In a study of carefully recorded histories of alcoholics in our hospital, two
important facts appear to be outstanding.  Expressed briefly, they are:
1) A majority or our patients do not wish to have an alcoholic problem.  They
lead busy lives & would like to enjoy the fruits of their efforts, but they
cannot stop the use of alcohol.
2) These patients cannot use alcohol in moderation.

The allergic nature of true alcoholism was postulated in a previous paper.  
We then endeavored to show that alcohol does not become a problem to every
person who uses it, & that the use of alcohol in itself does not produce a
chronic alcoholic.

The phenomenon of craving must be present as a manifestation of an allergy.  
Once established in an individual, one drink creates a desire for more.  It
sets this person aside as a separate entity.  It creates a conflict that ends
in a form of neurosis.

Looking further at the record of these unfortunates, we find that the
majority could not drink in moderation from the very beginning.  Whether 20,
30, or 50 years of age, they soon become a problem to themselves & to their
friends.

Now in analyzing these alcoholic-minded persons, there is no one physical or
psychical fact that is sufficiently constant to justify its use as the basis
of an accepted theory.  Such phrases as "escape from reality" & "inferiority
complex" hold true for some, but not all, while heredity, only son, & implied
spoiling in childhood, account for a few more.  They all lead to confusion &
have no answer.
Eliminate the constitutional psychopaths, the moral & mental defectives, &
there remains a large class, neurotic in type, for whom something is worth
doing.  Remember we are discussing the chronic alcoholic, not the man who
drinks more than is good for him but has no resulting problem.

Apparently all these people - good, bad & indifferent - have one thing in
common: they cannot drink in moderation.  We believe they show manifestations
of an allergy to alcohol.  They may abstain from use of alcohol for a month
or a year, but on taking it again in any form, they at once establish the
phenomenon of craving.  This fact is well known to all alcoholics & creates
their major problems in the early stages of their drinking habits.  They
complain about it, too.

Why, we naturally ask, in the early years of drinking, while they still have
the ability to choose, do these people not solve this problem by the complete
discontinuance of alcohol?  Some do, but many are like the rest of us who do
things we know we should not, but like to do them anyway.  Many really
believe they can drink as they see others doing, & enjoy themselves.  For
many reasons, most of which are social or even physical, the idea of drinking
is developed gradually.  As this idea advances, daily life becomes more
secure, but these men are unwilling to accept the facts as presented to them.
 The act of drinking (in the end damaging) is followed by certain comfortable
emotional states that make it a pleasure.  They prove to themselves that they
can stop drinking by going on the wagon for varying periods, but even as life
becomes more complicated, they still persist in that old, original idea.  Up
to this time, in what one might call the first period of alcoholism there are
methods employed to help these persons return to a normal life & accept the
fact that their old idea of drinking must be discarded forever.  We ourselves
have treated some of them with permanent results, but the majority continues
along the primrose path.  The history of these people & their families
present from now on, one of the real tragedies of human life & is too well
known to comment on further here.

This begins the second stage.  Understood by no one & not understanding
themselves, they enter an ever-widening circle, remorse, penance, new
transgressions, new penance, until they lose all capacity for spontaneous
action.  They sacrifice themselves for a perversive idea & defying the law of
nature (allergy) operating in their case, pay the penalty.  They have lost
all pleasure in normal life.  Based on their underlying neurotic nature, they
develop a compulsion type of thinking, and, although not a true compulsion
neurosis, it is surely a borderline type.  The patient now acts under what
has been called by Wechsler a psychic imperative, the dreaded terminal state
of paralysis of the will.  The predisposing factor in bringing about this
definite state of insecurity is the conflict brought about by alcoholism.

It is not within the scope of this paper to discuss the complications of the
obsessional neurosis, which are, in fact, the most elastic of all the
neuroses, but in this particular type it seems to permit a retreat from the
ever-increasing anxieties induced by the advancing chronic alcoholism.
This compulsive thinking is apparently a purely intellectual process
occurring more frequently among persons of relatively higher intellectual
attainment, from which class, by the way, comes the average chronic alcoholic.


Characteristic of all compulsion types of thinking is the relatively good
insight that accompanies them.  The victim knows his impulse to drink is
wrong but he is helpless before it.  Wives may plead, friends argue, &
employers threaten, but he is no longer amenable to impression.  He is unable
to resolve between opposing impulses.  He cries out in agony, "I must stop, I
cannot be like this; but I cannot stop; someone must help me."

If he has sufficient means, he has by now been treated by psychiatrists, good
men, who fully realize the unfavorable prognosis, but who, often without
remuneration, give freely of their time to help the victim.  I have often
seen psychoanalysis of an alcoholic, instead of breaking up the compulsive
thinking; start the person further theorizing on his own illness.

