Wednesday, 28.10.2020

Peter R. Martin: Historical Vocabulary of Addiction

Self-help

 

        According to the current electronic version of Oxford English Dictionary (OED), the noun self-help<//em>is a combination of the prefix self and the noun help with the prefix in objective relationship to the noun.  The definition of the term is: “The action or faculty of using one's own efforts and resources to achieve something, or provide for oneself, with little or no assistance from others; (in later use) specifically, the action of managing or overcoming personal or emotional problems in this way.” The word self was inherited from the Germanic and help is from Old English.   

        The notion of self-help first appeared in the English language translation of the ancient Roman poet Virgil’s Eclogues (Gent 1628): “All Selfe-helpe, and hope, both faild.” However, the use of self-help with respect to treatment of addiction is a more recent and evolving concept.  As indicated in OED, the word self-help has commonly taken the form of an attributive construct as in terms such as self-help bookself-help group, etc.  The long tradition of self-improvement guides in book form (not necessarily in a medical sense) dates to a volume appropriately titled, “Self-Help”, the first page of which began with the following aphorisms (Smiles 1859): “Heaven helps those who help themselves” is a well-tried maxim, embodying in a small compass the results of vast human experience.  The spirit of self-help is the root of all genuine growth in the individual; and, exhibited in the lives of many, it constitutes the true source of national vigor and strength. Help from without is often enfeebling in its effects, but help from within invariable invigorates.”  The author, the Scotsman Samuel Smiles (1812-1904), endorsed the notions of hard work, thrift and sobriety as the road to success for both elite and the masses.  Although the tradition of the self-help book has continued in its various forms to this day, its ultimate expression with respect to what is considered a serious medical illness is embodied in the generally known “Big Book” (Alcoholics Anonymous), first published in New York in 1939.  Of note, the noun Alcoholics Anonymous is defined in the latest electronic version of OED as originating in the United States where it is a proprietary term: “an association for the mutual support and rehabilitation of alcoholics; abbreviated A.A. The organization was founded at Akron, Ohio, in 1935.”  It is perhaps not a coincidence that the formation of A.A. was so close in time to to the end of Prohibition in the United States, a nationwide constitutional ban on the production, importation, transportation and sale of alcoholic beverages from 1920 to 1933.

        In the Foreword to the First Edition of the “Big Book,” quite clearly stated is that A.A. is not simply self-help, but rather, mutual support (Wilson 1939): “We, of Alcoholics Anonymous, are more than one hundred men and women who have recovered from a seemingly hopeless state of mind and body.  To show other alcoholics precisely how we have recovered is the main purpose of this book.  For them, we hope these pages will prove so convincing that no further authentication will be necessary. We think this account of our experiences will help everyone to better understand the alcoholic.  Many do not comprehend that the alcoholic is a very sick person.  And besides, we are sure that our way of living has its advantages for all.”  Therefore, social connection and shared beliefs between those in the fellowship are perceived as fundamental to the process of A.A., allowing social learning and modelling (Bandura and Walters 1963) as a means for a person suffering from alcoholism to achieve recovery.  Moreover, alcoholism is considered a medical illness in A.A., a notion for which there was almost a century of precedent by the time A.A. was established (Huss 1849).  A.A. was not the first mutual support organization for those suffering from alcoholism as early temperance societies (e.g., Washingtonians, Oxford Group) were first founded in America in the nineteenth century (Tyrrell 1979).  However, A.A. has become influential worldwide and has served as a model for healing and recovery through human connectedness with others sharing similar misfortunes from various chronic psychiatric, medical and social disorders/problems, not always related to alcohol/drug use disorders (Trice and Staudenmeier 1989).   

