Understanding and Counseling the Alcoholic by Howard J. Clinebell, Jr.
Howard J. Clinebell, Jr. Is Professor of Pastoral Counseling at the School of Theology at Claremont, California (1977). He is a member of the American Association of Marriage and Family Counselors, and the American Association of Pastoral Counselors. He is a licensed marriage, child and family counselor in the State of California. His personal website is http://members.aol.com/clinebellh/index.htm, and his email address is clinebellH@aol.com. This book is the Revised and Enlarged Edition published by Abingdon Press, Nashville, 10th Printing, 1990. Used by permission. This material ws prepared for Religion Online by Richard V. Kendall.
Chapter 1: What Is an Alcoholic?
Have you ever known an alcoholic? Have you ever tried to help such a person? Almost everyone reading this page can answer the first question in the affirmative. Many can do the same for the second. For few problems are as widespread as alcoholism. Directly or indirectly, most adults have had some experience with this perplexing sickness. It may have touched one’s immediate family; or it may have been experienced in an employee, a fellow worker, a friend or the friend of a friend, a distant relative, or a chance acquaintance. In a survey conducted in the state of Washington, 72 percent of the sample population had known at least one alcoholic. 1. Of these, 40.5 percent had been related as close friends or relatives of the alcoholic they had known.
Anyone whose work brings him into intimate touch with people is painfully acquainted with the problem of alcoholism. Ministers, physicians, psychotherapists, social workers, and others whose work includes helping people in trouble have the problem thrust at them many times in the course of their professional activity As I think back over my own professional experience, I am impressed by the variety of such encounters. I think, for example, of Mr. K., who stopped after choir practice to chat and during the conversation worked around to unburdening his soul of the grim story of his wife’s recent spree. I think of Mrs. L., who phoned to ask if I could help persuade her alcoholic husband to see a psychiatrist. I think of Bill, a member of the youth group, who came to tell of the trouble his family had been having with an alcoholic uncle who, though abstinent in AA, continued to be difficult to live with. I think of Joe, a promising young man of twenty-nine, who saw that his drinking was out of hand and, in desperation appealed for help. I think of Mr. B., a respectably dressed stranger who came to the parsonage door with a convincing story about needing a loan to redeem his tools which he had been forced to pawn during a prolonged illness. On investigation, his story proved to be a clever alcoholic ruse. I think of Mr. P., a business executive and church member, who after many years of periodic binges had been happily sober in AA for three years. I think of Mr. L., talented artist and frequent patron of the city hospital’s alcoholic ward, who could not admit that he had an alcoholic problem. I think of Mac, a member of another religious faith, who used to knock on my door every few weeks, asking for a "loan." (I had made the mistake of following the course of least resistance and had given him a small sum on the first occasion.) Each time Mac came, he looked more like death -- a condition toward which he was slipping with tragic alacrity. I think of Bert, a young man from a disturbed home, who consistently arrived at senior youth meetings with alcohol on his breath. I think of Mrs. R., a parishioner whom I felt sure was having serious trouble with alcohol, but who was expert on hiding the fact from everyone including herself. Any clergyman, physician, or social worker could duplicate and double this list.
As I write, I think of these and others who have crossed my path bearing an alcoholic cross. I think of the times I have felt completely helpless in the face of this problem -- the times I have failed -- the feelings of frustration that have accompanied the failures. I also recall the satisfaction that has attended the experiences in which I have been able to make even a meager contribution toward bettering a tragic situation.
Few problems have been so baffling in nature as alcoholism. Until recent years, little has been known about either the causes or cures of alcoholism. Much of what had been written had been of a propagandistic nature with only a flimsy foundation of objective facts. Many of the so-called cures were relatively ineffective. In some cases they were outright deceptions involving despicable exploitation of human misery. An atmosphere of hopelessness has clung to the problem. For many, it still clings. In the Washington state survey mentioned above, 53.3 percent of the sample population had never known an alcoholic who had recovered.
Alcoholism is still a baffling problem, but developments in recent years have brought the dawning of a new hope. A dozen or more scientific disciplines have focused their research eyes on the problem, bringing new understanding. Most important of all, from the standpoint of the alcoholic and his family, is the hope engendered by the wonderful success of AA.
There is no area of human suffering in which religion has given a more convincing demonstration of its therapeutic power than in the problem of alcoholism. For a long time it has been recognized that religion has tremendous resources for dealing with the problem. In his classic sermons on intemperance 2 published in 1827, Lyman Beecher made it clear that some sort of religious experience was the best hope for the alcoholic. Even those who had no professional interest in religion often shared this view. Around 1930 the director of a large chemical company in America sought help for hi alcoholism from the famous Swiss psychoanalyst Carl Gustav Jung. Dr. Jung went over his case very carefully and then told him that nothing but a religious conversion could give him any lasting help. The man returned to America where he received help in the Oxford Group Movement. Interestingly enough, he later became one of the "pre-founders" of an amazing group that has given us the most convincing evidence of the therapeutic effectiveness of religion -- Alcoholics Anonymous. This group has reclaimed from the scrap heap of society more than 375,000 "hopeless" alcoholics.
Our task in this volume will be to explore the ways in which religious resources may be used with greatest effectiveness in dealing with alcoholism. By implication, we may throw some light on religion as a resource for dealing with other human problems.
Recognizing the Problem
Whatever the problem, effective treatment depends on accurate recognition and diagnosis. For this reason the first concern of those who would help alcoholics is to recognize and understand the problem. Some time ago I attended a dinner and was seated beside a guest who plied me with questions concerning alcoholism. During the conversation she raised this problem; "I am concerned about a friend who seems to me to be drinking too much. How can I tell whether or not he is an alcoholic?" In answering her query I pointed out that it is often difficult or even impossible to be absolutely certain that a given person is afflicted with the alcoholic sickness, but that there is a useful rule of thumb which often gives one a valid clue. Put in the form of a question, it is this: Does the person’s drinking frequently or continuously interfere with his social relations, his role in the family, his job, his finances, or his health? If so, the chances are that that person is an alcoholic or on the verge of becoming one.
This simple test question can be rephrased as a useful definition of what is meant by the term "alcoholic" in this book. An alcoholic is anyone whose drinking interferes frequently or continuously with any of his important life adjustments and interpersonal relationships.
This definition points to the essential nature of alcoholic drinking which distinguishes it from other kinds of drinking behavior. If a drinker who is not an alcoholic finds that his drinking is interfering with his work, for instance, he will reduce his consumption. In contrast, the alcoholic will usually not even recognize the causal relation between his drinking and his job trouble; rather he will project the blame for his trouble on others. He cannot recognize the real cause of his difficulty because alcohol is very important to him. To recognize it as the offender would threaten the center around which he has organized his life. Even if he suspects that alcohol is a cause of his trouble,
he will not be able to reduce his consumption for any extended period. This is because his drinking is gradually becoming compulsive. He is driven by forces beyond his rational control. For reasons not completely known, he is losing the power of choice when alcohol is involved. The old phrase "driven to drink" can be accurately applied to him. He is driven by powerful forces within himself. Once he begins to drink, he usually will not be able to stop until he is "broke," unconscious, or until his digestive system revolts and refuses to take any more alcohol. An alcoholic, then, is a person for whom one drink frequently touches off a chain reaction leading to drinking that is excessive in the sense that it hampers his interpersonal life. It should be noted that some alcoholics are able to control their drinking for a considerable period before it results in a binge.
