New Insights into Alcoholism

By Jane O'Reilly

A major study tackles basic questions about problem drinking

Everybody knows an alcoholic, and everybody thinks he knows why the person drinks. Weak character. No self-control. Had a miserable childhood. Has a terrible marriage. Cannot face reality. Hates work. Is paranoid. The denials and rationalizations, the self-pity and selfimportance, the guilt and anguish are all parts of a predetermined type, the "alcoholic personality." Right?

Wrong. The alcoholic personality is the result of alcoholism, not the cause. This is the most startling and original conclusion of a new landmark study, The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery (Harvard University Press; $25), on the affliction that hits one American family in three. The author, Dr. George Vaillant, 48, a Harvard psychiatrist, is one of the most respected researchers in adult development. Vaillant tackles other key questions that specialists in the disorder have been debating for years: Can an alcoholic return to social drinking? Is there a genetic cause for the affliction? Why are some ethnic groups more likely to become alcoholics? How effective are hospital treatment centers?

It is a mark of Vaillant's achievement that his book, instead of sparking more controversy on a disputed subject, is being hailed by leaders in the field as a major breakthrough. Dr. William Mayer, acting head of the Federal Government's National Institute on Alcohol Abuse and Alcoholism, considers Vaillant's work to be "an unmatched contribution and a reasoned approach to solving the massive health and social problems relating to the excessive use of alcohol." Last week the American Medical Society on Alcoholism gave Dr. Vaillant its annual award "in commemoration of outstanding contribution and unstinting dedication" in the field of alcoholism research.

The key to Vaillant's work is that it is the first long-term study of alcoholism as it develops in individual lives. The usual approach is to examine alcoholics to see how their sickness evolved, a technique that is always blurred by the distortions of the victim's memory. Vaillant was able to begin at the beginning. For the past 16 years he has been the director of a unique research study that since 1940 has been following the lives of 200 Harvard graduates and 400 innercity, working-class men from Boston and Cambridge. In 1977 Vaillant published the first results of this research: Adaptation to Life, a study of factors in the Harvard group that led to success after college. In his new work, which focuses on 136 men who became alcoholics, Vaillant also draws on his experience as a director of the respected Cambridge Hospital Alcohol Program. Vaillant and his fellow researchers watched 26 from the Harvard group and 110 from the blue-collar group travel their individual paths to alcoholism and, equally important for the study, observed men with similar lives who did not develop problems.

People begin drinking socially for a myriad of reasons, including, most notably, peer pressure. But the answer to one question remains elusive: Why do people become alcoholics? In the continuum from a few too many drinks at a party to loss of control over drinking, where is the trigger point? Vaillant says that it is impossible to say, but at some level the casual drinker becomes physiologically and psychologically addicted to liquor. "You are an alcoholic," says Vaillant, "when you're not always in control of when you begin drinking and when you stop drinking."

But why do some people become addicted to alcohol if most do not? The reasons, says Vaillant, are as complex as people. Once hooked, argues Vaillant, an alcoholic drinks from habit and not to resolve conflict.

Although no one is predisposed by personality to become an alcoholic, Vaillant believes that a person is likely to drink too heavily--and find himself some day addicted--if he is demoralized, feels that he is a social outcast, is "susceptible to heavy-drinking peers," or can seemingly "handle" his liquor well, drinking everyone under the table. People who drink for a specific reason, such as a death or illness in the family, are more likely to be able to control the practice than those who use liquor for unknown reasons. Vaillant claims that a serious drinker does not proceed automatically down the path to alcoholism and, indeed, may be able to lead a remarkably stable and happy life. The study shows that moderate drinkers (who do not exceed an average of four drinks per day) often turn out to be better adjusted socially than total abstainers.

Recognizing alcoholism is simpler than pinpointing its causes. Says Vaillant: "The warning signs of alcoholism are when a person finds himself doing things when drinking that he regrets afterward, or if he has ever gone on the wagon, or tried to change brands to control his drinking." Some other danger signals: five or more drinks daily; problems with family or friends or at work over drinking; two or more blackouts while drinking.

Is an alcoholic predetermined by his genes? Vaillant believes there is a connection, noting that one out of three victims has a close relative who is alcoholic. But he doubts that researchers will ever find the biochemical marker. "I think it would be as unlikely as finding one for basketball playing," he says. "The best analogy is most coronary heart disease, which is not due to twisted genes or to a specific disease. There is a genetic contribution, and the rest of it is due to maladaptive lifestyle: too much fat, too little exercise. One gets alcoholism not because one does something terrible over the past week, but because, over time, one has done a lot of maladaptive things."

Certain ethnic groups, Vaillant found, are collectively maladaptive. Irish men in the study generally grew up in families where alcohol was forbidden, drinking took place apart from meals and away from home, and male drunkenness was tacitly admired. The Irish in the survey also became alcohol dependent seven times as frequently as the Italians, who as children learned that drunkenness was frowned on and drank with family groups and with meals (thus diminishing the addictive effect of the alcohol "high"). To Vaillant, these sharp differences (which are also true of the more alcoholic Northern Europeans as contrasted to moderate Jews) suggest that "one of the directions we should go is to teach children how to make intelligent drinking decisions." Vaillant, a social drinker, serves wine to his children, Anne, 16, and Henry, 17, on ceremonial occasions.

