Cite as: McPeake,J.D. (2012) William D. Silkworth, M.D., and the origin and development of Alcoholics Anonymous (A.A.). Dublin NH, 03444: The Dublin Group, Inc.,
www.dubgrp.comAbstractWilliam Duncan Silkworth, M.D. (WDS) had an important impact on the origin and development of A.A. This paper examines his contribution through a study of his biography (2002), his extant published and non-published papers in that biography, two additional papers not included in the biography, and an examination of other published information about the history of A.A. WDS developed the “illness” concept of alcoholism, he performed several remarkable clinical interventions without which A.A. would probably never have formed, provided most significantly, medical legitimacy for A.A. when few other medical professionals would. Through his published works he introduced the developing A.A. movement to the wider medical community focusing on treatment models, relapse, and co-morbidity, topics of active discussion in the addiction treatment literature to this day.
Key WordsWilliam Duncan Silkworth, William G. Wilson, alcoholism, chronic illness, hopelessness, alcoholism treatment, relapse, history of Alcoholics Anonymous (A.A.), moral psychology, essential psychic change, spiritual awakening (experience) spontaneous verses systematic, clinical intervention, detoxification, treatment model, medication.
IntroductionWilliam Duncan Silkworth , M.D. (1873-1951) is remembered today primarily for the authorship of the chapter “The Doctor’s Opinion” in Alcoholics Anonymous (2001) first published in 1939. A recent biography (2002) describes his life and work. It includes reprints of many of his professional talks and papers which were found in possession of WDS’ descendants. There are many references to WDS in the A.A. literature, as well as, the academic literature about A.A., alcoholism treatment and its history.
An 1899 graduate of Bellevue Hospital Medical College WDS, interned in the “inebriate clinic” at Bellevue Hospital beginning in 1896. He chose to continue to work with alcoholic and drug dependent patients as his professional specialty. By 1939 he had treated tens of thousands of such patients. WDS had well developed views on alcoholism that centered on the assumption that alcoholism was a chronic medical illness with well-defined symptomatology, no effective treatment, and a hopeless outcome. Alcoholism, WDS argued, was poorly understood by the medical community because it had not been systematically studied like other chronic illnesses. The reasons for this were legion: the “unsympathetic” nature of the patients, the prevailing view that alcohol use was under the “mental control” of the patient, and the belief that alcoholism was a vice, not an illness. Contrary to prevailing medical and social thinking WDS argued, that alcoholism required both a medical response to stabilize the patient and restore him to physical health, and a “moral psychological” approach that would produce an “essential psychic change.” This essential psychic change, he believed, was a curative experience that when maintained, would produce a remission. While there were occasional examples of “spontaneous remissions” there was no known method to systematically produce such a change in alcoholics.
In December of 1934, WDS was the Medical Superintendent at the Charles B. Towns Hospital in NYC. He treated-for the fourth time-William Griffiths Wilson, aka Bill Wilson, a formerly successful Wall Street businessman. WDS had previously concluded and had told Bill and his wife Lois Wilson, that Bill was a “hopeless” alcoholic with a very poor prognosis. During what proved to be his last detoxification, utilizing the bella donna (atropine) detoxification regimen of Towns and Lambert , Bill had a dramatic spiritual experience. The experience frightened Bill, although it also convinced him that he was free from his alcohol dependence. When Bill sought help from WDS to understand this disturbing experience, wondering if he was hallucinating, or perhaps insane, WDS produced what from this author’s viewpoint must be regarded as one of the most modest but historically significant clinical interventions in the history of psychiatry. According to Bill, WDS said “No Bill you are not crazy. There has been some basic psychological or spiritual event here. I’ve read about these things in books. Sometimes spiritual experiences do release people from alcoholism (1957, p.63).” WDS apparently talked with Bill about the experience for some time and famously noted that whatever had happened, Bill “had better hold on to it (2002, p. 48 ff.).”
This paper reviews WDS’s contribution to understanding alcoholism and other drug dependencies and provides a perspective on his contribution to alcoholism treatment, to the development of Alcoholics Anonymous (A.A.), and to the idea that some type of spiritual experience is essential in order to recover from alcoholism.