There are other indications which may be useful in recognizing incipient alcoholism. Anyone who uses alcohol as a persistent means of interpersonal adjustment -- who drinks regularly to allow himself to be more aggressive in his work or less shy at social functions -- is in danger. He may be near the intangible line that separates non-pathological from compulsive drinking. Again, anyone whose drinking behavior is in defiance of the standards of the group from which he derives his sense of belonging is suspect, so far as alcoholism is concerned. Sneaking drinks and drinking alone are two examples of such defiance. The fact that alcohol is more important to him than it should be is shown by the fact that he is willing to risk rejection by his in-group in order to satisfy his drinking demands.
Frequent drunkenness would seem to be the most obvious indication of alcoholism. A word of caution is in order. All alcoholism is attended by drunkenness, but not all drunkenness is indicative of alcoholism. Alcoholism and drunkenness are not synonymous. For example, what has been called "rough recreational drinking" was much more common during frontier days than today. Almost every weekend "the boys" would assemble to get and stay roaring drunk. This was the accepted social pattern among some frontier groups, and although there was a great deal of this kind of drunkenness, there was probably less alcoholism than there is today. This is not to suggest rough recreational drinking as a solution to alcoholism, but simply to show that drunkenness is not always a symptom of alcoholism. It is indicative of alcoholism when it interferes with interpersonal functioning, or is in defiance of the drinking mores of one’s group. Either of these indicates that the drinking is to a degree compulsive. Obviously a person who has a susceptibility to alcoholism will be more apt to become afflicted in a social group that encourages heavy drinking and drunkenness.
It is wise to remember that the alcoholic himself is often the last person to recognize that his drinking is a problem. And yet, those who specialize in helping people are sometimes asked to suggest aids to self-recognition of alcoholism. The literature of AA suggests:
We do not like to pronounce any individual an alcoholic, but you can quickly diagnose yourself. Step over to the nearest barroom and try some controlled drinking. Try to drink and stop abruptly. Try it more than once. It will not take long for you to decide, if you are honest with yourself about it. It may be worth a bad case of jitters if you get a full knowledge of your condition. 3.
The point of this experiment is that an alcoholic usually cannot control his drinking for more than a few successive occasions. (For this experiment to be reasonably conclusive, the person should be able to stop after one or two drinks for at least a month.)
The late Robert V. Scliger, a psychiatrist who worked extensively with alcoholics, offered this checklist:
ARE YOU AN ALCOHOLIC?
To answer this question, ask yourself the following questions and answer them as honestly as you can.
1. Do you lose time from work due to drinking?
2. Is drinking making your home life unhappy?
3. Do you drink because you are shy with other people?
4. Is drinking affecting your reputation?
5. Have you ever felt remorse after drinking?
6. Have you gotten into financial difficulties as a result of drinking?
7. Do you turn to lower companions and an inferior environment when drinking?
8. Does your drinking make you careless of your family’s welfare?
9. Has your ambition decreased since drinking?
10. Do you crave a drink at a definite time daily?
11. Do you want a drink the next morning?
12. Does drinking cause you to have difficulty sleeping?
13. Has your efficiency decreased since drinking?
14. Is drinking jeopardizing your job or business?
15. Do you drink to escape from worries or troubles?
16. Do you drink alone?
17. Have you ever had a complete loss of memory as a result of drinking?
18. Has your physician ever treated you for drinking?
19. Do you drink to build up your self-confidence?
20. Have you ever been to a hospital or institution on account of drinking?" 4.
"Yes" answers to even a few questions such as these constitute a warning that trouble may be ahead. There are two weaknesses to any scheme of self-recognition such as this. For one thing the alcoholic is often a master in self-deception and, as such, he does not recognize alcohol as the cause of the troubles listed. For another, the alcoholic may use such a list in a negative fashion. For example, I remember a woman who had had a serious alcoholic problem for years but who rationalized that she was not an alcoholic because she never drank in the morning.
Types of Alcoholics
One important reason why alcoholism is frequently difficult to recognize is that every case is different. There is a baffling variety of types and degrees of the disorder, so that if one uses any generalization as an infallible touchstone, he will be led astray in dealing with individuals. Some sample case histories taken from the author’s files will highlight this point. Names and other identifying data have been altered to preserve anonymity; the essentials, however, are unchanged.
Sidney L. was born in a mid-western city forty-seven years ago. His father was mean-tempered and harshly authoritarian. His mother died when Sidney was sixteen. He left school in the seventh grade and worked at a series of unskilled jobs. He began drinking at fourteen; his drinking was abnormal from the beginning. He began to drink in the mornings when he was twenty-three. In a few years he had become the neighborhood drunk and was spending a substantial share of his time "on the bum" living on Skid Rows around the country. At thirty he was sent to a state hospital for his alcoholism. Between then and forty-three he was in the state hospital eleven times. Between hospitalizations he lived in Salvation Army homes, missions, and public parks. He drank whatever was available, including rubbing alcohol and "smoke" (wood alcohol). He deteriorated physically, mentally, and morally. He suffered alcoholic hallucinations. At forty-three he was pronounced "a hopeless chronic alcoholic -- a menace to himself and society." He says, "I was living the life of oblivion. I had to beg to live. I was as helpless as a one-year-old baby." He wanted to die but did not have the nerve to take his own life.
Alcoholics of Sidney’s type can be recognized readily from their grossly asocial behavior. The Skid Row alcoholic who becomes open to help is sometimes called a "low-bottom" alcoholic, indicating that he has reached a low point of social disintegration.
Although the low-bottom alcoholic has provided the stereotype of what all alcoholics are supposed to be like, he represents less than one tenth of the total alcoholic population. In contrast to this group the vast majority of alcoholics are not living on Skid Row and are still able to hold jobs and live with their families. Such an alcoholic is "dragging his anchor" because of his drinking. He is less adequate as a father and husband, as well as less efficient in his work than he would otherwise be. He may have an above-average amount of absenteeism and is usually tired and run-down. Alcoholics who become open to help at this level of minimal social disintegration are called "high-bottom" or "high-high-bottom" alcoholics. Such alcoholics are the most difficult to recognize simply because alcohol has not cut them off from normal social intercourse, even though it is giving them trouble. The National Council on Alcoholism has estimated that "at least 85 per cent of alcoholics are ‘hidden’ in factories, offices and homes in large and small communities throughout the country." 5. All too frequently the alcoholic remains hidden until the final stages of his sickness.
The following case is illustrative of the high-bottom type:
William B., forty-five, was born in a small town in a western state. His parents both hated liquor and would not allow it in the house. William was valedictorian of his high-school class and graduated Phi Beta Kappa from college. He had the first drink when he was a senior in college. He drank very little during law school. Following graduation his drinking consisted of an occasional social cocktail. When he was thirty-three he began daily social drinking, following the example of an admired senior partner. He liked the boost alcohol gave his self-confidence. Gradually his drinking increased in volume. By the age of forty-one he began to feel caught in a "squirrel-cage" of drinking throughout the day. His remorse was intense because he was using money he could ill afford to spend on alcohol. In spite of his heavy drinking, he did not experience severe hangovers and did not miss a single day at work because of drinking. He did reach the point, however, at which he could hardly force himself to work. He would sit in his office and think about liquor. He became desperate when liquor began to lose its effect. At this point he contacted AA and had been sober for eight months at the time of the interview.
