: "The major force which seemed to lead a person under heavy stress to express his anxiety in alcoholism was the erratic frustration of his dependency desires" (in childhood).26. They found that a lower percentage of the boys who had experienced overt rejection by their mothers eventually became alcoholics than those whose mothers were alternatively loving and rejecting. (The overtly rejected produced a higher percentage of criminal behavior.) One third of the sons of the highly ambivalent mothers had become alcoholics in their thirties!
As Pavlov and others demonstrated, the erratic, unpredictable alternation between frustration and satisfaction of a need enhances the strength of that need. The McCords reason that the pre-alcoholic is involved in an endless quest to satisfy intense dependency needs which, in our culture, are unacceptable to the self-image of males. It is noteworthy that the lowest rates of alcoholism, in their study, were among persons raised in homes which seemed to satisfy dependency needs. Concerning the overall pattern of the pre alcoholic homes, the McCords state: "The typical alcoholic, as a child, under went a variety of experiences that heightened inner stress, intensified his desire for love, and produced a distorted self-image." 27
The general conclusions of the psychological studies in the field of alcohol ism show that there can be little doubt that psychological maladjustment is an important part of the soil of addiction. Two studies, for example, are conclusive on the point that behind the addiction there is an emotionally warped personality. Halpern reports: "It can be stated at the outset that not one of the Rorschach Test records obtained from the forty-seven subjects could be considered a normal one. In all of them was evidence of emotional disturbances." 28. Charles C. Hewitt summarizes his findings, in "A Personality Study of Alcohol Addiction," as follows: "Alcohol addiction, in the group studied in this survey, seems to be associated, with but few exceptions, with deep personality disorders. Even those exceptions are doubtless more apparent than real." 29
The assumption that all alcoholics have major underlying personality disorders which cause their alcoholism was sharply challenged by E. M. Jellinek. He stated that generalizations about alcoholics are often based on a biased population -- namely those who seek psychiatric help because they have serious personality disorders. He reports that many non-neurotic alcoholic addicts with only minor psychological vulnerabilities have been seen, especially in the viticulture countries. He concludes: "The contention that neurosis is a sine qua non of ‘alcoholism’ cannot be accepted." 30 However, the evidence seems clear that the vast majority of American alcoholics do suffer from relatively severe personality disorders which provide the soil in which the seed of addiction takes easy root when the person begins to drink. This is particularly true in those groups in which the heavy use of alcohol is not regarded as normal behavior. The greater the pressure to drink in a given group, the less the degree of psychological vulnerability required to become addicted.
One will not fully understand alcohol as a problem until one sees it as a "solution." For the alcoholic, alcohol serves as a magic but tragic solution to his personality problems. Because of his inner conflicts he is motivated by an intense need for the kind of satisfactions which alcohol can give. Let us examine the way in which alcohol "solves" the personality problems of the typical alcoholic. The alcoholic’s inner conflicts and anxiety cause intense psychic pain. Alcohol is a cheap, easily obtainable pain-killer. The physiologists classify it as an anesthetic. Various experiments on animals have shown that alcohol reduces the awareness of pain produced by neurotic conflicts. The Classic example is the experiment on cats by J. H. Masserman and K. S. Yum. The experimenters induced a neurosis in the cats by creating a conflict between their fear of pain and their need for food. The animals became thoroughly neurotic, losing all interest in normal cat-satisfactions. But when they were given an injection of alcohol, they were suddenly able to perform normally. Their neurotic conflict had been anesthetized. Soon they became addicted to spiked milk which they had ignored completely before their neurosis. Only when the neurosis was alleviated by reconditioning could their feline addiction be broken. 31. It is pertinent to note that anthropologist Donald Horton says, after a study of many cultures, "The primary function of alcoholic beverages in all societies is the reduction of anxiety." 32
Alcohol "solves" the problem of the alcoholic’s emotional immaturity by allowing him to regress psychologically to a level at which he can feel comfortable. Sober adult life demands too much for the immature individual, so he slips back via the Bacchus-trail to a level where the demands are minimal. Alcohol honors his low frustration tolerance by allowing him an easy way to escape frustrating situations. At the childish level to which he regresses under alcohol, adult responsibility vanishes and he can revel in the infantile grandiosity of the early stages of life.
Alcohol serves as a "solution" to the alcoholic’s guilt, low self-esteem, isolation, and perfectionism by depressing his self-critique. The alcoholic’s overweening conscience is relaxed by alcohol, and it ceases plaguing him for the time being. Further, the prolonged excessive use of alcohol serves to insure the social censure which registers as punishment with the masochistic alcoholic and thus helps him atone for his guilt. For the alcoholic with a rigid, puritanical conscience, alcohol allows behavior otherwise forbidden by his conscience. As has been said, "The superego is soluble in alcohol." Alcohol reduces the burden of repressed feelings by relaxing the mechanism of repression. A male alcoholic said, "The only time I had a temper was when I reached a certain point in a drunk." At other times he had pushed all hostile feelings out of consciousness by means of repression. Alcohol "solves" the alcoholic’s conflict concerning authority by allowing him to rebel temporarily against those upon whom he is actually becoming increasingly dependent. An under standing of the dynamics involved here is exceedingly important in counseling with families of alcoholics.
The alcoholic’s deep inferiority feelings are temporarily relieved by alcohol. For the time he can feel perfectly successful. As one alcoholic put it, "With a pint you can feel like you’re president." Thus perfectionism is satisfied in the grandiose, illusory world of alcohol. The widespread use of alcohol as a social lubricant is an indication of its power to "solve" the problem of inter personal isolation, a painful problem for the alcoholic. It allows him to accept himself temporarily and therefore to feel closeness to others.
The McCords, in the study cited above, point out that alcohol is highly functional in the psychic economy of an intensely dependent male who can not accept his dependency needs and strivings. Simultaneously, alcohol facilitates closeness and a kind of pseudo-dependency on others, and yet it permits the person to reinforce his defensive self-image of rugged virility by "drinking like a man." In their view, it is when the self-image of the strong, independent he-man breaks down, through the effects of prolonged excessive drinking, that alcoholism develops.
