The Natural History of Alcoholism Revisited [Hardcover]

The author of The Natural History of Alcoholism, George E. Vaillant, is a Professor of Psychiatry at Harvard Medical School. He is also Director of the Study of Adult Development at Harvard University Health Services and Director of Research in the Division of Psychiatry of Brigham Hospital and Women's Hospital in the Boston, Massachusetts area.

The insights on alcoholism in this book come from a long-term study conducted by the Harvard Medical School's Study of Adult Development (SAD). The following groups have funded SAD: the National Institute of Mental Health, the National Institute of Alcohol Abuse and Alcoholism, the National Institute of Aging, the William T. Grant Foundation, the Spencer Foundation, the Milton Fund and the Commonwealth Fund. SAD has followed 655 men from 1940 to the present, over 60 years. Other than this study, five to eight years is the most any other scientists have followed alcoholics. At the start of SAD, the subjects were young men, and none of them had yet manifested any symptoms of alcoholism. By following their lives over many decades, the researchers learned a great deal about how alcoholism, a chronic condition, manifests and changes over time.

In 1940, the participants of SAD were divided into two groups: (1) College Sample: 268 upper-class, male, Harvard sophomores were selected with 27 eventually excluded due to death, withdrawal from the study or lack of adequate information on them. Of the 241 that were left, at age 70, the lifetime prevalence of alcohol abuse was 22%. That is, during their adult life, 52 of them met the DSM-III criteria for alcohol abuse. (2) Core-City Sample: 456 lower-class boys from Boston's inner city were junior-high-school age at the start of the study. Of these, 414 were able to be adequately studied over time. By age 60, at some point in their adult lives 36%, or 150, of them met the DSM-III criteria for alcohol abuse. Dr. Vaillant states that the lifetime prevalence of alcohol abuse is 24% among white, middle-aged males, according to another study released 10 years ago of 20,000 adults. This figure falls between the 22% for the College sample and the 36% for the Core City sample.

Dr. Vaillant thoroughly discusses the findings of SAD on the following research questions: (1) Is alcoholism a symptom or a disease? (2) Does alcoholism usually get progressively worse? (3) Are alcoholics, before they begin to abuse alcohol, different from nonalcoholics? (4) Is abstinence a necessary goal of treatment, or can insisting on abstinence sometimes be counterproductive? (5) Is returning to safe, social drinking possible for some alcoholics? (6) Does treatment alter the natural history of alcoholism? (7) How helpful is Alcoholics Anonymous in the treatment of alcoholism?

Here are a few fascinating points on these issues that Dr. Vaillant reports:

Alcoholics participating in various recovery programs have, over time, little more success at recovery from alcoholism than if they were not treated at all.

Contrary to popular belief, alcoholism has a slow onset, often as long as 20 years.

In the case of moderate drinkers, "given enough education, willpower, social supports, and an undemanding lifestyle," their abuse of alcohol can be sustained for almost all their life without any major price in health or social success.

It isn't underlying psychopathology (personal and social problems due to either genetics or inadequate nurturing) that causes alcoholism. Rather, it is alcoholic drinking that produces psychopathology, including: psychological dependence on alcohol, problems with friends, family and coworkers, accidents, health problems, financial problems, blackouts, depression, anxiety, oral fixation, self-doubts, self-loathing, pessimism, self-defeating behavior, paranoia, aggression and violence leading to trouble with the police. When alcohol abuse ends, these destructive traits and actions frequently go away, leaving the recovered alcoholic no more dysfunctional than "normal" people.

After over 50 years of looking at the alcoholics from this study, Dr. Vaillant has concluded that while alcoholism progresses, getting heavier from age 18 to 40, after that, it starts to stabilize, and alcoholics are rarely worse off at 65 than they were at 45. By 65 one-third of alcoholics are either dead or in terrible health (progressive), one-third are abstinent or drinking in a safe, social manner (recovered), and one-third are trying to quit and haven't been able to (unrecovered). The progressives tend to have the worst symptoms (see the list above) once they start abusing alcohol and spent more years feeling out of control (progressing from bad to worse). Of the three groups, the ones most likely to recover are those at either end of the spectrum. Those who are the worst off have the most to lose if they don't quit--all they hold dear and their very lives. Those who have a mild drinking problem have relatively little to give up, and are much more likely to have supportive social connections (very important in giving up alcohol) because their behavior isn't as bad as that of the progressives, so they've alienated less people.

I highly recommend this book to all mental health professionals and medical doctors--especially general practitioners. I also recommend it to motivated non-professionals who have a personal stake in learning everything they can about addiction.