A Report
on a

Alcoholism

Training

Conference

ana the

Federal

Employee

Alcoholism
and the

Federal Employee

A Report on a Training Conference

April 1969
Washington, D.C.

U.S. DEPARTMENT OF HEALTH, EDUCATION,
AND WELFARE
Public Health Service

Health Services and Mental Health Administration
Division of Federal Employee Health

Bit by to Superintendent of Documents u TZT

Washington,

Table of Contents

Page

Foreword v

Introductory Remarks 1

Gordon S. Siegel, M.D.

What Is Alcoholism? Sin? Disease? Habit? 4

Gustave J. Weiland, M.D.

The Dimensions of the Problem in Occupational

Health 19

Harrison Trice, Ph. D.

Recognizing the Alcoholic 39

Richard Phillipson, M.D.

The Point of View of the Recovered Alcoholic. _ 51

Will B. and Jan S.

Community Resources 67

Paddy Cook

Recent Civil Service Commission Recommenda-

„ 76

tions

Frederick F. Bell

iii

Foreword

On April 9 and 10, 1969, in Washington, D.C., the Division
of Federal Employee Health held a two-day seminar on
alcoholism for Health Unit personnel serving government
employees.

The contents of this publication stem from that conference.

Included arc presentations of the guest speakers at the con-
ference and an edited version of the question and answer and dis-
cussion periods which followed each talk. No attempt has been
made to edit the thoughts of the speakers. Editing — such as
has been done — has been undertaken only to clarify sentence
structure or to cut out, in the case of discussions, repetitive
material.

This publication is offered both as a study guide for occupa-
tional health personnel wishing to stage their own conferences,
and as an overview of the beginning of governmental awareness
of the problem of alcoholism and occupational health.

Introductory Remarks
Gordon S. Siegel, M.D.

(Dr. Siegel is Director, Division of Federal Employee Health.
The Division, host at the Training Conference on Alcoholism,
operates 73 occupational health units serving 125,000 Federal
employees. The other primary responsibility of the Division is
to consult with any Federal agency desirous of instituting an
occupational health program for its employees.)

I want to welcome everyone here this morning. The Division
of Federal Employee Health, Public Health Service, as you
know, operates health units serving Government employees of
various agencies. Some Federal agencies run their own health
units. Some Federal agencies contract their health units out.
So actually we have only a piece of the action.

For the past year we have been holding our own inservice train-
ing courses for Division personnel: our own nurses, physicians,
and others. This meeting is one of our Division’s inservice training
courses.

It was set up primarily to train and orient the professional
personnel of the Division of Federal Employee Health.

As usual, with our training courses, we tried to make some
spaces available for participants from other Federal agencies
that are engaged in running their own Federal employee health
service.

Now, why this particular training session on alcoholism? There
is a story, probably sort of a bad story, about the husband who
comes home and finds a stranger hiding in the wifes closet.
And he says, “What are you doing here?” And the stranger says,
“Everybody has to be somewhere.”

In dealing with the problem of alcoholism, you have to start

somewhere.

As people working in employee health, physicians and nurses,
we have all been cognizant that problem drinking, alcoholism,
rail it what you will, is one of the major public health problems
in the United States, and it’s one of the major occupational

1

2

health problems. Any time you have a congregation of indi-
viduals, problem drinking is going to be one of the health prob-
lems affecting this group.

Particularly in the work situation, where in essence you are
taking a cross-section of the American adult population, alco-
holism is one of the health problems that occupational physicians
and nurses are faced with and that managers of work groups and
fellow employees are faced with.

We all know that in private industry in the United States,
there has been interest in problem drinking and in attempting
to do something constructive about it through managerial, occu-
pational health, union, and employee programs.

The Federal Government in a sense is “Johnny Come Lately”
to this problem in dealing with it in some organized, construc-
tive fashion. But that’s not surprising. The nature of our Govern-
ment is a check and balance system, and we usually move
cautiously in most areas.

Certainly the Civil Service Commission has taken active in-
terest in problem drinking as it affects the Federal work force;
we have entered into an era where Federal employees, Federal
managers, and we in Federal Employee Health are facing this
problem, and seeing what can be done in a constructive way to
deal with it. In health units of the Division of Federal Employee
Health we have had in my opinion no very constructive way to
deal with this problem in the past. Problem drinking, alcoholism,
is always a touchy problem, particularly in the work force where
an individual’s livelihood hinges on the outcome of many activi-
ties that go on in occupational health.

I think what we have done in the past in our health units is
to try to aid and assist individuals afflicted with this problem and
aid and assist Federal managers and supervisors beset with this
problem. We have done it sort of on a one-to-one or case-by-
case basis, whatever the particular physician or nurse in the
health unit might be able to do and was interested in doing
and was capable of doing, but without any real guidance, direc-
tion, or training.

We’d like to enter an era of a more organized approach in
attempting to work out a constructive program to deal with
alcoholism in our health units in the Public Health Service.

3

How to go about it? Well, as I said, you have got to start
somewhere. We decided a place to start would be to provide
post-graduate updating, education, and training for our own
professional staff.

How much our own professional staff knew about the problem
of alcoholism was unknown to us. At least based on the knowl-
edge of the headquarters staff, we all had a lot to learn and
refresh ourselves on.

Not only that, we have to overcome the hurdle of try ing to
set aside whatever emotional or subjective preconceptions we
have about this problem, and try to understand and deal with
it in some objective, some professional fashion.

So it was decided that it would be valuable as a starting point
in our Division to organize a training program, if you will, a
post-graduate education effort, for our own nurses and our own
physicians.

Since our Division has some 110 nurses and some 16 full-time
physicians and many part-time physicians, we have to bite this
off in pieces and chunks. This is the first group going through
the first training effort.

So much for background; so much for introduction.

This particular inservice training effort was organized through
the efforts of Mr. Theodore Chandler, the Chief of Information
and Health Education of the Division, and particularly also
Dr. Gustave Wciland, who is the psychiatric consultant to the
Division, Dr. Stuart Lcssans, who is in the office of the Chief
of Clinical Services, and Miss Ada Murphy, who is our chief
nurse for training. There are undoubtedly others of you who are
due credit, and I want to thank you all.

372-4 C3 — 70 2

What Is Alcoholism? Sin? Disease? Habit?

Gustave J. Weiland, M.D.

(Dr. Weiland, a member of the psychiatric staff of the National
Institute of Mental Health, serves as liaison officer between
NIMH and the Division of Federal Employee Health, and pro-
vides consultative services to the Division on psychiatric prob-
lems seen in the Health Units. )

What is alcoholism? Should it be viewed from a moral stand-
point? Should it be viewed from a public health medical view-
point? Is it purely a legal, purely a social issue? Should it be
seen as an administrative issue, something for the personnel
department to simply handle in terms of annual leave, sick leave,
leave without pay, all sorts of administrative machinery, to
handle the person who is simply not doing the work?

Well, there are a number of reasons why I as a psychiatrist
and as a person should be interested in alcoholism. I’m a member
of the National Institute for Mental Health, and, as you know,
NIMH has this rather grand task of promoting the mental
health of the nation. And alcoholism and alcoholic problems do
seem to have a great deal to do with the whole problem of the
mental health of the community and what to do to promote this.

So we have a separate Center and we have a particular inter-
est in it by all the members of the Institute.

As a physician I am bothered by any condition which accounts
for something like 12,000 deaths yearly, and a condition which
involves something like 3 percent of any work force.

These are men who are in their most productive years. Five
out of six alcoholics are men in the years of greatest productivity
from the age of 30 to 55. This is not an old man’s disease. It is
not really a degenerative disease. It is becoming more and more
a young man’s disease.

I am told that over the past few years the experience in AA
and certainly among the medical profession is to see it occurring
in a younger age group.

4

5

It certainly is a considerable hospital and clinic administra-
tive problem. In the psychiatric hospitals nationwide it accounts
for 14 percent of first- time admissions.

So it is a considerable statistical entity, something to count,
something to watch. And it is something I think to be concerned
with on a personal basis.

It has been called the billion dollar — or lately because of
inflation the two billion dollar — hangover.

When I drive after midnight, I am increasingly aware that
every mile or so there is someone on the highway who has been
drinking too much and is a definite safety hazard.

So there are a great many ways of viewing the whole problem
of drinking, and it brings a lot of different definitions. I rather
like the World Health Organization definition as being a dis-
order of behavior. I think that takes it out of the tone of the
moralistic point of view. It somehow gets away from the argu-
ment of just what kind of disease this is. WHO calls it :

“Disorder of behavior, with repeated drinking of alcohol
in excess of the dietary and social community norms, which
is to an extent interfering with work or family or other social
relationships.”

And I think that is an important definition for you people in
health units and working in various Federal agencies — to the
extent that it interferes with work and other social relationships.
This is I think your entree, your reason for concern about the
drinking habits of employees.

I understand a considerable number of Americans drink. I
would guess myself that the most reliable statistic is something
like 70 percent. We’re very much a drug and alcohol-oriented
society.

I have heard the description of America as being so drug-
oriented that we’re in it, it’s a part of our environment. It’s very
much like a goldfish swimming in water. I don’t imagine if a
fish could think as well as a human that he would be very well
aware of water. It’s as much a part of his environment as the air
we breathe is of ours.

Alcohol is so much around us on our social occasions and our
social practices that we become unaware of how much alcohol
and drugs arc available and used regularly by us.

6

I think you can agree with this if you think not only of the use
of alcohol but of the use of tobacco, the use of coffee, caffeine,
and the use of so many drugs to keep people going a little faster,
to slow them down a little more, to relax, to relieve tension. For
headache take aspirin; for tension take Compoz. It’s becoming
very much a part of the scene.

And what is it that makes it so much a part of concern in
occupational health? Well, I think we might think a minute
about how alcoholics come to your attention, how they come to
the attention of personnel people.

Would anyone have any thoughts about how alcoholics mani-
fest themselves in the health unit? How do they show up in your
health unit as needing attention?

A Participant. Usually a supervisor calls up and tells us he
has a problem.

Dr. Weiland. Yes. And why is he a problem for the
supervisor?

The Participant. Because he interferes with the performance
of other people.

Dr. Weiland. Yes. The work is not getting done in the office.
And why isn’t the work getting done in the office? Is he there 5
days a week? Is he the employee who is there 40 hours a week?
Is he the employee that is working overtime?

I think not. Most often he’s the missing employee. He puts in
the half-day. He’s half there when he is actually in the office.
And so he’s the one that rings up high usage of sick leave. He’s
the one that has to go on leave without pay. He’s the fellow
who is involved in the large percentage of accidents that show up
in your health units.

It has been estimated that something like 20 percent of the
people who have accidents are committing 80 percent of the
accidents. So there is quite a tendency to repetition in accidents.

I think you will find that in your health units you will see every
few months one or two persons who have most of the accidents
of one kind or another, the falls, the cuts, the slips, the sprains, all
sorts of things, which all interfere with their being able to work
and to remain on the job.

These are the people who are achievement-poor, who aren’t
getting the work done in the office. So they become an occupa-
tional health problem.

7

There are certain things about their personalities which tend
to keep them from fitting in very well in the office environment.
Some of these characteristics are that because of the moral aspect
of drinking they tend to be secretive. They tend to have to keep
it somehow on the sly that they come rolling in late in the morn-
ing, that they get out early for lunch, that they come back late
from lunch, that they have to chew chlorophyll or mint or some-
how hide themselves from other people in the office and from
the supervisor.

They have to keep out of things, and so they become very much
out of things in the office.

They are the procrastinators. They are the people who don’t
get their reports in on time, who don’t keep up to schedule with
things.

In situations where finances and a petty cash drawer are avail-
able, they are the people who are the “till-dippers”, the people
who are always short of cash, borrowing money from other
people in the office. And they are the people who run up the debts.

It’s a part of the way they live that they are running behind,
and they are running short in so many ways. They are running
behind often with their alimony. They are more likely to be
separated. They are more likely to be divorced. They are more
likely to be in a mess in a lot of different ways, which creates a
problem for the individual agency.

So these are some of the things that people with drinking
problems do in the offices and some of the reasons for health
units to be concerned about this, as well as personnel people.

But what to do about it? I’m quite convinced that the problem
is not really so much how to identify someone with a drinking
problem. All you have to do is get within range of them or work
in the same office, and it’s no secret. It has to be actively ignored
or has to be worked some way that the work gets done despite
their marginal participation.

So the problem is really how to handle these people.

Why is it then that doctors and nurses have a particular
problem in handling and dealing with people with drinking
problems? I think there are a number of reasons. Certainly
doctors and nurses are not inexperienced in dealing with anxious
people. This has been a part of the experience of each one of
you since you got into the hospital for training.

8

You have dealt with anxious people before. Why this particu-
lar class of anxious people? Well, I think there are a number
of things that are associated with how the alcoholic handles his
anxiety. You find the drug takers who will abuse prescriptions
and will take a great number of patent medicines, with bromides
and all kinds of sedatives. Part of the alcoholic’s experience is
that he expects that he should be able to regulate the amount of
anxiety and tension and discomfort that he should have to
endure.

Now, he has a rather good way of doing it. Alcohol is an excel-
lent antianxiety medication on the short term. It is a rather good
antidepressant for the short term. However, as he becomes in-
volved in the use of this potent food and drug, he soon becomes
involved in a cyclical phenomenon. The more he drinks to make
himself less anxious or less depressed, the more anxious and the
more depressed he then later feels.

I know what first comes to your mind is the hangover after
the night before. And, of course, the long term and very uncom-
fortable and profoundly unsettling phenomenon of the blackout,
and the other unsettling happenings when one has been in the
chronic alcoholic pattern.

But really I’m thinking more of the number of people I have
talked to who have been drinking for a rather short period of
time and notice that an hour after two or three drinks, instead
of feeling better, they feel much worse than before they were
drinking. There is this rebound of irritability and depression and
anxiety which has a cyclical effect in prolonging and intensifying
the drinking pattern.

So this is I think what is different about the alcoholic. He
regulates his own anxiety, or attempts to do it, in some short
term and ineffective way.

It is something that doctors and nurses are not used to
encountering — a patient who is set on dictating the terms of his
own treatment — and particularly in a way which is very frustrat-
ing not only to the helping people but to the drinking person
himself.

There are certain feelings that the drinking person provokes,
and I think if you would picture for yourself a moment someone
in your agency who has been in to the health unit and the kind
of feeling that he provokes in you and the other people in the

9

health unit you may be able to recall some characteristic feel-
ings. How do people with drinking problems make you feel,
make the other people in the health unit feel?

A Participant. Disgusted most of the time.

Dr. Weiland. Yes. They bring out disgust. Any other feelings?

The Participant. Also sometimes you extend sympathy be-
cause they tell you their family problems, and you realize what
they are doing to the family and also to themselves.

Dr. Weiland. Yes, there’s a lot of that. These people get you
extending a lot of justified sympathy. You can feel a lot for
them and for what’s been happening to them. They disappoint
you. They make you feel disgusted with them personally; as a
helping person they disappoint and they disgust you.

The Participant. And you don’t feel you are reaching them.
Because you tell them what you can do to help them and then
provide this opportunity, and then they fail to keep the appoint-
ment. So you feel that you’re not reaching that person. And I
don’t know whether we are at fault as people in the Health Unit
or if it’s the individual himself or herself.

Dr. Weiland. Well, in any event, it’s a very frustrating en-
gagement. It’s really a lack of engagement. You haven’t really
reached the person. The person lets you know that you haven’t
really reached him.

And, as Dr. Siegel has pointed out so well before, in agencies
and in offices when this kind of frustrating communication pat-
tern goes on for a little while and people haven’t reached one
another, the end result is indifference. People back off and say,
“Well, this kind of thing isn’t what I can handle. It isn’t part
of my job description, and it isn’t anything we can do anything
about.”

So there is a kind of apathy and indifference. I think it’s
something that extends on both sides of the possible doctor-
patient relationship.

There is a very pathetic victim image that comes out in deal-
ing with this person. Some people say, and I think somewhat
unsympathetically, that the person with a drinking problem is
playing the old “wooden leg” game: “You can’t expect any-
thing from me. I’ve got a wooden leg. I can’t be expected to do
something about my family troubles. I can’t be expected to keep

10

up with the work norms in the office. I can’t be expected to meet
schedules. I’ve got a sickness.”

And I think this is what gets doctors and nurses backing off
from the problem of the drinking employee. It’s this: “You
can’t expect me to follow your directions. You can’t expect me
to do what would be sensibly helpful to me.”

There is a great feeling of inferiority that is expressed : “I can’t
handle. I can’t do. I can’t be expected to do.” And yet, on the
other hand, I think there is a feeling of self-sufficiency which
the person with a drinking problem puts to you which is another
way of putting off and putting at a distance the potential helping
people. I think this feeling of self-depreciation is an important
part of it.

So along with the pleasure-seeking aspect or tension-relieving
aspects of the drinking pattern, there is a great and contradictory
tendency to avoid help, and, further than that, to inflict trouble
upon himself. It’s really a vicious cycle.

There is the demanding, indulgent side of it, and the great
frustration of the helping person. You know, “I’ve got to have
relief of my anxiety and tension. You can’t give it to me. You
haven’t been able to help me in the past, or you’ve tried to help
me with medication, or with advice, or with referral, but that
didn’t help. I wasn’t welcome there. They couldn’t help me.” —
this kind of thing which leads to a kind of disappointment and
rage in the parties involved.

And so then a kind of hostile indifference results. And along
with that, for the person with a drinking problem and especially
so for the professional person, there is a feeling of guilt and
self-castigation. “I should be able to do something about myself
and this drinking problem.” And the professional person, “I
really should be able to help that fellow somehow, and yet he
won’t let me.”

Often, after this backing off, there is again a coming together
with some reassurance, some feeling of acceptance, and then
the cycle goes off again, the demands, the frustration, the mutual
hostility. It’s a very unrewarding and unproductive and unsatis-
fying experience.

This sounds all very pessimistic. But I think it need not be so.
The need here is for some degree of objectivity, some degree

11

of professionalism, some degree of development of one’s
professionalism.

Dr. Siegel has put it quite well in pointing to this need to be
objective and to develop professionalism on this topic.

I think it is quite likely that the outcome can be much more
satisfactory if this can be developed.

The thing to be kept in mind for the doctors and the nurses is
that a problem about this is that doctors traditionally see it as a
very unusual disease. Alcoholism certainly won’t satisfy Koch’s
postulates. And there’s probably no other disease that you can
think of which can be treated by conditioned aversion, by simply
avoiding and forcing the avoidance of the alcoholic indulgence.