The tragedy of the use of alcohol as a solution to the interpersonal problems of living is twofold. For one thing, the solution is illusory. It can be maintained only so long as the anesthetic is present in the body. For another, the solution carries the seeds of its own destruction. As we have seen, the use of this solution intensifies the very problems to which it has served as an illusory answer. But, however tragic and unsatisfactory in the long run, alcohol gives a temporary answer to the pain and problems of the alcoholic. It does so in a relatively effortless way and, as such, fits his emotional immaturity.
Level Two: Factors Leading to the Selection of the Symptom
Why is it that of all the maladjusted persons who drink, only certain ones develop alcoholism? Or, why is it that a given individual’s psychic economy unconsciously turns to alcoholism from among all the possible symptoms? Here we are in the baffling area of "symptom choice" in which little is actually certain. It is clear, however, that the choice is below the level of consciousness in the individual.
Some exponents of the biochemical conception of the etiology of alcohol ism, such as R. J. Williams, mentioned earlier, claim that there is a metabolic peculiarity that specifically predisposes certain persons to alcoholism. This explanation has not been adequately substantiated as yet. Even if there are biochemical or metabolic factors in the underlying causes of alcoholism, it seems unlikely that they would be such as to specifically predispose to alcohol ism. The fact that some drug addicts switch from morphine to alcohol and back, as the supply of one or the other becomes inaccessible, seems to belie the existence of a specific physical predisposing factor.
Moving over into the psychological realm to look for an answer to our question, we find that there are a few students of alcoholism who believe that there is a unique "alcoholic personality," a distinctive syndrome of psychological attributes which predisposes to alcoholism. Tiebout held to this view although he pointed out that the distinctive factors have not as yet been isolated. In contrast, most researchers emphasize the heterogeneity of alcoholic personalities. Thirty-seven reports of organized research on the personality characteristics of chronic alcoholics were surveyed by E. H. Sutherland and his associates. They concluded that there is not satisfactory evidence that justifies the belief that emotionally disturbed persons of one type are more likely to become alcoholics than those of another type. 33 It is well to remember that the personality traits and conflicts discussed previously as of common occurrence among alcoholics also occur among nonalcoholic neurotics. It is a healthy thing to recall that the alcoholic’s conflicts are structured by the culture in which he lives, and that they are shared to a degree by even the so-called normal individuals Within that culture, including those who write books about alcoholics and those who try to help them.
Sociocultural factors seem to be of first importance in determining the selection of alcoholism as a symptom. The availability and attractiveness of alcohol as a means of interpersonal adjustment certainly influence the "choice" of an alcoholic symptom, as against other symptoms. The importance of avail ability is emphasized by the statistics on alcoholism during Prohibition. They show that there was a substantial drop in the rate of chronic alcoholism during the decade of 1920-30. According to Jellinek, this drop was the result of the greater inaccessibility of liquor during the years 1915-19 during which more and more states introduced prohibition, and the per capita rate of alcohol consumption dropped by twenty-two percent compared with the period 1910-14. And since the bootleg supply was insufficient and unorganized in these years, many alcoholics were checked in their course." 34.
This statement becomes intelligible if one remembers that chronic alcoholism rates are the product of excessive drinking several years before the rates are given.
The availability of alcohol does play a role in the causation of alcoholism on the level of symptom choice. Obviously, the person with underlying pathology will have many opportunities to "solve" his problem alcoholically when alcohol is thrust at him from all sides. If alcohol is relatively less available, he will tend to utilize other neurotic solutions.
A very important factor is the manner in which social attitudes determine the desirability or attractiveness of using alcohol as a means of personality adjustment. Here we return to the Jewish sub-cultural group and ask the postponed question: Why is it that the Jews, among whom drinking is so wide spread, have an infinitesimally low rate of alcoholism?
Fortunately for us there have been a number of intensive studies of this problem. Some have advanced the theory that the strong family and in-group ties of the Jewish culture provide a more secure childhood than in other groups, thus producing less need for artificial escape. Though this seems plausible at first glance, the statistics do not support it. Abraham Myerson, a student of the problem, points out that Jews have their full share of neuroses and psychoses of the depressive type. 35. R. F. Bales adds that Jews have a high rate of drug addiction. 36.
What about a physiological explanation of the low Jewish alcoholism rate? Charles R. Snyder observes: "The heterogeneity of Jews in terms of physical or racial characteristics casts doubt upon any kind of bio-racial explanation. This doubt is considerably strengthened by the failure of science to uncover any specific hereditary mechanisms sufficient to account for drinking pathologies." 37.
The most cogent explanation of the Jewish rate is that of cultural controls on inebriety. The Jewish child encounters the moderate use of alcohol from his earliest years. One study of Jewish children showed that 91 percent of those between five and seven had been introduced to alcoholic beverages and that most of them considered it just another food to like or dislike. 38. Sociologists say that the attitudes and behavior learned during the earliest years have the strongest controlling influence on a person’s later behavior. The Jewish child acquires strong inner controls as to the proper role of alcohol in one’s life. Since it is a part of his life from early years, there is little chance that alcohol can be used as a symbol of revolt against authority during adolescence.
The use of alcohol is closely integrated with the whole religio-social web of the Jewish community. Since the in-group ties are strong, the sanctioning power on the individual in the group is also strong. The one Jewish alcoholic interviewed by the author told of the unbearable guilt he experienced at thirty-two when he began to defy group sanctions by drinking alone. For a Jew the use of wine is closely associated with religious ceremonials. As Bales puts it, "In the Jewish culture wine stands for a whole complex of sacred things. Wine is variously alluded to as ‘the word of God’ and ‘the commandment of the Lord.’" 39. To use wine to excess is to abuse something sacred.
The Jewish culture has strong sanctions against drunkenness. As Myerson says, "To be a drunkard is to cease being a Jew." 40. Immanuel Kant attributed the low rate of drunkenness among Jews (as well as among clergymen and women) to their weak social position. Throughout history Jews have been surrounded by hostile and stronger groups so that drunkenness on the part of any individual endangers the whole group. If a Jew, with his pent-up rage against the oppressor, should become intoxicated and vent his repressed feeling, the entire Jewish group might suffer. This Kantian explanation is probably the historic reason for the existence of strong sanctions against drunkenness.
