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The immediate, desperate question for millions of Americans is neither why nor how a person becomes an alcoholic, but how to treat the affliction. The first step, writes Vaillant, is recognizing that alcoholism is "neither a psychological symptom nor some vague unnamed metabolic riddle waiting to be deciphered." It is not a sin, but a progressive disease that may take years to acquire, and from which it may take years to recover. Writes Vaillant: "The task is to convince the patient not that he or she is an alcoholic, but that he or she is a decent person who has an insidious disease—a disease that is highly treatable but, like diabetes, requires a great deal of responsibility from the patient." To Vaillant, the fact that half of all alcoholics do manage to recover is a solid sign of hope. He feels that too much attention has been paid to those who do not.
Some of Vaillant's most important, and controversial, conclusions about treating an alcoholic came as a surprise even to the author. Traditional psychiatric approaches may be helpful for treating accompanying symptoms, such as despair, paranoia or anxiety, he believes, but they are nearly useless in dealing with the underlying nature of alcoholism itself. In his book, he ruefully describes his own disillusionment with his profession's ability to cope with the disease. "I was working for the most exciting alcohol program in the world," he says. But the results at the clinic were no better than if the doctors had left the alcoholics alone.
Other professionals agree with Vaillant's glum assessment. "We don't do anything adequately," admits Dr. Robert Millman, director of the Alcohol and Drug Abuse Service at Payne Whitney Psychiatric Clinic in New York City. Explains Dr. Blume of the N.C.A., who is a psychiatrist: "Psychiatrists have been trained that alcoholism is a problem which comes from early-childhood experiences, but aren't taught how to treat alcoholics. They go after these 'underlying causes,' treatment doesn't work, the alcoholic gets worse and the psychiatrist decides that the disease is intractable."
What about expensive hospital treatment centers, now so fashionable that they have become a growth industry with companies listed on the New York Stock Exchange? Vaillant concludes flatly that they do not work in the long run, although he believes they may be useful in rescuing, however temporarily, a person who is about to collapse under the strain of his illness. Nor can a seriously ill alcoholic "will" himself to give up liquor.
"Recovery," says Vaillant, "occurs through a series of events coming together." One is that alcoholics usually need some kind of substitute for alcohol, such as tranquilizers or psychotherapy or a support group of people with similar problems. "Second, even though it's terribly unscientific, alcoholics usually do seem to need some kind of source of hope and selfesteem, or religious inspiration—whatever you want to call it—and that seems more important than hospital or psychiatric care."