Main ideas from Silkworth’s publications, speechs and other writings.Pharmacological Treatment of Opium Addiction (1908)
In 1908 WDS presented a paper to the New York County Medical Society entitled, “Notes of the Jungle Plant (Combretum Sundiacum)” (2002, p. 132). The paper describes six cases in which an infusion of combretum sundiacum and the daily amount of opium used by the addicted patient was administered and gradually tapered, over 10-21 days. The results of this un-blinded clinical study (N=6) concluded that five of the six participants were successfully detoxified on the regimen, with one relapsing quite quickly “ for reasons not clear to me.” From his observations WDS stated, “…that there may be present in this remedy an active ingredient, anti-opium in its properties (p. 134).” This paper includes some important aspects of WDS’s thinking about “morphinomania” and “dipsomania.”
WDS noted that “drug addiction,” the term he used in the paper, is an incurable disease that would benefit from “healthy and humane” treatment by physicians. Obviously, WDS supported exploration of pharmacological approaches to such treatment. He also emphasized the need for a harmonious relationship between the patient and the physician for treatment to be successful. He quoted approvingly from a correspondent commenting about the original monograph on this “jungle plant” that “will power” and the “grace of God” were also desirable for recovery.
Pharmacological Treatment of Opiate Addiction Follow-up Data on the “jungle plant” Clinical Trial (1909)
In this brief follow-up article, WDS stressed that permanent recovery is what counts in drug addiction and is what “we” are striving for. He reported seven follow-up cases, some from the previous article (1908). He noted two cases with 10 and 9 months of recovery respectively and five cases of varying length of treatment, all of whom are doing well. Obviously this type of follow-up would not meet contemporary standards but he was far ahead of his time in suggesting such outcome studies in the undeveloped addiction treatment field. WDS noted that many national governments were trying hard to “suppress the opium and morphine trade” but that physicians who actually caused much addiction through their prescribing practices were doing little or nothing to help the addicted person. They often treated such patients with indifference, if not worse attitudes. He noted that private corporations had stepped into the vacuum left by the unwillingness of physicians and provided treatment for addicted patients “on a very lucrative basis.” WDS offered guidance to physicians emphasizing that drug-addicted patients deserved and responded to respect and collaborative care. Additionally he advised recovery addicts needed to be monitored properly or they would continue their use. WDS said that if each community had one trained physician devoted to the treatment of addiction the medical profession could “actually solve the entire problem.”
“Am I not correct in stating that two ideas are generally accepted by the physician as essential to successful treatment? First, that the patient must cooperate with the physician; and second, that the patient will secretly take morphine unless most carefully watched. These ideas are certainly not compatible, Briefly, the physician must have the entire confidence of the patient and keep it. This cannot be emphasized too strongly. He also must exert to the utmost encouragement, tact, sympathy, and perseverance. If he has a secret understanding with the relatives or friends, the patient will almost surely detect it and resent it deeply.The patient must be imbued with the idea that you have confidence in him. Too much must not be expected at first. That at once would lead to misunderstanding. The withdrawal of the drug must be undertaken according to the judgment of the physician in each individual case, the tendency being to hurry and overmedicate the patient for the purpose of relieving unavoidable or natural symptoms. Ask the patient to do only what your experience teaches you he can do; as you increase his responsibilities he will take them up cheerfully, and you will find that almost imperceptibly the patient changes from a vacillating drug victim to an earnest man, who needs no watchful attendance, has no thought of his former drug, and who, by completing your treatment of his own volition, assures you doubly of its permanence.We are continually searching for a specific cure as of old men sought the fountain of perpetual youth. In reality, the cure lies within ourselves, as those cases I present must convince you (p. 116).” The Allergy Theory (March 1937)
After a very long publication hiatus (1908-1937) WDS published a 1937 paper (2002 ) in which he set forth his “allergy” theory of alcoholism. The most important aspects of this paper are WDS’s intention to describe the symptoms, diagnosis and physical basis of an illness: alcoholism. WDS begins by noting that most physicians regard alcoholism as a “chronic condition” with a fatal outcome, but within the voluntary control of the patient. He notes further the “astounding” economic and social costs of alcoholism and the growing trend for women to be affected because of their new acceptance in bars. He notes the emergence of the “vicious” social institution of the cocktail hour and the negative effect of the “new freedoms.” In sum, he predicts in his introduction an increase in alcoholism in both sexes and all ages. This potential expansion will put a heavy responsibility on physicians who for the most part inhabit an environment that conceptualizes alcoholism as a vice, not a disease, and who, in any case, have few tools to treat alcoholism. This state of affairs exists, WDS writes, because the data about alcoholism: ”have not been correlated or analyzed with the same interest that attaches to other conditions that are no more serious but elicit more sympathy.”
