These four personality profiles will be recognized by all who come into contact with alcoholics either professionally or as companions. However, some alcoholics do not belong to any of these types. There are other people who drink excessively if they are emotionally overtaxed and cannot resolve the stressful situation by rational thinking. When a man can see only one element in a conflict, the other element being outside his awareness, no effort of will can solve his difficulty.
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This is the model for the development of neurosis and if he did not turn to drink such a person might manifest a full-blown neurotic illness. In this sense, alcoholism can represent an attempt to ward off a psychological illness.
A company director drank whenever he was required to speak up for himself. If he had to make a proposal at a board meeting, or if he had to converse with a comparative stranger at a dinner, he would experience anxiety as a vague pain in the stomach. * Like a bath running away ‘ is how he described it. ?At dinner parties, ' he said, ‹“I'm absolutely hammering at myself to get a flicker out, to think of something, but I just can't. At work when called to exert his authority and correct an employee he was stifled by the disproportionate rage he feared he might express. ?It's a curious thing to say, but I see red. My head gets bigger. I really do think I see red. I feel as if I might fall down. It distresses me that my position calls on me sometimes to hound people, to keep them up to the mark. He was excessively strict with himself and felt it wrong to do things just for pleasure. So harshly did he judge himself that he was angry if he overslept by five minutes. He regarded his alcoholism as due to weak will.
That man was troubled by morbid unconscious phantasies. In some cases stresses arise out of actual events which tax a man beyond what he could be expected to bear. A patient told this story:
I had a horror of alcohol. I didn't touch it until I got my wings in the Air Force. Then three of my friends were killed in the space of three days. The expectation of life seemed to me six weeks, so I decided to try drinking. I started to take a couple of whiskies in the evening. Within eight months I found that I could drink whisky as fast as other people in the squadron drank beer. I had quite a capacity. Throughout my service years I took a fair bucket.
He drank not only through fear but also with the thought that he should live as fully as he could in the few weeks of life remaining to him. He saw friends with severe burns and visualized himself similarly injured. For him alcohol heightened the joy of surviving each flying mission.
Drink is used as a medicine by people under stress. It does not serve as a tonic or as a sedative but as a pain-killer. With its help they can, temporarily at least, cope with their ordeals. Afterwards, when the stress is over, a man may get himself really drunk, this time to relax and unwind.
The categories of alcholic personalities which we have described are not mutually exclusive. Many alcoholics share characteristics of more than one type. Moreover, they are not the only types of personality seen among excessive drinkers; no personality is immune from alcoholism and any physician who sees a great deal of the problem knows patients who do not conform to these descriptions. Nevertheless, they are the commonest personalities to be met with, and we have tried to indicate the function that alcohol serves for each of them. To sum these up, we see that the psychological satisfactions of drinking are:
1. The lessening of frustration with increase in gratification.
2. The temporary attainment of a firmer social footing.
3. The release from social inhibition of important parts of the self which normally have to be kept repressed at great cost to the individual's self-integration.
People with any of the personality types we have described do not necessarily become alcoholics or even drink to excess. In fact it is a small minority who do. Drinking is only one possible recourse that they may adopt in order to come to terms with themselves or with others. These personality traits are common and though possession of them may prevent an individual from living his life as productively as he might otherwise do, they are not incompatible with a useful and ordered life.
We have described the personality types commonly found among established alcoholics and the function that alcohol serves for each of them. The psychiatrist cannot say with any certainty how much these personality types are the product and how much the cause of drinking. He dare not presume that the facets of personality which he observes were there before excessive drinking began for he knows that his patient has inevitably been altered by the effects of his drinking, not only physically but also psychologically and in his relationships with others.
Yet if we are seeking the causes of alcoholism, the reasons why people take to excessive drinking, the previous personality of the alcoholic becomes a matter of vital concern. What were they like before they began to drink? Although we cannot answer this directly from a study of people who are already alcoholics there are grounds for believing that the observed personality patterns were there before the alcoholism. In the first place, personality characteristics such as we have described are very slow to alter. Secondly, our patients who possess these personalities all seemed to have good reasons to drink excessively, reasons which were there before they became alcoholics. Drink, that is to say, appeared to offer a resolution of their immediate situational or inter-personal difficulties. Despite these cogent grounds, however, we must repeat that we can only make inferences about the previous personality of alcoholics. What is called for is examination,
Before they begin to drink excessively, of people who later develop alcoholism. Obviously this presents formidable difficulties but some attempts have been made.
Children of alcoholics have been studied and it is clear that alcoholics' sons, more than other boys, will become drinkers. These sons have been described as having ‹“passive-aggressive' personalities: an outward show of acquiescence and docility concealed strong inner feelings of anger and rebellion. 1 The suggestion has been made that the process of concealment or repression of hostility sets up strains; in time the psychological devices holding down the resentment become a burden, and these predisposed people become adults without ever having learned how to respond properly in anger-provoking situations.
Two hundred and twenty-five delinquent boys were studied in considerable detail in Somerville and Cambridge, U.S. A. And were carefully followed up twenty years later. 2 Twenty-four of them (11 per cent) were then recognized as ‹“alcoholic'. The authors' definition of an alcoholic was someone who had been referred to hospital for alcoholism, was known to social agencies as an alcoholic, had been a member of Alcoholics Anonymous or had been convicted at least once for public drunkenness. Compared with the other children they had, as boys, been outwardly self-confident and ostensibly seemed less troubled by morbid fears; they had been disapproving of their mothers and had no strong ties to their brothers and sisters. They had over-emphasized their independence. Yet later in life, as adults, many of them stood revealed as excessively dependent. By drinking it appeared that they satisfied their dependency needs while at the same time continuing to present a fagade of masculinity.
Another investigation traced the subsequent careers of boys who had attended a child guidance clinic. 1 Alcoholism in subsequent life was found to be much more common among them than among a matched comparison group who had not been sent as children to psychiatrists. The children who later became alcoholic had been characterized by anti-social rather than neurotic behaviour. Their fathers had been inadequate parents, this inadequacy also taking the form of anti-social behaviour. The results of this study suggest that alcoholism may be the counterpart in later life of psychological troubles which had been present earlier.
These few studies are the only ones that have systematically examined alcoholics before they began to drink excessively. The evidence from them is not at variance with what we know of the personality of established alcoholics. Yet it is not enough to permit us to delineate a pre-alcoholic personality. Very varied types of people drink, go on to drink excessively and ultimately become alcoholic. We have recognized certain personality traits that are commonly found among their number but it is hardly possible to predict whether anyone who has not yet started to drink excessively is likely to do so in the future. Proneness to alcoholism is better recognized by studying someone's existing drinking habits than by assessment of his personality structure.
I. Robins, L. N., Bates, W. M. and O'Neal, P. (1962). ‹“Adult Drinking Problems of Former Problem Children'. In Society, Culture and Drinking Patterns, ed. Pittman, D. J. and Snyder, C. R. New York: John Wiley & Sons.
In a search for the causes of alcoholism we need to consider: physical factors, including heredity; social and cultural factors; psychological and personality factors.
We have reviewed each of these areas and we can now try to draw the threads together.