        As a result of A.A. and related programs, a vocabulary has emerged, which while idiosyncratic, is understood in psychiatry and other specialities of medicine.  For example, the noun Al-Anon is defined in OED as: “A mutual support organization for the families and friends of alcoholics, especially those of a member of Alcoholics Anonymous.” The noun Alateen is: “A division of the Al-Anon mutual support organization, dedicated to helping (especially teenage) children who are affected by the alcoholism of a family member (especially a parent) or friend.”  The noun twelve step was first used in the “Big Book” (Wilson 1939): “He has read this volume and says he is prepared to go through with the twelve steps of The Program of Recovery.”  In OED twelve step is defined as: “The twelve stages of a programme designed by Alcoholics Anonymous to help people recover from alcoholism; (hence) twelve stages comprising any similar programme designed to help people recover from addiction or compulsive behaviour.”  The term connotes sequential passage through the tasks of recovery via twelve steps each of which represents: “An act of bodily motion consisting in raising the foot from the ground and bringing it down again in a fresh position; usually, an act of this kind as constituting by repetition the progressive motion of a human being or animal in walking, running, or climbing.”  In the vernacular of A.A., the noun is even used as a verb (twelve stepping) the ultimate indication of a widely accepted and understood concept (Clark and Clark 1979).

        Although the “Big Book” contends that for those who live according to its principles, “we hope these pages will prove so convincing that no further authentication will be necessary.” In addition, the chapter entitled “How it works” begins: “Rarely have we seen a person fail who has thoroughly followed our path.  Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who constitutionally incapable of being honest with themselves.”  Although this may seem circular thinking and hardly follows the scientific method, there are clearly those who are successful with Alcoholics Anonymous and the challenge is to understand why.  Alcoholics Anonymous has received scientific recognition by a Lasker Award in 1951: “in recognition of its unique and highly successful approach to that age-old public health and social problem, alcoholism…
Alcoholics Anonymous works upon the novel principle that a recovered alcoholic can reach and treat a fellow sufferer as no one else can. In so doing, the recovered alcoholic maintains his own sobriety; the man he treats soon becomes a physician to the next new applicant, thus creating an ever-expanding chain reaction of liberation, with patients welded together by bonds of common suffering, common understanding and stimulating action in a great cause…
It enjoys the goodwill and often the warm endorsement of many medical and scientific groups…
Historians may one day point to Alcoholics Anonymous as a society which did far more than achieve a considerable measure of success with alcoholism and its stigma; they may recognize Alcoholics Anonymous to have been a great venture in social pioneering which forged a new instrument for social action; a new therapy based on the kinship of common suffering; one having a vast potential for the myriad other ills of mankind (laskerfoundation.org/awards).

        Psychiatrists who worked with alcoholics in the 1950s referred patients to A.A., “Yet they believed only 10 per cent of the persons who join A.A. remain sober for over two years. This against the claim of A.A. that 60 per cent or more of their fellowship are recovered emphasized the pessimism of the psychiatrists questioned (Hayman 1955).” Of course, one of the methodological issues in research conducted on A.A. has been that “A self-help group such as A.A. is also self-selecting, and the person who cannot identify with the image is self-excluding” (Edwards, Hensman, Hawker and Williamson 1966).  Additionally, the “treatment” employed is not fully standardized nor subject to experimental modification by virtue of the organization, and hence, all research is descriptive by its very nature (Bebbington 1976).  All the same, A.A. is so widely used that a panel of experts of the Institute of Medicine commented (1990): “Given its great importance in U.S. treatment programs, it is unfortunate that A.A. has not been the subject of more empirical research… the enduring success of this organization in attracting alcoholics to recovery is itself worthy of study. There is, therefore, a pressing need for high-quality research on the impact and mechanisms of AA.”

        Psychological research has demonstrated that participation in A.A. is of demonstrable benefit and highly cost-effective compared to other approaches that are available, however, the mechanisms involved are unclear (Project MATCH Research Group 1998; Kelly 2017).   Foster Kennedy (1884-1952), who was professor of neurology at Cornell University and former president of the American Neurological Association, stated in the Appendix to the “Big Book” (Wilson  1939): “This organization of Alcoholics Anonymous call on two of the greatest reservoirs of power known to man, religion and that instinct for association with one’s fellows…the ‘herd instinct’.”  So, the scientific challenge is perhaps no longer to determine whether and in whom A.A. is helpful but to better understand the social forces that are fundamental to the fellowship.  There has been a long history of research related to the fundamental human link, namely the maternal-child bond in humans (Bowlby 1969) and non-human primates (Harlow and Zimmermann 1959), which has evolved to reflect our understanding of neurobiology and to ask questions related to other human connections and social emotions (Insel and Young 2001), all of which seem highly relevant to understanding how mutual support groups might help in healing addiction.  The self-absorption and anhedonia of continuous drinking yields to the awakening of altruism and the joy of recovery, aided by mutual support.