Many people want to drink. Prohibition showed this, WDS notes, but most people drink by choice. Intoxication is different from alcoholism. Alcohol is not a dominant factor in the lives of normal people who choose to drink, and if the average drinker desires seriously enough to stop drinking, they can and do. There is, however a particular type of drinker, who at a certain point in his drinking experiences a “change.” This change can frequently be described clearly both by the individual and those around him and it is marked by the “spree,” a word with a terribly innocuous connotation.
“The spree is characterized by certain definite physical symptoms in all such cases. The phenomenon of craving is prominent; there are complete loss of appetite, insomnia, dry, skin, and hypermotor activity. He has a feeling of anxiety which amounts to a nameless terror. He presents the picture of a person who has just finished a race but must have more stimulation to start again at once. Alcohol itself does not produce these symptoms in the average individual any more than the daily use of alcohol produces a chronic alcoholic in the absence of constitutional allergy. But note that, in sharp contrast to the progress of these developments, he may not, in many cases, actually be taking any more liquor on the average than one of his associates who does not get into the same state as himself, in whom the phenomenon of craving is not present. His friends and family remark the alterations occurring in him. He, himself, notices them and also what is apparent to everyone else, that a very little alcohol has an effect on him altogether out of proportion to the amount taken, and different from what he used to expect. It is not at all unusual, in fact it is the rule, for such a person to say, for example: ‘I drank for twenty years but it never affected me this way before.’ It is to be noted here, that it does not take twenty years to form a habit. One case epitomized the whole clinical picture in these words: ‘I can make more money in a day than you can in a year. I can, and do, handle big things. I carry on transactions that keep two or three telephones on my desk busy all day. But I can’t take a drink any more. What is the difference between you and me? ‘A psychiatrist tells me it is in here (indicating his head); that I can’t face reality.’ That particular person does nothing else. He lives and faces reality all day. (2002, p.140)”
The description above, according to WDS, marks the early stages of alcoholism. However, after four to six months:
“At this point, even during periods of partial or complete sobriety he develops a state of anxiety amounting to a vague fear, then depression and lack of concentration, with gradually growing indifference or complete apathy toward his former interests. Unreliability, changes in personality, loss of appetite, insomnia and tachycardia follow. He is under such tension in the effort to control himself that he has to have a drink in order to hold himself together. At the same time, and we have observed few exceptions to this, these individuals will tell you that they have no liking for liquor but dread to take it; and, to anyone who has watched such a person, it is obvious that this is true. But he believes he must have it, even though he realizes that, in his particular case, a single drink will plunge him into such a condition that a prolonged spree will be the inevitable result. After the first drink, and only then, does he experience the physical phenomenon of craving (2002, p.141).”
WDS says: “The inevitable conclusion is that true alcoholism is an allergic state, the result of gradually increasing sensitization by alcohol over a more or less extended period of time… some are allergic from birth, but the condition usually develops later in life. The development and course of these cases are quite comparable with the history of hay fever patients…”
Further WDS notes: “such patients may be deprived of liquor altogether for a long period, for a year or longer, for example, and become apparently normal. They are still allergic, however, and a single drink will develop the full symptomatology again.”
“There is another class of allergics who exhibit periodicity. At certain regular intervals, predictable in a given case almost to a day, varying from a few months to a year, these patients desire liquor. After a prolonged spree, they are apparently normal during the succeeding interval.” WDS relates such periodic alcoholics to other periodic illnesses such as manic depressive illness.
With respect to treatment, WDS defers this to a series of future papers but notes that first “physical treatment is necessary to revitalize and normalize cells and coax them into producing their own defense mechanism.” He is also unequivocal on the point that the patient must understand that he cannot for physiological reasons use any alcohol. He notes: “He must understand and accept the situation as a law of nature operating inexorably.”
An Early Model of Treatment for Alcoholism (April 1937)
A month later, in April of 1937, WDS published a companion piece (2002, p. 144) that described the early, acute phases, of alcoholism treatment. There are two groups to be treated. The first, group has reached an “acute crisis” and needs hospitalization “to bring the patient safely through the crisis” and to prevent delirium tremens. The second group consists of those alcoholics who can avoid a crisis with prompt treatment. This group is much smaller because it is unusual for alcoholics to seek earlier treatment, and the physician, if consulted, often fails to recognize alcoholism and treat it appropriately.