So it’s a rather unusual disease and has led to a great deal of
dispute about whether or not it actually is a disease. I think many
people will agree that it is a symptom, and it is a symptom that
is developed to the proportion that it is a medical disease
problem.

I think nurses — particularly — in addition to the problem of
the doctors — need to realize that these are people who are dif-
ficult and demanding and who arouse strong feelings of disgust
and disappointment. They can be expected to arouse hope and
to arouse disappointment, and the chance of affecting the out-
come somewhat is largely dependent on your ability to establish
some objective and less personally involved stance.

A Participant. Doctor, don’t you feel that we have to deal
with our own anxieties about our own drinking that are reflected
as we try to deal with these people?

It reminds me of how I might become this way, and I think I
can really put up some defenses which constrict my objectivity
in dealing with these people. They threaten my drinking.

Dr. Weiland. Yes. I think that’s an enormous part of the
difficulty in dealing with the drinking employee. Because the
great majority of us drink, we have many conflicting feelings
about drinking which is a part of our society and a part of our-
selves. However, there is a positive aspect to this, and I think
it is related to the saying that every surgeon should have a
surgical scar as a part of his training.

I think one of the meanings of this is not only just seeing the
whole process of surgery from the point of view of the patient,
but being able to empathize with the surgical patient in a differ-

12

ait way, having had that kind of difficulty. If we can be aware
of this; if we can be aware that perhaps a person with a drinking
problem is not too different from us in our difficulties in control-
ling smoking or controlling overeating, we can see that there
is a great deal of common ground here.

A Participant. May I add that I have had the experience
of trying to promote programs for alcoholism in business and
industry, and I have found recommendations stalled on particu-
lar desks in the executive echelon. And I find that this is the
man who sees that he might become the first patient and will
block the development of such a program because he’s afraid
of his drinking experience.

And I think this is a critical matter in trying to develop the
program within an organization.

Dr. Weiland. Yes. It’s all part of the wider problem — how
to deal with this in some sensible, strategic sense within your
agency.

The Participant. In my particular situation oftentimes I
know of the problem because it is brought to me by other em-
ployees, but the person who is really having the difficulty avoids
the health unit. The coworkers will, when he gets into difficulty,
get a cab and take him home. He never gets into the health unit
situation.

Dr. Weiland. So how to deal with the person who doesn’t
come to the health unit as a patient? This is a considerable
problem.

I think you’ll see this with other types of emotional problems,
and I rather feel that it’s related to the kind of welcome and to
the kind of resources which the other people in the office believe
are available at the health uni t.

There is a great pessimism generally in the community about
alcoholism and what can be done about the employee who
drinks. So I think you will find that they are not going to bring
him to the health unit because they fear he will then go to the
personnel office and then he will be fired.

This is an unreal fantasy, because the personnel office is itself
struggling with knowing about more people who drink than they
can deal with, than they can tell their managers and supervisors
how to manage.

13

Dr. Siegel. I think you touched on a very important area that
is usually not discussed even in a professional meeting such as
this, the anxiety on the part of the physician and nurse, which
I think is related to a fear of failure in being able to deal with
this particular type of health problem.

Even though I think as physicians and nurses we realize there
are many diseases and illnesses of which we will not be able to
influence the outcome, at least usually we are hopeful or we try.
But alcoholism is one area that I think engenders a tremendous
amount of anxiety, because from the beginning we feel that we
are doomed to failure, and it makes us very anxious, very unsure
of ourselves.

And maybe this area is almost unique in producing this kind
of reaction among physicians and nurses.

I know that’s what bothered me when I had alcoholic patients
that I had to deal with in a clinical situation. And I began to
analyze: Why the great difficulty? It was tremendous anxiety
on my own part. They were threatening me professionally. I
was going to have to admit or be forced to show that I couldn’t
deal with this situation. I really didn’t know how to deal with
this situation.

And when you threaten a professional on his professionalism,
you make him very, very anxious.

Dr. Weiland. I’m glad you didn’t really ask that as a ques-
tion, because I don’t have any good answer to that kind of situa-
tion, except to suggest sharing the problem with other profes-
sionals who can help to deal with it somewhat more adequately.

I can share with you my anxiety as a physician and psychiatrist
and tell you that psychiatrists generally are not particularly
helpful about curing alcoholism. When I have a patient referred
to me because he is an alcoholic, I get that sinking feeling, and
then I think, “Well, now, what within this is at all workable?”
In other words, I’m already thinking in terms of the physician
who is confronted with late-stage carcinomatous disease. I have
that kin d of feeling. What can I do that will be in any way
remedial? What can I do that will be in any way hopeful in
the situation?

You know, if I get a different kind of story and I am told that
this is someone in the midst of a depression or who, to control
irrational fears, has begun to use alcohol, all of a sudden I have

14

a different feeling about the therapeutic situation. I feel it’s
workable. I feel that something can be done.

But if I am told that this is a problem of long-standing
behavior habit, I realize that this is a hard thing to deal with,
and I’m not as hopeful.

Dr. Siegel. I think both of these points bear on why people
aren’t brought or don’t come to health units. And this is an area
that we will have to dig into and work on in our health units.

And it relates too to the question on policy. It’s anxiety-
producing not to have an organizational policy. But I have come
around to sort of thinking that even in situations where we can’t
get organizational policies, we will make a health unit policy and
disseminate knowledge about what the health unit policy is going
to be and how we’re going to handle people with this problem.

Dr. Weiland. Yes, I think you will have to resign yourselves
to the fact that you will be dealing in an unclear and ambiguous
area where people are not rushing forward to take responsibility
for action.

A Participant. I had a lady who came in for a minor illness.
I think it was just a cold at that time. And in the course of con-
versation she told me that she was a chronic alcoholic, but was
not drinking at that time. She had stopped drinking 6 months
previously.

And so in the conversation I said, “Well, if you have a prob-
lem, come see us before you start drinking.”

Two weeks ago she came in, and said she had had her first
drink that morning at 8 o’clock and she needed help. She told
me that she was going to group therapy at the D.C. Mental
Hygiene Clinic. So I called her caseworker, and she said that
they would see her at 11:30 that morning. Well, since that time
I have not seen the lady, but her office told me that she had tried
to commit suicide later on.

But when she saw me that morning she said she was very
depressed following her meetings. This was in the group therapy
clinic she was attending. And she felt she was deriving no help
from these sessions; she came away more depressed than when
she arrived at the meeting.

Dr. Weiland. Dissatisfaction? Rage?

The Participant. Yes.

15

Dr. Weiland. An inability to handle and contain the rage
and a great feeling of wanting out of the situation. And I think
this is the suicidal potential of these people. And it’s a difficult
problem to deal with.

I don’t think I mentioned another particular problem that
medical personnel have in dealing with the referral to Alcoholics
Anonymous. A A has a marvelous way of dealing with this by
asking that the person identify himself as an alcoholic with a
drinking problem that no one can really help but the person
himself.

Now, this is a marvelous approach and has been effective with
a large number of people. But I think the fact that AA was
started — although there have been medical people involved
from the very beginning — in a nonmedical context and has re-
mained in a nonmedical context brings about difficulty with
many medical personnel not only in arranging referral but in
continuing followup. And this is a tremendous gap which is hard
to bridge.

It is easier for you to say, “Get in touch with the D.C. Hospital
and the group therapy person there,” because it’s still in medical
channels. But I think the other problem has to be considered too.

A Participant. I think the development of an agency policy
statement is helpful, but it’s not exactly 100 percent of the prob-
lem’s solution. Because after you get the statement, you have to
get employee acceptance. Many times they will say, “Oh, yes,
that’s a good policy, but I don’t believe it.”

So the development of an agency policy per se is just the first
step, in my opinion. You have to have a program to back it up and
to prove to the employees that you really mean what you say.

Dr. Weiland. Yes. And speaking of programs, this means
that you may have to begin a new relationship with some of your
personnel people, some of your administrative people, to work
out and put into effect a program or policy.

The Participant. I think not only should we conduct train-
ing programs for the health unit staffs of nurses and doctors,
but also I think the Civil Service Commission should get involved
in training the supervisors on what will be available through the
Government, what will be done for alcoholics. Because the
supervisor oftentimes is really the one who will direct the em-

16

ployee to the health service if he knows something can be done
through the health service.

This is one thing that has not been developed in many of the
agencies and departments.

Dr. Weiland. That’s very good, and that would fit in with
the whole pattern of reciprocal training agreements for execu-
tives with the Civil Service Commission.

Dr. Siegel. Could you make some comment, Dr. Weiland, on
the propaganda of alcoholism as it is being given now to the
general public? What is the general public’s expectation of what
physicians and nurses can do in alcoholism and the kind of con-
flicts or difficulties that this might cause to the professional
person?

I think in setting up this meeting, we wanted to place emphases
on understanding alcoholism as it affects the physician and the
nurse. And I think what the public expects from a physician and
nurse is part of the picture.

By the public, that includes the work force of the particular
location.

Dr. Weiland. What are your other reactions on this? Have
you had unrealistic expectations from the viewpoint of the medi-
cal education on alcoholism as a disease?

I felt that it has worked against me as a therapist with
patients, when patients say, “Well, you know, I’ve got trouble
with drinking,” as though then, “Now, what are you going to
do about it?” — as though, well, alcoholism is a disease and what
kind of penicillin do you want to try on this?

And, as you all well know, drugs like Antabuse and Temposil
aren t for everybody. They are risky drugs. They work for a few
people who are extremely reliable with drug usage, which
people with drinking problems by and large are not. They are
reliable for people who are compulsive in a certain way and
cooperative with a medical regimen in a certain way.

So they are really helpful for very few people. And I think
the expectation is that there’s going to be an Antabuse, a magic
pill from the physician, and there isn’t; not from any doctor or
nurse.

Dr. Siegel. How do you communicate this to the patient?

Dr. Weiland. How do you do it in your health unit? How
does it come up?

17

A Participant. I use the concept of illness to try to relieve
their self-deprecation and their shame. I relate it rather awk-
wardly to, “This is not unlike the deficiency disease, diabetes, and
in a great sense it’s not your fault.” I try to give them some relief
and comfort to be able to get to talk to them.

Then I proceed to try to show the difference : “This is not an
ordinary disease. There is no medicine that can help you, but
this is a matter of your trying to find out how to live without
alcohol, how to deal with your life without alcohol.”

But the concept of disease used to relieve their shame is a great
asset.

Dr. Weiland. And it’s not only to relieve shame, but I think,
also to insure acceptance. People aren’t brought to the health
unit because of their drinking; people don’t see drinking as some-
thing which is treated by doctors and nurses. The concept of
alcoholism as a disease indicates that doctors and nurses are
interested in treating it.

But I think that’s a very good approach of describing the
difference between, say, the drinking problem and appendicitis
in which someone can be brought in, anesthetized entirely without
his cooperation, and operated on in a curative way.

Then you can think of so many different diseases, everything
from appendicitis to sinusitis, which operate in an entirely differ-
ent way, and are more chronic, more of a disease which can be
worked on with the cooperation of the patient and one which
depends in great degree on the resources, the assets, the favorable
life situation and other aspects which can be utilized by the
patient to help lick his disease.

Someone who can’t afford a proper diet can’t alleviate his
diabetes. Someone who is very favorably situated is more likely
to be able to have favorable outcome of the disease and of the
alcoholism.

A Participant. If a person goes to some referral source, some
clinic or individual doctor, or whatever, if we have been lucky —
and I use that word — if we have been lucky, he goes not saying,
“Give me a nostrum, give me penicillin,” but he goes saying,
“What can I do that you can help me out with?” — rather than
“Help me!”

18

This is where I think the health unit is of service to the pro-
fessional who wants to get the best help he can even from way
down the line.

Dr. Weiland. I see that as part of the treatment, because it
is so important and so much assuring the long-term result — that
you begin to prepare a person to look at his illness, look at his
difficulty, in a certain way.

In other words, I don’t see anything particularly contradictory
in the AA scheme which goes about it in a different way, which
throws each alcoholic back on his own evaluation of himself and
on his own resources, to some extent, on his own will to recover.

And the other contradiction is that they supply so much in the
“good Samaritan” approach in their support. So they offer some-
thing in a different way.

But I think there is tremendous usefulness in the doctor and
nurse preparing the person for treatment, and I think it is a
part of a good start for treatment.

The Dimensions of the Problem in Occupational Health
Harrison Trice, Ph. D.

(Dr. Trice is a professor at the New York State School of
Industrial and Labor Relations of Cornell University. He has
written prolifically on the problem of alcoholism in industry.)

Your chairman asked me a moment ago when I came in a few
moments late if I wanted to be introduced as “doctor.” I told
him that I think it would be better if he called me “professor.”

I say that because my teen-age daughter, who is now going
through the throes of that transition period, recently answered
the phone when someone said, “Is Dr. Trice there?” and she
said in a facetious moment, “Yes, he’s here, but he’s the kind
of doctor that doesn’t do anyone any good.”

So since then I have decided to be called “professor,” which
seems to fit a little more what I do anyway.

My major activity is largely research. I don’t know whether
you have any specific content of that word “research.” It’s a
many-splcndorcd word meaning many things to many people.

But as I was sitting here a moment ago listening to your dis-
cussion, I was attempting to see if perhaps some of the prepared
statements that I had made might not be altered a bit and some
of the research that we had done in the past might not be put
a little closer into the context of your discussion.

As I get one of the main drifts of the points that many of you
were making in the interchange, you were interested in treat-
ment and treatment results, whether they be by way of referral
or by way of what you do as medical personnel. And I think this
fits somewhat by way of introduction.

We have done a great deal of research in the area of the impact
of alcoholism and other behavior disorders.

If you look at the depressive disorders, I think they have a
sharp impact on the work world. I don’t want to build alcoholism
up as some predominant phenomenon in the work world.

In our research we have discovered that the impact on the
supervisor, on the nurse, and on the medical department seems

20

to be greater from the alcoholic employee than from either the
psychotic or the psychoneurotic, using those in their broadest
connotation.

But I thought that it might be more interesting for me to briefly
discuss some of our research activities regarding the evaluation
of therapeutic efforts and the evaluation of training efforts. To
me, these two things are really very similar.

We have recently conducted a very large study trying to evalu-
ate the effectiveness of training supervisors about alcoholism and
other problem employees or therapeutic efforts regarding the
alcoholic employee. I think these are in many ways quite similar,
in that they change actions allegedly, and you can try to evaluate
them.

In any event, let me give you some of the circumstances under
which therapy appeared to be the most effective.

We might preface this by saying that as we attempted to
evaluate three or four different therapeutic approaches, we
found that any one of them produced results. In other words,
I think it’s possible for you to say that if you take a random
sample of alcoholics and submit them to psychotherapy of some
persuasion but within the psychotherapeutic ideology or origin,
you will discover that you get a sizeable amount of response.
Fifteen, 20, at least 25 or 30 percent will respond.

If you take just the opposite, a somatically-oriented therapy,
such as conditioned reflex, you will also get a sizeable amount.
But apparently it never gets much over 25 or 30 percent.

Alcoholics Anonymous, as much as I love it (I have had the
privilege of serving on their Board of Trustees for the last 15
years), never gets much more than 15 to 20 percent of the
population, regardless of how often they are exposed, because
there is a selective process going on.

So I think that any treatment get results. Unfortunately, the
big problem is to up the results.

Just let me describe in the work world situation the kinds of
circumstances in which these results have moved up very sharply.

When an organization — I don’t care whether it’s the govern-
ment, whether it’s an esoteric small industry, or whether it’s a
large utility; I don’t care what type it is — has a substantial pro-
gram, if that program and policy are operative and if there is
a relatively earlier referral, recognition or treatment — I did not

21

say “early” ; I don’t think there is such a thing — and if there is
realistic confrontation by line supervision in terms of work per-
formance, response to therapy goes up very sharply.

I think I’m a fairly cynical statistician. Yet I am ready to
accept the results of a sizable number of these work-based pro-
grams in which, by reasonably good followup and fairly careful
evaluation, almost 50 percent success has been attained. It was
due I think to the presence of a very realistic policy which had
in it the provisions for crisis precipitation.

Secondly it has in it the kind of training that was realistic to
supervisors but which set the stage for earlier recognition.

And I think it was characterized by realistic confrontation by
line supervision on the basis of poor job performance.

If there is any one thing we know about the developing alco-
holic, it is that his condition begins to impair role performance.
As a matter of fact, as a sociologist, that is my definition of
alcoholism.

As sociologists we deal with roles and the performance of
roles in organizations. And when people have a series of expec-
tations which they are going to fulfill to perform that role and
they do not do it, then we speak of them as being deviant. And
certainly this characterizes the developing alcoholic.

We have a vast amount of basic, solid evidence to demonstrate
the extent to which there is clear-cut role impairment, and to
the extent that the organization policy provides for the proper
kind of training and support. It’s one thing to have a policy. It’s
one thing to implement it well with staff people and with top
management. It’s quite a different thing to overcome the gap
between there and line management.

It’s not too difficult, however. It has been done.

If, however, it is present sufficiently so that the supervisor
does realistically confront, then the treatment resources have
delivered to them an individual that is more motivated.

I could describe to you briefly the studies we have done of
dropouts in community clinics. Why is it that people come to
the clinic two or three times and never come back? They are not
put in that kind of crisis bind which says, basically, “You are
going to have to realize that the payoffs from alcohol are no
longer there.”

22

Alcohol has worked for the alcoholic — much as it may sound
strange to us, it has worked for him emotionally. He has man-
aged to do a whole series of things in defense of his drinking,
and they have worked.

Not only does alcohol do a lot for him in his emotional makeup,
but he has learned ways of managing people who attempt to
get him to stop.

He is a Ulysses S. Grant and a Robert E. Lee combined, if I
may exaggerate — an excellent field general, and an excellent
manipulator. He’s been doing it for a long time.

He can do the same thing to his boss he does to his wife. He
snaps out of it, snaps out of it beautifully 3 or 4 or 5 or 6 weeks,
makes his wife queen for a week, makes his boss feel like a dirty
stinker for having thought of referring him to the medical de-
partment or personnel, or of using discipline.

Until there is a realistic confrontation that may produce a
crisis, we will never make much headway in the efforts to do
something realistic about alcoholism.

I have questions about the word “disease” or “illness.” But if
we use it, let’s make sure we say the word “unique” in front of
it. Because alcoholism is a unique disorder, unique in that until
the alcoholic faces a clear-cut crisis in terms of the use of his
drinking, we have very little chance of producing the kind of
changes that we want to bring about in therapy and treatment.