A Jew may be very neurotic, but the chances are that he will not be an alcoholic. To be such would be to suffer rejection by his group. Thus the Jewish community makes alcoholism undesirable as a symptom. 41.
In contrast, the American scene as a whole has no unified attitudes toward either drinking or drunkenness. The young non-Jewish American finds himself in the midst of a sea of attitudinal crosscurrents, the most dangerous of which encourage the frenzied search for thrills and the use of alcohol as a symbol of ‘being a man." Harvard sociologist Robert F. Bales has stated that the rate of alcoholism will tend to rise when a society by its attitude "positively suggests drinking to the individual as a means of relieving his inner tensions." 42. There are pressures in American life which do exactly this by identifying alcohol with gracious living, with a sense of warm fellowship, and with being emancipated and sophisticated. Alcohol employed as a frequent means of interpersonal adaptation often becomes a "glass crutch."
In order to understand the extent and complexity of the confusion which exists in our country on the matter of attitudes toward alcohol, it is necessary to examine the relationships between these attitudes and the class and ethnic structure of our society. An excellent discussion of these relationships as they developed historically in our country is found in Chapters I and II of Drinking in College by Robert Straus and Selden D. Bacon. The confusion of attitudes which exists in our society at large is both reflected and intensified by the conflict of attitudes within the churches on the subject. Think of the gulf that separates the fundamental attitudes toward drinking of a certain upper-class Episcopal church with its occasional "sherry parties" after services from the attitudes of a middle-class Baptist church with its annual "temperance speaker." In their study mentioned above, Straus and Bacon write:
American church groups are in sharp disagreement, sometimes in open conflict, as to both the nature of the problem and what should be done about it. Although all agree that drunkenness is a problem, many feel that the real difficulty is drinking and that abstinence, whether achieved by persuasion or force, is the only answer. Over 40 million Americans belong to church groups that hold the latter belief. About an equal number belong to sects holding other views. There are groups within the sects on both sides which disagree with the stand taken by the majority: there are total abstinence groups in churches which do not stand for total abstinence; there are "moderation" groups in churches which stand for total abstinence. Nor do the conflict and confusion stop at this point. There are individual churches which clearly fail to adhere to the denominational policy. Perhaps most significant of all, large numbers of individual members of total abstinence churches, who otherwise accept their religion and participate in its activities, reject their church’s policy on this matter in thought or action, sometimes quite openly. . . . Major denominations have formally changed their policies in the last decade. - . - Bitter antagonisms have even flared openly at formal meetings." 43.
The confusion of basic philosophy concerning alcohol is caused in part by, the marked differences in attitudes toward alcohol on the part of the various socioeconomic classes in our country. Straus and Bacon, for example, in their study of over 15,000 college students, found that the incidence of abstention from alcohol on the part of the parents decreased in each category as they moved from lower to higher family income. (Since the study was of parents of college students it is probable that it did not include a proportional sampling of the lowest classes on the socioeconomic scale.) Imitation of the drinking habits of the upper classes is one important factor in influencing th drinking patterns of the middle classes. Such imitation is thus a part of the. whole picture of social climbing in our country. There are other factors a work which tend to make the militant temperance movement predominantly, a middle-class concern. Though there is widespread discontent among the class with the one-track approach of the movement, there is as yet no recognized position which has developed as an acceptable alternative. The differences in general class background of various denominations tend to influence the approach which their members and leaders take toward alcoholics. Compare the attitudes of the so-called temperance churches, for example, with that of the Episcopal Church where an understanding exists on the part of those members taking Antabuse that they will not be expected to take the wine in the service, but will be allowed to take only the wafer.
Social class differences in drinking patterns constitute significant, though not fully understood, influences on the development of pathological drinking behavior. Therefore, these differences must be taken into account both in the understanding of the sociocultural factors in the causation of alcoholism and in its prevention. At the Yale Summer School of Alcohol Studies in 1943, social anthropologist John Dollard delivered a lecture on "Drinking Mores of the Social Classes." His analysis, though frankly speculative and provisional, was widely accepted as authoritative. Since it has served as a point of departure for most subsequent studies, it may be useful to present its basic ideas:
In the Upper classes, drinking is not a moral issue. People at the top of our social structure drink a good deal; both sexes drink. Men and women drink in the same groups, in party style. There are, however, certain stiff controls here which do not exist in some of the Lower classes. One is condemned in the Upper classes, not for drinking, not for drunkenness, but for antisocial behavior while drunk. Fighting is taboo; aggressive behavior is heavily penalized even when expressed only in verbal assaults.
It is crucial to recognize the attitude of the Upper classes toward drinking be cause behavior patterns tend to shift downward in our society. Middle groups are likely to become tolerant and, perhaps, ultimately imitate the customs of the top most groups into which they, as individuals, would like to move. It might be said that the failure of Prohibition legislation lay in our social class system, for the highest people socially did not taboo drinking and their social customs were stronger than legislative controls.
In the Lower-Upper class we have the "cocktail set" who drink a good bit more recklessly than the people in the old families of the Upper-Upper class. The new families of wealth are in a rather insecure, frustrating position. They are constantly comparing themselves with the families who socially "own" the territory in which they live. . . . Realizing that their great-grandfather was "just a butcher," rather than a powerful landowner, they suffer from a helpless feeling of inadequacy. Parental controls are weak and the scars from social competition painful, so Lower-UpperYoung people may try to escape from social discomforts by drunkenness. . .
In the Upper-Middle class we have a strong evaluation of wealth and talent, and, ordinary moral values have restraint. However, the apparent nearness to the upper classes and partial identification with this group have some effect on the drinking habits in the Upper-Middle class. In general, the men drink on social occasions, at their poker games, and at casual gatherings in friends’ houses, but Upper-Middle class women rarely drink. Drinking is not customary in mixed groups. Evidently, Upper-Middles have a neutral attitude toward drinking.