WDS recognizes three initial treatment phases: (1) management of the acute crisis, (2) “physical normalization and cell revitalization,” and (3) “mental and normal stabilization. This last phase naturally involves some psychotherapy and some ‘moral psychology.’”
In acute crisis WDS says hospitalization is needed (although home treatment is possible) and the most serious problem is management of acute delirium, (i.e. delirium tremens.) He offers a symptom checklist for assessment of delerium tremens. He notes that alcohol must not be abruptly discontinued and offers an alcohol-based titration of an ounce of alcohol per hour with clinical adjustment depending on symptoms. Further medical aspects of withdrawal are discussed, some quite different from contemporary best practices (e.g., the emphasis on dehydrating the patient). WDS further notes that with proper early diagnosis, however rare, the whole hospital withdrawal process would be and should be unnecessary. This would move the patient into the second phase of early treatment that from WDS’ perspective involves dealing with the allergy itself.
WDS notes “the proper treatment is one which will desensitize the cells, restore them to normal, and add to their defensive mechanism by activating them and re-energizing them.” In this area WDS was influenced by his brief studies in Leipzig with Bechhold (2002, p.21) who advanced a colloid theory of cellular change that WDS appeared to think could reverse the allergy process. He had continued to study colloidal biology and colloid medication such as colloid gold and colloid iodine complex. Based on current research these preparations were placebos and it was the rest, proper diet, and compassionate care alcoholics were receiving in the hospital environment that led to a restoration of physical health subsequent to detoxification.
It is in the third phase of early treatment, WDS labels this a “psychotherapeutic and moral psychological approach,” that one observes the roots of contemporary approaches to alcoholism. WDS says that once an individual has been moved through the acute phase of treatment (“detoxicated”) and restored to relative health (“re-normalized”) one discovers that most of these individuals “…are as normal as the rest of us except they have become allergic to alcohol.” The first step then is to give the patient “…an intelligent conception of their “anaphylactic condition.”
“Our approach is somewhat as follows: We endeavor to impress upon the patient that his condition is physical and not mental as regards the drug; that the reasons he gives for drinking (social and financial problems, escape from a feeling of inferiority, etc) are but alibis. He has a medical problem to face, that a law of nature is working inexorably in his case as in a diabetic. We define allergy and interpret its characteristics, until we are sure he has grasped the fundamental nature of his case. He can then appreciate that only by entirely avoiding the toxic factor, alcohol, can he avoid an, ‘attack’ of alcoholism.
If we can bring our “detoxicated” and cell normalized patient, who has lost his craving for alcohol, to this viewpoint, he will be in a position to make a decision to forego its use. Without quibbling over words, we wish to differentiate between a decision and a resolution, or declaration, of which the alcoholic has probably made many. A resolution is an expression of a momentary emotional desire to reform. Its influence lasts only until he has an impulse to take a drink. A decision, on the other hand, is the expression of mental conviction, based on an intelligent conception of his condition. After a resolution the individual must fight constantly with himself; the old environmental forces are still arrayed against him, and finally he succumbs to his old means of escape. However, if he has made a decision, through understanding of facts appealing to his intelligence, he has changed his entire attitude. He can go back to his former environment, mix with his drinking friends (without concern, because his craving has been counteracted), and meet his worries and disappointments as a normal person; he is free from all emotional restrictions that formerly activated him to drink. No will power is needed because he is not tempted to drink.
We have seen this reasoning operate successfully in many cases, even as we have seen many failures following what we term resolutions or declarations. (2002,p. 150ff).”
In describing moral psychology, WDS continues: “We believe that this decision is in the nature of an inspiration. The patient knows he has reached a lasting conclusion, and experiences a great sense of relief. These individuals, introverts for the most part, whose interests center entirely in themselves, once they have made their decision, frequently ask how they can help others.”
It would appear from the foregoing that in 1937 WDS had not achieved the complete understanding that “self-knowledge” and “individual intellectual decisions” are quite different from the completely irrational surrender to a “higher power” called for by the still nascent A.A. movement he was shepherding. He would move quickly to this latter position, which was quite consistent with what he had learned about alcoholism in his family of origin and his sociocultural environment: “Young Silkworth was told quite early of the need for crisis, reform, and conversion when dealing with alcoholism (2002, P. 10)”
1939 was busy for WDS as far as publications were concerned. The book Alcoholics Anonymous (2001) was first published that spring with his chapter “The Doctor’s Opinion.” In addition, he published two medical articles (2002) “Psychological Rehabilitation of Alcoholics” and “A New Approach to Psychotherapy in Chronic Alcoholism.” This second article, initially appearing in Journal Lancet, was later included by Bill Wilson, as Appendix E in his history of A.A., Alcoholics Anonymous Comes of Age, first published in 1957. A summary of these three articles follows.