One of the best places, in my judgment, to produce those crises
or realistic confrontations is in the work world.

Having watched a lot of spouses try to face reality with these
individuals, I am convinced it doesn’t come from there.

But I have seen a lot of union and management people, fore-
men and supervisors, who got fed up to the gills and who said,
“Look, it’s not your drinking we’re talking about. That’s your
private life. But we have every reason to intervene because your
performance is no good. I’m sick and tired as the shop steward of
finding some way of making up your absenteeism. And you are
a stinking griever. You have caused me more trouble. Even
though you are a nice guy and we have loved you, the end has
come.”

The supervisor basically in realistic confrontation says, “Look,
it goes like this: First, I never know what to expect from you,
even though you are a good man and in the past have been a

23

good man. Second, I’m always looking for replacements for
you. Third, you put me in a bad light in many instances.”

We could go on with a series of these. I can provide you with
the research data. This is the combined expression of supervisors
and union shop stewards in five different companies in large
organizations. And they basically have a potential for confron-
tation, even though the potential is at times wishy-washy, and
supervisors definitely go through a vacillation.

A point I would like to leave with you is that the potential for
this kind of realistic confrontation is probably the greatest in
the work world. And until that reality comes out in the open and
is set clearly on the table for what it is, we have very little chance
of making therapeutic headway.

I think that we can add to this the fact that in terms of earlier
recognition this occurs in the work world probably as soon as
any place.

It is a myth to believe that the alcoholic is hidden. He is not
hidden. He may be hidden from high staff people. He may be
hidden from top management people. But the people who work
with him know it, and they come to know it pretty fast. They
don’t come to attach it right away, and they are wishy-washy,
and they vacillate, and they will go through stages.

The point is again that the potential for confrontation, for
crisis precipitation, and for earlier recognition is there in the
work world. And if we can take advantage of it, I think we have
put the alcoholic in the kind of situation where, when it reaches
you, you have some chance.

That’s what all the data is telling us. He is still intact in job
and family. He is realistically confronted — and, if necessary,
crisis is produced.

Incidentally, it has been our experience that alcoholics invest
an awful lot in the job. We all invest a lot in the job, even though
you may not emotionally get a lot out of your job. Your profes-
sionals do I’m sure. But even at many job levels there are fringe
benefit investments. There are all sorts of investments. It’s the
last bastion of defense for many alcoholics.

Any time he can bring the paycheck home, he can shut his wife
up in a big hurry. And I have seen that happen many times.

The job is the last bastion of defense. And when it begins to

24

crumble, you have a real chance of getting in and working t
a responsive person.

Now, if we take a look, for example, at the statistics regarc
individuals who have reached the stage of being in State me
hospitals we do find results, but never much over 20 percent.

Or if you come down to the stereotype of the alcoholi
American society, skid row — We seem to be obsessed in
society with skid row. I can’t understand why. It doesn’t rr
up more than 5 or 6 percent of the alcoholic population to b
with. And yet if you look at some of the major endeavors in
field today, you would find that vast proportions of our resou
and funds are being aimed at that 5 percent.

The alcoholic typically is still working, typically still in a
still in a family, still intact. This is the reason you people ai
important. Because you are the people who really count in
area of alcoholism.

It’s not the welfare worker, as much as I respect her. It’s
the judge down in municipal court. It’s you people. Thei
where the chance really is.

When we evaluate the therapeutic efforts that are mad
the skid row level, if you get 5 or 10 percent results you are r<
lucky. I have the greatest respect for those herculean efforts,
they’re not going to get anywhere.

Suppose they do get the five out of a hundred. That’s won
ful. But it’s going to do very little for the basic public health p
lem that is alcoholism. Whereas if you deal with it in the v
world, you have these advantages and these factors involved.

These are just some of my responses quickly to the discus
that was going on here. And I couldn’t help but feel that I o
tie in to those a little bit with respect to the work world.

I know when I first got out of the service during World Wa
I was very conscientious, and I used to write out my lectures
read them to students at 8 : 30 in the morning, and I was ah
somewhat puzzled as to why they went to sleep. I thought
had a fairly good night’s sleep.

I had an old uncle who was an emeritus professor, and I a
him if he would come around and tell me what he liked a;
what I did, which he did one morning.

He said, “Well, son, there are three things you did wt

25

First, you read it. Second, you didn’t read it very well. Third, it
wasn’t worth reading anyway.”

So I haven’t read anything to anybody since.

Let me address myself to the formal letter here. I was to talk
about the dimensions of the problem in occupational health.
And, by the way, I like that word “occupational health.” If
there is anything that I have encountered as a professor working
with industry and work organizations over the years, it’s their
rejection of these designations like “alcoholism.”

Now, I know people in the alcoholism field don’t exactly like
me when I say this. But, as I say, I’m not in the alcoholism field.
I’m in the field of industrial labor relations.

The simple truth is that you have to identify this with other
health problems.

The people in the alcoholism field are scared alcoholism will
get lost if you don’t spotlight it. I don’t think it will. It plays a
prominent role in the problem. Yet it never affects over 3 or 4
percent in any organization — maybe 5 or 6 percent in some and
down to 1 .5 or 2 percent in others.

There has been a lot of statistical ballyhoo. I hold the line
fairly firmly. Somebody has to prove to me that the current evi-
dence is wrong — that there’s 10 or 12 percent in a typical work
force.

If you get a unique company that is made up completely of
Irishmen, all men, between the ages of 48 and 60, who are in a
huge metropolitan district you can probably get the rate up to
6 or 7 percent.

But if you just take the opposite, as many government units do,
where you have almost an equal sex ratio, you can’t start stam-
peding this notion that we are just rampant with alcoholism.

I tried that once over in Baltimore 10 or 12 years ago and
learned my lesson. I scared the hospital administration out of
their skins, and instead of opening the doors for alcoholics,
they slammed them shut against the flood which they thought
was imminent at any time.

So I want to make it very clear that in terms of the dimensions
of the problem it centers around 3 or 4 percent. And, after all,
there are other problems.

26

The problems of the depressed employee which we have been
looking at lately strike me as certainly of as great an impact as is
alcoholism.

That I think is the first dimension of the problem.

A second point that can be mentioned here is that the alco-
holic continues to work through most of his disorder. It is not a
case in which his illness comes on very quickly and reaches a
climactic stage and then in one way or another either gets much
worse or improves. We have found in studying a series of the
phobias and other forms of the psychoneuroses as labelled by
company psychiatrists in two or three large companies in New
York City that alcoholism was a much longer progressive dis-
order, covering a much longer span. The absenteeism that
characterizes the developing alcoholic clearly shows this.

If you compare his absenteeism in retrospect to persons who
have been diagnosed as psychoneurotic or even psychotic, you
will find his absenteeism is much more chronic, whereas the
other two are much more precipitous. It suddenly goes zooming
up and drops off, whereas the alcoholic’s is just way up over
a long period of time.

So basically, the alcoholic continues to work.

He is concentrated largely, as I said in the male category. If
you look at national epidemiological data, alcoholism still
remains a breadwinner disorder.

Furthermore, it is age-concentrated. If it were somewhat more
distributed in age, as were some of the other behavior disorders,
it would have less impact. But it is clearly concentrated in the
productive years, the mature years, those years of 35 to 55, in
which the individual is expected to make the major contribution
to his organization.

It is not class-concentrated as many people think. Some of
the basic data we have indicate that it is spread quite evenly
across the various occupations and across the various social
classes, in contrast to such severe disorders as schizophrenia.

What this says in practical terms is that your executives, your
professionals are just as apt to fall prey to this disorder as are
your janitors. This is clearly a fact which I believe we can
tentatively accept, although the research data in my judgment
is not as good as it should be.

27

Now, when you look at the job impact, there is beyond doubt
a sharp impact on work efficiency and work effectiveness.

This varies with respect to job level. If you are a top manager,
your work efficiency declines in a much different way than if
you are a guard in this building. It is much more cyclical at
that level, and you work in much more severe spurts and starts.
In the spurts you are very, very creative, and for a period of
time certainly you are not visible because of your intense ability
to cover up.

I think we can summarize by saying that, regardless of the
occupational level, there is sizable evidence to show a clear-cut
job impairment. And, as I said a moment ago, from the purely
sociological standpoint that is the definition of alcoholism. It is
the impairment of central roles, the recurrent use of alcohol
to the point that it impairs specific central roles.

At that point I think that you can cut through a great deal
of the clinical confusion, and certainly you can communicate
with people in the work world with that very simple definition.

When you come to absenteeism, as I mentioned a moment
ago, there are many kinds of absenteeism that the alcoholic has
invented. Not only does he have off -the- job absenteeism, he has
on-the-job absenteeism. That may sound a little strange to you
at first, but certainly it isn’t, I think, too far-fetched.

First, he has a lot of partial absenteeism at work. He comes to
work, but he disappears. You can’t find him. He is extremely
adroit even under highly scheduled conditions in finding ways
of being away from his post.

There is a whole series of “no report,” and that begins to
characterize the alcoholic.

Again, if you study the way absentee patterns rim in large
organizations, you inevitably discover he is associated with no
report. He doesn’t report. He doesn’t call in. He doesn’t let
anyone know. That becomes a part of that tremendous head-
ache that I was talking to you a moment ago about as far as
the supervisor is concerned.

In any event, we can clearly say that, regardless of the kind
of absenteeism, off-the-job, on-the-job, or other varieties, the
alcoholic certainly ranks very high.

Where accidents are concerned, oddly enough, the myth that
he has many on-the-job accidents is not correct. He does not.

372nt63— 70 5

28

One of the main reasons is that he is protecting the job. The job
is in many ways his last bastion of defense, his last justification
for his drinking.

Consequently, on-the-job accidents are not nearly as high as
you would suspect. The old notion that he is constantly pro-
ducing the major accident rate is certainly erroneous.

I think there are two or three interesting reasons for that. One
is the one I mentioned a moment ago. He becomes extra cautious
and wants to defend himself from spotlighting. Another factor
is his absenteeism. It’s very difficult to have an accident if you’re
not there.

By the way, we discover that he does have accidents, a sizable
number of accidents, but they are off the job, and they are rela-
tively minor. For example, one large study out in San Francisco
shows that out of about 150 fatal accidents by alcoholics, only
two occurred at work. The rest were elsewhere.

People often talk about the coverup at work. The coverup at
work does occur, but it seems to have three major characteristics
to it or three major types. One is self-coverup, the individual
doing all the covering up of his drinking himself and the response
to his drinking. This occurs mostly at the higher levels.

We have case histories of presidents of companies who have
gone all the way through their alcoholism and no one ever knew
it except an extremely small coterie of persons that surrounded
and protected them. They engaged in self-coverup at a tre-
mendous rate.

You get coverup that stems from associates, fellow workers.
This occurs more in middle-level occupational statuses where
the coverup is largely performed either by the developing alco-
holic or with the immediate help of a work group.

For example, in studying large construction gangs and groups,
we discovered that the specific work group did a great deal of
the basic coverup. They knew about the developing drinking
problem and were acutely aware of it. But they would shift the
individual around at certain times. They would fill out his time
sheet for him; a whole series of things of this nature.

When you get down to the lowest occupational levels, you
find that many times there is no coverup at all, just very open
dri nking . You get into the occupations that make up our lower
statuses, and there is no such thing as coverup. That, of course,

29

is the reason that we identify in the work world the lower status
occupations first. And this is what typically happens.

The data clearly tell us that the likelihood of the janitor
becoming an alcoholic, being identified, and being referred, is
much higher than the executive director.

So much, I think, for turnover. That is a job behavior. We
find that alcoholics aren’t job hoppers either. If you again focus
on the skid row alcoholic, as has so often been the case, sure,
you find job hoppers. But when you compare by occupational
level the alcoholic with the nonalcoholic, you find the alcoholic
supervisor is going to be with you for a long time.

Firing is a myth to a degree in the work world these days. You
don’t fire these guys. But firing especially if there is a union
around, is something that is becoming more and more antiquated
and almost unheard of in two or three large industries in which
I have worked — for the very simple reason that it is almost
impossible to secure that kind of discharge through the union
apparatus.

So the upshot is that the company keeps its alcoholic
employees.

So much for the demography of the matter from the job
standpoint.

We covered age concentration, sex concentration, the num-
ber of persons typically in the work world situations. We covered
social class concentration. Then we have looked briefly at job
impact.

The supervisor seems to go through what we might call ap-
proximately four stages of response to the alcoholic employee.
We have studied a sizable number of supervisors who have been
the bosses of developing alcoholics, and through a series of other
data it seems that we can describe what we might call four
different phases.

The first one would be the disrupted but normal stage. During
this period a whole series of job disruptions occurs because of
excessive drinking, but the supervisor manages to stretch his
definition of normalcy and hold on to it. In other words, there
are no dramatic symptoms in these early phases.

The main thing that happens is something inside the devel-
oping alcoholic which he manages to cover up fairly nicely.
Minor hand tremors, increased nervousness, hangovers, avoid-

30

ance of the boss and work associates, morning drinking before
work; many of these things begin to cover up the pattern of his
suffering, because he is suffering a good deal.

And he presents to his supervisor a relatively normal but at
times more disrupted than usual pattern. So we can talk about
the phase that is disrupted but still normal from the standpoint
of the supervisor.

The second is what you might call the blocked awareness
stage. It is the period in which the supervisor becomes acutely
aware that this impairment which is beginning to pile up now
is due to drinking, and he becomes acutely aware of declining
quantity and quality of work and a noticeable spasmodic pace
in many instances.

He is aware of it, but a whole series of things prevent him
from doing anything about it. One is that numerous jobs have
low visibility.

In one large company we studied, we discovered that the alco-
holics that received the latest treatment were in mobile jobs,
jobs that had relatively low visibility.

Then a second reason, of course, is the status level of the devi-
ant drinker. If the deviant drinker has substantial power in the
organization and higher status, there is less tendency to respond
to his disruption.

In one large utility, we discovered that if the employee was
middle-class white-collar, there was far greater reluctance. The
supervisor just didn’t believe a guy like that would act that way.
But he was very, very ready to say, “Oh, the janitor is a drunk.”

So even though he begins to realize impairment of the job, even
though this impairment begins to pile up and mount, he still
is very reluctant to do anything about it.

And then there is a sizable degree of tolerance for the deviant
drinkers. Alcohol in our society is both red and green simul-
taneously. We have a fantastic amount of ambivalence about
its use.

One of the startling things we have discovered in working
with a lot of supervisors and shop stewards and work world
people is the extent to which they will normalize these deviations,
find reasons for saying, “Well, yes, we know it was disruptive,
but we are going to put up with it because if we did anything,

31

it would be more difficult than just going ahead and putting up
with it.” A high degree of tolerance.

And, finally, I think that there are various procedures in the
organization itself that make the supervisor very reluctant. One
of the most obvious ones is the discipline procedure that governs
unionized companies. And I presume in the Federal Civil Serv-
ice you have many of the same things. I would certainly be
surprised if you didn’t.

What this all amounts to is a phase which we can call the
seesaw phase. This is a period in which these disruptions and
headaches and difficulties of the alcoholic employee pile up,
pressing the supervisor to do something, but there also emerge
numerous of these barriers to do something. And there is a
seesaw.

Putting it in terms of one supervisor we worked with for a long
time, “He pulls me both ways. There is a tug-of-war going on
inside me, and I don’t want to do anything.”

So there is a seesaw phase.

All this time, of course, the alcoholic is getting worse, and
all this time he is manipulating.

Then there really comes finally a phase which is a fairly long
period of time from the early recognition that alcohol was the
problem, which we can call the “decision to recognize” stage.
And we can put a lot of detail in this if you want to. But there
grow a series of on-the-job signs and symptoms along with in-
creased job impairment and job difficulties, in which the super-
visor finally says, “This person is different. He is abnormal. I will
call him an alcoholic.”

And these phases I think retard early recognition. And this
is one of the reasons I said earlier that I don’t like to talk about
“early recognition.” I doubt that there is such an animal.

I think we can conclude very quickly by saying that if you
think the alcoholic and his wife have problems, then I can assure
you that the alcoholic and his supervisor and his shop steward
or his union representative have problems.

And I believe that, to go back to the points I made in the
beginning, if organizations such as the Federal and State govern-
ments can formulate realistic policies that set the stage for
supporting the supervisor in earlier recognition, in realistic con-

32

frontation and referral, that we can clearly produce reasonable
results.

There are no panaceas, by any means. At the same time, as
we look at the results of work-based programs in which the
alcoholic is still intact, we are struck by the fact that here results
are being achieved that are relatively impressive. And there is
every reason to believe that, as we learn more about how to match
therapy with personality and with social conditions, the results
will be even better.

If, however, we wait until the situation grows so bad that the
individual is apt to be hospitalized, then our chances have gone
way down.

And certainly if we delay until the late stages, we have very
little opportunity of doing much of anything.

A Participant. I would like to say I did have one question
when I came here, but you have answered it for me. That is,
I could never understand how alcoholics lasted so long in indus-
try. Why didn’t someone just say to them, “You’re not function-
ing; you have got to do better or go”? And this is just what you
have explained.

Professor Trice. There is a phenomenon which we sociologists
call the normalization function. It happens in work groups. We
normalize deviant behavior for a variety of reasons.

One of the most prominent reasons is that it occurs among
persons with whom we have emotional bonds, in primary groups,
and this is what happens in many work groups.

Or you can put it on another basis — a “keep it among the
boys” kind of thing.

And we normalize these things rather frequently.

Many studies of deviant behavior consistently show that until
those individuals that immediately surround the alcoholic are
ready to see him as different, then treatment personnel rarely
even get hold of him at all.

Studies of how people get to a psychiatrist’s office show this
over and over — that the psychiatrist is somewhat handicapped
by the fact that he cannot reach into the family or work group
and get the individual out of the network for earlier treatment.

We have clearly found that training will speed this up, pro-
vided it has two characteristics:

First, that it’s training which is realistic in terms of the real

33

headaches that the alcoholic employee produces, because that
will create social distance between the supervisor and the indi-
vidual and he is willing to take action.

I think when we talk in fantasy terms about early recognition,
we are deluding ourselves. But we can talk about “earlier” recog-
nition at a time when he will respond to therapy.

We have a good number of studies which clearly show that the
alcoholic has to be pretty well into alcoholism before he responds.

If you get him in those real early stages, he is not going to
respond. There are too many reward systems operating.

The second point is if this training of supervisors refers to
problem employees and you use problem employees as a way to
train supervisors about general supervision, then it has a saliency
for them.