William B. had not lost his job, his home, or his wife; yet he had been drinking alcoholically for two years before he came into AA.
Both Sidney and William were "steady" alcoholics in that they drank heavily nearly every day. In contrast, the "periodic" alcoholic is one who is abstinent for periods ranging from a few days to several months between the times when a wave of craving hits him and he goes on a bender. The case of Henry P., a low-bottom alcoholic, is illustrative of the "periodic." It might be well to point out that periodics probably appear most frequently among high-bottom alcoholics, however.
Henry began drinking during Prohibition at the age of fifteen. By the time he was eighteen he was having trouble controlling the length of his bouts with alcohol. He left school after his junior year in high school to take a job. By the age of twenty he had worked his way up to an executive position. He held this position until twenty-seven when he was fired because of his drinking. Of his drinking pattern he says, "I would be dry for a couple of months, then a terrible urge would come over me like a wave and I’d disappear for weeks on a bender. I’d come home finally with all my money gone." One drink never interested him. His disintegration was rapid in all departments of his life. By the age of thirty-nine he was living in doorways on a Skid Row. He was jailed repeatedly; twice he tried to take his life. Finally a judge suggested he go to AA. He had been sober for four years (after twenty years of problem drinking) at the time of the interview and had established a successful business.
It is axiomatic among students of alcoholism that the sickness is no respecter of persons. It can happen to anyone, regardless of age, sex, occupation, education, social or national background. On the subject of age, for example, it is interesting that there was an age range of from twenty-eight to seventy among the alcoholics interviewed by the writer. There are almost endless variations in the pattern by which the addiction develops. Some alcoholics, for example, embark on their addiction after extended periods of controlled or social drinking, often at a time of personal crisis. The case of Mary P. illustrates this type:
Mary P., age forty-four, was born in a southern state. There was a great deal of conflict between her parents. Her father died when she was twelve. Her mother is described as "very nervous and neurotic -- a cold, straight-laced person who didn’t like people." Mary was an only child. She had few friends her own age. Often she got her way by means of temper tantrums. At seventeen she left home, "to get away from mother," and went to a large city to work. At twenty she married a man twelve years her senior who proved to be an alcoholic. The marriage lasted four years. She had begun drinking at the age of nineteen to give herself courage for social situations. When Mary was about thirty-five, she suffered the shock of a disappointment in love. After fifteen years of uneventful social drinking, she began to drink excessively. She began to drink alone and in the morning. After a while she began to hallucinate and even attempted to jump from a window when the ambulance arrived to take her to the city hospital. Of her drinking she says, "It was escapism -- the realities were too unpleasant." At the time of the interview, Mary had been sober for nearly three years in AA.
Many alcoholics embark on their pathological drinking from what seems like a relatively adequate psychological adjustment. About an equal number are quite obviously disturbed personalities. Those who begin addictive drinking early in life, or with no period of social drinking, are often of the latter type. Take Rita K., age twenty-eight, for example:
Rita was born in an eastern city. Her father was a weak sort of man who was nagged and dominated by his wife. Of her father Rita says, "He never really cared about me." Her mother is described as "a destructive bitch who was opposed to spanking but who nagged instead." Rita still feels sick inside when she thinks of her mother telling her at age eight that she was egocentric and silly. Later her mother predicted that she was going to become a prostitute. Rita was extremely shy and unhappy during her erratic childhood. She suffered from terrible guilt concerning masturbation. For days she went without saying more than a few words to anyone. She recalls, "I couldn’t get along with anyone." After college she held a series of jobs, following which she enlisted in the army. Six months later she was given a medical discharge with a diagnosis of dementia praecox. There seems to be considerable doubt about the accuracy of the diagnosis. She has been to a series of psychiatrists and has been "diagnosed as everything." Rita began to drink when she was fifteen. She found she was able to flirt after a few drinks. Before she was sixteen she was getting drunk at every opportunity. She says, "I always liked to get drunk; it was the only purpose of drinking for me. My drinking was a problem to me from the start." At the time of the interview Rita had been sober for about four months. Concerning her drinking as related to her psychological problems, she said, "Drinking is not my only problem, but it’s my first one now."
Rita has come to the valid insight that she must learn to live without alcohol if she is to be in a position to work on her psychological problems. Like Henry P., Rita is a periodic alcoholic.
Of the various classifications of alcoholics by types, the best-known is that devised by the late E. M. Jellinek, father of scientific alcoholism research. Acquaintance with this typology will help alert the clergyman to the multiple forms in which the illness can occur. Jellinek began with a broad operational definition: alcoholism is "any use of alcoholic beverages that causes any damage to the individual or society or both." 6 He then went on to identify five types:
Alpha alcoholism is a purely psychological dependence on alcohol to relieve pain -- emotional or bodily. Drinking damages interpersonal relationships, but there is no loss of control or other evidence of physiological addiction. Some students prefer to use "problem drinking" rather than alcoholism in describing this non-addicted excessive drinking, since there is apparently no loss of the ability to control the intake of alcohol. The clergyman often encounters such problem drinking in those marital difficulties in which excessive (but non-compulsive) drinking both reflects and intensifies the pain in the relationships. If the marital conflict can be reduced, this type of drinking usually diminishes and comes within nondestructive limits.
Beta alcoholism is characterized by such nutritional deficiency diseases as gastritis, cirrhosis of the liver, and polyneuropathy, without loss of control, withdrawal, or other addictive manifestations. It tends to occur in certain hard- drinking social groups in which there are poor nutritional habits. Damage is primarily physiological, with reduced life expectancy, reduced earning capacity, and reduced family stability resulting. The pastor may encounter this problem in social and economically disadvantaged groups. The nutritional deficiency diseases may also occur in the three following types of alcoholism.
Gamma alcoholism, the type from which the vast majority of American alcoholics suffer, is synonymous with "steady alcoholism." Like the Delta and Epsilon types, it involves a true physiological addiction. Loss of control, craving, increased tissue tolerance to alcohol, and withdrawal symptoms are present. It is the most destructive type, progressively impairing all areas of the person’s functioning, including his health. It has been estimated that 85 percent of AA members are Gamma alcoholics.
Delta alcoholism, often called "plateau alcoholism," is identified by the need to maintain a certain minimum level of inebriation much of the time, rather than consistently seeking the maximum impact of alcohol on the central nervous system, as the Gamma alcoholic tends to do. This type is found among Skid Row alcoholics who may ration their supply in order to distribute its effects over a longer time. It is prevalent among French alcoholics, and it is probably much more common than has been suspected among women alcoholics in the U.S. Characteristically, the person "nips" on alcohol a considerable part of the day; he maintains an "all-day glow," but may seldom become obviously intoxicated. Because of this and the fact that, unlike Gamma alcoholism, social disintegration tends to occur subtly and gradually, the Delta alcoholic is often able to hide his problem for many years.
Epsilon alcoholism is the "periodic" form of the problem, in which the person is usually abstinent between binges. Although relatively little is known scientifically about this type, it is probable that it occurs in persons subject to manic-depressive mood swings. The individual may begin a binge when he feels the skid into painful depression beginning. 7.