The Doctor’s Opinion section of Alcoholics Anonymous.
The “Doctor’s Opinion” chapter represents the “medical estimate” of the “plan of recovery” outlined in Alcoholics Anonymous. WDS begins in a short “To whom it may concern” letter that one of his patients, of the “hopeless” alcoholic type, developed some ideas about “possible means of recovery” during his fourth treatment. Presenting this program to other alcoholics was an essential part of this new program. In turn these alcoholics too, must then present it to other sufferers. The success of this program, WDS writes, appears of “extreme medical importance” because this program may be a “remedy” for thousands of cases heretofore regarded as “hopeless.”
The writers of Alcoholics Anonymous interrupt then to write that there is more to follow from the physician (WDS) but they want to emphasize three of the physicians points: the physical nature of the sickness of alcoholism; their evaluation of the allergy theory “It makes good sense”; and their support for hospitalization at the front end of care so the brain can be cleared. This latter point represents an early recognition of the compromised neuropsychological status of the alcoholic.
WDS continues: Physicians have known for “a long time” that “moral psychology” was “of urgent importance” to alcoholics, but such approaches were outside their knowledge and clinical skills. Bill Wilson, WDS’ patient, having recovered himself through a spiritual experience, developed some moral psychological ideas that he successfully “put into practical application.” Indeed, WDS allowed him to present these ideas to patients at Town’s Hospital. The results of these ideas were not, WDS says, just “interesting,” they were “amazing.” WDS remarks on the unselfishness, absence of a profit motive, community spirit, self-confidence, and belief in a Power greater than the self that was demonstrated in this group of men. It is an inspiration, he notes, to those who have worked “long and wearily in the alcoholic field.”
WDS then repeats some of his well established ideas: that alcoholism is a physical illness manifesting itself as an allergy, that when the illness is active a single drink initiates craving, that there is no safe use of alcohol for these individuals, and that alcoholic drinking creates astonishingly grave and often irremediable life problems. To be effective, a psychological response must have “depth and weight” and “ be grounded in a power (WDS does not use caps here) greater than themselves.” To the weary, frustrated, discouraged psychiatrist who had been working with alcoholics for years nothing he had observed had been as effective as this program developed by Bill Wilson and the other recovering alcoholics.
WDS goes on to note that people like the effect of alcohol and pursue it despite the “elusiveness” of the effect. For the alcoholic, however, it becomes more important than normal life and without alcohol they are famously “restless, irritable and discontented…”-- unless they can drink. When they drink, however, craving develops, and they pass through the stages of a spree and this pattern is repeated over and over again. The only remedy appears to be “an entire psychic change.” Once this psychic change has occurred, however, the alcoholic who “seemed doomed” can, by following “a few simple rules,” easily resist the temptation to drink. Faced with this sea of relapsing and apparently untreatable alcoholics, giving everything he can to their treatment, the physician feels his limitations acutely, and further feels that something more than human power is needed to produce the required “essential psychic change.”
WDS muses that alcoholism is not a “problem of mental control.” Alcoholics are individuals who have changed in some physical manner that produces the phenomenon of “craving.” Craving is beyond their power to control. The problems that develop as a result of their compulsive drinking can lead them to commit suicide rather than continue as they are. While there may be “types” of alcoholics, it is this phenomenon of “craving” after consuming one drink that is the essential symptom of this disorder. Abstinence is the only remedy and death from alcoholism will be the ultimate result if abstinence cannot be achieved. Bill Wilson and his colleagues have a solution. WDS has seen the “amazing,” “astounding,” results and he urges every alcoholic to read the book Alcoholics Anonymous.