We have been in this situation over and over. We have had
a bunch of supervisors come in, and talked to them about alco-
holism. You ought to hear the hearing aids go off. Some first-
class resistances come up.

Then we attempted it in the area of the problem employee.
What we did was take a series of psychiatric definitions of behav-
ior and turn them into specific kinds of behavior on the job
and use them as cases.

That produced far less resistance and more change, more
response to the training.

Then we stumbled upon something serendipitously — namely,
that if we use these problem employee cases as a way to talk about
general supervision, every supervisor is worried about filling his
role.

“How do I get to be a good supervisor? I want to do a good
job of it.” And it’s a fairly difficult role.

So then we turn these things into examples of how you go
about being a good supervisor.

In other words, the way to put the process of supervision
into bold relief is : How do you handle the problem employee?
And you put a couple of alcoholism cases in there along with
four or five others, and they will learn a lot about alcoholism.

However, if you set them down for 10 to 15 weeks and say,
“We’re going to train you in alcoholism,” it’s certainly our expe-
rience, and our data indicates, that you are just going to be
creating more problems than you are going to resolve.

34

You see, that is again the problem of parochialism in this area,
the problem of focusing only on alcohol, which I think is very
unfortunate, and this gets back again to the fact that you are
talking here about occupational health in many dimensions.

A Participant. Specifically, what would you recommend the
policy be for the problem worker?

Professor Trice. Well, I think, number one, there are a series
of these phenomena. If you want to take alcoholism as an ex-
ample, I think, first, large-scale organizations need to clearly
state they are health problems, they are behavioral health prob-
lems. You see, if you study the reaction of the general public
to the notion of mental illness, you get some rather strange
reaction.

I mean I hear a lot of people rather in fantasy terms say,
“We’ve changed the conception.” We have a little bit — but not
much.

And certainly as far as alcoholism is concerned, we haven’t
convinced the general public the alcoholic is sick. There are
two very good studies to show that.

But I think the point is this : That large organizations set up
a policy saying, “Look, this individual suffers from” — whatever
phrase you want to use — “a behavior disorder, an illness” — But
he suffers.

I have worked with a lot of alcoholics when they were having
real fun. And I don’t want to imply that that’s not in the picture.
When I first encountered this phenomenon I guess about 20
years ago at the University of Wisconsin, I got very intrigued
with the questions of what is loss of control among alcoholics.
So I followed a bunch of them around. We, believe it or not,
spent $1,000 drinking with them. So we saw them in their native
habitats. And I can assure you that developing alcoholism in
some of its stages is not all the misery the official line claims that
it is.

But let me assure you, at certain stages when the alcoholic
comes out of it he is in real misery. So it is a disorder, malady,
illness, whatever phrase fits the organization.

The second point is that you are going to include it under the
same kind of constructive rehabilitation support. I don’t know
what your fringe benefits are here, but you are going to treat it
the same way. You are going to do something. Thirdly, and I

35

think this covers more than alcoholism, you are going to en-
courage in every conceivable way a realistic confrontation.

I have used the word “constructive coercion” on some occa-
sions. I think perhaps the better word is “realistic confrontation.”

Of course, there is a whole field in social psychiatry called the
utilization of the crisis, and that is what I really am t alkin g about
here. Instead of utilizing the natural crisis for mental health
purposes, the use of what Alcoholics Anonymous calls “hitting
the bottom” is I think realistic.

Some companies get that in by stating in simple terms: “After
a series of realistic confrontations by the supervisor based on
work performance, the company will consider specific kinds of
coercive measures.”

What happens is that a crisis — a clear-cut choice — is presented
to the alcoholic. He is given to understand that he must “shape
up or ship out” or, more to the point, that he must seek treatment
or his job will be endangered.

Dr. Siegel. My question bears on the same area of realistic
confrontation. How can the medical department of organiza-
tions encourage, assist, or influence managements of these orga-
nizations to promote constructive confrontation?

Professor Trice. This can be accomplished by stimulating
that kind of realistic training which doesn’t focus exclusively on
alcoholism or problem employees but uses problem employees as
an example for good supervision, how to be a supervisor, and
participating in that training itself if you can.

We discovered in two large companies that the nurse had
more impact in training situations about many of these matters
than anybody else. That includes the training director, the doctor.

We began to study this a little bit. What it boils down to is the
nurse still carried a medical kind of halo and authority about her,
that she has much less social distance than does the doctor. She
is accepted, and many times she is turned to. So often, she is the
key to training.

There are certainly other approaches to this. One is that you
can educate line supervision when you deal with cases like this
and get them at a later point. The doctor attempts in dealing
with line management people: “Look, Joe, if you could just
have worked with us earlier. How can you work with us earlier?”

372 — 463 — 70 6

36

Another is to study the basic problem of line-staff relationships
in general. How do you reduce resistance of line people to staff
participation? Get to blow line people as much as you can.

Any organization has tremendous conflicts between line and
staff. It’s just built into organizational life. Get to know line
people as much as you can, interacting with them in a variety
of ways. Then when this one instance comes up, you have a
chance perhaps for educating them, and they will turn to you
quicker.

I suggest using the nurse sometimes to bridge the gap. Once
this is accomplished the doctor is less formidable.

A Participant. You tell us that we need to think in terms of
work performance, crisis precipitation, and early recognition. We
medical people think this is what people expect from us, and
this isn’t really our job — management.

When the alcoholic comes to the health unit, we are thinking
in terms of what can we do medically. This person who comes
says, “Now, you say I’m sick. Go tell management.” And then
this person becomes a cripple.

This I think is the reason for the confusion on what is our job
for these alcoholics.

Professor Trice. Certainly I don’t assume any of those first
points are your job. That’s line management’s position.

The Participant. We don’t either, but sometimes I think
management feels, “What are you going to do about this?”

Professor Trice. I think it certainly can be your role to partici-
pate in communicating and educating management to this.

The supervisor of an alcoholic goes through many of the denial
processes the alcoholic goes through. And he has many of these
vacillations. But if he will turn to anybody, in our experience,
he’ll turn to his own peers. He won’t go upstairs about it many
times. It puts him in a bad light.

You have a unique opportunity to educate him, because if you
have any absenteeism rules, regulations, et cetera, you may be
getting to this guy more frequently, and he may actually turn
to somebody. He is going to start trying to turn to somebody.
And to us the most unthreatening person that has some kind of
knowledge is the industrial nurse.

Second is the question of referral. I think your ability and

37

knowledge of referral to AA or to community resources is very
valuable.

A Participant. Don’t you think if these supervisors could be
made to realize that they really aren’t being kind when these
people have a problem — they would get them, early, if possible,
and not let them keep on going and not performing.

Professor Trice. Many of these guys will listen to what you
have just said. They won’t listen to me at all. They deal with
you. If you said what you just now said to such persons on cer-
tain occasions, you could have some impact on them.

Training can have an impact on them too — and does. You
can speed up this recognition process I describe.

We have had industrial nurses come in and say just this sort of
thing to management, and they will listen, and they will change.
We can’t get them to change. We get a bunch of them down
around a table, and the rejection is quite high.

If we get another supervisor who has been through it to act
as the conference leader and discuss it with them, then we get
changes, and we talk about the extent to which this represents
the way to be a good supervisor. You learn how to be a super-
visor through working with the alcoholic employee or the
problem employee.

So what I am saying is that you can do just what you have
just now done in your organization and have quite an impact.

Dr. Phillipson. Would you care to say anything at all as to
how management might work a bit more with unions to hasten
the crisis precipitation?

Professor Trice. This is the greatest stumbling block in the
work world. The first step is to keep the union fully informed.

I am quite distressed over a series of developments in com-
panies and State governments in which the union has been left
out or told later. The union has three reactions. The first is,
“We have to protect this guy.” The second is “He paid his dues,
and if he is confronted this way and management knew it, we
are going to walk the last mile with him.” And the third reac-
tion, which is sometimes the most constructive, is that, “We are
just going to sit back and wait and see, and maybe we will
support you and maybe we won’t.”

Well, if you people do anything in the Federal Government,
get the union involved, aware of what you are doing, represented,

38

with some degree of consensus. Change your policy if neces-
sary. The upcoming field in unions today is in governmental serv-
ice, both Federal, State and municipal. You can stumble all over
yourself on policy like this if you don’t include them and if
you don’t do it in a realistic way. They can be very potent.

If you have a shop steward and a foreman confronting realis-
tically at the same time along with somebody in the family and
circle of friends you have a chance, a real chance.

Recognizing the Alcoholic
Richard Phillipson, M.D.

(A psychiatrist, Dr. Phillipson is Visiting Scientist with the
National Center for the Prevention and Control of Alcoholism,
NIMH. He is a British subject, and for many years served in the
British Army and Civil Service. )

Dr. Weiland did cover in a large measure the question of the
recognition of the alcoholic, the detection of him. And that’s
just as well, because I haven’t a tremendous amount of personal
experience to give you on this, for the very simple reason that this
whole question of the recognition of the alcoholic within the
Civil Service is a field that I’ve only become acquainted with to
any great degree in the last 6 months in this country.

Previous to that I did have 8 years at the Ministry of Health
in London, but we were doing little or nothing about recognizing
the employees’ drinking problem.

Prior to that, I had 26 years in the British Army, and my last
post was Chief of Army Psychiatry.

In the British Army the psychiatrist looked after alcoholics in
the army, the navy, and the air force, so we did have a little
experience with this challenging health problem.

I will tell you a little more about that, because I think it is
possibly of interest though different from the problem that is
facing you now.

How are we different? Of course, we are very different because
we are such a closed environment, a closed community. If the
soldier is not on parade when he should be on parade, the
sergeant-major knows about it very quickly, and before long
that soldier knows that the sergeant-major knows.

And similarly, if the officer is not on the job, his commanding
officer knows pretty quickly, and he knows the reason why.

In most areas in the British Armed Services, especially over-
seas at any rate, you can buy liquor from the army. You pay
for it monthly in arrears when you pay your monthly messing

39

40

and mess account. And in various areas it is not possible to buy
alcohol anywhere but from the equivalent of the PX.

So, naturally, your consumption of alcohol is known by the
size of your mess bill. And this is another very small point. But
alcoholics as a whole in the army come to light much more
readily.

There are other reasons why they come to light that are more
applicable to your situation. When dealing with male alcoholics,
change in work performance, absenteeism, and attitude are
indications to the supervisor or fellow worker that all is not well
with an employee. But who is the first person who knows really,
even before the supervisor or even before his fellow workers?
I think the first person who knows about the male alcoholic is
his spouse. Of course she knows. But how is she going to let
you know?

In the British Army this was very simple. For example, when
I was the commanding officer of various hospitals, my wife
had a part to play. She was ex officio, as the wife of the com-
manding officer, the chairwoman — or the chairman — of the
wives’ club. And the wives’ club met every week regularly as a
routine, one morning a week, with various activities.

There was the “well baby” clinic. All the mothers who had
babies brought them to be weighed. And my wife and the district
nurse, or whoever it was, took part in the solemn process of weigh-
ing the well baby. And then they got down to the coffee and the
buns and the “natter” — what we men used to refer to as the
“nappy natter.” And this is where, quite frequently, the news
came out that Mrs. Brown was very worried because her hus-
band was drinking too much or had some other health problem.

I mustn’t deal too much with the British Army because as
days go by it is shrinking, and being smaller it was very much
easier to run, in certain ways, than is your Army.

Early in November last year I went to consult at an Army
camp where one reasonably-sized special program for the treat-
ment of Army alcoholics is in progress and has been for some 2
years. It is run by a very active young physician. He scheduled
an afternoon meeting with all the line commanding officers, and
colonels and brigadiers of this very large training base. We also
got quite a few of the staff officers, including the chief of staff.
The general commanding the base was represented by his chief

41

of staff, and we had a very good discussion for the whole of the
afternoon, on what to do about the soldier with this health
problem.

I don’t want to belabor the point, but an important considera-
tion in all three U.S. armed services is that alcoholism is not
considered an illness. Alcoholism per se is not in the line of duty;
that is, it is a self-inflicted injury, and if the soldier is diagnosed
as an alcoholic he is almost certain to get a dishonorable dis-
charge and to lose all pension benefits.

Now, this is a very awkward matter and leads to a lot of
maneuvering similar to what had been going on in other work
settings. Should you be diagnosed as having cirrhosis of the liver,
gastritis, or peripheral neuritis, you are normally given an honor-
able discharge and receive all the pension benefits to which you
are entitled. So, as I said, this leads to a lot of maneuvering.

One of the commanding officers got up and asked, “Gould
you tell me what I do with a sergeant who is on parade every
morning at 5:30 and works right through the day drilling the
men? It’s a very big training base; they are drilling throughout
the day and training in many other ways. He works right up to
the last minute he should but I know from my wife who knows
from his wife or from other wives in the wives’ club, because they
have the same situation, that within an hour of getting home he
has gone through at least a bottle and possibly two bottles —
that is, two fifths — of bourbon, and within 3 hours he is ‘out
of this world.’ He’s impossible to live with and he just wakes up
in time to get on duty. How do I deal with that? Because as
far as I’m concerned he’s a first-class sergeant.”

I replied, “Surely, the Army works by night as well as by day.
A nd surely if you have night exercises often enough this man
won’t be available.”

And to my amazement he said, “Oh, but that wouldn’t be
fair, would it?” In other words, here was a very senior supervisor
who was putting up just the same resistance that many
supervisors do.

I referred briefly during Dr. Weiland’s talk to this question
of training of supervisors which is already taking place in
Albany, N.Y. This is being carried out by the Civil Service Com-
mission, but the Department of Mental Health plays a part in

42

this training. I went up there and sat in on one of these training
sessions.

Most of the class were men. There were one or two ladies.
I’m pretty certain there wasn’t one volunteer among them. They
appeared to be not overly impressed with some very good instruc-
tion. Questions were slow.

But near the end of the last session — and this is frequently
a point where you get the very best, just at the last minute, when
half the people want to leave because you have already over-
run your time — a young man got up, very big, well-built, some-
what red of face — it might have been due to the sun, might have
been due to other things — and he said, “You’ve been talking
about early signs of alcoholism. How do I know when one of the
men that I am supervising is becoming an alcoholic?” This
rather surprised the man who was giving the talk, and he turned
to me and said, “Doctor, would you mind taking this question?”

And I was very glad I did, because I gave a very quick run-
down on the blackout and gave them a picture of a man who has
been out drinking, a heavy drinker, who wakes up one morning
and hasn’t any memory of the night before at all. He has no
conception of where he was the night before.

And then he has a glimmer of an idea that perhaps he was
out in his car. Then he suddenly says to himself, “My God, I
wonder if the car is in the garage?”

He manages to stagger out of bed, although he has a frightful
hangover, and he crawls downstairs, looks in the garage, and
is happy to see the car there.

And I repeated, “He still has and never will have any memory
of how he got home.”

Then I said, “Ladies and gentlemen, this to me,” (Don’t for-
get these were supervisors, so I went into detail that I wouldn’t
need to do with you) “This is a very good example of a warning
sign that that man should quit dr inkin g, and if he’s going to
start again ever, it should be in the long distant future when
he knows better how to handle alcohol.”

To my absolute amazement, this man replied, “But, doctor,
surely everybody who drinks experiences that.”

In other words, he was possibly having blackouts but he didn’t
realize at all that this was in any way an early sign of dependence
on alcohol.

43

Questions and comments like this sometimes suggest personal
involvement, but one must not jump to conclusions.

Well, this is wandering in a certain way from the real essence
of what I should be talking about — how to recognize the
alcoholic.

First, a definition of alcoholism. The subcommittee on Alco-
holism of the World Health Organization defines the condition
as covering “those excessive drinkers whose dependence on alco-
holism has attained such a degree that it shows a noticeable
mental disturbance or an interference with their bodily and social
and economic functioning” — and the last is most important — “or
who show the prodromal signs of such development.”

Now, I believe this is the important thing. What are the pro-
dromal signs of the development of all of these symptoms — the
mental disturbance, interference with bodily and social and
economic functioning.

Like all definitions, of course, the WHO never went on to
describe what were the prodromal signs of such development.
But there are readings that are of assistance in this.

One I would recommend is “Problems in Addiction” which
is one of a series of books by the Fordham University Press, the
Pastoral Psychology Series No. 2, edited by William C. Bier.
This, in my opinion, is worth looking at because it does bring
out to a certain extent the early signs of problem drinking.

These early signs were very interesting to me, because I think
we may be making a mistake here in concentrating so much on
the problem of alcoholism and so little on the problem of intoxi-
cation, particularly when we are talking to young people, in just
the same way as we in Britain may have been making a mistake
in the past decade in talking so much about the dangers of
smoking and lung cancer and so little about the dangers of
smoking and bronchitis.

We know that 3 to 6 percent of those who drink are likely to
become alcoholic. But how many of those other 94 to 97 percent
are likely to become intoxicated, and when intoxicated, although
anything but alcoholics, are likely to get into the most frightful
trouble on the roads and elsewhere?

I feel sure that there is much more reward to come from instruc-
tion to the young about the dangers of intoxication than about

44

the dangers of alcoholism, which we all agree still occurs in the
late 30’s, the 40’s, and 50’s.

But it is not only the young who need to be taught about the
dangers of intoxication. I see you are able to obtain a driver’s
license in some States at the age of 14, whereas in Britain you
are not allowed to drive a motorcar until you are 16.

But we in Britain do allow you to drink when you are 16 also,
whereas in certain States you don’t allow your young to drink
until they are aged 21. So you are more permissive with driving,
but you are much more restrictive with drinking. And, of course,
we all know that the young drink in many, many situations long
before the permitted age.

At another meeting 2 weeks ago, a doctor from Lansing, Mich.,
spoke of a program for alcoholism that he was running. He devel-
oped liaison with the judges in the local courts, so that a new
procedure was developed for handing any young man brought
before the court on a charge of drunken driving. This charge
was put in abeyance for 2 months. Once a week for the interven-
ing 8 weeks the young man attended a compulsory series of
lectures by this doctor and his staff on the problem of intoxication
and driving.

I won’t say he goes through an exact examination at the end
of the eight sessions that he visits — and he pays $5 for each ses-
sion — but if he doesn’t get a good report on his attendance, when
he appears before the judge to have his case heard, he’s much
more likely to get a more severe sentence for his drunken driving
than he is if he has a good attendance record and gets a good
report.

This to me is a very good attempt at prevention.