We know that, as a rule, the only relief from psychoanalysis is in making the
so-called transfer, & experience has taught us that this is gratifyingly
successful if accomplished.  If successful, it must be based on respect &
confidence on the part of the patient.  It can seldom be accomplished in this
class of patients, except by one who has suffered in the same manner & has
recovered.  In other words, to accomplish the transfer of this compulsive
idea by the plan we have seen developed, an ex-alcoholic who has recovered by
the same means be the medium employed.  Such a medium can explain
convincingly, not only that the transfer of the compulsive thinking can be
made, but also he can prove how he did it himself successfully.

We physicians have realized for a long time that some form of moral
psychology was of urgent importance to alcoholics, but its application
presented difficulties beyond our conception.  What with our ultramodern
standards, our scientific approach to everything, we are perhaps not well
equipped to apply the powers of good lying outside our synthetic knowledge.

About four years ago, we hospitalized a young man for severe chronic
alcoholism, &, while under our care he developed a plan that seemed to me to
be a combination of psychology & religion.  He never drank any form of
alcohol again.

Later he requested the privilege of being allowed to tell his story to other
patients &, perhaps with some misgiving, we consented.  The cases we have
followed through have been most interesting: in fact many of them are
amazing.  The unselfishness of these men as we have come to know them, the
entire absence of profit motive & their community spirit, are indeed
inspiring to one who has labored long & wearily in the field of alcoholism.  
They believe in themselves, & still more in the Power which pulls chronic
alcoholics back from the gates of death.

Of course, prior to & in preparation for the application of this plan, it is,
in my opinion, essential to detoxicate the alcoholics by hospitalization.  
You then have a subject whose brain is clear & whose mind is receptive &
temporarily free from his craving.  I hesitate here to attempt even an
outline of the plan as employed by these men.  Sufficient to say, perhaps,
that following many failures, they gradually devised a plan or procedure that
led them to make this so-called transfer to one greater than themselves, to
God.

The whole story is admirably told in a book written by them entitled
"Alcoholics Anonymous".  It would seem to me that they have wrung from the
Eternal a new application of an old truth that is sufficient equipment to
restore the patient in his fight for sobriety.  The results seem to flow
naturally from a follow-up of honest effort.

To make any such plan practical they have also projected this transfer beyond
the individual to the group.  The information of these men into groups, each
one with the hand of fellowship passing on his experiences to others, helping
those who have newly joined to adjust themselves, actively engaged in
gathering in new members, seems to me the most practical application of their
moral psychology, to assure their "transfer" of being permanent.  (Although I
have met some 30 or more of these ex-alcoholics.  I relate my experience with
two of them.)

About one year prior to this experience a man was brought in to be treated
for chronic alcoholism.  He had but partially recovered from a gastric
hemorrhage & seemed to be a case of pathological mental deterioration.  He
had lost everything worthwhile in life, & was only living, one might say, to
drink.  He frankly admitted & believed that for him there was no hope.  
Following the elimination of alcohol there was found to be no permanent brain
injury.  He accepted the plan outlined in the book.  One year later he called
to see me, & I experienced a very strange sensation.  I knew the man by name &
partly recognized his features, but there all resemblance ended.  From a
trembling, despairing, nervous wreck, had emerged a man brimming over with
self-reliance & contentment.  I talked with him for some time, but was not
able to bring myself to feel that I had known him before.  To me he was a
stranger, & so he left me.  More than three years have now passed with no
return to alcohol.

When I need a mental uplift, I often think of another case brought in by a
physician, prominent in New York City.  The patient made his own diagnosis, &
deciding that his condition was hopeless, had hidden in a deserted barn,
determined to die.  He was rescued by a searching party, & in desperate
condition brought to me.  Following his physical rehabilitation, he had a
talk with me in which he frankly stated he thought the treatment a waste of
time & effort, unless I could assure him, which no one ever had, that in the
future he could have the will power to resist the impulse to drink.  His
alcoholic problem was so complex, & his depression so great, that we felt his
only hope would be through what we then called "moral psychology," & we
doubted if even that would have any effect.  However, he did adopt the ideas
contained in this book.  He has not had a drink for more than three years.  I
see him now & then, & he is as fine a specimen as one could wish to meet.
 

Re: Pyschological Rehabilitation......
This was actually an edited version (of a much longer Medical Record original
submission) of another and separate expanded speech given in May, 1939
resultant of Dr. Tiebout public comments on surrender and psychology in
alcoholic treatment ( and had no direct relationship to the Doctor's Opinion,
a letter written at Bill W's request upon the recommendation form Dr. Esther
Richard's of Johns Hopkins Hospital, -- and edited for the BB by Bill W).
The main result was a reinforcement of the concept of "the terminal state of
paralysis of the will", a predisposing factor to alcoholism. The follow up
article that same year "A New Approach to Psychotherapy in Chronic
Alcoholism" was really the second half of the speech, and an attempt at
presenting the overlying images of spiritual healing, psychology, and
physical treatment in one speech.