Psychological Rehabilitation of Alcoholics (1939)
Later in 1939 (Alcoholics Anonymous was published in April) WDS published two papers. The first titled, “ Psychological Rehabilitation of Alcoholics.” He notes in the introduction that most of his patients do not wish to have alcoholism, but they cannot use alcohol in moderation, although they enjoy the effects of alcohol. He reminds the reader that craving is an indication of the allergy to alcohol and that most of the alcoholics he has observed “…could not drink in moderation from the very beginning.” Indeed the only thing these people have in common is that they cannot drink in moderation. There is no other psychological or physical characteristic (i.e., other than the physical disease, the “allergy”) that makes them similar. Also “…many are like the rest of us who do things we know we should not, but like to do them anyway.” While a few of his patients accepted the fact “… that their old idea of drinking must be discarded forever.” the vast majority of alcoholics WDS treated, progressed beyond the point of return. “The history of these people and their families, present from now on, one of the real tragedies of human life…”
The alcoholic progresses into a “circle” of remorse, penance, new transgressions, new penance, “until they lose all capacity for spontaneous activity.” They resemble compulsive neurotics and, like them, have relatively good insight but are unable to control with their impulses, articulated as, “I must stop. I cannot be like this; but I cannot stop, someone must help me.” WDS comments that relief for obsessional neurosis in psychoanalysis (just at that time gathering momentum in the U.S.) is accompanied by “transference.” The alcoholic can only accomplish this with another “ex-alcoholic.” Through the medium of the “ex-alcoholic” and the “plan” they have developed, WDS has seen cases of recovery that are not just “interesting” but “amazing.” These men, he notes, are utilizing the “old truth” of “spiritual experience” leading to recovery and the power of the group--but in a powerful, new, and systematic manner.
Psychotherapy in Chronic Alcoholism (1939)
The very next week WDS had a second paper published “A new Approach to Psychotherapy in Chronic Alcoholism.” This paper was the result of “of four years of close observation” of the beginnings of “a new approach to the problem of permanent recovery from chronic alcoholism.” It was based on his intimate clinical knowledge of the founder of A.A., Bill Wilson, and many of his NYC and East Coast recovering colleagues. “The central idea” WDS says, “is that of a fellowship of ex-alcoholic men and women banded together for mutual help.” Each member is “duty bound” to assist alcoholic newcomers and “in an endless chain” there is a “large growth possibility.” WDS observed, “These ex-alcoholics frequently find that unless they spend time helping others to health, they cannot stay sober themselves.” He noted that the nascent fellowship was a totally humanitarian and nonprofessional enterprise, no dues or fees, no organization of the ordinary kind. At the time of his writing there were about 150 members in NYC and the east Coast and a slightly larger group in the Mid-west. It was a heterogeneous group “though business and professional types predominate.” And “The unselfishness, the extremes to which these men and women go to help each other, the spirit of democracy, tolerance and sanity which prevails, are astonishing to those who know something of the alcoholic personality.”
There is, however, a more central principle, WDS goes on, that may explain this organization and the changes in the personalities of the participants. “Each alcoholic has had, and is able to maintain a vital spiritual or ‘religious experience’…which is accompanied by marked changes in personality…Sometimes (this change) occurs with amazing rapidity, and in nearly all cases these changes are evident within a few months, often less. WDS notes that “spontaneous” or “sporadic” changes of this sort as a result of religious experience, are “centuries old,” but these alcoholics have found an approach that “systematically” produces such changes sufficient to be effective in at least half the cases. This is particularly notable says WDS, when it is remembered that most of these cases were adjudged “hopeless” and doomed.
Then WDS briefly outlines the new approach:
“The essential features of this new approach, without psychological embellishment are:
1. The ex-alcoholics capitalize upon a fact which they have so well demonstrated, namely: that one alcoholic can secure the confidence of another in a way and to a degree almost impossible of attainment by a non-alcoholic outsider.
2. After having fully identified themselves with their ‘prospect’ by a recital of symptoms, behavior, anecdotes, etc. these men allow the patient to draw the inference that if he is seriously alcoholic, there may be no hope for him save a spiritual experience. They cite their own cases and quote medical opinion to prove their point. If the patient insists that he is not an alcoholic to that degree, they recommend he try to stay sober in his own way. Usually, however, the patient agrees at once. If he does not, a few more painful relapses often convince him.
3. Once the patient agrees that he is powerless, he finds himself in a serious dilemma. He sees clearly that he must have a spiritual experience or be destroyed by alcohol.
4. This dilemma brings about a crisis in the patient’s life. He finds himself in a situation which, he believes, cannot be untangled by human means. He has been placed in this position by another alcoholic who has recovered through a spiritual experience. This peculiar ability which an alcoholic who has recovered exercises upon one who has not recovered, is the main secret of the unprecedented success which these men and women are having. They can penetrate and carry conviction where the physician or the clergyman cannot. Under these conditions, the patient turns to religion with an entire willingness and readily accepts, without reservation, a simple religious proposal. He is able to acquire much more than a set of religious beliefs; he undergoes the profound mental and emotional changes common to religious ‘experience’. (See William James’ Varieties of Religious Experience). Then too, the patient’s hope is renewed and his imagination is fired by the idea of membership in a group of ex-alcoholics where he will be enabled to save the lives and homes of those who have suffered as he has suffered.