The high number of children of alcoholics who become addicted, Vaillant believes, is due less to biological factors than to poor role models. Being raised in a warm, close-knit family does not lessen a child's chances of becoming an alcoholic, nor does coming from a family with many problems increase the risk. Vaillant is reluctant to make predictions about behavior, but believes that the best sign that a child may not develop into an alcoholic as an adult is an "ineffable" quality--ego strength--that seems to come from experiencing a sense of competence when the person is young.

The hottest argument among experts on alcoholism these days is over whether an alcoholic can ever again return to social drinking without inevitably suffering a relapse. Vaillant, who constantly repeats that alcoholism is a problem that can be described only in grays, not in black or white, says that it all depends on how sick the alcoholic is: "If you have a little bit of alcoholism, as if you have a little bit of diabetes, you can control it." But Vaillant warns, "By the time a clinician identifies a person as an alcoholic, it's almost always too late to return to social drinking." On this issue, Vaillant is supported by the National Council on Alcoholism. Says Dr. Sheila Blume, medical director of the N.C.A.: "The alcohol-dependent or loss-of-control alcoholic is not able to return to drinking."

Dr. John Wallace, director of Edgehill Newport, a 165-bed alcohol-treatment program in Newport, R.I., says flatly that the suggestion that an alcoholic might be able to return to social drinking safely is "a serious ethical problem, because at least 97% of alcoholics, if you let them drink, could die."

The immediate, desperate question for millions of Americans is neither why nor how a person becomes an alcoholic, but how to treat the affliction. The first step, writes Vaillant, is recognizing that alcoholism is "neither a psychological symptom nor some vague unnamed metabolic riddle waiting to be deciphered." It is not a sin, but a progressive disease that may take years to acquire, and from which it may take years to recover. Writes Vaillant: "The task is to convince the patient not that he or she is an alcoholic, but that he or she is a decent person who has an insidious disease--a disease that is highly treatable but, like diabetes, requires a great deal of responsibility from the patient." To Vaillant, the fact that half of all alcoholics do manage to recover is a solid sign of hope. He feels that too much attention has been paid to those who do not.

Some of Vaillant's most important, and controversial, conclusions about treating an alcoholic came as a surprise even to the author. Traditional psychiatric approaches may be helpful for treating accompanying symptoms, such as despair, paranoia or anxiety, he believes, but they are nearly useless in dealing with the underlying nature of alcoholism itself. In his book, he ruefully describes his own disillusionment with his profession's ability to cope with the disease. "I was working for the most exciting alcohol program in the world," he says. But the results at the clinic were no better than if the doctors had left the alcoholics alone.

Other professionals agree with Vaillant's glum assessment. "We don't do anything adequately," admits Dr. Robert Millman, director of the Alcohol and Drug Abuse Service at Payne Whitney Psychiatric Clinic in New York City. Explains Dr. Blume of the N.C.A., who is a psychiatrist: "Psychiatrists have been trained that alcoholism is a problem which comes from early-childhood experiences, but aren't taught how to treat alcoholics. They go after these 'underlying causes,' treatment doesn't work, the alcoholic gets worse and the psychiatrist decides that the disease is intractable."

What about expensive hospital treatment centers, now so fashionable that they have become a growth industry with companies listed on the New York Stock Exchange? Vaillant concludes flatly that they do not work in the long run, although he believes they may be useful in rescuing, however temporarily, a person who is about to collapse under the strain of his illness. Nor can a seriously ill alcoholic "will" himself to give up liquor.

"Recovery," says Vaillant, "occurs through a series of events coming together." One is that alcoholics usually need some kind of substitute for alcohol, such as tranquilizers or psychotherapy or a support group of people with similar problems. "Second, even though it's terribly unscientific, alcoholics usually do seem to need some kind of source of hope and selfesteem, or religious inspiration--whatever you want to call it--and that seems more important than hospital or psychiatric care."

What Vaillant calls the "natural healing processes" that relieve suffering and create hope are best fostered today, he believes, by Alcoholics Anonymous. He argues that the first step to sobriety is an acceptance of the first precept of A.A.: "I am powerless over alcohol." Says Vaillant: "A.A. is the most effective means of treating alcoholism, and it worked for sophisticated, Harvard-educated loners as well as for gregarious blue-collar workers."

One of the most impressive aspects of Vaillant's work is his own deep respect, strengthened instead of diminished after close analysis of 600 lives, for the capacity of human beings to heal even their most inexplicable and terrifying afflictions themselves. He also argues persuasively that it is not only essential, but possible, for alcoholics to regain control of their lives. --By Jane O'Reilly. Reported by Mary Carpenter/New York and Ruth Mehrtens Galvin/Boston

With reporting by Mary Carpenter/New York and Ruth Mehrtens Galvin/Boston This file is automatically generated by a robot program, so viewer discretion is required.