Surprisingly, absence of risk factors for alcohol abuse did not predict successful remission. The skills that get you out of a hole are likely independent of the forces that got you in. The remitted alcoholics abused alcohol for an average of two decades at least, and the severity of their alcoholism and their genetic vulnerability had been if anything greater than that of their nonremitting counterparts. Limited education, which is also a risk factor for alcohol abuse, did not inhibit stable remission. Indeed, the less-educated Inner City men were significantly more likely than their Grant Study counterparts to become abstinent. Although the per capita cigarette consumption of the alcoholics was almost twice that of the nonalcoholics, the severity of cigarette abuse among alcoholics was not statistically associated with eventual abstinence.
7. Is recovery through AA the exception or the rule? For both cohorts, regular AA attendance was strongly associated with sustained abstinence. All four of the factors in Table 9.3 are embodied in the AA program and in many other incorrectly named “self-help” recovery programs organized along similar lines. I put self-help in quotes because AA is as much about self-help as a barn-raising. In both of these community activities, success is at least as much about helping other people as about helping yourself. Four variables were associated with Study men joining AA: severity of alcoholism, Irish ethnicity, absence of maternal neglect, and a warm childhood environment.
Of the nine alcohol-dependent College men who achieved stable abstinence, five (56 percent) attended AA for between 30 and 2,000 meetings. Two other alcohol-dependent College men attended about 50 meetings but relapsed. Of the thirty-nine alcohol-dependent Inner City men with stable abstinence, at least fourteen (36 percent) attended AA for 50 to 2,000 meetings. The Problem Drinking Score assessment of the alcohol-dependent Inner City men with fewer than 30 AA visits was about 9. Men who attended more than 29 AA visits (the mean was 400) had a mean problem drinking score of 12—a very significant difference. One doesn’t usually seek painful hip replacement before one’s arthritis has become quite severe, and “hitting bottom” increases the alcoholic’s willingness to sit on hard church chairs, drink bad coffee, and take “the cotton out of one’s ears and put it in one’s mouth” several times a week. In both cohorts, the men who were stably abstinent attended about twenty times as many AA meetings as the chronically alcoholic (Table 9.4).
Table 9.4 Question: How Does AA Work? Answer: AA Works Fine!
Very significant = p<.001; Significant = p<. 01; NS = Not Significant.
THE STORY OF JAMES O’NEILL
The story of James O’Neill illustrates how alcoholism reverses what are commonly thought to be cause and effect; it demonstrates that alcoholism is the horse in life’s troubles, not the cart. O’Neill behaved very badly while drinking, but—however difficult this may be to believe—in 1950, before his alcohol abuse began, he had been assessed by the Study staff as a man of “unqualified” ethical character, and the rather prim director of the Health Services had described him as a “straightforward, decent, honest fellow, should be a good bet in any community.”
James O’Neill did not come to psychiatric attention until 1957, thirteen years after his Harvard graduation, when he was first admitted to a psychiatric ward at aVA hospital. A thirty-six-year-old father of four and former assistant professor of economics, O’Neill described himself as a “failure at his marital and professional responsibilities because of drinking and missing teaching appointments.” His admission note stated, “Present symptoms include excessive drinking, insomnia, guilt and anxiety feeling.” The diagnosis was “behavior disorder, inadequate personality.”
O’Neill provided the following history, paraphrased from his hospital record. He began drinking and gambling in the summer of 1948, while depressed over a poor performance on his Ph.D. generals. He was drinking during the daytime, and missing teaching appointments. However, he did continue to teach and to keep his family together. He finished his Ph.D. without difficulty, and in 1955 he left his large West Coast school for a research university in the South.
At the time of his admission, O’Neill expressed suspicion and anger toward the important people in his life, all of whom, he alleged, had treated him badly. Otherwise he showed little emotion, and the interviewer commented: “His pattern of drinking, sexual infidelity, gambling and irresponsible borrowing led him to recognize from his reading that it adds up to diagnosis of psychopathic personality, especially since he has experienced no real remorse about it.” It was known that he had given his son some books to sell, and that four books from the university library were among them; he was accused of stealing university property, and fired for moral turpitude. He assured the hospital staff that he did not sell university books knowingly.