5. The fellowship is entirely indifferent concerning the individual manner of spiritual approach so long as the patient is willing to turn his life and his problems over to the care and direction of the Creator. The patient may picture the deity any way he likes. No effort whatever is made to convert him to some particular faith or creed. Many creeds are represented among the group and the greatest harmony prevails. It is emphasized that the fellowship is non-sectarian and that the patient is entirely free to follow his own inclination. Not a trace of aggressive evangelism is exhibited.
6. If the patient indicates a willingness to go on, a suggestion is made that he do certain things which are obviously good psychology, good morals, and good religion regardless of creed:
a. That he make a moral appraisal of himself, and confidentially discuss his findings with a competent person whom he trusts.
b. That he try to adjust bad personal relationships, setting right, so far as possible, such wrongs as he may have done in the past.
c. That he commit himself daily, or hourly if need be, to God’s care and direction, asking for strength.
d. That, if possible, he attend weekly meetings of the fellowship and actively lend a hand with alcoholic newcomers (2002, p. 150 ff.).”
WDS notes that while this is a summary of the procedure it is very much individualized. Ex-alcoholics (a term frequently used by WDS but no longer in use) are flexible and always ready to apply new methods if the new ones produce better results. Despite the religious factor, individual choice is encouraged and there is no “unhealthy emotionalism and prejudice.” Hospitalization is strongly encouraged so that the alcoholic avoids the dangers of “delirium tremens, ‘wet brain,’ or other complications. When the patient has been thoroughly “detoxicated” s/he is asked if they desire permanent sobriety. If so, they are introduced to a member of the fellowship.
WDS rhetorically asks why after all the approaches over all of the years by all of the well-meaning physicians, family members, clergy, and others does this method work? He offers four reasons why the fellowship’s methods “cut deeper”:
“1. Because of their alcoholic experiences and successful recoveries they secure a high degree of confidence from their prospects.
2. Because of this initial confidence, identical experience, and the fact that the discussion is pitched on moral and religious grounds, the patient tells his story and makes his self-appraisal with extreme thoroughness and honesty. He stops living alone and finds himself within reach of a fellowship with whom he can discuss his problems as they arise.
3. Because of the ex-alcoholic brotherhood, the patient, too, is able to save other alcoholics from destruction. At one and the same time, the patient acquires an ideal, a hobby, a strenuous avocation, and a social life which he enjoys among other ex-alcoholics and their families. These factors make powerfully for extraversion.
4. Because of object aplenty in whom to vest his confidence, the patient can turn to the individuals to whom he first gave his confidence, the ex-alcoholic group as a whole, or the Deity. It is paramount to note that the religious factor is all important from the beginning. Newcomers have been unable to stay sober when they have tried the program minus the Deity (2002, p. 162).”
Generally, WDS notes, recovered alcoholics are not fighting the temptation to drink. He lists several examples, “from the moment of my experience the thought of taking a drinking myself hardly ever occurred. I had the feeling of being in a position of neutrality. I was not fighting.” or “The problem was removed; it simply ceased to exist for me. This new state of mind came about in my case at once and automatically.” Another example, “On the occasions that thought of drinking occurred, “ (they had) new found ability to think the drink through, to work with another alcoholic, or to enter upon a brief period of prayer and meditation. I now have a defense against alcoholism… as long as I keep myself spiritually fit…”
WDS notes that as a first step in extending their work to all parts of the country they the ex-alcoholics (who had not yet named their movement) had prepared a volume of 400 pages called Alcoholics Anonymous. He wonders further: “Will the movement spread? Will all of these recoveries be permanent? No one can say. Yet we, at this hospital, from our observation of many cases, are willing to record our present opinion as a strong “Yes” to both questions.”