Now, how do we deal with this question of recognition of the
alcoholic? Quite frankly, I don’t really know but the experience
developed by the employers in the private sector suggest several
examples that can be useful to Civil Service employers and
employees.

Programs are being developed for Civil Service employees in
two States, New York and Pennsylvania. Experience coming from
these relatively new programs indicates that supervisors are play-
ing a major role and that some employees with dri nkin g problems
are seeking health services voluntarily. Much depends on how

45

well the environment has changed so that drinking problems are
accepted as are other physical and mental health problems.

I take the point from Professor Trice that in the case of industry
it’s very much easier because industry has got together with the
sociologists and others who can be of such tremendous help in
furnishing the hard data that are required. They have recognized
the problem, and they are working with it.

And, happily, the unions are starting to work more closely
with top management also and there is no reason why these kinds
of relationships cannot be developed by the Federal Civil Service.

As I mentioned to Professor Trice after his talk, I was in New
York City discussing this question with a person who is a senior
management consultant there on alcoholism in industry. This
man said to me, “I’m getting somewhere with the unions as well
as with management; they are beginning to understand the con-
cept ‘Don’t let Charley die’.” He manages to persuade unions
and management, as well as supervisors, that they all have a duty
to keep Charley alive no matter what his illness.

This is a possible way, as Professor Trice so rightly put it, that
you ladies who are nurses can get together much more readily
than we doctors — and especially we psychiatrists — with the
supervisors and the shop stewards. They are unlikely to be suspi-
cious of nurses, the same is not true of other health professionals.
They are likely to listen to you, and I would hope that this would
be another fruitful way of getting early recognition of the em-
ployee with the drinking problem.

I would like to run down very briefly, if I might, the indicators
mentioned in the “Key Step,” because I have given you very few
indicators. Many of them have been referred to already, but I
would like to expand on one or two of them if I may.

1. The first one is repeated Friday, Monday, or halfday
absences. Well, that’s an easy one.

2. Secondly, frequent reporting of absences by members of
the employee’s family or persons other than the employee
himself. He doesn’t report in, but his family get anxious,
and they report in.

3. Unusual excuses for absence.

4. Lying about inconsequential matters.

5. Display of an increasing lack of responsibility.

46

6. Mood changes in a previously stable employee. Fairly
similar to the developing anxiety state that one found in
the soldier over-exposed to stress in the front lines.

7. Frequent loud talking or irritability. This is frequently
in my experience covered up at work especially within
the hearing of the supervisor.

8. Avoidance of the supervisor.

9. Long lunch periods.

10. Frequent use of breath purifiers. I am not too happy
about this one because it could be used for so many other
quite reasonable complaints or problems.

11. Hand tremors, flushed face, or other commonly recog-
nized physical signs. Again this one could be due to
alcohol but could be due to other things.

One would hate to say to a person who isn’t an alcoholic, be-
cause he has a red face or because he is using a breath purifier,
“Do you have a drinking problem?” Redness of the face appears
in many other unrelated conditions and although I’m not going
to go so far as to say I would rather miss an alcoholic than do
this, I would very much regret having accused or suggested to
somebody that he had a drinking problem when all he had
was some other personal problem about which he was very
self-conscious.

The one thing I would like to know is : Is there a lot of absen-
teeism? Are there more accidents that are causing physical ill-
nesses, broken bones, and all the rest of it, that are being missed
by us professionals? Data like this have been developed by the
employers in the private sector and it could be that similar ap-
proaches could be made within the Civil Service.

I am sure that I have talked enough. If I can answer any ques-
tions on the basis of my previous 8 years experience in addiction
units in Britain, or the very much briefer but in many ways more
stimulating experience I have had in your country in the last 6
months with the National Center, I will be happy to do so.

Dr. Siegel. Doctor, you struck something that we have all
faced up to, and this is the problem you mention in the Army,
it’s true at least by the letter of the law under Civil Service that
inability to perform duty because of alcoholism pure and simple
is a line of duty “no-no.” It’s malfeasance rather than due to

47

illness. So a good deal of maneuvering has to be done to get
around this.

Are there any experiences you would like to relate or comments
as to how to do the best maneuvering and what is the medical
department’s role as long as such maneuvering has to be done?

Dr. Phillipson. First of all, within the British Army, as Chief
of Army Psychiatry, I was able to get alterations in certain policies
very readily. The way I dealt with the alcoholic — and when
I say dealt, I mean the way I got all psychiatrists in the British
Army to deal with it, with the approval of the staff and the
Surgeon General was this:

A soldier or an officer sent to us because of a drinking problem
was admitted to the hospital, was offered treatment if he wanted
it (group therapy, individual psychotherapy, Antabuse if he was
suitable and wanted it) , all the various physical and psychiatric
methods of treatment that were available.

Upon completion of his treatment, he had adequate followup
treatment within the unit to which he went. And he didn’t neces-
sarily go back to the same unit from whence he came.

This is a very important point because quite frequently the
immediately precipitating factor may be within the unit, or, at
any rate, his problem is so well known within the unit that he
ought to be given a fresh start.

On completion of treatment he was told that if he relapsed he
could come back again, and could have a second chance, but if
he relapsed once again, I used what I call the “third offender’s
act.” I don’t know if you have the same legal term, but for any
crime, especially of the young in Britain there is the first offend-
er’s act by which you are almost certainly going to be what we
call “let off with a caution.”

But I implemented what I called the “third offender’s act” —
that if a man relapsed a second time, unless there was a very
good reason for him to be separated medically, he was available
for separation administratively.

This didn’t imply the rigid dishonorable discharge that you
have in your services, but it did imply that if he didn’t have
pensionable service, he didn’t get a pension.

Pensionable service with us in those days was 22 years. And
the bulk of our soldiers and officers who got into trouble with
alcohol eventually were separated almost invariably with between

48

16 and 18 years of service. It was what we call the “drunken
major syndrome,” because the officers were nearly all majors,
and a majority of the other ranks, the soldiers, were company
sergeant-majors. Some of them were sergeants, but they generally
made, by 16 years of service, company sergeant-major. So, as the
majority of this problem group were in the major or company
sergeant-major rank, it became known as the “drunken major
syndrome.” And the funny thing is that it’s exactly the same in
your Army.

With us, the man with 15 to 17 years of service had not earned
a pension. He had to do 22 years. If he got a medical discharge,
he got a modified pension. A lot depended on what the man’s
outfit said to us. If they said, “No, this man had really been a
very poor soldier and he has committed a lot of minor and even
major offenses, including monetary offenses” — he was separated
administratively and didn’t get a pension. You may say this is
hard, and it was very hard, especially on the dependents.

But where I had a frightful conflict of conscience was that if
I separated him medically, he got a pension — and what happens
with a man in his middle 30’s to whom you give a pension as an
alcoholic? Is he going to be alive 5 years later?

Certainly my experience down in Alabama, last week, with
the moonshine souped up with chlorox is indicative. If you give
a man down there a pension of $2,000 a year and he buys a little
farm and makes moonshine and somebody else “soups it up”
with chlorox for him, he is not going to live 3 years, much less 5.

So are you right in being kind — in giving him the benefit of
the doubt and separating him medically, and giving him a
pension?

If he doesn’t have a pension, he is going to have to work. If he
has to work, he is going to live longer. There are two things you
need for continued alcoholism. One is the susceptibility to alco-
hol, and the other is the availability of alcohol.

Even in your country, where it’s a third the price it is in mine,
you still have to have a certain number of dollars to buy alcohol,
and if you haven’t got that money coming in regularly and have
to work for it, you may live longer.

Professor Trice. I’m very much intrigued, Doctor, by your
point that you would not give this pension, because I think it
underscores what to me is vital. And that is that in the final

49

analysis there has to be some sort of realistic confrontation
that is carried through, some sort of “constructive coercion.”
Some people think it’s too strong. But it seems to me you are
saying the same thing.

I have been in companies who faced the same dilemma: Shall
we really now follow through completely? And some of them
have hired this person later after they did follow through com-
pletely. But they were forced to follow through, even though
there was a mild risk of suicide, a slightly higher risk of suicide,
though not too much.

Dr. Phillipson. I should add here, please don’t think alco-
holism per se is attributable to military service. A lot of people
would like this to be so.

Professor Trice. We discovered that the military service
didn’t have much higher rates than other occupational groups,
from what little data we could get. And it was the same point.
After 17 or 20 years of service, and at certain occupational levels
where the guys had gotten stuck — the “major syndrome,” the
assistant manager level in a large grocery chain — that seems to
be where it was lodging.

Dr. Phillipson. Yes. And strangely enough, the one program
in industry in civil life that we got off the ground a few years ago
in Britain was in the equivalent of your PX, what we call the
“NAFFI,” the Navy, Army, and Air Force Institute, which sells
canteen supplies to the soldiers both at home and overseas.

At home it is not much of a problem, but overseas this is an
entirely civil organization within the military setup, and alco-
holism within the civilian-staffed military canteens overseas is
a tremendous problem, one of the reasons being, of course, that
alcohol is so very much cheaper.

If I can dwell for just 30 seconds on this, to give you an idea
of how “you’ve never had it so good” here as compared to Britain,
a bottle of scotch in Britain now is about $8 to $9. Overseas
with the soldiers it’s about 80 cents. And when you say to the
soldier “You know, you have really got to cut it down,” he says,
“Doctor, please sir, I can’t afford not to drink— 80 cents
compared to $8.”

This was the best British scotch which was exported to them.
If they bought the local stuff, of course, it was half again as
cheap, but possibly not quite so pure.

50

And there was another question too. When a patient does come
to you and says, “All right, I have got a problem, and what are
you going to do about it?” do you have to preach total abstinence?

I wonder. If you do, he is almost certainly not going to come
back to you straightaway.

You do preach, in my philosophy, total abstinence as far as
possible, but you do admit that this can be to a certain degree
a chronic relapsing disorder and that if he does relapse, you
will still be there and you will still take him back again.

I thought of that when you brought up that first point about
these people making you feel so helpless because there is so little
you can do for them. Well, there may be very little you can do
for them, but you musn’t let it get you down, because even doing
a little for them sometimes does result in quite a lot coming
out of it.

The Point of View of the Recovered Alcoholic
Will B. and Jan S.

(Will B. and Jan S. are members of Alcoholics Anonymous.
George C., who speaks from the audience, is a third member
of AA, who accompanied them. )

My name is Will B., and I am an alcoholic.

I came to Washington nearly 20 years ago because my sister
was in trouble with alcohol. I am happy to say that today she
is all right. She’s now living in San Antonio and reunited with
her son and grandchildren.

She had an interval of sobriety. Then she went overseas, and
took the AA program to Okinawa. She returned, and things
weren’t going her way, so she said, “To hell with it all,” and
started to drink again.

And in her second interval of alcoholic drinking, she nearly
died and had nurses around the clock.

But she did stop, and she’s all right.

Some 15 years later I was in trouble with alcohol — I who had
said I would never become an alcoholic, that I would never
drink unless I drank in a nice place, that I would never dr ink
unless I had the right glass.

But I passed over that invisible line from social drinking, what-
ever that is, to alcoholic drinking, which eventually meant to me
that I drank a fifth each night.

Now, I could rationalize this because I had a heart condition,
and when I had angina pains I knew that a shot glass of bourbon
would ease those pains — and more pleasantly than nitroglycerin.

But it got to a point where all night long I kept getting out
of bed for one more shot glass of bourbon. And I did not keep
the liquor near me. I kept it so I had to get up and walk to the
kitchen. Eventually I was drinking a fifth a night, and later on
I was drinking another fifth during the day.

I knew I was an alcoholic long before I decided to do any-
thing about it. In fact, I had read the original “Saturday Eve-

52

rung Post” article by Jack Alexander that gave the first national
publicity to what AA was doing.

And I had no intention of stopping drinking, because I really
was having a good time. If you think you’re having a good time,
then you are.

But there came a point — and the late Dr. Theibout, in maki n g
a reference to “bottoms,” says that a bottom can be any place the
alcoholic decides that he’s had enough. Well, I called AA head-
quarters one time and asked for the nearest meeting.

And I went to the nearest meeting. But I fooled around with
AA for 10 months, or, as somebody put it, I was an “outpatient
of AA.”

But at the end of 10 months I moved, because I had to take
care of my sister who had become diabetic, who had a condition
that the hospital called tightening of the arteries, and was no
longer able to work. And I moved 4 years ago, on April 1st.

As usual, I called the liquor store and I asked them to send
over a fifth. And on April 1, I drank half that fifth, and on
April 2, 1 drank the other half. And that has been my last drink
to this moment.

Somewhere in there I decided I had had enough. And I
embraced the principles of AA.

Here I will stop and tell you what Alcoholics Anonymous is.

Alcoholics Anonymous is a fellowship of men and women
who share their experience, strength and hope with each other
that they may solve their common problem and help others to
recover from alcoholism.

The only requirement for membership is a desire to stop
drinking. There are no dues or fees for AA membership. We
are self-supporting through our own contributions. AA is not
allied with any sect, denomination, politics, organization, or
institution, does not wish to engage in any controversy, neither
endorses nor opposes any causes. Our primary purpose is to
stay sober and help other alcoholics to achieve sobriety.

As part of helping the other alcoholics, my next speaker, an
associate who is in the audience, and I man the desk at head-
quarters. And the queries that come in are, you know: “Where
is there a meeting? What can I do about my alcoholic husband?
What can I do about my father, my mother?” Some of them are
utterly ridiculous. And I have learned that history repeats itself.

53

About 3 years ago I had a call, and I said, “Decatur 2-1933,
may I help you?” And a woman’s voice said, “Yes.” Then she
said, “You sound happy.” I said, “I wouldn’t say I’m happy,
but I’m content.”

And we talked for a few minutes. And she said, “You sound
young and vibrant, why don’t you come over and explain the
AA program to me?” I said, “Well, I’m not that young, and
I lost all my vibrancy at the end of World War II and the years
I spent in New York drinking.”

Then we settled for a more orthodox way. I would get in touch
with a woman in her community to make what is known as a
“12th step caH.”

About 3 weeks ago, I answered the telephone. I said, “Decatur
2-1933, may I help you?” And a woman said, “Yes, I hope you
can.” We talked along for a few minutes, and she said, “You
sound young.” And I said, “But I’m not that young. I was in
World War II.”

So then we talked along. She wanted to know my profession.
And I am a writer, and I am a conservationist, and I was born
in upstate New York. She said “Tell me why are so many writers
alcoholics?” And I said, “Well, I honestly don’t know.” And
she cited Edgar Allen Poe, may he rest in peace. And I went
on to talk about the man who wrote “The Edge of the Volcano,”
Malcolm Lowery, and others over whom alcohol had triumphed.

She said, “Well, look at their contributions.” And I said, “Well,
yes, but perhaps if they hadn’t drunk alcoholically, they would
have made even greater contributions.” “Well,” she said, “I’m
a writer too. And if I thought I could leave any sort of literary
heritage, I’d go right on drinking.”

I said, “You know lady, that’s your privilege.” Then she said,
“What’s your religion?” And I said, “I’m an Episcopalian.” She
said, “Tell me, why are so many Episcopalians alcoholics?”

Well, this is, you know, part of the game. I had no answer.
Writers don’t have a corner on alcoholism. Episcopalians, free-
wheeling as we are, don’t have a comer on the disease, if you
want to call it a disease, which I think is listed as fourth on the
list of killers.

There is a little squib I cut out of “Today’s Health” of last
month. It says: “About one in every eight beginning drinkers
eventually will suffer from alcoholism, according to the National

54

Institute of Mental Health. There are an estimated 6.5 million
alcoholics in the United States today.” I don’t know whether
that 6.5 million includes those of us who belong to AA. A rough
estimate of our membership is about 400,000.

AA works apparently well for some of us. There seems to be
a percentage who never get the program. A man that Jan and
George and I know was found dead a week ago down in
Orange, Va.

Now, perhaps he was one of those people that have a deep-
seated emotional problem. Maybe alcoholism was only a symptom
of something that bugged him to the point where he went out
and drank again. That I don’t know.

Anything I say is only Will B. speaking and his reaction to the
program. I do know a great many alcoholics are arrogant, and
I do know that I was. I wrote three extremely successful books.
One was a selection of the Outdoor Life Book Club. Another
was on display at the Palais Wilson in Geneva as an example of
good bookmaking. And the third was used in a seminar on
East/West cultural relations in New Zealand.

I got stranded in Montana once, when I was on a field trip,
and I didn’t have any money. I wrote to my publisher for money
and he sent it to me. I was also once introduced at a Washington
Booksellers Association dinner as “Washington’s own Will B.”

Now, this sort of thing really can do a lot for your ego, and
perhaps you really become arrogant, and you have to lose this
arrogance and self-centeredness and a number of other quali-
ties — described as a conversion process — before you really can
stop drinking happily and become content and live the so-called
normal life with your associations in the workday and social
world.

I lost the compulsion to drink. I rarely think about drinking
anymore. Sunday I was asked to dinner for Easter, and for my
birthday, and my hostess said “wouldn’t I have a sherry?” And
I said no. And then we went to dinner, and it was “wouldn’t I
have a drink?” And I said no. And wouldn’t I have a liqueur.
And I said no. It doesn’t bother me to say no, because it’s really
no one’s business why I no longer drink. I am a person that has
freedom of choice. And I always can drink if I should be foolish
enough to go out and take that first drink. For my own thinking,
if I ever drink again, I will never make it back.

55

I used to say I was never hospitalized for drinking. But in
retrospect I know I was, because I awoke one morning with a
pulse of 200 — and that’s an awful lot of pulse — and I was sent
to Georgetown University Hospital as an emergency case. Then
2 months later I had a variation of this pulse business.

And at a doctors’ and dentists’ retreat, to which my doctor
always invites me, I had a coronary in bed and was brought up
to Georgetown University Hospital. Now, I realize that all three
of these heart attacks or variations or accelerated pulses were
due to lots of drinking, lack of sleep, and little food.

Of course, since then I have had two more variations of
a heart flareup and was also walking around with double
pneumonia.

I once called for the Rector of my church, and subsequently
I got Father William A. Wendt from St. Stephen’s and the In-
carnation, and, to make it very brief, I said to him, after I had
talked a while, “I don’t know why I’m not dead, Father.” And
he looked at me and he said, “Will, you’re not dead because
you’re not supposed to be dead.”

In other words, I guess I’m supposed to go on writing, and,
within the limits of not very good health and with Meniere’s
Syndrome, try to help other alcoholics.

Now, I would like to introduce a woman I admire enormously;
one who can present you the woman’s view of what it means to
drink alcoholically. And then we will be happy to answer any
questions you have about AA.