In the Lower-Middle class we would expect to find, with both sexes, a very strong taboo on drinking. Lower-Middle people value highly the traits of respectability which differentiates them from the Lower group. They emphasize this by rejecting the customs found in the Lower classes . . . Lower-Middle men and women are the most stringent in exerting social control over drinking.
In the Upper-Lower class, which is the chief labor group, there is much more drinking. The Upper-Lowers do not have the same taboos as the Lower Middles, but they do have some occupational restraints. A railway workman, for example, will tend to have an occupational taboo on drinking in some situations. In general the Upper-Lowers drink at home and in the taverns, which provide a kind of club for Lower-class people. But if they are to be mobile into Lower-Middle class, they have to change such habits.
Lower-class persons usually become openly aggressive when drinking because they have not been trained to exercise the control of aggression that is demanded of those at the top. In the Lower class, it is not a disgrace to get drunk and fight even if this behavior has dangerous consequences. A Lower-class man may be aggressive in the family toward wife and children. This group does not have the "drink like a gentleman" taboo. Differences in ethnic backgrounds are also conspicuous in the drinking customs of the Upper-Lower class -- Irish, Jewish and Italian immigrants, for instance, retain customs that still have a "home color" when they settle in this country. .
In the Lower-Lower class, drinking is socially unrestrained. There is the Saturday-night-to-Monday-morning binge, without much social control. Both men and women drink, although usually not in mixed groups. In the Lower-Lower class there is overt aggression; people are arrested for drunkenness, breaking the peace. There is much chronic drunkenness in this class. 44.
There can be no doubt that the use of alcoholic beverages in our culture is encompassed by powerful status implications. A study by Gregory Stone gave partial support to Dollard’s analysis. 45. He substantiated the fact that the lower-middle class tends to deprecate drinking, for example. A study by Joseph L. Lawrence and Milton A. Maxwell in the state of Washington indi cated that the heavy and unrestrained drinking at the bottom of the social scale, which Dollard had postulated, did not seem to be the pattern of the majority of this group, particularly the women. 46. They suggest that this view may be a part of the stereotype of the lower class. It is evident that additional sociological research is needed to give a more comprehensive scientific picture of the role of social class in the causation of alcoholism. Two volumes which report the findings of a wide spectrum of sociological and anthropological studies of drinking are Society, Culture, and Drinking Patterns, edited by Pittman and Snyder (see above, Chapter 1, n. 23) and Alcoholism and Society by Morris E. Chafetz and Harold W. Demone, Jr. 47.
Significant empirical evidence concerning the amount of drinking and of problem drinking among various social class groups was made available in 1963 when Harold A. Mulford reported on a scientific survey of a cross section of the non-institutionalized adult population in the United States. Certain of his findings which are relevant to the subject under consideration are presented in the table below. The figures in column one represent the percentage of a given group who use beverage alcohol. Column two gives the percentage of the drinkers who could be classified as "heavy drinkers" 48. (i.e. they drink medium or large quantities more than once a month). Column three gives the percentage of drinkers who had experienced serious trouble as a result of drinking. 49 Income, occupation, and education are three "status characteristics" which are used in determining an individual’s social class. The occupations given are illustrative of occupational categories with gradually increasing status from bottom to top.
Several generalizations may be drawn from these data. First, the percentage of those who drink tends to rise with income, education, occupational status, and size of community of residence. Although the trend is less clear, the percentage of heavy drinkers among the total drinkers seems to increase as these four factors rise. The percentage of those who have serious troubles as a result of drinking rises with the size of the community. In matters of education and occupational status, the percentage of problem drinking seems to be greater at each end of the continuum. Percentage of drinkers declines with age.
It is noteworthy that 7 percent of the Jewish drinkers, in this study, reported serious troubles from their drinking. This may mean that the traditional con trols which tended to keep Jews from developing alcoholism are weakening as Jews become increasingly integrated into the mainstream of American life, including its drinking patterns.
Certain Measures of Drinking Behavior, U.S.A. 1963 50.
Percentage of Percentage of
Percentage Heavy Troubles from
Who Drink Drinkers Drinking
$10,000 and over 87 14 9
$7,000-9,999 85 12 10
$5,000-6,999 68 11 9
$3,000-4,999 64 5 12
Under $3,000 54 8 7
Percentage of Percentage of
Percentage Heavy Troubles from
Who Drink Drinkers Drinking
Physicians; lawyers; dentists 100 0 20
College professors; engineers 87 24 17
Veterinarians; dept. store heads 80 11 5
Insurance agents; draftsmen 84 15 6
Bookkeepers; musicians 76 12 7
Electricians; construction foremen 83 13 9
Machinists; small business proprietors 73 11 12
Mechanics; shipping clerks 76 19 19
Farmers; carpenters 67 11 15
Laborers; janitors 69 10 16
More than 16 79 21 13
16 89 15 4
13-15 76 6 9
12 79 10 9
9-11 70 13 11
8 60 10 11
0-7 46 7 16
Residence Community Size
500,000 and over 76 13 13
75,000-499,999 71 10 13
10,000-74,999 76 11 8
2,500-9,999 69 12 8
Under 2,500 60 5 6
Males 79 16 16
Females 63 4 2
60 and over 56 9 8
40-59 70 12 10
21-39 79 10 10
Jewish 90 7 7
Roman Catholic 89 12 10
Lutheran 85 13 5
Presbyterian, Episcopalians, and
Congregationalists 81 12 6
Methodists 61 5 8
Baptists 48 9 16
The melting-pot aspect of American life adds further to the conflict of attitudes and values concerning alcohol. A certain minister tells of overhearing an informal but heated discussion on the subject among three pre-adolescent boys. One of the boys was from an Italian, the second from a Jewish, and the third from a New England Protestant background. Each was a part of a tradition which had led him to feel deeply that it was "normal" to use alcohol in certain ways or not to use it. Their attitudes had been absorbed as they grew up in one of three very different groups. These attitudes were deeply ingrained in them, and it was disturbing to them to encounter other patterns in their playmates. The variety of their attitudes, projected on a larger screen with many other sub-cultural points of view added, is the picture of America’s crazy-quilt philosophy for understanding and dealing with the problems of alcohol. Straus and Bacon give a succinct description of the situation: "At the present time American drinking practices and attitudes -- and the philosophies and programs for meeting the problems associated with drinking -- can still be summed up in one word: confusion." 51. It is within this baffling environment that young people must attempt to arrive at their own set of values and practices.