As Jellinek recognized, there is nothing absolute about this (or any) typology. The same individual may slip from one type into another -- e.g., from Alpha or Beta into Gamma; or from Epsilon into Gamma. There may be other types or patterns of alcoholism not yet identified. The value of this typology for the pastor is that of emphasizing the existence of alcoholisms and identifying those forms which he may encounter in his work.
The word "alcoholic" will be used in this book to refer only to the three addictive types -- steady, plateau, and periodic (Gamma, Delta, and Epsilon) -- in which loss of control is a crucial factor which must be faced in counseling. The special problems of counseling with "problem drinkers" (Alpha alcoholics) will be discussed briefly in Chapter 9.
Terms Related to the Subject of Alcoholism
Before proceeding, let us glance at some of the terms which we will use and which one is likely to encounter in the general literature on alcoholism. We have defined "alcoholic" and by inference "alcoholism." The term "problem drinker" may refer to a non-addicted excessive drinker (alpha alcoholism), or it is sometimes used as a synonym for "alcoholic" as defined previously. In counseling and educational work, "problem drinker" often is a valuable substitute for the term "alcoholic." This is true in those cases in which "alcoholic" is a stumbling block for the person or persons involved because of their preconceived stereotype concerning the term. "Alcohol addict" is roughly synonymous with "alcoholic" (Gamma, Delta, or Epsilon types) and is useful to keep in mind, in that it conveys a sense of the intensity of the compulsion involved. "Chronic alcoholism" usually refers to the advanced stages of the illness. It is during these stages that medical and psychiatric "complications" frequently occur.
These complications are the physical and psychological diseases resulting directly or indirectly from the prolonged excessive use of alcohol. They include polyneuropathy, pellagra, cirrhosis of the liver, Korsakoff’s psychosis, delirium tremens, acute alcoholic hallucinosis, and others. Such complications are suffered by one out of four alcoholics in our country. An alcoholic who is so afflicted is in need of immediate medical attention and often hospitalization.
The terms "high bottom" and "low bottom" refer, as has been suggested, to the degree of social disintegration that has occurred by the time the person "hits bottom" or becomes open to help. These terms are so completely relative as to be of limited usefulness except when describing those at the two extremes. Steady and periodic alcoholics occur among both high- and low-bottom alcoholics, although it seems likely that a much smaller proportion of low-bottom alcoholics are periodics than is true among high-bottom alcoholics.
How Alcoholism Develops
It is essential that we know something of the developmental pattern of alcoholism. It is important from a practical standpoint that one be able to recognize alcoholism at various stages. Early detection and treatment are as vital in this as in any other sickness. Knowledge of the danger signals or the early symptoms can be a valuable asset to a counselor. On the other hand, if we are to understand how religion meets the problem, we must know as much as possible about the problem. What experiences has the alcoholic been through, and how does he feel when he finally turns to a religious group for help? Again it is worth repeating for emphasis that no two alcoholics are alike and that all generalizations, therefore, are somewhat dangerous. However, it is true that there is a certain pattern of experiences which is characteristic of many, though not all, alcoholics. We need to know more about this pattern. Let us, therefore, trace the path by which the "glass crutch" develops and crumbles. The most systematic study of this process is that done by the late E. M. Jellinek, as reported in "Phases in the Drinking History of Alcoholics: Analysis of a Survey Conducted by the Grapevine, Official Organ of Alcoholics Anonymous." 8. Here is a summary of Jellinek’s findings concerning thirty-four kinds of characteristic alcoholic behavior and the average ages at which each first occurred:
THE ADDICTIVE PATTERN
Characteristic Number Average or Mean Age
1. Getting drunk 98 18.8
2. Blackouts 89 25.2
3. Sneaking drinks 89 25.9
4. Week-end drunks 74 27.2
5. Loss of control 95 27.6
6. Extravagant behav. 77 27.6
7. Rationalization 81 29.2
8. Losing friends 63 29.7
9. Morning drinks 91 29.9
10. Indifference to quality 84 30.0
11. Losing working time 90 30.4
12. Midweek drunks 78 30.4
13. Family disapproval 95 30.5
14. Losing job advancements 96 30.6
15. Go on water wagon 80 30.7
16. Losing job 56 30.9
17. Daytime drunks 85 31,0
18. Solitary drinking 87 31.2
19. Antisocial behavior 60 31.3
20. Benders 89 31.8
21. Remorse 91 32.2
22. Protecting supply 77 32.5
23. Tremors 90 32.7
24. Changing drinking pattern73 32.7
25. Fears 72. 32.9
26. Resentment 69 33.1
27. Seeking psychiatric help 53 35.0
28. Sedatives 60 35.5
29. Felt religious need 60 35.7
30. Seeking medical advice 80 35.8
31. Hospitalization 60 36.8
32. Admit to self inability to control 98 38.1
33. Admit to others inability to con. 91 39.5
34. Reached lowest point (hit bototm) 97 40.7
It is important for the person who is interested in helping alcoholics to keep this list of forms of characteristic alcoholic behavior in mind, remembering that no single form of behavior except "getting drunk" applied to all the alcoholics reporting. Because these thirty-four forms of behavior are of common occurrence among alcoholics, they constitute a useful guide, not only in identifying an individual as an alcoholic, but in helping to ascertain approximately at what stage he has arrived in his sickness. However, the order and average age of first occurrence varies tremendously from one alcoholic to another. For this reason, the list should not be used in a mechanical fashion. With this in mind, we will utilize the list, supplemented by case-history material collected by the author, to follow the drinking history of "Mr. X," a statistically average alcoholic. To repeat for emphasis, no person exactly like Mr. X exists. Every alcoholic is an individual, and therefore his alcoholism develops according to a unique pattern. However, there is a certain general pattern of development which applies, with modifications, to many alcoholics. To trace this general pattern is now our task.
Mr. X begins drinking at about sixteen and one-half when he becomes a part of a group for whom drinking is a folkway. (Only about 10 percent of alcoholics begin as solitary drinkers.) He is about eighteen and one-half when he first becomes intoxicated. If his need for the effects of alcohol had been relatively more intense, he might have become intoxicated on the occasion of his first drink. One alcoholic of this type said, "I never liked the taste of liquor; I would get in the half-world of alcohol and want to stay there, even in the early years."
X represents the majority of alcoholics who become addicted following a period of what appears to be normal drinking. Long before it gives him trouble, however, X’s drinking is abnormal. Alcohol is a social lubricant, and X needs a lot of lubrication. At the time X only knows that he "feels good" when he drinks -- more adequate and self-confident. Someday, in retrospect, he may say with one of the interviewees, "My drinking was alcoholic from the beginning because it meant too much to me." This was a danger signal which he could not recognize.
According to Marty Mann in her book, New Primer on Alcoholism, 9. the major psychological symptom of the early stage of alcoholism is growing dependence on alcohol. X is gradually using alcohol more and more as a means of interpersonal adjustment. He is experiencing its "pampering" effects. He begins to feel that he is not at his best unless he is "fortified." He drinks at the slightest provocation -- when he feels depressed or elated, when he has a success or failure in his work, to help him sleep, and to combat the "tired feeling" (which is increasingly present). He organizes his life more and more around his drinking times during the day.
X has good competitive resources and a strong success drive. In spite of his drinking, he does well in his work. Occasionally, when something has irritated him, he gets very drunk. But he is still able to control the occasions and general length of drunkenness. His drinking is not yet a symptom of the full-blown disease of alcoholism.