The psychiatric record continues:
During all of the time that O’Neill was frequenting bars, contacting bookies and registering in hotels to philander, he always used his own name. It’s interesting that when he was carrying on his nefarious pursuits, he got considerable satisfaction out of it being known that he was a professor. . . . When his mother died in 1949, he felt no remorse [sic] at her death. He did not remember the year of his mother’s death. In view of the fact that he dates his extracurricular activities as beginning in 1948, this confusion is probably significant.
During his eight-month hospital stay, the patient . . . was able to work out a great deal of feelings toward his family, in particular toward his mother and also toward his wife. The patient felt quite hostile and anxious about the fact . . . that his parents were always very cold. . . . He harbored many feelings of hostility toward his wife whom he feels does not appreciate the fact that she’s married to such an intelligent college professor. All she wants is to have money and bigger homes.
The discharge diagnosis was “anxiety reaction manifested by feelings of ambivalence about his family, his parents and his work.” The precipitating stress was considered to be “death of the patient’s mother and a long history of drinking and gambling and going into debt.” His predisposition was considered to be “an emotionally unstable personality for the past 20 years.” At one point the VA even called him “schizophrenic.” A diagnosis of alcoholism was never even considered.
But the Grant Study record told a completely different story. In college, James O’Neill had been the embodiment of the Grant Study’s ideals of optimal health and achievement. He was one of the brightest men in the Study, and after three years of observation he received an A in psychological soundness. A child psychiatrist blind to his life after age eighteen was asked to compare his childhood environment with those of his Grant Study peers. She placed it in the top third, and summarized the raw data on his childhood as follows:
O’Neill was born in a difficult delivery. The mother was told not to have more children. His parents were reliable, consistent, obsessive, devoted parents. They were relatively understanding, and their expectations appear to have been more non-verbal than explicit. The father was characterized as easy to meet, the mother was seen as more quiet; no alcoholism was reported. Warmth, thoughtfulness and devotion to the home were some of the comments. The subject spoke of going to his father first with any problems, but of being closer to his mother than to his father. His peer relations were reported to have been good, and little or no conflict with his parents was reported.
She went on to predict that O’Neill would develop into “an obsessional, hard-working, non-alcoholic citizen, whose work would be related to law, diplomacy and possibly teaching. He would rely on his intellect and verbal abilities to help in his work. He would probably marry and be relatively straight with his children. He would probably expect high standards from them.”
Other observers summed O’Neill up equally favorably in the years before he turned thirty. The dean’s office ranked his stability as “A” while he was in college; the Study internist described him as “enthusiastic, whimsical, direct, confidant, no grudges or chips, impressed me as an outstanding fellow.” The s
taff psychiatrist was impressed by his “combination of warmth, vitality and personality,” and also put him in the “A” group. When he was twenty-one, he married his childhood sweetheart, with whom he had been in love since he was sixteen; in 1950, six years after they married, the marriage still seemed solid. When O’Neill was twenty-three, his commanding officer wrote that he gave “superior” attention to duty and was a particularly desirable officer.
From the prospective record it was also possible to record a more accurate picture of O’Neill’s feelings about his mother’s death. The child psychiatrist who assessed the prospective record saw his as among the best mother-child relationships in the Study. His mother’s physician commented that O’Neill had been “devoted and helpful during the illness,” and in 1950, six months after her death, a Study observer noted that O’Neill felt her loss deeply. It was only seven years later, on his admission to the VA, that O’Neill reported having no feelings toward his mother and blamed her alleged coldness for his current unhappiness. Over time, alcoholics develop excellent collections of “resentments.”
