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Despite the public's growing acceptance of addiction as a biopsychosocial disease from which recovery is possible, an ideological chasm persists between psychiatry AA.
Despite the public's growing acceptance of addiction as a biopsychosocial disease from which recovery is possible, an ideological chasm persists between psychiatry and Alcoholics Anonymous (AA). Some psychiatrists remain put off by the "spiritual" aspects of AA; some die-hard members of AA insist that alcoholics should never use psychotherapy or prescribed drugs.
This turf battle between AA and psychiatry harms the addicted patient and society. It results in only marginal recovery, organic damage or death to patients, and frustration among fanatical adherents of either camp. (Of all the alcoholics and drug addicts out there, only a lucky few actually experience both solid sobriety and good mental health, mostly because they or their families were exposed to both 12-Step programs and psychiatry-at the right time and in the right way.)
What makes this standoff ironic is that one of our very own, namely Carl Jung, played a crucial role in the genesis of Alcoholics Anonymous. We learn this from a Jan. 23, 1961 letter written to Jung by Bill Wilson (a.k.a. Bill W., a cofounder of Alcoholics Anonymous):
My dear Dr. Jung...a certain conversation you once had with one of your patients, a Mr. Roland H., back in the early 1930s, did play a critical role in the founding of our fellowship...you frankly told him of his hopelessness, so far as any further medical or psychiatric treatment might be concerned. The candid and humble statement of yours was beyond doubt the first foundation stone upon which our society has since been built.
What Jung had told the dying Roland H. was that only a spiritual experience could save him.
What Psychiatrists Need to Accept
1. In the real world of addiction therapy, the diagnosis of alcoholism is based on the patient's psychosocial functioning. What causes a problem is a problem, i.e., if the patient's alcohol/drug use causes problems-then the alcohol/drug use is a problem that needs to be aggressively treated.
2. Treatment begins with total abstinence from alcohol and other mind-altering drugs, regardless of what else may be troubling the patient.
3. Treatment of any concurrent disease (e.g., diabetes by an internist or schizophrenia by a psychiatrist) is not effective if the patient continues to use alcohol or drugs PRN.
4. The addicted patient refuses to stop drinking or drugging-the psychiatrist should stop treating the patient. (Treatment may be continued if the patient is relapsing and still going to 12-Step meetings.)
It is instructional to elaborate on this difficult point by looking at the treatment encounter between a famous psychoanalyst and a famous alcoholic patient. I'm referring to Lawrence Kubie, M.D., "a famous psychoanalyst of that period" as described by his patient, the famous comedian Sid Caesar in his autobiography, Where Have I Been, published by Crown in 1982.
I began my sessions with Dr. Kubie in December 1957. He said to me "Why are you here?" I said, "Well, I'd like to stop drinking, if I can."
He said, "You stop drinking by stopping drinking."
I said, "I'm aware of that. The thought has occurred to me."
He said, "Well, the Christmas holidays are coming up. You will have no drinks. Nothing."
I said, "Wait a minute. I'm going to have to go to NBC parties. I'm gonna have to go to sponsors' parties...I'll give it a try."
He said, "You won't give it a try. You'll do."
When I came back for my next session with Kubie, I said, "Well, I only had three drinks in all this time..." I was about to continue when he flicked on his intercom to his secretary. He said, "Case of S.C. will be closed and the file put away." Then turning to me, "You are dismissed, Mr. Caesar."
I was really very hostile. It was not one of my finer moments.
The sad thing about it is that he was right. If I had only known then what I know now: That the only way to stop drinking is by stopping drinking. If he had only tried to get across to me with less authoritarianism, more sensitivity.
There followed many more visits with different doctors who prescribed a variety of drugs. There were also numerous attempts at "controlled drinking" until November 1978, when sobriety finally began.
What AA Can Provide that Psychiatrists Cannot
1. Sober social meeting places with sober alcoholics/addicts.
2. Twenty-four-hour-a-day STAT availability of individual supportive counsel by the patient's 12-Step sponsor or the AA group-at no cost to the patient or society.
3. A spirituality-based recovery program.
(In this connection, it is pertinent to ponder Jung's ideas. In his reply letter to Bill W., dated Jan. 30, 1961, Jung said that recovery can be achieved "by an act of grace or through a personal and honest contact with friends or through a high education of the mind beyond the confines of mere rationalism.")
What Psychiatrists Can Provide that AA Cannot
1. Safe medical detoxification.
2. Differential diagnosis to rule out other mental or physical disorders.
3. Drugs prescribed as needed or helpful. (No antidepressants for at least one month. Initially, all alcoholics are depressed. If they are not depressed, they are still in denial or they are psychotic.)
4. Psychiatric evaluation and treatment of family members.
5. Written, required documentation of the patient's progress (mental status and social/occupational functioning) to employers, DMV, Federal Aviation Administration, etc.
What About Psychotherapy?
Many patients-after they have attained months or even years of sobriety-will seek psychotherapy, alone or with family members. That is the time when we psychiatrists can provide something that 12-Step groups actually forbid, namely "cross-talk." By that I mean individual and/or group therapy involving clarification, questioning, challenging, confrontation, working with transference and even using drug urine testing as a clinical tool.
But here is a trap psychiatrists have to carefully avoid: In the forefront of all psychotherapy must remain the principle that the patient remain abstinent and involved in Alcoholics Anonymous. (There is a growing acceptance, even among members of the American Psychoanalytic Association, that psychoanalysis alone for addicts or alcoholics is inadequate. Psychotherapy with such patients can be done only if the patients are making a sincere effort to stay clean and sober and are continuing to be in 12-Step groups).
Bill Wilson and Jung recognized alcoholism for what it was in 1931, and what it still is today: During medical detoxification the doctor may literally pull the patient's body from death's door. But while the patient's brain is still clouded by the effects of alcohol, psychotherapy has to take a back seat. (As Dr. Stan [ASKING AU] Gitlow is fond of saying, "You can't teach navigation on the deck of a sinking ship.")
Although the physician or psychiatrist may continue to lend support, the patient initially has to rely on Alcoholics Anonymous or other 12-Step groups to attain and maintain sobriety.
Bill Wilson's letter to Jung concludes: "Many thoughtful members of Alcoholics Anonymous are students of your writingother members have-following their recovery in AA-been much helped by your practitioners. Please be certain that your place in the affection and the history of our fellowship is like no other. Gratefully yours, William G.W."
Psychiatrists can be crucial in addiction treatment because they are trained to provide elements of treatment that others-including the AA group, the AA sponsor or other physicians-cannot. But this will only work if the psychiatrist can work with certain concepts that formerly were considered insurmountable dogmas and obstacles, namely total abstinence, spiritual recovery and the patient's participation in Alcoholics Anonymous.
Bill Wilson himself reminds us in his later writings that he, too, underwent successful psychotherapy after he had gotten sober in Alcoholics Anonymous.
In order to treat alcoholics successfully, psychiatrists must undergo an attitudinal change. In my case, I have enjoyed professional success and personal satisfaction because I approach my alcoholic and other drug-addicted patients with two basic concepts in mind:
1. Alcoholism is not a Valium dependency;
2. Life is not an alcohol deficiency.
If I stick to these principles, my patients may grumble, but they stay in treatment because they have already learned the hard way that these concepts are valid.
In the coming decades, research will show that addictions, in part, depend on the vagaries of neurotransmitters, receptor sites and whatever else we may discover. But until these mechanisms are more clearly understood, our addicted patients will rely on us to hold the line with a treatment approach that works.
As for helping addicted patients to return to social drinking or casual drug use-it doesn't work. These patients have alcoholism, not alcoholwasm.