        Finally, the notion of stigma that is associated with addiction must not be forgotten and the self-loathing and social isolation that those who have lost control over their lives feel by virtue of addiction.  There is a tendency to blame oneself rather than understanding that one is suffering from an illness; acceptance by others is vital in eventually finding self-worth.  Self-help has its origins in finding the answer to one’s problems rather than benefitting from a professional to help to do so.  On one hand, it represents independence and know-how that are considered attributes, but on the other, it is unrealistic, especially if one recognizes that the problem is as serious and potentially life-threatening as is addiction.  Recognizing and accepting this is, in fact, part of the problem in recovery as outlined previously (Martin, Weinberg and Bealer 2007).  The notion of self-help and why Alcoholics Anonymous was implemented derives from the still highly prevalent belief that addiction is not really an illness and hence does not “merit” medical assistance (not to mention that physicians were at best ambivalent about whether addicts were “worthy” patients).  Another perspective is that addiction is much more complex than a simple medical illness and requires more than medical intervention, namely, the person in his/her entirety must be remade through illumination or a mystical experience.  Man’s search for meaning in life is a spiritual phenomenon that is not possible with limbic anesthesia of continuous drunkenness that for shorter and shorter periods removes anxiety, pain, and emotional suffering, all human emotions that in health must be reckoned with.  So, the notion of self-help is not that at all. Self-help is shorthand for mutual support from others on the same journey and formation of social connections that aid recovery in a scientifically explicable process.  However, it would probably work best if it also used all medicine has to offer, including psychosocial treatments because it is a bone fide illness, not simply a failing.

 

References:

Albert and Mary Lasker Foundation. 1951 - Alcoholics Anonymous. Hist. Awards. laskerfoundation.org/awards.

Bandura A, Walters RH. Social learning and personality development. New York: Holt, Rinehart and Winston; 1963.

Bebbington PE. The Efficacy of Alcoholics Anonymous: The Elusiveness of Hard Data. Br J Psychiatry. 1976;128(6):572-80.

Bowlby J. Attachment and loss. New York: Basic Books; 1969.

Clark EV, Clark HH. When Nouns Surface as Verbs. Language. 1979;55(4):767-811.

Edwards G, Hensman C, Hawker A, Williamson V. Who goes to Alcoholics Anonymous? Lancet. 1966;2(7459):382-4.

Gent WL (translator). Virgils Eclogues. London: Printed by William Iones, dwelling in Red-crosse-street, 1628.

Harlow HF, Zimmermann RR. Affectional responses in the infant monkey; orphaned baby monkeys develop a strong and persistent attachment to inanimate surrogate mothers. Science. 1959;130(3373):421-32.

Hayman M. What psychiatrists think about alcoholism. Calif Med. 1955;83(6):435-40.

Huss M. Alcoholismus chronicus, eller Chronisk Alkoholssjukdom; est bidrag till dyskrasiernas kännedom, etc. Stockholm; 1849.

Insel TR, Young LJ. The neurobiology of attachment. Nat Rev Neurosci. 2001;2(2):129-36.

Institute of Medicine (US) Committee on Treatment of Alcohol Problems. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press; 1990.

Kelly JF. Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research. Addiction. 2017;112(6):929-36.

Martin PR, Weinberg BA, Bealer BK. Healing Addiction: An Integrated Pharmacopsychosocial Approach to Treatment. Hoboken, New Jersey: John Wiley & Sons, Inc.; 2007.

Project MATCH Research Group. Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH Three-Year Drinking Outcomes. Alcohol Clin Exp Res. 1998;22(6):1300-11.

Smiles S. Self-Help. John Murry, London; 1859.

Trice HM, Staudenmeier WJ. A Sociocultural History of Alcoholics Anonymous. In: Galanter M, editor. Recent Dev Alcohol Treat Res. Boston, MA: Springer US; 1989. p. 11-35.

Tyrrell IR. Sobering up: from temperance to prohibition in ante-bellum America, 1800-1860. Westport, Conn: Greenwood Press; 1979.

Wilson B. Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism.  Works Publishing Company, New York City. 1939.

 

January 2, 2020