X’s tolerance for alcohol is increasing, i.e., he must drink more to get the same effect. After a period of particularly heavy consumption at around twenty-five, a new symptom appears. X "pulls a blank." He awakens the morning after a party to make the frightening discovery that he remembers nothing that happened after a certain point the night before. His friends assure him that he did not pass out and that his behavior was about as usual. This temporary amnesia disturbs X, and he vows with himself to "take it easy on the hard stuff." Among students of alcoholism it is believed that the occurrence of a blackout may indicate that a new process -- possibly a physiological one -- has begun. About 90 percent of alcoholics have them. Blackouts can be considered danger signals in that they occur approximately three times as commonly among pre-alcoholics as among drinkers who will not become alcoholics.
There are other omens of approaching alcoholism in X’s behavior. He sneaks drinks. At parties X slips out to the kitchen for an extra one. He may drink before he goes to a party, just to be sure he has enough. He gulps drinks. Everyone else drinks too slowly for him. He may begin carrying a secret supply. He lies about his drinking. He becomes defensive about how much he drinks. He lies to himself to hide the fact that his drinking is not the same as his friends’. He may feel some remorse about an embarrassing episode and promise himself to go "on the wagon" when his work lets up. Alcohol is beginning to cause him trouble.
One day when X is around twenty-seven and one-half, he drops into his favorite gin mill for his usual two drinks before supper. Against his conscious intention he "winds up cockeyed." He is mystified by his own lack of control, but he rationalizes that he has been under special strain lately. Before long X is consistently drinking more than he intends. About the same time (two years after his first blackout) X’s Friday night drunks expand to include the entire weekend. He has "lost control." It is noteworthy that loss of control usually occurs so gradually as to be imperceptible. The person first loses control of the amount he drinks and second of the occasion of excessive drinking. He begins to experience a craving for alcohol. Once he begins to drink, he often cannot stop. This fact determines the course of his alcoholism. He could probably still stop drinking at this point if he were aware of his need for help and could find it. But X rationalizes each experience of excess. He convinces himself (via spurious reasoning) that external circumstances cause his excess and that he can stop when he "really wants to." Lacking awareness of the nature of his problem, X starts on the search for the secret of controlled drinking. To learn the magic formula for "drinking like a gentleman" becomes almost an obsession. The search leads in one direction for an alcoholic -- downward.
As we saw in the case of Mary P., some environmental crisis may coincide with the onset of addiction. In the case of X, who represents the majority, no reason is apparent for his "crossing the line" into uncontrollable drinking. Perhaps it is simply that the inner pressures which have been gradually accumulating have surpassed the critical load.
Whatever the cause, X is now drinking compulsively. He is literally getting drunk against his intention. For reasons which we shall examine subsequently, he is blind to his condition. He defends himself by an elaborate system of alibis and self-deception from the truth that his drinking is out of control. He is caught in the talons of a compulsion that determines his behavior from a subconscious level -- below the rational or volitional activities of his mind. Yet he continues to believe that his problem is a matter of external circumstances ("A wife like mine would drive anyone to drink.") or of "bracing up and using a little more will power."
In the early years of his drinking, alcohol had been a neurotic solution to the problem of X’s interpersonal inadequacy. Now the solution has also become a problem. X is now drinking to overcome the pain caused by previous drinking. This use of alcohol marks the beginning of the actual addiction. A vicious cycle is established. To the extent that X regards his trouble as a matter of weak willpower, he thinks of himself as a moral jellyfish. The resultant guilt over his alcoholic behavior causes him additional psychological pain and internal chaos. So X increases the consumption of his favorite pain-killer, alcohol.
The vicious cycle of addiction also operates on the physiological level. One gray morning when X is about thirty, he is in such bad shape that he can’t navigate. His nerves are playing "Chopsticks," and there are drums in his head. Through the fog comes the dim recollection of hearing someone once say, "Only the hair of the dog that bit you can cure a bad hangover." So he pours himself a double shot and drinks it as he sits on the edge of the bed. He manages to keep it down, and by the time he has finished a cigarette, things begin to look better. He has found the quick, but disastrous, cure for all hangovers. He is now using alcohol as a self-prescribed medicine to cure the symptoms induced by previous drinking. The morning drink becomes standard practice. This is regarded as an almost sure sign that the person is in trouble.
X’s addiction spreads like a cancer, gradually disrupting the various departments of his life. At this point it is well to remember that many alcoholics become disorganized in one area but maintain stability in other areas of their lives. For example, one may continue to hold his job even though his social and domestic life is completely disrupted. This fact often confuses the one who is attempting to identify alcoholism in a particular case. Let us say that X represents the case in which alcoholism gradually creeps into all areas of life. His inner life has already been hit by the spiraling fears and resentments of compulsive drinking. This inner chaos is now reflected in his home life. His trying, irrational, egocentric behavior gives rise to a continuous round of quarrels, sprees, promises, ad infinitum. Of the author’s male interviewees, 65 percent had been divorced at least once. In many other cases, the spouse remained, in spite of everything, as a masochistic leaning-post for the alcoholic.
About the same time (age thirty), X’s vocational life is hit. He loses time from his work because of hangovers. Even when he is there physically, he is half absent mentally. As a result he is bypassed when advancements come. This gives him added reason to drink. Finally his boss has had enough. X quits in righteous indignation (just before he is fired) and gets roaring drunk.
Alcohol strikes his social life about the same time. Well-meaning friends plead: "You’ve got everything to live for. Why don’t you cut down for the kids’ sake?" or "Can’t you see what you’re doing to yourself? Try sticking to beer." The more he drinks, the less he cares about his friends, except for an easy "touch." The friends gradually disappear. Then X has his first bitter taste of the "penal treatment" for alcoholism. He lands in jail for drunken and disorderly conduct. He is pushed around by the police. (Hopefully, there is a growing number of courts which refer alcoholics to some treatment facilities. May their tribe increase!) The humiliation of all his experiences -- at home, on the job, with his friends, and with the law -- adds fuel to the flame of X’s motive for drinking. X now drinks to anesthetize the sense of failure, guilt, and isolation resulting from his drinking behavior. He is trapped in a vicious cycle of drinking to overcome the effects of drinking -- the "squirrel cage" of alcoholism.
What has happened to X? His excessive drinking was originally a symptom of his interpersonal inadequacy. Now the symptom has gone berserk and created what, in terms of therapy, is another disease entity. This "runaway symptom" 10 must be halted if X is to be salvaged.
After the age of thirty, statistically average alcoholic X’s disintegration moves rapidly. He now organizes his life around drinking. He plans his day in terms of it. He becomes increasingly indifferent to the quality of his liquor. At about the age of thirty-one he begins to have drunks in the daytime and during the middle of the week. This shows that his compulsion is driving him with greater force so that he becomes intoxicated at the times which are least socially acceptable. At about the same age X begins to manifest the social isolation which is typical of alcoholics. Solitary or "lone wolf" drinking is one expression. Antisocial acts -- aggressive, often malicious behavior -- are another. These indicate that the inhibiting power of social sanctions is weakening as X withdraws from normal society. Antisocial acts are his way of striking back at a rejecting society, as well as securing punishment which his guilt makes him crave. Each experience of interpersonal pain drives him deeper into his isolation and thickens his defensive shell of alcoholic grandiosity. This shell makes him difficult to reach with help. He lives more in the private world in which illusory "successes" compensate for real failures.