Several writers have mentioned the absence of unified cultural controls on drunkenness (comparable to those in the Jewish culture). The mere fact that an intoxicated man, at a certain stage of inebriation, has considerable entertainment value shows that our culture has sometimes made drunkenness socially rewarding. To the extent that it makes it either acceptable or rewarding behavior, it has indeed encouraged the "choice" of alcoholism as a symptom.
The discrepancy between the male and female rates of alcoholism is a vivid demonstration of this truth. The ratio is approximately four and one-half males to one female. This is due in part to the fact that 79 percent of the male population drink, as against 63 percent of the female. More important is the fact that in most groups a man who frequently becomes intoxicated loses much less social standing than a woman who is known to drink to excess. As someone has put it, if a group of college boys become intoxicated and create a commotion, most people will shrug their shoulders and say, "Well, boys will be boys." But if a group of college girls did the same thing, there would be a vocal response of moral indignation and decisive action on the part of the dean. It is noteworthy that the Mulford study figures, cited above, showed that heavy drinkers were four times as prevalent among male as among female drinkers. Even more striking is the fact that serious troubles from drinking were found to occur eight times as frequently among male drinkers as among female drinkers.
The high rate of alcoholism among Americans of Irish descent is thought to be due to the pressures in this subculture which encourage the use of alcohol as a means of interpersonal adjustment. This is what was behind the observation of one interviewee that "you don’t have to be Irish to be an alcoholic, but it helps."
To summarize, the most important factors in the selection of the alcoholic symptom seem to be the availability and attractiveness of alcohol in a particular cultural group. If a person with a strong need for anxiety reduction lives in a setting which imposes heavy social penalties (loss of social standing) on drunkenness, he will probably turn to non-alcoholic escapes. If, on the other hand, a person who, in spite of his inner conflicts, can manage his interpersonal relations with fair adequacy without alcohol is placed in a group which encourages habits of excess, he may come to employ alcohol addictively.
Level Three: Factors Which Perpetuate the Addiction
Why is it that once a person crosses a certain line in his drinking he is caught in a vicious cycle from which he usually cannot extricate himself unaided? And why is it that the addiction must grind on to such lengths before the person "hits bottom" and is open to help? Obviously these are key questions so far as both prevention and therapy are concerned.
It seems probable that the metabolic and endocrine changes observed in the later stages of alcoholism may play an important part in the perpetuation of the addiction. It is noteworthy that for some unknown reason an alcoholic can apparently never again drink in moderation. There are examples in the literature of alcoholics who have had long and successful psychoanalytic therapy to remove their major inner conflicts. In spite of this therapy, they were still unable to drink moderately. It is possible that some irreversible change in biochemistry gives the alcoholic a sensitivity or "allergy" (as AA has long claimed) to alcohol, so that one drink sets off a chain reaction leading inevitably to a drunk.
The "rat experiment" at Yale is a useful story to remember for counseling purposes, and it emphasizes the need for an open mind in this area. A group of experimental rats were found to prefer straight water to water spiked with alcohol. The enzyme system of their livers was then disturbed by surgery. They then favored the alcohol-water solution, rapidly developing an addiction to it. For ninety days all alcohol was removed. When reintroduced to the experimental situation, even after restoration of their enzyme balance, they went on with their addiction where they had left off. 52.
The phenomenon of craving which helps perpetuate a binge may be caused by one or more of several X factors of a physiological nature -- depletion of chlorides in the blood, faulty elimination of certain waste products produced in the metabolism of alcohol, lack of vitamins in the brain, or some upsetting of the enzyme balance.
On the psychological side it is helpful to remember that the alcoholic’s drinking is compulsive. When he crosses the line into his addiction, he becomes the puppet of his subconscious drives and conflicts. Because of the nature of a compulsion -- most people including alcoholics think of their pet compulsions as normal -- it is difficult for the alcoholic to recognize that his behavior is abnormal.
It is necessary now to return to the concept of alcohol as a "solution" for the alcoholic. Remember that by the time he reaches the stage of addiction, he has come to regard alcohol as a solution rather than a problem. So complete is his dependence on this solution that it is very difficult for him even to visualize any other solution for himself. He has organized his personality around alcohol. Becoming abstinent is not simply a matter of giving up a pleasant satisfaction. It is, in effect, giving up the core around which he has organized his life. This factor makes the alcoholic hold on to alcohol long after the solution has brought its own destruction.
So far as the individual bender is concerned, there seems to be a profound psychological factor involved in the dynamics of the problem. We have said that alcohol allows the person to regress to a comfortable level in his psycho social development. For many alcoholics this may be the "oral" stage of infancy. The person finds inner unity by going back to the level at which he last experienced it. Once he has found this unity, he is unable to return to adult life. So the binge continues. The craving for this infantile comfort may be an important factor in the "craving phenomenon" and therefore in the perpetuation of addiction.
Our culture’s attitudes toward alcoholism help to drive the person deeper and deeper into the addiction in which he is trapped. A substantial percentage of the American people still see alcoholism in moralistic, willpower terms, rather than as a genuine sickness which requires treatment. Thirty-five percent of respondents in a nationwide survey by Elmo Roper and Associates considered the alcoholic as "morally weak"; 58 percent accepted the alcoholic as "sick"; and 7 percent expressed no opinion. 53 There is evidence that much of the acceptance of the sickness conception is relatively superficial. Jellinek put his finger on this problem when he declared: "Generally, it may be said not only of the public at large but of the medical profession, industry and labor and all the other sections of public opinion, that their feeling is that the idea that ‘alcoholism’ is an illness ‘is true, but not really true.’ "
An Iowa survey supported Jellinek’s view. Only 24 percent of the sample accepted the sickness view without reservations; 34 percent described the alcoholic as "weak" ("weak willed" or "morally weak"), without mentioning sickness; and 41 percent described him as both "weak" and "sick." Five out of eight who endorsed the illness concept also retain the moral weakness view. 55.