Jan.

Jan. My name is Jan, and I’m an alcoholic. By the grace of
God and AA, I am a recovering one. And I say “recovering,”
because I think our recovery is an on-going thing. I feel that there
is always more for me to learn, and there is certainly plenty of
learning available if I will grasp it.

I will qualify myself very briefly by saying I spent 21 years
drinking to excess, because I liked to. And I would like to blame
my parents, because it is very fashionable to blame your parents.
But, terrible as I think they were, I think everything that occurred
to me because of them was through love and through a sense of
responsibility. I feel now that a standard was imposed upon me
which I couldn’t fit, and I think this probably had good intention
behind it, but I could not conform to this standard. And so,

56

consequently, I always felt inferior and inadequate and in the
wrong. So when I discovered booze at age 16, during Prohibition,
by the way, it performed some kind of “magic” that made me no
longer inadequate, inferior, in the wrong.

A certain amount of booze made me level with everybody else,
and a certain amount more made me superior to everybody else.
So why wouldn’t I seek this?

I pursued it for about 21 years because I believed it did so
much with its magic and I believed it so beneficial. I think now
that my emotional growth was arrested at age 16 until the day
I approached AA.

Needless to say, it went from bad to worse, and it took more
to get the same effect. And I began to switch from pleasure
drinking to dependency drinking, to needing drinking, needing
liquor to keep going. And this is not any fun.

In the meantime I was gradually learning a few tricks to main-
tain my right to drink. I was learning to lie and cheat and con-
nive and compromise my own interior code. So, with all, I was
drinking prodigious amounts, far more than a lot of men I
know. A lot of men that I used to drink with couldn’t keep up
with me. I could drink well over a fifth a day. And at the height
of my best drinking and worst behavior, which were synonymous,
I was drinking maybe two fifths a day, plus all the beer I needed
to quench my thirst — but still functioning, driving a car, taking
drunks home, doing things.

And during that period I married a playmate who was of the
same persuasion, also alcoholic. And the only reason I married
him was because he was the wildest man I knew, and everybody
else I knew was pretty dull, pretty conventional.

I’m glad to say he’s now in AA, too, but we’re no longer
married.

I came into AA in 1952 when all the self-loathing that was
driving me came to the surface — over a very small thing. I was
about to write a bad check to get another bottle. And this is
very mediocre as a confrontation with self, because there have
been some very startling awakenings in AA. Other people have
had much worse things happen to them than that. But this
focused it for me.

* lad now I called AA — without any real hope,

we I was so different. But I found when I came

57

to AA that I fit some place in the middle. I wasn’t the worst, and
I wasn’t the best.

Since then, using the simplicity of the AA program and the
guidelines provided, I have learned how very, very sick I was.
Maybe “condition” is the better word for it, because I do think
“disease” implies that you can’t help it. And there seems to be
something volitional in alcoholism. Nobody can activate mine
but me.

However, these are points for professionals and not for me.
My alcoholism is a fact, not a theory, so I will deal with my facts.

I found that I was not only sick at the physical level but spirit-
ually, emotionally, and mentally. I needed what I was receiving
in AA. I had no realization that these needs were not met until
they started being met.

I needed to belong. I needed to be in an environment where
I was not judged. My own self-condemnation and judgment of
myself was so harsh that I imputed it to other people.

But in AA the environment was quite different. It was an
environment that sustained me, conveyed to me a belief in me
as a person, and it was for me the great environment for recover-
ing, for pursuing the search for authentic self-hood.

I think that all the energies of my past, in my drinking days
were devoted to either apologizing for or defending the way I
am programed. And I learned in AA there’s nothing wrong
with the way I am programed; that I’m not a nut, I’m not
weak in character, I’m not morally deficient, that there isn’t
one thing wrong with being an alcoholic, that it does not impose
any limits on me except the limits I voluntarily choose.

I used to think when I was new in AA that these people were
very obsessive about this word “sobriety,” but I have come to
believe that maybe this is the word that trips people who are
not alcoholic who try to help us, that “sober” has deteriorated
in meaning to simply mean “nondrunk.” AA has perhaps recap-
tured the old meaning — a quality of spirit which embraced
wisdom, judgment, balance, and other virtues such as compas-
sion, sensitivity to the needs of others, a response to those needs.

This is what sobriety has meant to me, to grow in this direc-
tion towards a relatedness to other people and relatedness to the
world around me, that I have finally found something worth
conforming to.

58

For a woman in particular to know herself to be a drunk is
absolutely devastating. I think we are far more dishonest and
far more skillful at lying and conning and far less apt to believe
that we can be brought back, that we can be brought to a point
of respecting ourselves or deserving the respect of others.

This is one of AA’s miracles as far as I am concerned that the
guidelines are provided in the program, that it is a very whole
program from my point of view. It does assist me physically,
mentally, spiritually, and emotionally towards growth. But it
has to be at my pace, and it has to be through channels that I
choose.

I have learned the channels through which my energies should
flow so that they can be more effective. I have learned also that
I am not a parasite, that I can be contributive, that I have some
value.

Nobody could have gotten this across to me before, because
I was so bound up with phony complexities.

However, nobody — but nobody — could have convinced me
that I would ever have any fun without the bottle. But I have
had more fun in a diversity of ways in the last 17 years in AA
than I ever had in that thoughtless and superficial and frivolous
pursuit that I indulged in before.

I think it is very difficult to get this across to an alcoholic. I
think everything about the condition, disease, or whatever it is,
contributes to keeping us blind to this being the problem. Every-
thing else is the problem. Other people are the problem — the
boss, the husband, the wife, the other anything — anything but
“poor little me.” I’m a “victim.”

The fact that AA can penetrate this kind of self-delusion —
because self-delusion in active alcoholism is pretty total — I think
is a great miracle.

I think also it is a miracle that an alcoholic would be open
for that split second of truth to reach for the telephone and call
AA. I am so grateful that it happened to me, and for me, like
many other AA’s. I want to convey the message and do what I
can to support others.

I think this is all I’m going to say now.

Well. Thank you, Jan.

Jan mentioned one point — an alcoholic really has no one to
blame but himself. This is not original with me. Granted that

59

alcoholic drinking makes you irresponsible. You may have some
excuse to drink when you don’t know what it does to you. But
once you know what alcohol does to you, then in a sense, almost
paradoxical, you have a responsibility never, never, never to
drink again.

This sounds sort of tough. But once the practicing alcoholic
knows that he shouldn’t practice his disease, as somebody has
said, then he should not drink again.

If any of you good people have some question that you would
like to ask about AA or ask Jan or me or George sitting over
there, how we stopped drinking, which is the great big question —
and let me say here there are other ways to stop drinking than
that we in AA have found. For us our way is the most successful.

A Participant. Maybe I could start you off with one. We
are going to, in our Federal employee health program, be looking
for ways to relate to community resources and to refer people
with drinking problems to community resources.

Obviously, one of the preeminent resources is Alcoholics
Anonymous. It is my understanding at any rate that AA would
be loath to pick up the telephone and hear somebody say, “Hey,
we’ve got a fellow we’re sending over to you.”

Would you care to discuss ways in which we could perhaps
relate to the AA program as far as referral is concerned?

Will. Well, that little leaflet we brought down; “AA in Your
Community,” is helpful. We do get calls when we are told that
they are sending somebody around and what can we do to help
the individual in question? At 2627 Connecticut Avenue, which
is the Washington Area Inter-Group Association quarters, we
keep, of course, a file of all the groups in the area, and there are
nearly a hundred in Greater Washington, and we keep a number
of places for referrals.

Members of AA maintain the Metropolis Club at 921 12th
Street, which is a place for people who are coming out of rehab
programs to go. It is a place for recovering alcoholics to go. It
is open from 10 to 10. There is always coffee there and somebody
to talk to, and there are meetings throughout the day, and
every night.

Members of AA also maintain a women’s home, and this is
for women with a similar problem of no place to go. And there

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are a number of halfway houses, so-called, around town where
the destitute alcoholic can be put up.

Through the rehab program at St. Elizabeths they are trying to
set up a series of half-way houses where there is some supervision.

The man in charge of the alcohol and drug program at D.C.
General tells me they hold patients 5 and 10 days longer than
necessary because half the patients over there have no place to
go when they are discharged.

I think this is something the Federal Government and the
D.C. Government are working on to try and establish a series
of halfway houses or rest homes or whatever you want to call
them.

We also keep at headquarters a referral for Gamblers Anony-
mous, Narcotics Anonymous, the problem of suicide, which of
course, can all be tied in with alcoholic d rinking

Of course, primarily Alcoholics Anonymous is to help the
person who wants to stop drinking with his problem. It is a self-
help program, as somebody mentioned. And AA cannot implant
the desire to stop drinking. I know from my sister, because her
husband wanted her to stop, her mother and father wanted her
to stop, I wanted her to stop, but she did not stop until she was
ready to stop or hit her so-called bottom.

Twenty-six twenty-seven Connecticut Avenue is open from
10 until 10, and we welcome your calls. And we can send you
the local directory. We can send you literature. And we can
refer you to New York.

There are Spanish and French editions of some AA literature.

There is also the Northern Virginia Group Association where
you can call from 10 to 10. These places are all listed in the
directory of the meetings around town. There are beginners’
groups. There are women’s groups. There are classes, there are
steps. And there are open meetings.

George C. (from the floor). Well, the question I think the
gentleman asked is about somebody sending somebody. By all

m w? WC WlU talk t0 anybody you send U P there if ^ comes up.

What we have resented is third-party calls about somebody
else s drinking. We can’t help anybody there. At the information
desk, we deal with the rather unique alcoholic, one seeking help.
And if anybody is sent there, somebody at the desk — in three-
hour shifts from 10 to 10 — will be very happy to talk to the person

61

and try to relate to him or put him in contact with somebody
who can relate to him.

The only thing we object to, as I said before, is a third party
calling about someone else’s drinking.

But if a person comes up to the desk or we can talk to a person
by phone — if they are willing to get on the phone and talk to
somebody on the desk, we can help them.

Will. I walked into 2627 Connecticut Avenue the other day
and somebody introduced me to Joe. And Joe said, “I know Will.
I came in and talked to him about AA 3 years ago, and I haven’t
had a drink since.” He also talked to George.

Neither of us, you know, actually did anything about Joe’s
drinking. He had to do it himself. But he did come of his own
volition seeking help, and he did go out and attend meetings and
read literature, and he is one of the most highly successful taxi
drivers that I know, making anywhere from $12,000 to $15,000
a year.

So AA has paid off for Joe.

A Participant. The idea of hitting bottom is pretty under-
standable, and Jan described it very vividly in a very few words
when she found her moment like this.

I have never heard of such a moment being described with
AL-ANON, and in my experience the spouse of the alcoholic
has an insidious parallel disease that is almost as worthy of
naming as alcoholism.

Now, I have never heard anyone mention such a hitting bottom
for the spouse of an alcoholic, and I have had practically no suc-
cess in getting either spouse or parent or child of an alcoholic to
look into the AL-ANON group.

Will. I don’t think AL-ANON is stressed enough. A friend
of my sister said she could not have got through her husband’s
drinking and subsequently being found dead in a cheap hotel in
New York. Connie went to AL-ANON regularly and said it was
a real help to her.

I think the spouse or any member in the family of a practicing
alcoholic has to realize that his or her life is becoming unmanage-
able, just as the alcoholic’s is becoming unmanageable. An alco-
holic who is drinking affects the lives of about 13 people around
him.

So the wife or husband of the practicing alcoholic or the chil-

62

dren have to realize that this drinking is affecting their lives and
perhaps should go to AL-ANON or AL-A-TEEN.

In talking to people on the telephone, and again, this is only
my way — Jan’s is different, and George’s is still different — but
if a woman calls about her husband and says, “his drinking is
driving me crazy, what do I do?” I suggest AL-ANON, because,
after all, if she would get so exercised over somebody drinking,
she reaches a point where she is no good if a real crisis comes
along.

So if anyone realizes that somebody else’s drinking is making
his or her life unmanageable, then I think he or she should seek
help in AL-ANON or AL-A-TEEN.

When I was drinking alcoholically, my parents didn’t know
about it. They were dead, thank goodness. But I was affecting
my sister’s life. I was affecting my editors’ lives, my illustrators’
lives, the people here in the Book Guild of Washington, and any-
one that I was closely associated with.

So to some degree I was making the lives of all these people
unmanageable, which now of course I realize I had absolutely
no right to do.

A Participant. I guess the point is that I don’t believe that
I can tell the alcoholic to go to AA, and I know I can’t call up AA
and say, “Look, I’ve got this guy here.” In my book it just doesn’t
work. He’s got to go himself. So, you wait until he’s ready to go,
and he goes, and whatever you can do to help him make up his
mind to go, you do. But you don’t do anything to him or at him.

When you are dealing in an industrial situation, you can give
this help a little more overtly.

But, when you know darned well that you have got two people
in mortal combat, the alcoholic and his wife, you know that AL-
ANON would do her some good, you’re in the same position.
You can’t get to her though, and, of course, you can’t say, “You
go to AL-ANON,” because that doesn’t work any more than it
does for the alcoholic.

Will. Jan, would you like to see if you could shed some light
on the woman?

Jan. I don’t know if I can shed any light, because so often we
encounter spouses who think this is the alcoholic’s problem, that
it’s not the nonalcoholic spouse’s, that he should do something
about it, that it’s not their concern.

63

Women have called and said they have gone to AL-ANON
and it was a gossip session or they have indicated that they are
just as sick as poppa and might be largely contributive to his
drinking.

There are some women who call to whom I feel like saying,
“If I were your husband, Fd be drinking all the time.”

And usually these are the AL-ANON refusers. They are prob-
ably afraid to go because the AL-ANON ladies would tell them
just this: “You’re making a vast contribution to his drinking.”

And I don’t know how you motivate a husband or a wife to
seek AL-ANON. They call, and they want you to give a magic
solution to their problem of what to do with him, where to put
him. All we know is our own story.

Will. Thank you, Jan. Don’t go away. Give me moral support.

You know, I’m terribly sorry for all of you people who are up
against working with a practicing alcoholic. Because, alcoholism
is baffling, it’s cunning, and it’s insidious, and most practicing
alcoholics have what I consider a horrible illogical logic. Seem-
ingly they can make absolutely good sense, though, upon reflec-
tion, you know all the time it isn’t sense at all.

They are always a few jumps ahead of you. And to illustrate
this, I have a friend here in town, a woman, who was a problem
drinker and the despair of her family. They wanted to get her
sober enough for her daughter’s wedding. So, they sent her to
her sister in Europe, thinking that sister would look after her.

And, of course, they searched her room, and they searched
her luggage, and she still continued to get drunk. But they never
thought of searching her sister’s room where she had stashed her
liquor. So, you see, I’m sorry for all of you who are trying to work
with the practicing alcoholic, because we are con men and
women. We can lie faster than you can possibly think about.

Jan said her moment of truth came when she was about to
write a bad check. I had the great pleasure of going into my
bank yesterday and paying off two notes, and this is the very
bank which once sent me a letter saying that my account wasn’t
satisfactory.

You get into things quite by accident. I like to gamble too, and
I used to go and play the slot machines over on 301. And inno-
cently I had a check bounce, and I went over about it and got
quite exercised about it, and they said, “Well, don’t worry about

64

it. It takes a week for a check to clear between Waldorf, Md.
and Washington, D.C.”

Now, I had never known that, you see. So, naturally when I
ran out of money, I would write a check. Now, this is sheer, sheer
alcoholic thinking.

I would go over on 301, partly drunk, knowing I was going to
get drunker. I would ride along saying to myself, “If F. Scott
Fitzgerald could drink and was a writer, why can’t I?” Of course,
look what happened to F. Scott Fitzgerald. And I’m here talking
to you.

But you really have a hell of a confrontation when you are
going to try to help the alcoholic employee, unless he wants to
be helped.

We go through this. Jan is on the desk at AA, George is on
the desk. And I am on the desk. And we go through this two or
three times in each stint.

Somebody calls or the individual himself calls and says, “What
do I do?” And you tell him what to do, he doesn’t want to do
any of it, and he isn’t going to until he is ready.

Jan. I’d say this, Will — that trying to help an alcoholic is
difficult because you like them. I have met wonderful people in
AA, and I know wonderful people who are still struggling with
the bottle. They are very likeable.

And I think that one thing that is very, very difficult to do —
and it takes real love — is the direct encounter: “You’re lying.”
Because you don’t know what the reaction is going to be. But
you have to be willing for this.

I complained to my minister who once told me I was too hard-
boiled with people, I said, “Well, I want you to know that I got
fed to the teeth with people who permitted me to lie to them.”
I knew they knew, and they knew I knew, and it was just a little
game we played, and they couldn’t bring themselves to tell me
what a liar I was, and they postponed my getting close to myself
and finding out. This I can’t do anymore.

Dr. Siegel. What right things and what wrong things, in your
experience, do doctors and nurses do in their relations with
patients who are alcoholics? I think you have touched on one.
You might want to elaborate on it.

Is this a problem you have found in your own dealings through
your lives with doctors and nurses and their dealing with you?

65

5 J AN - I avoided doctors because I was afraid to be told that
I’d have to cut down on my drinking. And I wouldn’t have told
the truth anyhow. The classic answer is, “Oh, I have had a couple
of drinks.” But you mean a couple after the first 200.

Well, my sisters and my parents, my husband, my friends, these
were the ones I wanted to fool, and I didn’t want them to make
any personal remarks to me.

Will. That isn’t quite what you mean.

Jan. No, but it might come better from a doctor, a nurse, or
somebody I would really believe was genuinely concerned about
me and wasn’t judging and would appeal to whatever assets I
had, if any.

Will. My doctor is interested in helping alcoholics. In fact,
I have had him to a meeting. And he calls me to help. You see,
it’s the business of not quite understanding how the program
works, which nobody understands completely. Remember, we
have been down the road ahead of the man or woman who comes
to speak to us. And we sound at times extremely tough to the
outsider.

But if they are repeaters or “slippees” there comes a time when
you have to get tough. Somebody here mentioned this this morn-
ing. I think you did, Professor Trice. There comes a time when
the boss gets tough, the wife gets tough, the doctor gets tough.
You actually have “crisis confrontations.”

Sometimes you can speed it along. Other times the person has
to reach the point of desperation.

My doctor asked me the other day does a patient with whom
he is working have to lose everything. I said, “No, he doesn’t have
to lose everything. But he may have to lose his wife, job, friends,
the whole works before it gets through to him that he has a
problem.”