Social isolation is accelerated by the onset of benders, which provide ample opportunity for brooding and self-pity. His binges usually last as long as he can get liquor or keep it on his stomach. Jellinek once pointed out that "a man who stays drunk for days without regard to family, work and other duties commits such a gross violation of all cultural standards that his action cannot be a matter of choice unless his is a psychopathic constitution." 11. For this reason the onset of benders may be regarded as the beginning of the acute phase of alcoholism.
The end of each bender brings a horror-filled hangover. Of this, Marty Mann says, "The widely experienced hangover of the nonalcoholic drinker is but a pale approximation of the epic horror known to the alcoholic . . .an all-encompassing onslaught on himself." 12 One of the interviewees described such hangover: "You feel like you’re falling apart. Your whole body cries out for alcohol. You shake and shake." The important things to remember is that during or following such hangovers, the alcoholic’s defenses may be beaten down enough by the experience to render him open to receiving help.
Following a painful hangover, X may try a series of self-help plans. He goes on the wagon. He manages to remain abstinent for several weeks, but he is filled with self-pity and is socially unbearable. A speaker at an AA meeting recalled, "My wife said to me, ‘You’ve been dry for three months but you’re the same s.o.b. you’ve always been.’" X’s period on the water wagon ends in a humpty-dumpty act in the form of a long spree. Then he tries changing his pattern of drinking to find the secret of control. He decides that it must be the fourth drink that causes him to lose control, or certain kinds of drinks that cause him trouble. He changes his brand or drinks only with his left hand. When all experiments fail, he tries changing geographic location. "After all," he rationalizes, "wouldn’t New York make anybody want to get drunk?" So he moves to the country and gets drunk in the village saloon.
By the age of thirty-two, X is beset with nameless fears. Blackouts occur on nearly every drunk. On one bender he finds himself in a cheap hotel in a city eight hundred miles from home. He has no recollection of how he got there. About two years after his benders begin, X starts to show the "personality change" which is so typical that some students of alcoholism have labeled it the "alcoholic syndrome." Before his addiction X had been known as a good-natured fellow, honest and reasonably unselfish. Now he has become mean and selfish, watching the dire effects of his drinking on his family with apparent indifference. Freud once wrote (in Totem and Taboo), "Neurotics live in a special world in which only the ‘neurotic standard of currency’ counts." This is also true of alcoholics. X begins to live in a world in which only the alcoholic standard of currency has any value. Extramural values like honesty have less and less meaning. He will lie and steal (even from close friends, if he still has any) to achieve his one value -- his pearl of great price -- alcohol. He will pawn his coat in the middle of the winter. As one alcoholic put it, "For me alcohol was a necessity; my coat wasn’t."
X invests amazing ingenuity in protecting his supply, hiding bottles on ropes out the window and in the water closet of the toilet. If conventional beverage alcohol is denied him, he will turn to hair tonic, vanilla, and even Sterno to get his alcohol. Drinking is no longer an option with him; he must drink to live.
By about thirty-five, X is desperate enough to seek help. Approximately two thirds of Jellinek’s cases reported feeling a religious need. X may begin to pray. The usual gist of his prayers is, "Get me off this hook, and I’ll never do it again." Along with X’s other relationships, his relation to organized religion has disintegrated. If he is a Protestant, he probably began to get away from his church about the time he started having blackouts; if he is a Catholic, this avoidance behavior occurred somewhat later. In his desperation X may become a religious "taster" -- now Unity, now Christian Science, now his wife’s church. He may go to see one or more clergymen -- to placate his wife, make an easy touch, or because he feels a genuine religious need. He may prefer a minister who does not know him although this depends on the nature of his previous relationship to clergymen.
At about the same age that X seeks religious help, he may also try psychiatric and medical help. The doctor tells him that he has a bad liver and must give up alcohol. This warning may effect a brief sobriety, or he may walk out of the doctor’s office into the nearest bar like a rebellious child. At the age of thirty-seven, after a protracted binge, X has his first hospitalization for alcoholism (although the doctor may have to register him under some other diagnostic label to get him into an unenlightened hospital). if the hospital is enlightened, so far as alcoholism is concerned, he will receive medication for acute intoxication and vitamin therapy, to make up for the vitamin deficiency caused by the weeks of "drinking his meals." In addition, he may be visited by members of AA who have a working relationship with the hospital administration. If the hospital merely "dries him out" and treats his physical condition, without giving attention to the underlying trouble, X will be drunk within a few hours, days, or weeks after release. As the months stagger past, X lands in a series of sanitariums, rest homes, and "cure" establishments. Sixty-nine percent of the author’s male interviewees had been hospitalized; six of these forty-one had been in thirty times or more.
The failure of each attempt to get help plunges X deeper into the dismal morass of advanced alcoholism. He drinks around the clock. Every moment of partial sobriety is filled with irrational thoughts and fears. One alcoholic said, "I was a façade with a puddle of fear behind." He loses all sense of time. The need for alcohol provides the only continuity in his life. The withdrawal of alcohol at any time brings all the tortures of hell. His jitters are now best described as "leaps." The pleasant sedative effect of his early drinking is now gone. As one alcoholic puts it, "I just tipped back the bottle and skidded into oblivion." More and more alcohol is required to produce blessed oblivion. So he may begin to use "goof balls" (barbiturates) to enhance the waning effects of alcohol. If he does, he has added another layer to his complex problem. He may become addicted to drugs as well as alcohol.
[Note: AA regards the abuse of barbiturates and tranquilizers as a major hazard for alcoholics. See "Tranquilizers, Sedatives, and the Alcoholic" (AA World Service, 1959). One danger is derived from the mutually reinforcing effects of alcohol and these drugs, resulting in accidental and potentially fatal overdoses.]
As his reality situation becomes increasingly grim, X requires an increasingly grandiose self-concept to protect his alcoholic ego. This picture of himself can be maintained only by longer flights into the reality-denying world of alcoholic fantasy. His pre-alcoholic inferiority feelings are now grounded in reality. He is not only unemployed; he is practically unemployable. Fears of the future form a vicious alliance with terrible remorse (usually hidden from others) about the past. X feels that nobody understands him. His inner conflicts have grown to almost complete paralysis. Even little tasks like tying his shoelaces become impossible without a drink. Two hands are required to get the glass of whiskey to his lips. He hides himself in cheap hotels -- drinking, drinking, drinking -- until he is taken to the city hospital in alcoholic delirium. He feels cornered -- trapped like a rat.
By this time X may be a physical wreck. His face may be bloated, his eyeballs yellow. His endocrine and metabolic systems are apt to be acutely disturbed. His steps are uncertain. His hands tremble. There is a vacant expression in his eyes. However, the extent of physical disturbance which some alcoholics can hide even in the advanced stages of the illness is often amazing.
At the age of thirty-eight and one-half, Xs’ alibi or rationalization system, by which he has for so long defended his ego, begins to crumble. He stands before the (to him) humiliating truth that he is unable to control his drinking. The fact that has been painfully obvious to others for a long time is now forced upon him. He is licked, and he knows it. In spite of this it takes another year or more for him to admit to others that he cannot control his drinking.