Public attitudes such as these militate against early detection and treatment of alcoholism. An individual is in his culture as a fish is in water. The person who is beginning to have trouble with alcohol naturally reflects the attitudes of his culture and erroneously regards his difficulty as a matter of willpower. As the tentacles of his compulsion close tighter around him, he struggles all the harder to "use a little more willpower" and to solve the problem himself. To admit that he cannot is tantamount to admitting he is mentally unbalanced or a moral jellyfish. Thus the culture drives him away from, rather than toward, the help he desperately needs. On the one hand his assumption that his problem is essentially one of willpower, and on the other hand, the fact that he is caught by a compulsion, make it increasingly necessary for his defensive rationalization system to work overtime. He must convince himself that he can stop when he really wants to and that it is not his drinking but external circumstances that are to blame for his troubles. All these factors tend to perpetuate his addiction and to make it necessary for him to reach a point of tragic spiritual, mental, and moral bankruptcy before he can accept help. There are important implications in all that we have been considering so far as the prevention and early treatment of alcoholism are concerned.
We have discussed the three levels on which the causes of alcoholism can be seen to operate. Now we turn to a causative factor which plays a role on each of the three levels, but which we treat separately for the sake of emphasis, because of its distinctive importance for our purposes. The religious philosophical factor should be seen as the fourth factor in the etiology of alcoholism, the other three being the physiological, the psychological, and the cultural.
Level Four: Philosophical and Religious Factors in the Etiology of Alcoholism
An understanding of the distinctive contribution of a religious approach to alcoholism is dependent on insight into what might be called the vertical dimension of the alcoholic’s problem. For in addition to disturbances in the interpersonal plane, the horizontal dimension, the alcoholic also suffers from disturbances in his relationship to the Ultimate.
There are three kinds of anxiety involved in the etiology of alcoholism: neurotic, historical, and existential. These three are involved in all neurotic problems. Anxiety -- of whatever variety -- rises from a threat to the essential security of a person and is therefore an experience of the total personality. The psychiatrist Harry Stack Sullivan called it a "cosmic" experience, a shaking of the individual’s world and his perception of it. In contrast, "fear" is a reaction to a specific danger. Anxiety is an unspecific feeling of uncertainty and helplessness. The alcoholic’s burden is not simply fear, but also free-floating anxiety.
As we have seen, much of the alcoholic’s anxiety is pathological or neurotic, the result of inner conflict and repression which threaten his sense of worth. The individual who has repressed all his anger in order to feel acceptable to himself, having grown up in an environment where anger was taboo, feels anxiety whenever hostile feelings threaten to enter his awareness. Neurotic anxiety is thus a mechanism for keeping unacceptable feelings and drives out of awareness. It is the burden of neurotic anxiety which the psychotherapist often is able to reduce. This is the kind of anxiety we have already discussed in considering the psychological factors in the soil of addiction.
Neurotic anxiety is intermixed and increased by historical anxiety, that arising from the crisis of our time. Modern man has had many of his philosophical props knocked from under him. Traditional and comfortable certainties about God, man, and the universe have been threatened or destroyed for many by the impact of two world wars and the scientific revolutions wrought by Copernicus, Darwin, and Freud. Many who have never integrated the meaning of these major scientific discoveries into their philosophies of life find their hold on traditional certainties weakened by the indirect but profound influence of our scientifically minded culture. Man feels himself to be the accidental denizen of an insignificant grain of cosmic dust lost in the mechanical emptiness of an exploding universe which will ultimately snuff out his feeble life. He feels his impotence in the face of mass social forces over which he has no control. So, meaninglessness is a constant threat to his philosophical existence.
One of the two alcoholics interviewed who classed themselves as atheists described the problem when he spoke of what he called "my cockeyed philosophy of life": "A fellow sleeps to get strong, so he can work to get money to eat and have a place to sleep, so that he can get strong and be able to work to get money, and so on."
The collapse of a man’s Weltanschauung leaves him at the mercy of the third type of anxiety -- his existential anxiety. Existential anxiety -- the anxiety arising from man’s nature, the very facts of his existence as man -- would seem to be an important factor in everyone’s life, including alcoholics and those who would help them. In his book entitled Shaking of the Foundations, the late Paul Tillich put it clearly: "Man’s essential loneliness and seclusion, his insecurity and feeling of strangeness, his temporality and melancholy are qualities which are felt even apart from their transformation by guilt. They are his heritage of finitude." 56. Existential anxiety is the threat to his essential self which inheres in man’s "heritage of finitude." Man is the animal who knows he will die. He is a part of nature, subject to its powers, to sickness, pain, and death. Yet he can transcend nature and view his own end. In Thus Spake Zarathustra, Nietzsche put it thus, "Man is a rope connecting animal and superman." 57. From the awareness of his own contingency arises man’s existential anxiety. In German philosophical literature this anxiety is called Urangst, or ultimate anxiety. Tillich, in his Terry Lectures at Yale, 58. has given us the most incisive treatment of non-pathological anxiety from the theological standpoint. Psychoanalysts such as Rollo May, Karen Homey, and Erich Fromm have dealt with it from the psychological point of view.
Existential anxiety arises also from man’s rational capacities. Fromm observes:
Self-awareness, reason and imagination have disrupted the "harmony" which characterizes animal existence. Their emergence has made man into an anomaly, into the freak of the universe. He is a part of nature, subject to her physical laws and unable to change them, yet he transcends the rest of nature. . . . He is home less, yet chained to the home he shares with all creatures. . . . Being aware of him self, he realizes his powerlessness and the limitations of his existence. He visualizes his own end: death. Never is he free from the dichotomy of his existence. . . Reason, man’s blessing, is also his curse. 59.’