Professor Trice. Do you people find this is one of the most
difficult points to get across? We do anyway. We talk about
crisis precipitation, constructive coercion. These people say
“damn inhuman! How horrible. You should be helping some-
body. You’re clobbering them.”

I find this one of the most difficult points to communicate in
any kind of situation. People will hear just about everything you
say except that. They just don’t want to do it.

66

Will. As I say, my doctor asks me, “How tough do you get?”
And he found he had a patient who was conning him into pre-
scribing some kind of cough medicine. Of course, the cough
medicine was loaded with alcohol.

So then he cut off that particular kind of cough medicine.

We are a very devious bunch. We can figure out ways to get
cough medicine and codeine, and you can drink vanilla extract,
and lemon extract has more alcohol than vanilla extract.

You know, you can drink all these things and get a large charge
out of them. But I wouldn’t.

Because a Washington man drank some men’s cologne a year
ago. Why — I don’t know. Maybe he didn’t want his wife to
know. Maybe he got his bottles confused. But when his wife
found him, he was immobilized.

And at first everybody said, “Isn’t it lucky that she found him
before he died?”

Well, this particular cologne has some sort of a property in
it that has a paralyzing effect, and this man has lain in bed for
more than a year now paralyzed. He opens his eyes, but no one
knows whether he knows what they are saying to him.

I’m not sure he is lucky. But some are lucky. They are the ones
who — for whatever reason — constructive coercion, a dis affected
wife, or a shock of some sufficient magnitude — have stopped
drinking. That’s what all this is about. And sometimes you just
have to be tough — very tough. But maybe that’s the way you
save a life.

Community Resources
Paddy Cook

(Mrs. Cook is a member of the staff of the Washington Area
Council on Alcoholism, a voluntary health agency supported by
the United Givers Fund and contributing members.)

We have three main purposes. The first is in terms of informa-
tion and education, to erase the stigma surrounding alcoholism
in the community. This means consulting with groups wherever
we are called in, sending literature, making speeches, holding
discussions, showing films, etc.

The second is counseling for referral to treatment resources
and education and information to families, to employers, to
friends, to associates, and to alcoholics when they call our agency.

And the third is as a community catalyst to promote proper
treatment facilities for alcoholics through legal and legislative
channels. Primarily I think this agency has been working in that
direction for the past 2 or 3 years.

We have been very instrumental in having the law changed in
the District of Columbia from handling chronic court offenders
or skidrow alcoholics as criminals, to handling them in the public
health area.

This, of course, is only part of the problem. About 3 to 15
percent of alcoholics are visible to the public eye, the people
who are littering the streets or who are homeless men with an
alcoholic problem or who are unable to support their families.
Of course, you are primarily concerned with the other percent-
age who are still employed, still living with families, still with
many community and social ties.

We get calls in the agency from every stratum of society for
various kinds of problems; how to find a nursing home for a
mother who has been an alcoholic for a good many years, and for
whom treatment has not been successful, and who needs care in
her old age ; walk-in’s from the street in various stages of with-
drawal who need immediate detoxification. Daughters or
mothers or wives who are concerned about a member of the

67

68

family who is drinking and who are just beginning to face the
problem of alcoholism that is disrupting their family in various
ways.

We try to keep track of these things and focus the community
attention on the greatest areas of need in terms of treatment
resources. We maintain a directory of resources for alcoholics
in the metropolitan Washington area, and we use this primarily
as the basis for our referrals.

We do some counseling for referral. If the person is not ready
to accept or we can’t immediately determine what kind of a
referral he would accept, then we have two or three interviews
with that person before a successful referral is made.

We maintain lists of private doctors, psychiatrists, psycholo-
gists who are experienced in treating alcoholics. We also know
a number of ministers who are experienced and to some degree
mental health-oriented.

Sometimes we may refer the family to a child guidance agency
or to a family and child services agency, if that seems to be the
piece of the string that we can get hold of and that they can
accept at that moment.

In other words, not all of our referrals are directly in terms
of the alcoholic problem itself. It may be to another agency, a
legal agency, for instance.

A Participant. Is it possible that your agency would have
anyone available to drive a woman to her first visit to an AA
meeting?

This is a very realistic problem. I worry about alcoholic women
who are living alone in an apartment in the heart of Washington
and I am asking them to go to their first AA meeting. After they
get there, they are probably going to make contact. But this
initial trip by this lonely woman in an apartment can be very
difficult for her.

Mrs. Cook. We are open 9 to 5, and we have four people
on the staff. However, we have boards and committees, and we
have an action committee, for instance, which consists of a num-
ber of women, and there are members of AA in that committee.

I think if you called our agency, we could probably make con-
tact with an AA person who would assist her to get to the first
meeting — if the woman is willing.

69

I mean that I don’t think anybody will want to go and drag
her out of an apartment.

A Participant. When you refer to your agency, does the per-
son have to be a resident of the District of Columbia?

Mrs. Cook. No. We serve the entire metropolitan Washing-
ton area. We are an affiliate of the National Council on Alco-
holism. About 70 affiliates are scattered all over the United
States.

But we often receive requests for assistance from a relative
here about someone in Wisconsin, for instance. We can help the
family get in touch with a council or treatment facility close to
the problem.

In the case of a family that is just beginning and is very tenta-
tive and doesn’t even want to give you a name over the telephone,
we can send them something and then have them call back in
terms of exploring further into the problem.

I’m sure you are all aware that alcoholism is not something
you solve in 10 minutes with most people, particularly when the
family is just beginning to look at this as some kind of an illness
and not a moral or judgmental problem.

Dr. Siegel. One thing you mentioned interested me. You say
you do maintain or have access to the names of physicians in the
area who will deal with alcoholism in their practice?

Mrs. Cook. Right.

Dr. Siegel. This is a problem in the health unit; the indi-
vidual who for one reason or another does come in and is willing
to accept referral to a physician, but either doesn’t have a family
physician or indicates he doesn’t have a physician willing to deal
with his particular problem.

I think this is a valuable service.

Mrs. Cook. Right. We find that some physicians are not will-
ing to accept the patient or to go beyond the immediate physical
problem that is presented to them.

The physician may treat the person for whatever the symptom
is without going further in getting at the alcoholic problem.

So that often a person has been under treatment by his family
physician for some time without ever having had indicated to
him that the real problem may be the alcohol that he is
consuming.

70

And, of course, from our point of view, the simplest part of
treating an alcoholic is to get him sort of patched up. It is going
beyond that into the problems causing his drinking and into the
whole progressive illness itself and getting him to accept it that
is difficult.

You can send somebody in and have him dried out and re-
turned to the community — the same situation, the same job, the
same way of handling his troubledness. And he is going to go right
back to the same process a number of times most likely.

A Participant. Have you had any success or do you have
any clever tricks for getting the spouse, male or female, of the
alcoholic to an AL-ANON meeting?

Mrs. Cook. No clever tricks. Just lots of times a fairly blunt
appraisal of the facts. If it’s been going on for some time, there
is usually trouble in the marriage. The wife will have as much
responsibility for determining her role and reassessing her han-
dling of her husband, since, whatever has been happening, they
have each been picking up patterns of responding to each other,
to the job, whatever the situation is that has become unhealthy.
This often takes some kind of an outside evaluation, whether it’s
through AL-ANON, or through the wife going for therapy or for
some kind of counseling herself.

We are not trying to say, “You’re just as responsible as he is,”
in a punitive way, but that, “You both have a role to play in this
problem, and you can both relearn or reevaluate what is going
on, and preferably with some outside, fairly objective opinion.”

Dr. Siegel. It has been my impression generally that one of
the cultural ground rules for a work organization is you don’t
invite contact or get involved with the family.

So I think that in our health unit there is very little contact
with family generally and as to supervisors and the work situa-
tion, there is probably even less contact with family.

Now, some of you may have other experiences. I think this is
a general rule. We don’t have family contact in the context of
what we generally do.

Mrs. Cook. In other words, you are there, one step away
from the supervisor, to make some sort of at least tentative diag-
nosis of alcoholism or a problem, and then refer them on for
further treatment?

71

Dr. Weiland. Well, I think you have to keep in mind what
the health unit is and its responsibility. Perhaps others here could
spell it out for you better. But it is a matter of the responsibility
for health maintenance and early diagnosis and evaluation rather
than taking over in any way the role of community agencies or
private physicians or other people.

Dr. Phillipson. This hypothetical lady coming to you with
the problem of her husband drinking — do you take down much
in the way of data from her as to where her husband works, et
cetera?

Mrs. Cook. To some degree. It’s very individual. We do have
a form sheet, but we do not always fill out everything on that
sheet. In determining the referral that is most appropriate for
that person, you pick at whatever string is loose.

Dr. Phillipson. What I’m really getting at is this: I was
talking yesterday about the means of finding out the size of the
problem. As we already know now, the health units here don’t,
rather by custom, deal with the employee’s spouse. They don’t
see the wife. You may be seeing the wives of Federal employees
who we don’t know have a problem.

Mrs. Cook. Right. We are working at two ends of the same
question I’m sure.

Now, what should we be doing in this area? Yes, we do get
wives who say that their husbands work for a government agency.
I can’t be any more specific than that. But our tendency is not
to involve the government agency.

Sometimes we get referrals from health clinics in private in-
dustry, and then we are working more in the line of the job and
using that as the area where we can get the person involved.

But in terms of when the wife calls and she may say her hus-
band works for the bus company, unless we actually know what
the policy is and have worked with somebody there, our tendency
is not to go to the company and say, “We know you have got a
problem. What can we do to help?”

But when we make a referral to a public health department
clinic, sometimes they do work directly with the spouse or the
employer, as they get into the details of the problem.

Dr. Phillipson. Do you get many situations where the wife
has come without the husband’s knowledge and doesn’t want the
husband to know she has come?

72

Mrs. Cook. Many times the wife makes the first opening ploy
without the husband’s knowledge. We try and get her to go back
and talk to the husband directly to begin immediately with the
problem, to say, “I have come.”

Sometimes the way to get to the husband is to get the wife to
seek help, to say, “Look, you’ve got a problem, but I’m having
a problem too, and I’m going to take care of mine, so I’m going
to my therapist tomorrow.” Or, “I have just been to the Council
on Alcoholism.”

Many times this will bring the husband in 2 weeks later, be-
cause she is reacting in a different way than she has been doing.
Either she has been dominating him or she has been getting all
the black eyes, but suddenly she’s doing something different, and
this may be enough. Lots of times the man will then come in.

Of course, we are at an advantage. When they call us they
are calling an agency which has that tag name of “alcoholism”
included in it. And they have gone that far in recognizing that
this may be the source of some of their problems, whereas when
you are seeing them I presume that they have not made that
much of an assessment of themselves or that this could be a way
of interpreting it.

A Participant. What do you do with this information?

Mrs. Cook. We collect it sporadically, because the agency
has, as I said, for the past 3 years been more concerned with col-
lecting statistics on court offenders and working in the area of
legislation, so that there was a large gap.

We are now collecting it. It should be documented and more
carefully researched in terms of what is happening.

A Participant. If you send this person to another clinic on
a referral basis, do you give this clinic this information? Or do
they go and get the information they want?

Mrs. Cook. Most of the time they go and get the informa-
tion they want.

A Participant. You do not give this information to the
clinic? I m trying to see how much of this what we think would
be confidential information goes to someone else.

Mrs. Cook. Sometimes, say, in referring to a private psychi-
atrist, we may say to the person, “We would like to refer you to
a particular man we are thinking about. Do you mind if we call

73

him. and discuss whether he would have room for you or whether
he could fit you into something now?”

In other words, we wouldn’t go without permission to some-
body and offer a name for referral.

Also, we try and get the person who is seeking help to go on his
own to the treatment resource.

So we primarily would be asking them to go on, giving them
the information with which they could go on for treatment.

A Participant. What do you think about communications
between your agency and a government agency about wife and
husband? What could come out of this do you think?

Mrs. Cook. I don’t know, except that it would depend upon
what the main source of the problem is. If it seems to be in a
marital situation, you are probably not going to have too much
success. It depends on how valuable the job is to the man and how
much trouble he is having with his wife, and if that is the source
of the friction and the problem, then, probably success is not
going to come unless both of those people get involved in
something.

A Participant. Of course, we don’t have any type of cross-
communications, but I just wondered what could be the advan-
tage if we happened to have it. I’m trying to think in terms of
what we cam do to help.

Mrs. Cook. Let me ask you what your feelings are on that.

A Participant. I don’t know. We’re too tied up with confi-
dentiality of all of our records. But it seems to me that if the
agency is having this problem, we know about it, and if we would
have a call from another health agency, there would be possibility
of communication.

It may be that the wife should go home and tell the husband,
“I have gone to this agency. Now you go to the nurse and discuss
it, and then she can call the person.” Some way of cross-
communication.

I think it would be a good idea, really.

Mrs. Cook. I think it’s a good idea to involve the significant
people in the person’s life. But you have to do it without violating
confidentiality.

You do have to stay with the client that you are working with
all the way through on this kind of situation.

74

We are not really involved in treatment either, just as you
aren’t. This is part of the problem.

A Participant. Personnel can call a family in and discuss a
problem like this with them.

Dr. Siegel. I think personnel rarely does, realistically.

Mrs. Cook. Where do you send most of the people that you
see? To whom do you refer them, if you are not doing the
treating?

Dr. Siegel. A private physician. We have stayed out of a lot
of areas which take more than the private physician, like your
community resources. We diagnose the diabetic, the person with
visual defects, and the referral is usually made to an M.D. prac-
ticing in the community, which is in a way a relatively easy type
of referral to do.

Mrs. Cook. Right. And then how much follow-through is
there? Do you check to see if the person has seen him? Do you
find the physicians to whom you refer these people work along
with you also in getting them involved? This is our problem.

Dr. Siegel. It varies. It’s probably no different than any
American community. Highly varied.

A Participant. I don’t think a private physician has the
time that you need to work with an alcoholic . I think they want
to refer them to an organization also, say AA or some rehab cen-
ter, more than trying to take care of them themselves.

Dr. Siegel. I think your question was how does a private
physician work with us? And in the Public Health Service we
have done really very few referrals to private physicians for
alcoholism. We don’t have any basis of making the judgment
as to what is the effect.

Mrs. Cook. There is a group here that has a psychiatrist and
a couple of internists on the staff, and they also have an admissions
policy at one of the local hospitals. And they work closely with
AA when someone is really on a bender and is having a lot of
problems. This may involve 20 phone calls just getting across;
“Put on your clothes. Call the taxi, and put on your clothes.”

And then 20 minutes later, “I know you can make it. Put on
your clothes.”

You would be surprised. It can go on for about 4 hours just
getting the woman dressed and in a taxi and to the physician.

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We feel safe if we have gotten her to a physician whom we
know will get her admitted to the hospital and will send some-
body to see her during the time she is in the hospital and try to
get her involved in an AA program or to a psychiatrist or make
some further assessment of it.

And that is always the problem, because she may well go into
that hospital and get sobered up, and come back and go through
the whole procedure four or five more times before she finally
begins digging in to the basic problem, which is tough.

Dr. Siegel. The focus of this meeting has been on the prob-
lem. You deal with the disease as the disease, i.e., the thera-
peutics, how to get the person with the illness better. But we will
have to face in our health unit activities the question of what
we can do in terms of primary prevention.

Mrs. Cook. Right. There are lots of people who think the
skid row alcoholic is pretty unsolvable and we will have to pro-
vide community resources to support him rather than to deal with
him as a criminal.

And as you back up, the alcoholic is going to be more difficult
to treat than working on an area of primary prevention.

You may not be focusing on this, obviously, but it may be
something that has to come about before you have much success.

Dr. Siegel. Can we take some comfort that Washington, as
far as the United States is concerned, is pretty favorably situated
in terms of what the community does have available here for
this problem?

Mrs. Cook. We need much more. We are very innovative,
and I think that the focus in the United States is going to be on
what happens. And I think that as community people, it’s very
important to become aware of what is happening in the com-
munity and supporting more treatment and facilities.

Recent Civil Service Commission Recommendations
Frederick F. Bell

(Mr. Bell is an Occupational Health Specialist, Division
of Occupational Health and Safety, U.S. Civil Service
Commission.)

Words are problems. I think that is one of the keys to the
Civil Service Commission’s view on alcoholism.

Can you visualize attending a staff meeting without words?
Can you imagine going into your boss’ office and listening to
music and looking at pictures?

Words are necessary. But they are only symbols. They have
no properties. The word “bucket” doesn’t hold water. It just rep-
resents a contrivance that does. We send out word symbols when
we talk, and we get into trouble if the fellow that we talk
to doesn’t receive the same meaning that we transmitted. So
whether or not our words are “clean” or “dirty” depends on what
the receiver perceives them to be.

Now, what has this to do with alcoholism? And why should I
speak to you about semantics when I hope you are interested in
the Civil Service Commission’s view on alcoholism?

If I say the Civil Service Commission wants every agency to
have a vigorous alcoholism program, we get into all sorts of
problems. So, since general semantics is a search for the signifi-
cant, I think I had better try to introduce you to the “significant”
the Civil Service Commission has identified.

The Commission is the personnel arm of Government. It is
in the people business. It finds employees. It recruits them. It
tries to train them, provide career ladders for them, and .make
certain they are treated fairly and equitably. It retires them. It
replaces them.

And it does those things with a dual outlook. First, it has a
legitimate and real concern for the employee. It wants to keep
the employee happy. If it doesn’t keep him happy, Government
won’t keep him at all.

76

77

Also, it has a concern for management, and in many ways it
tries and sometimes succeeds in aiding agencies to optimally use
employee resources.

One of the ways it is trying to do this is by exhorting, prodding,
explaining, and convincing agencies to maintain employees in
the same sense that they maintain typewriters, cars, and com-
puters. Here is where our signals may get crossed. I’m spe akin g
of occupational health.

But, when I speak of occupational health, I may mean some-
thing entirely different than you as health professionals recog niz e
or than a private in the Army or a secretary in the typing pool
does. So, therefore, let me try to convey to you what I and what
the Civil Service Commission mean when we use the symbols
“occupational health.” Occupational health to us is not one thing.
It is not a health unit. It is not a first aid cabinet, a screening
exam, or a physical exam. Rather, it is all of these things, plus a
myriad more.

We view it as preventive health services, emergency health
care, effective environmental health programs, vital safety pro-
grams, physical fitness programs, occupational mental health
programs, and much, much more.