O’Neill was one of the lostest of the Study’s lost sheep. He had stopped returning questionnaires long before his hospitalization. It was not until 1972 that he finally brought the Study up to date on the progression of his life and his alcoholism. He had begun drinking heavily in 1948 while still in graduate school, and by 1950 he was drinking in the morning. In 1951 O’Neill’s wife’s uncle, an early member of AA, had suggested the possibility of alcoholism. But his wife insisted to the Grant Study, with whom she had maintained connection even while O’Neill did not, that her husband was not abusing alcohol. Furthermore, in 1952, at his first admission, the health services at his university whitewashed his drinking as due to “combat fatigue.” His prospective 1946 military record revealed, however, that O’Neill had experienced no combat in World War II.
In 1972 I interviewed O’Neill, and he filled in some long-standing gaps. We met in his apartment. He was balding and sported a distinguished mustache; his clothes were worn but elegant. He came across as an energetic man who kept a tight rein on his feelings. At first during the interview he had a lot of trouble looking at me and seemed very restless. He chain-smoked, walked back and forth, lay down first on one bed and then on the other. Although he avoided eye contact, there was a serious awareness of me as a person, and I always felt he was talking to me. He behaved like a cross between a diffident professor and a newly released prisoner of war. As he put it to me, “I’m hyper-emotional; I’m a very oversexed guy. The feelings are there, but it’s getting them out that’s hard. The cauldron is always bubbling. In Alcoholics Anonymous, I’m known as Dr. Anti-Serenity.”
He admitted that he had been chronically intoxicated between 1952 and 1955 while writing his Ph.D. thesis, and that he had regularly sold books from the university library to buy alcohol. By 1954 his wife had begun to complain about his drinking; by 1955 it was campus gossip. But no diagnosis of alcoholism was made during his 1957 VA hospital admission or the subsequent one in 1962. In our 1972 interview, I felt that O’Neill himself still did not understand the cause-and-effect relationship between his drinking and his misery.
In 1970, O’Neill became sober in Alcoholics Anonymous. By our 1972 interview, AA was clearly the most important force in his life, besides his wife. He made frequent reference to it; when I asked him what his dominant mood was, he replied, “Incredulity. . . . I consider myself lucky. Most people in Alcoholics Anonymous do.”
Even after two years of complete sobriety, O’Neill described himself to me as “a classical psychopath, totally incapable of commitment to any man alive.” To me, though, he felt like a lonely but kindly man. I never had the feeling that he was cold or self-absorbed. If anything, he suffered from a hypertrophy of conscience, not a lack thereof. Remember that, although alcohol does not help insomnia, chronic anxiety, or depression, it is the best antidote for guilt that we have.
As I was leaving, I noticed several books related to gambling on the bookshelves. Aha, I thought. Were these the lingering remnants of the sociopathy he talked about? No, as it turned out. Once sober, he had sublimated his interest in gambling. He had consulted to the governor of Louisiana while the state lottery there was being set up—a considerably more profitable occupation for an economist than frequenting racetracks. In other words, with the remission of his alcoholism, O’Neill’s ego functioning had matured; instead of compulsively acting out his interest in gambling, he had yoked his passion to his Ph.D. in economics, and harnessed them both in a socially and personally constructive way.
In closing, O’Neill told me that he could not agree with AA in calling alcoholism a disease. “I think that I will the taking up of a drink,” he said. “I have a great deal of shame and guilt and remorse and think that’s healthy.” I heartily disagreed; I suspect that his shame had facilitated his denial of his alcoholism for twenty years, and that by reframing it as a disease, AA had rescued him. Sadly, O’Neill died two years after our interview from coronary heart disease, a fate undoubtedly hastened by twenty-five years of chain smoking.
THE STORY OF FRANCIS LOWELL
The history of Francis Lowell, aka Bill Loman, illustrates how different alcoholism looks to sociologists and to physicians. In this case, the two viewers were myself! Without realizing it, I narrated one man’s story twice, never recognizing him the second time as a person I had studied fifteen years before.