Man’s capacity for feeling "I ought" is a blessing but also a burden, a source of existential anxiety. The creation myth in Genesis states this symbolically -- the expulsion from Eden was the result of eating the fruit of a tree which made men "as gods, knowing good and evil" (Gen. 3:5). Thoreau witnessed to the eternal restlessness of man’s spirit when he said that human beings are always "searching for some lost Eden." 60. Fromm says, "Having lost paradise, the unity with nature, he has become the eternal wanderer (Odysseus, Oedipus, Abraham, Faust) •" 61. And it was Mark Twain who once quipped, "Man is the only animal that blushes or needs to."
Existential anxiety also arises from what Toynbee calls the "Promethean elan," 62. man’s drive to assert himself. Viewing man’s evolution during his 650,000 or so years on this planet, one realizes that he is involved in a perennial struggle to achieve autonomy, to rise above primitive dependence on the herd. He is a separate self with distinctive needs and potentialities; yet he needs the herd. When he gets too far from the herd, he becomes anxious. As Tillich has put it, modern man "is the autonomous man who has become insecure in his autonomy." 63.
Existential anxiety is unneurotic, yet it is the basis or ground of all neurotic anxiety. It is normal -- the experience of all men. It becomes unbearable when a load of neurotic anxiety is added to it. A man is oppressed by its weight on his back only when his back also bears a heavy burden of neurotic anxiety. Because of this, existential anxiety is an important consideration for the understanding of alcoholism.
Both historical and existential anxiety contribute to all three levels of the causation of alcoholism. Since they complicate the alcoholic’s neurotic anxiety, they contribute to the soil of addiction by helping to render him vulnerable. On the level of symptom choice-the second level -- they operate by creating religious and philosophical needs for which alcohol provides pseudo-satisfactions. On the third level these forms of anxiety contribute to the perpetuation of the addiction in the sense that they become more and more pronounced as the alcoholic continues to try to satisfy his religious needs by means of alcohol. That is, the more he drinks, the more hopeless and meaningless life seems to him.
The thesis stated above, that alcohol provides a pseudo-satisfaction for the alcoholic’s religious needs, is so fundamental to an understanding of both alcoholism and any religious approach to it, that it will be discussed at some length in Chapter 6. Suffice it to say here that alcohol seems to have the capacity to allay temporarily the alcoholic’s existential anxiety. It gives him feelings of transcending his finitude, of participating in the larger life. The fact that alcohol is related dynamically in its effects to mystical elation was pointed out by William James in his Gifford Lectures .64. The alcoholic thus seeks to satisfy his religious needs by non-religious means. The tragedy of this is that by so doing he only magnifies his religious needs in the long run.
In this chapter we have been reviewing the causative factors involved in alcoholism as they operate on three levels:
(1) We have seen that there may be biochemical factors and that there most certainly are psychological factors in the soil of addiction which renders certain persons vulnerable to alcoholism.
(2) We have seen that the availability of alcohol and its attractiveness as a symptom, as determined by social attitudes toward drinking and drunkenness, have a great deal to do with the matter of symptom selection.
(3) We have observed that physiological changes as well as cultural attitudes toward alcoholism (which regard it as a question of willpower rather than a sickness) probably contribute to the perpetuation of the addiction once it is established. 65. We have traced the way in which alcohol serves as a neurotic "solution" to the alcoholic’s inner problems. We have described the philosophical and religious factors which influence all three levels of causation and have indicated the manner in which alcohol serves as a pseudo solution to historical and existential anxiety. In Chapter 1 we saw the way in which the solution carried the seeds of its own destruction. It is when his alcoholic solution collapses that the alcoholic turns to religious solutions.
I. Carney Landis and M. M. Bolles, Textbook of Abnormal Psychology (New York: The Macmillan Company, 1964), p. 194.
2. Religion in Illness and Health (New York: Harper & Brothers, 1942), p. 37.
3. Lupica Benedict, "A New Dawn for Alcoholics," Healthways, IV (May, 1950), 39.
4. Harold A. Mulford, "Drinking and Deviant Drinking, U.S.A., 1963," QJSA, XXV, 637.
5. "Culture and Jewish Sobriety: the Ingroup-Outgroup Factor" in Society, Culture, and Drinking Patterns, p. 188. Many studies have confirmed the low rates of alcoholism about Jews. For example: Rates of rejection in the Armed Forces for chronic alcoholism in ‘World War 1(60,000 cases): Irish -- 3.0%; Negro -- 2.2%; Italian -- i .2%; Jewish -- 0.2%; Chinese -- O.0%. (Cited by Donald Glad, "Attitudes and Experiences of American-Jewish and American-Irish Male Youths as Related to Differences in Adult Rates of Inebriety," QJSA, VIII [December, 1947], 408.) Or, consider this example: First-admission rates for alcoholic psychosis (to mental hospitals in New York State) of those born in foreign countries (figures are per 100,000 of the same nationality in New York state hospitals, 1929-31): Irish -- 25.6%; Scandinavian -- 7.8%; Italian -- 48%; English -- 4.3%; German -- 3.8%; Jews (all nationalities) -- 0.5%. (Cited by Landis and Bolles, Textbook of Abnormal Psychology, p. 236.)
6. E. M. Jellinek, Lecture at the Yale Summer School of Alcohol Studies, July, 1949.
7. Religion in Illness and Health, p. 37
8. Henry D. Thoreau, Walden: or, Life in the Woods (New York: Dodd, Mead & Company, 1946), p. 9.
9. "The Addictive Drinker," QJSA, X (December, 1949), 412.
10. The Disease Concept of Alcoholism, p. 87.
11. Ibid., p. 108.
13. James J. Smith, "A Medical Approach to Problem Drinking," QISA, X (September,1949), 251.
14. "Meeting of the Medical Society of the State of New York," .New York Times, May 10, 1950.
15. "A Critique of Physiopathological Theories of the Etiology of Alcoholism," QJSA, XI (March, 1950), 113-14.
16. (Austin: University of Texas Press, 1959).
17. Anne Roe, "Children of Alcoholic Parents Raised in Foster Homes," Alcohol, Science and Society (New haven: Journal of Studies on Alcohol, 1945) pp. 115-28.