At about forty, X reaches his "bottom." This is a matter of emotional bankruptcy and does not necessarily involve living on Skid Row. Having hit bottom, X is what one student of alcoholism has called a "ripe alcoholic." For the first time he is really open to outside help. If none is available, he may attempt suicide. What brings X to his bottom? Perhaps a specific and crushing humiliation. Perhaps the fact that liquor -- his god -- has let him down by losing its effect. Perhaps some physical illness tips the scales in his psychic economy so that it becomes more painful to drink than not to drink. In many cases there are no obvious causes. Whether or not there is a precipitant, the feeling most commonly described is, "I was sick of myself and wanted to die."
Within a few years after this there comes a fork in X’s path. He must find help or risk going under. Going under means a "wet brain" (one of the alcoholic psychoses) and the booby hatch, Skid Row, and a welfare grave. Or, he may go on for years teetering on the brink of destruction.
Many of the alcoholics who come to religious groups and leaders for help have gone through something like the course which we have traced. Many others who come in contact with ministers are of the hidden type -- men and women who are holding jobs and living with their families. One of the stereotypes which has been very slow in becoming dislodged from our thinking is that alcoholism is synonymous with extreme social disruption or deterioration. Actually the ability of many alcoholics to maintain stability in some areas of their lives over extended periods is quite amazing. Some alcoholics who come for help have paused for years at one stage or another of the developmental pattern. Others have gone through the stages described with greater rapidity. Some may have had entirely different developmental patterns. Because a person does not fit the typical pattern does not mean that he is not an alcoholic. If his drinking interferes with any of his basic interpersonal relationships, then he is an alcoholic.
Some of the alcoholics interviewed by the author were fortunate. They reached their "bottom" long before they had come to the level of physical, mental, moral, and religious disintegration described in Mr. X. Some had actually "gone under" and then had come back via a religious solution. In either case -- high-bottom or low -- they were desperate and defeated when they found a religious solution. Otherwise they would not have been able to accept help.
The Woman Alcoholic
The problem of the woman alcoholic has received increased attention in recent years, particularly by those who treat alcoholism and are impressed with the substantial numbers of women seeking help. To what extent this reflects a "greater rate of emergence of formerly hidden alcoholism among women" 13 and to what extent a rise in the number of women alcoholics (associated with the increase of women drinkers since World War II) is not really known.
In a study by psychologist Edith S. Lisansky, forty-six women alcoholics and fifty-five men alcoholics were compared.14 All of them came to Connecticut alcoholism outpatient clinics voluntarily. The male and female groups were found to be approximately the same in social class, age, education, and ethnic background. Marital disruption was prevalent among both groups (and to a similar extent). Alcoholism in a parent, sibling, or a spouse was more common among the women alcoholics than among the men. Thirty-five percent of the women, but only 9 percent of the men, reported alcoholism in their spouses. Apparently alcoholics tend to attract alcoholics to some extent. Lisansky found that the average woman alcoholic had begun to drink later and had lost control of her drinking later than the average male alcoholic. Only about half as many men as women could point to a specific life crisis which seemed to precipitate excessive drinking -- e.g. divorce, death of a parent, an unhappy love affair. The study showed that a "significantly greater proportion of women alcoholics drink alone, presumably at home. Frequently reported patterns were going to bed at night with a bottle and sipping at home during the day." 15. Significantly, the women sought help sooner after the beginning of addictive drinking than did the men. This may be due either to a telescoping of the stages of the illness or to less resistance to seeking help on the part of the woman alcoholic, perhaps both.
Probably because they tended to drink alone and at home, in a "plateau" pattern, the women in the study had a markedly lower rate of arrests and mental hospital commitments than the men. It is likely that "respectable" hidden (or semi-hidden) women alcoholics who stay out of difficulty in the community constitute the vast majority of female alcoholics. This does not mean that the plight of women alcoholics is less tragic than that of male alcoholics. In some ways, it is more tragic in its devastating impact on the emotional health of the family organism. One experienced therapist with alcoholics declares:
Many women alcoholics start drinking when their husbands leave for work in the morning and their children are off to school. Yet, somehow, they manage to pull themselves together to get the evening meal on the table. The discovery of their illness . . . waits for months or even years while the guilt and the fear and the loneliness torment them. 16.
Several students of the problem have said that women alcoholics show much greater personality abnormality than do male alcoholics. Clinical evidence is often cited which seems to support this view. The inference drawn from this is that women alcoholics are generally more difficult to treat than are male alcoholics. Lisansky makes an important observation about this:
As a rule, women alcoholics, like men, are not seen in clinics or hospitals until the drinking problem has gone on for some years. It is likely that the social consequences of the drinking problem, i.e., family breakup, job dismissal, rejection by friends and associates, and general social disapproval, are greater for the woman alcoholic who is known as such. The woman patient who appears at a clinic or hospital after years of uncontrolled drinking could therefore conceivably be a more disturbed individual than her male counterpart as a result of her alcoholism and its socially punishing consequences, and not because she was initially, in her pre-alcoholic personality, a more disturbed individual. 17.
The Lisansky study compared the women outpatient clinic patients with a group of women alcoholics who had been committed to a state farm for various offenses. Striking differences between the social background of the two groups were found. The state farm group showed more psychopathology, greater marital disruption, less drinking alone, and four times the sexual promiscuity associated with drinking, as compared with the clinic group. Lisansky concludes that at least two subgroups must be distinguished among "women alcoholics" -- the "respectable" woman whose drinking is relatively concealed and the woman alcoholic whose drinking makes her an obvious problem to society and not just to herself and her family. It is possible, Lisansky speculates, that there are other subgroups -- e.g. unmarried middle-aged women who become alcoholic because of feelings of loneliness and diminished self-esteem.
The Size and Cost of the Problem of Alcoholism
Of the approximately eighty million adults in the United States who drink -- about seventy-one percent of the adult population 18. -- between five and six million can be considered "alcoholics" by our definition. The National Council on Alcoholism estimates six and one-half million, whereas the Rutgers University Center of Alcohol Studies holds that our most reliable evidence points to an estimate close to five million. 19. For every female alcoholic in the U.S.A., there are between four and five male alcoholics.20. The Rutgers Center put the 1965 estimates at 4,200,000 male alcoholics and 800,000
female alcoholics.21. Of every one hundred males who drink, nine and one-half are alcoholics. For every one hundred adults in the United States, 4.2 are alcoholics. The rates vary greatly from one geographical region and state to another, within the country. For example, Nevada with 6.6 alcoholics per one hundred adults, and California with 6.4 stand in sharp contrast to Idaho with 1.9 and Alabama with 1.8. Variations of alcoholism rates among countries are also striking.22. France has the highest rate with 5.7 alcoholics per one hundred adults.
There seems to be no evidence of a substantial rise in the rate of alcoholism 23 either among drinkers or in the total adult population since 1948. But there has been an enormous expansion of the total number of drinkers since 1940 -- a rise of thirty-seven million. This increase reflects both the expansion of the population and the rise in the percentage of those who use alcohol. Thus, without a marked rise in the rate of alcoholism, the total number of alcoholics nearly doubled between 1940 and 1966 (from 2,600,000 to 5,000,000 plus).