Wouldn’t Government be silly if it hired a fellow for $10,000,
and then poured another $10,000 into training him and, over
the years, let him acquire $100,000 worth of expertise and then
lost him because it would not spend $25 to find a cancer or
glaucoma.

I don’t think that anyone in this room would disagree that it
makes sense for management to try to help the employee solve
whatever makes him a problem rather than losing its investment
in him.

Supervisors have been doing this since the first supervisor.
Now, hopefully, management is going to help them. Hence,
Federal occupational health programs. Hence, Federal alcohol-
ism programs. I hope that you see this view, this management
outlook, that is so totally different but yet not contrary to what
you as professional health people must hold.

Now, also in occupational health, and still under the Civil
Service Commission’s definition for maintenance of employees,
is the idea of preventive programs to deal with troubled and
troublesome employees. The logic is the same. If a supervisor

78

has a problem employee, basic economic good sense says that a
good employee who turns sour is worth such attention, that is
less than the cost of replacing him.

Accordingly, on an economic basis alone — and certainly not
the only considerations are economic — the occupational health
program is justified.

Now, let’s get into the Commission’s view on alcoholism pro-
grams. “Alcoholism” means several things. I am not going to
match definitions or details with Harry Trice, Gus Weiland, and
the rest of the experts that have been before you, but I do want
to point out that “alcoholism”, or the several “alcoholisms”,
mean to medical professionals something different than they
mean to most people.

To a nonphysician — and I’m sorry to say to some unenlightened
physicians — the term “alcoholism” means a drunk, usually a
no-good drunk.

You might find interesting the fact that of all human con-
cepts^ — love, hate, money, things, et cetera — the concept of
“drunk” has more symbols than any. For a subject that many still
hold as taboo, it is interesting that, while most concepts have only
a half-dozen to a dozen synonyms, the “Dictionary of American
Slang” lists 321 slang expressions for the drunk concept — 321 —
and that does not include nonslang words such as “alcoholic”,
“intoxicated”, “inebriated”, “under the influence”, et cetera.
Therefore, an “alcoholism” program could be called a “spifli-
cated” program or a program to deal with employees who are
“basted”, “behind the cork”, or “over the bay.”

For the sake of clarity, though, let’s agree that “alcoholism”
means something specific and that its meaning is medical.

If we grant this, then we cannot have an “alcoholism” pro-
gram. Obviously, Government supervisors are not physicians.
Supervisors cannot diagnose alcoholism. They can tell if an em-
ployee is a problem, and as they delve into what type of a prob-
lem he may be, they can tell or at least gain a pretty solid hunch
that he is a problem to them because he drinks differently than
most people; because he is a “problem drinker.”

Therefore, although Government cannot have a practicable
program to control or to deal with alcoholics, it can have one to
deal with problem drinkers.

Now, we have taken considerable time to set the stage. But, I

79

think that we can now communicate. Perhaps our symbols will
be better attuned to one another.

We should have clearly in mind that the Civil Service Com-
mission’s role is directed to helping both management and em-
ployees, and that the Commission’s interest in drinking problems
is exactly the same as the interest it has in heart attacks. It is
focused in the broad area of occupational health and on into
the broader area of personnel management. Now we can talk
about the Commission’s suggestions to agencies on how to deal
effectively with problem drinking among employees.

In November 1967 — a year and a half ago — Government first
officially recognized that some of its employees might be problem
drinkers, alcoholics. I will use the two terms interchangeably
now that we know what we are talking about.

At that time a few agencies, a handful, had going alcoholism
programs, Social Security Administration in Baltimore. Navy
had a program. The Department of State has a program and so
does part of the Army. At that time, the Department of Labor
was developing a paper program that ultimately was put into
effect.

But to most of the agencies and to 99 percent of the 3 million
employees, the very thought of alcoholism was taboo.

In November 1967, the Commission sponsored “A Conference
On Drinking Problems.” It brought experts on alcoholism from
industry, education, medicine, organized labor, and Government
together with representatives who had been designated by each
agency head to learn about problem drinking and, further, to
learn what could be done about it.

The report of the conference was the publication, “The First
Step.” It presents the thoughts and considerations of many of
the key authorities on alcoholism in this country.

Over the next year the full tapes of the conference were con-
densed, sifted, distilled if you will, and the distillate gathered
into a second publication released only in mid-February 1969.
It is titled “The Key Step.”

Briefly, “The Key Step” contains the Commission’s advice to
agencies. And that advice is based on the opinions of our experts
from the conference.

First, agencies should issue a public policy statement covering
recognition of problem drinking as a health condition, guarantee-

80

ing freedom from invasions of privacy, and outlining the pro-
gram that will be conducted.

Second, agencies should establish an organization within the
agency to administer the program. This doesn’t mean new peo-
ple. The organization would be headed up by one man at
headquarters level, hopefully the agency’s occupational health
officer.

Then, there should be a “program coordinator” in every
agency installation around the country. That program coordina-
tor would be the real key to the success of the program. He is the
person to whom supervisors will turn with their problem drinking
employees.

He will also maintain liaison with community facilities, arrange
for referrals, including referrals to the health unit if there is a
health unit, and he will arrange for referrals to community
agencies.

Then also as part of “The Key Step” program — and this is
rather innovative — sick leave is to be granted for purposes of
attending a rehabilitation program connected with alcoholism.

The programs, as I am sure Harry Trice told you, will use the
“raising the bottom” or “constructive coercion” techniques, be-
cause the employee is a problem employee and his job is in
jeopardy.

When communicated to all agencies and installations across
the Nation, I think the program will work. It helps everyone, the
supervisor, the agency, and the employee.

I’d like to go on to tell you how I think medical professionals
can help in getting this program across.

Our largest job is not ferreting out alcoholics. From a manage-
ment standpoint, we don’t want to dig into the lives and habits
of employees who are doing their jobs well. Instead, we want
to communicate with those employees. We want to educate them
so that “no-good drunk” doesn’t pop into their minds when they
hear the term “alcoholic” or “problem drinker.”

If we can get across to the employee through conversation,
Harry Trice’s and others’ writings and literature, what alco-
holism is and its results, the way it progressively rots the victim
until he is better off dead, and usually is, then maybe he will
keep an eye on himself. Maybe if he knows some of the signs of
developing alcoholism and recognizes them in himself, he will

81

seek aid — if not from the Federal program, from AA or from a
community resource, medical or otherwise.

That, in my opinion is our most important job — communicat-
ing with the non-problem employees. If we can accomplish it,
we will find that troubled employees will volunteer for our alco-
holism programs, and they will seek us out, and when that hap-
pens consistently, our job will be pretty well complete.

One of the most important ways medical professionals can
help is to talk about alcoholism to groups and individuals. But
don’t talk to them from the pedestal. Come down. Don’t use
terms like “detoxification.” Recognize in your own mind the
non-medical aspects of alcoholism and help your employer and
the employees that come to you for guidance by spreading infor-
mation about it.

By “nonmedical,” I mean several things. To be specific, the
basis for Federal alcoholism programs is cost benefits, the same
as for any program. The fact that employees benefit from occu-
pational health programs, including alcoholism programs, is quite
a nice coincidence but isn’t the main factor.

When a supervisor is aware that one of his employees is not
pulling his share of the load, whether it is because of his inability,
indifference, health, whatever, the supervisor must act. How he
solves the problem — by dressing down the employee, by buoying
him up, by referring the employee to a health unit or to some-
place else, or by withholding a step increase, or by initiating
disciplinary action — is irrevelant. The work must get done, and
the supervisor must see that it is done.

The alcoholism program is one way to help the supervisor
get it done. Accordingly, the universality of “The Key Step” pro-
gram is a very important thing. Everyone has a supervisor. We
want the supervisor to take action, whether the affected problem
employee is a line employee or a top management person.

I mentioned “The Key Step” program’s policy statement. If I
may, let me take 2 minutes to read it and then I would like to
open a discussion period.

We are suggesting that agencies issue something like this :

“Alcoholism is a serious and expensive national health prob-
lem. The Federal Government probably has a lower rate of
alcoholism among employees than does industry. Because of the
Government’s size, however, it is probable that, in absolute num-

82

bers, there may be thousands of Federal employees who have
drinking problems. Accordingly, this agency recognizes that
alcoholism is an illness that may affect, now or at some future
time, the health, work performance, and conduct of some of its
employees. This statement establishes, within the occupational
health program, a policy and program to assist employees whose
drinking habits are causing or contributing to job difficulties.

“This agency is not concerned with the private decision of
an employee to use or not to use beverage alcohol off the job.
However, when its use impairs his work performance, attend-
ance, conduct, or reliability, it is the responsibility of management
to take action.

“The alcoholism program introduces nondisciplinary pro-
cedures under which an employee with a drinking problem is
offered rehabilitative assistance. If he refuses such assistance, or
if the course of rehabilitation fails to achieve professional expec-
tations, regular disciplinary procedures for dealing with problem
employees will be used.

“This agency will :

“Remain neutral on the decision of its employees to use,
or not to use, beverage alcohol while not on duty;

“Implement a formal program to identify and offer reha-
bilitative guidance to employees whose drinking habits have
resulted in job difficulties, including poor attendance and
conduct;

“Recognize that individuals who suffer from alcoholism
are entitled to the same respect, confidentiality of medical
treatment, and records handling as employees who suffer
from any other health condition that affects job
performance;

“Conduct all phases of its program on alcoholism in the
highest professional manner;

“Grant sick leave for employees to participate in ap-
proved rehabilitative programs; and

Encourage the use of established community resources
and facilities, as available, as sources of rehabilitative care.”

The Key Step” goes on to describe the organization that I
previously mentioned, and then to give advice on implementing
the program. Essentially it is a very simple program.

83

The reactions to it from industry and from all participants in
the conference on drinking problems have been unanimously
favorable.

One of the areas in which I expected to hear criticism but
have not was that adequate facilities are not available in the
communities. I might comment on that even though no objec-
tions have been voiced. Government is not in business to rehabili-
tate its employees. Some agencies have rehabilitative missions,
but the Corps of Engineers, for example, is not interested in
performing rehabilitative services for its alcoholic employees any
more than it is interested in providing surgeons to remove gall-
stones from a crane operator. It, like most agencies, will rely on
health or rehabilitative resources in the community.

To say that they are insufficient or inadequate is much the
same as saying treatment facilities for orthopedic cases are
inadequate.

The answer from our standpoint is: Use what is avail-
able. Go where adequate facilities are available. Or work to
establish adequate facilities in the community or in your own
agencies.

The Government, as a rule, does not provide medical treat-
ment to its employees. Instead, it shares the costs of a health
benefits program. All health insurance plans now provide some
benefit for alcoholism. Accordingly, the employee is usually well
able to pay for the service he needs if money is a consideration in
his rehabilitative program.

Additionally, voluntary health agencies and facilities will be
and are intended to be a key part of our suggested program.

I think we are now ready for questions.

Dr. Ederma. In one sense I don’t quite agree with you. For
example, when we go after diabetes, let’s say, we know that the
diabetic can be handled, because there is some consensus about
what to do about a diabetic once he is detected. And we can refer
him to a private physician or medical facility.

In alcoholism, this is not that clear. And if you listen to the
speakers even this morning from the community, they already
have in the area, for example, some 5,000 chronic alcoholics that
need a place to go and probably don’t have a place to go.

And if you think in the Washington area we have about —
What? 250,000 civilian employees?

84

Mr. Bell. Yes.

Dr. Ederma. And if we have a very active program in trying
to find alcoholics and to detect them and trying to do something
about it, sooner or later we will defeat our purpose.

Mr. Bell. Well, this is assuming that most of the Govern-
ment populations are drunks. I’m not sure that this is true. I’m
not sure that our problem is even the 3 percent figure that is
bandied around.

Secondly, in the Washington area there are more than 150 AA
chapters. There are many AL-ANON chapters, and a few AL-A-
TEEN chapters.

Theresa Abbot’s group has quite a thick directory of private
sources of rehabilitative assistance. With the insurance programs,
I think that these should be used.

I do not deny there is a problem. I think that we are probably
more fortunate here in Washington than most areas. I am saying
that, although it would be gratifying for every agency or group
of agencies to develop a potential for handling alcoholism in its
health units around the country, preferably the Division of Fed-
eral Employee Health as far as I’m concerned, I don’t believe
that the identification and educational facets of an alcoholism
program should be hampered significantly by the lack of that
achievement.

I’ll supply my own question here. I heard one about the legality
or legal problem of supervisors identifying someone as an alco-
holic. Of course, the supervisor doesn’t identify anyone as an
alcoholic under our suggested program. The problem employee
is about ready to get fired or, at least, to receive some sort of
discipline. Instead of that, the supervisor thinks that there may
be a problem, and he refers him on for competent diagnosis or
assistance. That is all.

Dr. Phillipson. When you say he “refers,” would it be more
correct to say he “encourages” the employee?

Mr. Bell. Yes. Actually, you are confronting the man with
a choice of seeking some rehabilitative assistance— “Look, John,
I m going to have to write you up on this, but maybe we can get
out of it if you will go up to the health unit and have them look
at you. I don t see much problem there. You could offer the
employee the choice of having a chance to retain his job — or of
discipline.

85

A Participant. You can coerce him.

Mr. Bell. Sure.

Dr. Phillipson. You cannot give him a lawful order, “You
will go and see the doctor.”

You can say to him, “If you don’t go to see the doctor, you may
be fired because of your job performance.”

Mr. Bell. That’s right. But, of course, he should understand
that the rehabilitation program will only work to his advantage
if it succeeds.

A Participant. You speak of giving them sick leave for
rehabilitation purpose. How is this to be handled? Because
usually these people do not have very much sick leave to start
with. They have already used it.

Mr. Bell. You can advance sick leave.

A Participant. More than 30 days?

Mr. Bell. This would be according to the regular agency
policies on sick leave. I think we can cover our guidelines very
briefly here. Probably, a request for sick leave which can be iden-
tified as being directly related to problem drinking would arise
only when an employee is away from work to obtain treatment
for his condition under an approved course of rehabilitation.
Granting sick leave or advanced sick leave is appropriate for this
purpose. Under other circumstances, the granting of sick leave
is subject to existing agency policy.

Dr. Siegel. One factor is important to realize. This is a con-
stant problem in Government. There is some general overall
Government “corporate structure.” Individual companies within
the corporation operate differently. And it’s appropriate.
Because the mission of the Department of Interior is a lot dif-
ferent than the mission of the Agriculture Department, for exam-
ple. And the way they run their business is different.

So we are going to find this situation where some agencies may
say, “No, we can’t afford to advance sick leave,” and other will.

You have to live with this sort of business. In the Division of
Federal Employee Health we serve many different agencies out
of a unified health emit. But that’s our headache to some degree.

I think the fact we are meeting here is going a long way in
what I consider to be making an advance.

I think in the last 2 days we have learned that if the individual
with this problem can be motivated to seek to do something about

86

it, it’s a big step taken down the road. And I think there are
enough facilities in the community of various and sundry sources.

For example, most diabetics we refer to GP’s or internists. But
it has also been taught to us that persons who have drinking
problems probably are helped by a variety of methods. AA may
be for one. The psychiatrist for another. The internist for an-
other. The minister for another. Just a decision, very little sup-
port, and the man just decides — the revelation comes. He’s
going to quit. That eases the referral problem.

Mr. Bell. This is where the health professional can play an
absolutely key role. If there is a health unit available, the decid-
ing of the type of referral is most important.

Disability retirement is often brought up. A person cannot be
retired on disability on grounds of alcoholism. However, in recent
years I believe that in practically every case of an alcoholic whose
application was submitted, either personally or by the agency,
the Commission found emotional or physical problems that were
prime factors allowing disability retirement.

A Participant. The issuing of a policy statement is the first
step. But I believe there still will exist a credibility gap between
the issuance of a statement and the acceptance by the employee.

And since every agency rightfully has the right to regulate
its own program, and since the supervisor is the key man, what
I would suggest is that, rather than have the agencies train their
own supervisors in recognition, that the Civil Service Commis-
sion give some type of universal training, so that a third party is
involved and the people lose that suspicion of the agency and
more readily accept the policy that is offered.

Mr. Bell. There is now under development a reimbursable
training program in our Bureau of Training designed for super-
visors, not specifically for alcoholism, but to instruct supervisors
in how to handle a problem employee, whether his problem is
alcoholism, emotional instability of one sort or another, or what.
Hopefully, this will be ready for piloting about September. It
will be conducted eventually in 10 regional centers of the Com-
mission and Washington.

Yes, Ma’am?

A Participant. How would one obtain this particular
information?

87

Mr. Bell. That’s really up to the agency. Maybe I can help a
little bit. We are building, in the Commission’s Division of Occu-
pational Health and Safety, a staff of 10 active people around
the country whose sole purpose in life will be to promote occu-
pational health.

Many facets of the subject are not suitable for promotion at
the moment because of budget, personnel ceilings, et cetera. But
we can promote other areas. If we have our people calling on
agencies and saying, “Look, this course can do your people some
good, I think you will possibly get there a little easier than you
have in the past.

A Participant. In your policy statement I believe you used
the phrase that there will be a “protection from invasion of the
employee s privacy.” Do you want to discuss that, how this can
be accomplished?

Mr. Bell. This, of course, is a huge area. I can’t cover it in
the minute and a half I have left. Perhaps I can read a couple of
paragraphs from “The Key Step.” We say:

“The importance of keeping accurate records of cases han-
dled under the program cannot be overemphasized. Supervisors
should document the results of discussions and the actions they
take to try to motivate the employee to correct deficiencies in
his job performance. They should also record the symptoms of
problem drinking in order to assist the rehabilitative experts in
charting an appropriate course of treatment for the employee.

“The program administrator should be the focal point for
records relating to the employee’s drinking problems and his
course of rehabilitation. Program administrators should release
record information only on a strict “need to know” basis. Rec-
ords should be confidential. Records containing medical infor-
mation should be handled according to the prescribed procedures
for maintaining medical records. Records created and main-
tained by the supervisor or program administrator should not
be filed in the employee’s official personnel folder. Official Per-
sonnel Folder records should not include mention of an em-
ployee’s alcohol problems or efforts to rehabilitate him except
as they apply to specific charges leading to disciplinary actions,
e.g., “Drinking on Duty.”

Again we have an occupational mental health committee with
representatives of NIMH, personnel people, Civil Service Com-

88

mission, Division of Federal Employee Health. Their first meet-
ing is scheduled for next Monday morning. And one of their
main concerns will be how to protect the employee from unwar-
ranted invasions of privacy. You will see more on this.

Public Health Service Publication Number 2020