18. (New York: McGraw-Hill Book Company, 1949).
19. Two interviews were incomplete at this point, and two were with brothers.
20. C. Buhler and D. W. Lefevcr, "A Rorschach Study on the Psychological Characteris tics of Alcoholics" (New Haven: Hillhouse Press, 1948), p. 61.
21. "Part II, Psychological Test Results" in Studies of Compulsive Drinkers, ed. J. F. Cushman and C. Landis (New Haven: Hillhouse Press, 1946), p. 84.
22. "A Rorschach Study," p. 37.
23. H. W. Main (pseud.), If a Man Be Mad (Garden City: Doubleday & Company,
1945), p. 152.
24. "The Sexual Adjustment of Alcoholics. A Clinical Study of a Selected Sample," QJSA, XVI (December, 1955), 675-80.
25. (Stanford, Calif.: Stanford University Press, 1960).
26. Ibid., p. 152.
27. Ibid., p. viii.
28. Studies of Compulsive Drinkers, p. 83.
29. QJSA, IV (December, 1943), 368-86.
30. The Disease Concept of Alcoholism, p. 107.
31. "An Analysis of the Influence of Alcohol on Experimental Neuroses in Cats," Psychosomatic Medicine, VI (1946) ,36-52.
32. "The Function of Alcohol in Primitive Societies: A Cross-Cultural Study," QJSA, IV (September, 1943), No. 2, 233.
33. "Personality Traits and the Alcoholic, A Critique of
Existing Studies," QJSA, XI (December, 1950).
34. "Recent Trends in Alcoholism and in Alcohol Consumption" (New Haven: Hillhouse Press, 1947), p. 20.
35. "Alcohol: A Study of Social Ambivalence," QJSA, I (June, 1940), No. 1, 17.
36. "Cultural Differences in Rates of Alcoholism," QJSA, VI (March, 1946), No. 4, 497.
37. "Culture and Jewish Sobriety: The Ingroup-Outgroup Factor" in Society, Culture, and Drinking Patterns, pp. 188-89.
38. Ruth H. Landman, "Drinking Patterns of Children and Adolescents Attending Religious Schools," QJSA, XIII (March, 1952), 91.
39. "Cultural Differences in Rates of Alcoholism," p. 491.
40. "Alcohol: A Study of Social Ambivalence," p. 17.
41. It is significant that the Jewish controls on excessive drinking seem to be weakening as American Jews become less intensely identified with their ingroup and with the Orthodox religious position. Charles R. Snyder reports: "As religious affiliation shifts from Orthodox to Conservative to Reform and to Secular, signs of drinking pathologies show marked and systematic increase. Moreover, these changes cannot be attributed to the direct influence of social class or generational factors." ("Culture and Jewish Sobriety: The Ingroup-Outgroup Factor," p. 190.)
42. "Cultural Differences in Rates of Alcoholism," p. 482.
43. Drinking in College (New Haven: Yale University Press, 1953), p. 14.
44. From Alcohol, Science and Society, pp. 99-100. Dollard used the six-social-class framework suggested by W. Lloyd Warner. Class status is defined by such matters as occupation, the length of a family’s residence in a community, income and property, the quality and place of residence, the mores and values which guide them, and education.
45. Gregory P. Stone, "Drinking Styles and Status Arrangements" in Society, Culture, and Drinking Patterns, pp. 121-40.
46. "Drinking and Socio-Economic Status" in Society, Culture, and Drinking Patterns, pp. 141-45.
47. (New York: Oxford University Press, 1962); see especially chapter 4.
48. See "Drinking and Deviant Drinking U.S.A.. 1963." Mulford set up five categories in terms of quantity and frequency of drinking. Those whom I have designated "heavy drinkers" were in the fifth category.
49. Troubles from drinking included the following: being left or being threatened to be left by one’s spouse; losing a job or being threatened with firing; being warned by a doctor that drinking is injurious to the subject’s health; being arrested on some charge involving alcohol; being accused by a family member of overspending on alcohol.
50. The complete table, including numbers in each category and data on geographical regions, is given on pp. 640-41 of the Mulford article. The table is entitled "Distribution of the Adult Population and of Selected Social Segments by Certain Measures of Drinking Behavior, U.S.A., 1963."
51. Drinking in College, p. 34.
52. E. M. Jellinek, Lecture at the Yale Summer School of Alcohol Studies, July, 1949.
53. From a survey in 1958, reported in Jellinek’s Disease Concept of Alcoholism, p. 183.
54. Ibid., p. 185.
55. H. A. Mulford and D. E. Miller, "Measuring Public Acceptance of the Alcoholic as a Sick Person," QJSA, XXV (1964), 314-23.
56. (New York: Charles Scribner’s Sons, 1948), p. 170.
57. The Works of Friedrich Nietzsche (New York: The Tudor Publishing Company, 1931).
58. The Courage to Be (New Haven: Yale University Press, 1952).
59. Psychoanalysis and Religion (New Haven: Yale University Press, 1950), p. 22.
60. Walden: or, Life in the Woods, p. 54.
61. Psychoanalysis and Religion, p. 23.
62. A. J. Toynbee, A Study of History (Somervell’s abridgment; New York: Oxford University Press, 1947), p. 276.
63. The Protestant Era (Chicago: University of Chicago Press, 1948), p. 192.
64. The Varieties of Religious Experience, A Study in Human Nature (New York: Longmans, Green and Company, 1902).
65. This tentative model for understanding the causes of problem drinking is offered in the report of the Cooperative Commission on the Study of Alcoholism: "An individual who (1) responds to beverage alcohol in a certain way, perhaps physiologically determined, by experiencing intense relief and relaxation, and who (2) has certain personality characteristics, such as difficulty in dealing with and overcoming depression, frustration, and anxiety, and who (3) is a member of a culture in which there is both pressure to drink and culturally induced guilt and confusion regarding what kinds of drinking behavior are appropriate, is more likely to develop trouble than will most other people." See Thomas F. A. Plaut, Alcohol Problems, A Report to the Nation (New York: Oxford University Press, 1967), p. 49.