It is striking to note that alcoholism is more than five times more prevalent than cancer. Psychiatrist Karl Menninger has stated that the alcoholics in the United States constitute our largest single mental health problem. In speaking at the annual meeting of the National Council of Churches’ Department of Pastoral Services, he said, "Nothing looms as large on the horizon. Every day we see horrifying examples of men and women who drink up every penny they own and make serious critical errors in judgment that affect you and me. It is a problem which is taking a tremendous mental, social and physical toll." 24.
The economic, social, and cultural costs of alcoholism are staggering in their dimensions. The economic liability of having a large proportion of 4.25 million adult males out of fully productive relationship with the community is gigantic. The illness most frequently reaches its full-blown form between ages thirty-five and fifty, normally a time of maximum productivity. The estimated two million employed alcoholics probably cost industry a billion dollars annually in absenteeism, high accident rates, and inefficiency. When AA had only sixty thousand members, they had an estimated annual earning capacity of $150,000,000. In New York City, where there are at least 200,000 alcoholics, the annual loss of wages due to this sickness is estimated at $50,000,000. Family relief costs each year, in New York City, due to alcoholism, are approximately $2,600,000.25 Twenty-two percent of male first admissions to mental hospitals in 1964 were given the diagnosis of alcoholism.
There are other less tangible costs. Untreated alcoholism takes twelve years off the life expectancy of its victims and makes their later years a kind of living death by crushing potentialities for constructive relationships. The social costs of this, though impossible to measure, are astronomical. The pain and destructiveness are certainly not limited to the alcoholics themselves. Around each alcoholic there is what has been fittingly termed a "circle of tragedy" composed of all those whose lives are in close touch with his. The total number of persons involved in these circles has been estimated at twenty million by Marty Mann, director of the National Council on Alcoholism. Obviously the psychological damage to the children of alcoholics is impossible to estimate. Or take the cultural costs. For every artist who appears to be more creative when under the influence there are probably a dozen who "drink their poems," their symphonies, their novels, and their plays. In his book The Other Side of the Bottle,26. Dwight Anderson gives us a poignant example of this facet of the tragedy of alcoholism. He points out that the familiar words "All the world is sad and dreary, everywhere I roam," reflect the pathos of the alcoholic’s inner world. Their author died in the alcoholic ward of New York’s Bellevue Hospital at the age of thirty-eight. In his pocket was a torn piece of paper on which were penciled the words for a song, "Dear friends and gentle hearts," a lyric which might have been loved like "Jeanie with the Light Brown Hair." The story of alcoholism is replete with such might-have-beens.
In this chapter we have given what can be considered a working definition of alcoholism : A person is an alcoholic if one or more of his major adjustments in living -- health, vocational, social, or marital -- is periodically or continuously hampered by drinking. We have described the types and developmental pattern of alcoholism from the beginning when alcohol is a neurotic solution to interpersonal problems, to the point at which the solution itself becomes the chief problem. We have discussed the problem of the woman alcoholic. Lastly, we have described the size and seriousness of the problem. Let us now examine the causes of alcoholism.
1. M. A. Maxwell, "Drinking Behavior in the State of Washington," QJSA, XIII (June, 1952), 236.
2. Six Sermons on the Nature, Origin, Signs, Evils and Remedy of Intemperance (New York: American Tract Society, 1827).
3. Alcoholics Anonymous, The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism (New York: Works Publishing, 1950), p. 43.
4. "How to Help an Alcoholic, A Brief Medical Summarization with Practical Suggestions and Tests" (Columbus, Ohio: School and College Service, 1951).
5. From "Alcoholism: A Major Health Problem, A Major Public Responsibility," report of the National Committee on Alcoholism presented to the Annual Meeting on March 18, 1955.
6. The Disease Concept of Alcoholism (New Haven: Hillhouse Press, 1960), p. 35.
7. See ibid., pp. 36-41, for a discussion of these five types.
8. QJSA, VII (June, 1946), 8-9.
9. (New York: Holt, Rinehart & Winston, 1950), P. 24.
10. For this highly descriptive term, I am indebted to the late Harry Tiebout, a psychiatrist who did a great deal of work with alcoholics.
11. QISA, VII (June, 1946), p. 72.
12. New Primer on Alcoholism, p. 40.
13. Mark Keller and Vera Efron, "The Prevalence of Alcoholism," QJSA, XVI (December, 1955), 631-32.
14. Edith S. Lisansky, "Alcoholism in Women: Social and Psychological Concomitants," QJSA, XVIII (December, 1957), No. 4, 588-623.
15. Ibid., p. 605.
16. Genevieve Burton in "The Woman Alcoholic," The Evening Bulletin (Philadelphia), October 18, 1966, p. 19.
17. "Alcoholism in Women," p. 590.
18. Harold A. Mulford, "Drinking and Deviant Drinking, U.S.A., 1963," QJSA, XXV (December, 1964), No. 4, 639. Based on a survey done by the National Opinion Research Center showing that 79 percent of the U.S. males and 63 percent of the U.S. females drink. (A 1946 survey showed that 75 percent of males and 56 percent of females drank.) Mark Keller of Rutgers estimates that the total drinking population, including the fifteen to twenty-one age group, was 93½ million in 1965. A national survey conducted in 1964-65 showed that 68 percent of adults drink. The difference between this figure and the 71 percent figure of the 1963 survey may reflect sampling variation rather than a change in drinking practices.
19. Mark Keller, Lecture at the 1966 Rutgers Summer School of Alcohol Studies, "Trends in Drinking and Trends in Alcoholism, with a Critique of Statistics and Statwistics."
20. The National Council on Alcoholism estimates that there are four male alcoholics to every female alcoholic; the Rutgers Center puts the ratio at 5.3 to 1, in 1965 (see Keller lecture).
21. See Keller lecture.
22. Accurate comparisons of alcoholism rates in different countries are extremely difficult to make because of wide variations in the way vital statistics are collected and recorded in this field. Data on deaths from cirrhosis of the liver (per 100,000 of the population) are available, e.g. Australia -- 5.0%; Austria -- 15.6%; Belgium -- 8.2%; Canada -- 5.2%; Denmark -- 6.4%; England -- 2 .6%; France -- 31 9%; W. Germany -- i 2.4%; Italy -- i 3.9%; Israel -- 3 .3%; Japan -- 8 .6%; Netherlands -- 3.4%; Sweden -- 4.4%; Switzerland -- i 3.1%; U.S.A. -- i0.2%. "Jellinek’s formula," by which alcoholism rates in this country are estimated, is based on the assumption that there is a significant and relatively constant correlation between deaths from cirrhosis of the liver and alcoholism. No direct inference about international alcoholism rates should be drawn from comparing cirrhosis of the liver mortality rates, however, since the variations in the relationship between these rates and alcoholism rates, from country to country, are not known. The above figures can only be taken as suggestive. The figures are from Epidemiological and Vital Statistics Report, XI, No. 4 (Geneva: World Health Organization, 1958), 136-38.
23. Mark Keller, "The Definition of Alcoholism & the Estimate of Its Prevalance" in Society, Culture, and Drinking Patterns, ed. by David J. Pittman and Charles R. Snyder (New York: John Wiley & Sons, 1962), p. 326.
24. The Clipsheet, Methodist Board of Temperance, Washington, D.C.., July 25, 1955.
25. From a study conducted by the Committee on Alcoholism of the Welfare and Health Council of New York in 1952.
26. (New York: A. A. Wyn, 1950), p. 28.
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