Francis Lowell was an effective and well-paid upper-class New York lawyer. In 1995 I used his life as evidence that the misuse of alcohol, like heavy smoking, is not a disease, but a lifestyle choice.32 Given enough education, willpower, social support, and a forgiving occupation, a fortunate drinker could drink as long and as much as he wanted. In college Lowell had been a heavy social user of alcohol, and very guarded about answering Grant Study questions related to his alcohol use. By age twenty-five, this gregarious man had established a pattern of heavy drinking Friday through Sunday, and none during the rest of the week. He continued this pattern over the next forty years. His heavy weekend drinking sometimes expanded into five-day binges, with a loss of one or two days of work, but Lowell abused alcohol from age thirty to age seventy without any noticeable decline in his physical health or serious damage to his legal career (most of his clients were rich family members).
Lowell was aware that he had a problem with his drinking by the time he was thirty. He felt guilty about how much he drank; his friends criticized his drinking; he failed to keep his promises to cut down; and when he was drinking he avoided his relatives. At age thirty-nine he had his first drunk-driving arrest; there was a second one at age forty-seven. He had his only detoxification at age fifty-two, but his physical exam and liver chemistries were normal. At age fifty-six, Francis Lowell said of himself, “No doubt about it, I do drink heavily at times,” but he never stopped drinking, except for giving it up for Lent. Many weeks he drank within social limits, and usually he did not drink during the week. He attributed his successful steady pattern of alcohol abuse to the fact that his stomach would not tolerate more than five days of drinking. And, he added, “I don’t want to sound pompous, but a sense of duty drilled into me from family and from St. Paul’s School contributes to my control. . . . You just can’t let everything go.”
By fifty-nine, Francis Lowell was making $200,000. His heavy alcohol intake did not interfere with his work, although his career did not advance after sixty. And it did not (much) interfere with his relationships; it had contributed to his loss of the woman who had most touched his heart, but by remaining single he limited further damage. After he turned sixty-two, his doctor began encouraging him to cut down on his drinking, and at age sixty-six he had a seizure “possibly related to alcohol.” Nevertheless, at seventy Francis Lowell was still working forty hours a week and earning his handsome salary. Compared to his college classmates he was still very active physically, and his liver chemistries were still normal. I wrote in my first biography of him,
“At no time in his life has he described a wish to become abstinent and he continued to drink ten drinks a day on the weekend.” In short, I believed that Francis Lowell had a lifelong problem with alcohol, but not a “progressive disease.”
THE STORY OF BILL LOMAN
But alcoholism has an unstable, chameleon-like quality. After I had forgotten my original description of Lowell, I wrote the life history of a chronic alcoholic whom I called Bill Loman. It wasn’t until after the fact that I discovered that I had written about the same man in 1983, seeing his life from a very different point of view, and making a point very different from the one I was aiming at the second time. Although there had been only four more years of follow-up and a little bit more data, my view of Lowell/Loman had shifted from the sociological to the medical one. Light can act as both wave and particle, and alcoholism can present as both habit and disease. Only years of observation allow us to identify both of these patterns in the same person. Bill Lo-man was one of the Study’s great illustrations that the genes for alcoholism can derail anyone, no matter how promising his beginnings.
Bill Loman was a man destined for great things; he became a tragic figure not because he deserves our scorn, but because he had the disease of alcoholism as his implacable enemy. At St. Paul’s School, Loman had been a senior prefect and captain of the football team. He was elected to the most prestigious club at Harvard, and he graduated magna cum laude. College descriptions of Loman included “unspoiled by his wealth,” “well-poised and very attractive,” “rather mature.”
His World War II record was exemplary too. He won three battle stars for active participation in the Battle of the Bulge and the crossing of the Roer and the Rhine Rivers. His commanding officer described him as “intensely loyal, collected and cool under most trying conditions. . . . Sense of humor never deserts him.” He was promoted to first lieutenant and then to captain. The Study director, summing up the twenty-five-year-old Loman’s military record, remarked, “This boy could go quite far.” After the war, Loman went to Harvard Law School and finished in the top tenth of his class. He returned to New York to practice corporate law at a prestigious firm. He was elected to the very best clubs in the city, and spent his weekends playing golf and bridge with other members. At thirty, he was an upper-class football captain poised to be a superstar when he grew up.
Triumphs of Experience: The Men of the Harvard Grant Study Page 31