An Analysis of Relapse (1947)
In 1947 the A.A. Grapevine published an article by WDS about a topic that was, and is, a controversial issue in recovery from alcoholism: “Slips and Human Nature.” WDS says that the apparently surprising fact that a recovered alcoholic returns to drinking, which often elicits the idea that alcoholics are in some way different from “normal individuals,” is “largely twaddle.” WDS says there is nothing unpredictable about this just as there is nothing unpredictable about the diabetic, the tubercular patient or the cardiac patient, (i.e., the person with a chronic illness) experiencing a relapse. Despite professionals “and the alcoholic” attributing special “alcoholic behaviors” to the alcoholic, there are no special personality traits or special behaviors associated with alcoholics. Alcoholics are just like everyone else. They represent the whole of mankind, just as people with other chronic diseases.
The “slip,” or more accurately the “relapse,” demonstrates “a marked similarity between the alcoholic’s behavior and ‘normal’ victims of other diseases. The diabetic, the tubercular, the cardiac patients are prescribed a stringent treatment regimen and when they violate this regimen, nothing happens “at first.” Soon they are disregarding the directions given… Eventually (they have) a relapse. All these and most other chronic disease patients decided they don’t have to follow directions. WDS says (italics in the original) “And that’s human nature! Its life! It’s happening all the time, not merely among alcoholics but among all kinds of people. The preventative is plain. The patient must have full knowledge of his condition, keep in mind the facts of his case and the nature of his disease and follow directions.” The directions, according to WDS are to be found in A.A. He concludes: “… there is no more reason to be talking about ‘the alcoholic mind’ than there is to try and describe something called the ‘cardiac mind’ or the ‘t.b. mind.’ I think we’ll help the alcoholic more if we can first recognize that he is primarily a human being—afflicted with human nature.”
Duffy’s Tavern (1945) Unpublished Article
In 1945, WDS, at the request of the A.A. Foundation (a vehicle separate from A.A. but incorporated by A.A. members) started a post-detoxification program at Knickerbocker Hospital. It was similar to the program at Towns Hospital, using A.A. members and A.A. principles to treat the patients. The “program” only lasted five days subsequent to detoxification and patients were referred for other medical services as needed or to “A.A. Farms.” A.A. farms were residential programs, often rural venues, run by A.A. members. This model of detoxification followed by a period of education in and practice of A. A. principles would evolve into the “Minnesota Model.” WDS described the model of care in the unpublished article “Duffy’s Tavern,” (2002, p.174) the informal name for the unit at Knickerbocker, which emphasized “a spiritual rather than scientific atmosphere.”
In this article WDS, contrary to his image, as a modest and unassuming man grabs for some credit. Perhaps at this time he felt marginalized and underappreciated. He writes, “On the fourth day, the patient is ready for Dr. W.D. Silkworth, the gentleman who directs the treatment of all Duffy’s Tavern habitués. This remarkable man attended Bill W., founder of A.A., on his last drunk in 1934. During that treatment, Bill W. experienced the vision that changed his life and plotted the path of the A.A. movement. Since then, Dr Silkworth and Bill W. have worked closely together. But for the doctor’s insight and tolerance, A.A. might never have been born. He did not tell Bill W. he had an hallucination. He said instead, ‘Whatever it is, hang onto it.’ (2002, p.175).” Poignantly at this time WDS was close to the end of his career and probably felt justifiably under valued.
The Success of A.A.
In a subsequent talk in 1949 (2002, p.180) WDS contrasts the dismal 2% successful treatment outcome, with the much more encouraging results of the new inpatient model of care he had pioneered using A.A. members, A.A. principles, and ultimately referral to A.A. At that time the figure of 50% successful outcomes was offered as about average for these new programs. Nevertheless, he noted, that much scientific progress still needed to be made and alluded to the introduction of a new medicine , probably disulfiram, as a very positive development.
Rx for Sobriety
In another Grapevine article in 1945 (2002, p. 190) WDS tackles the issue of belief in a power greater than the self as the essential principle of A.A. “Why does this moral issue and belief in a power greater than oneself appear to be the essential principle of A.A.? First, an important comparison is to be found in the fact that all other plans involving psychoanalysis, will power, restraint, and other ingenious ideas have failed in 95 per cent of the cases. A second is that all movements of reform minus a moral issue have passed into oblivion.
“Whatever may be the opinions one professes in the matter of philosophy—whether one is a spiritualist or a scientific materialist—one should recognize the reciprocal influence which the moral and physical exert upon each other. Alcoholism is a mental and physical issue. Physically a man has developed an illness. He cannot use alcohol in moderation, at least not for a period of enduring length. If the alcoholic starts to drink, he sooner or later develops the phenomenon of craving. Mentally this same alcoholic develops an obsessive type of thinking which, in itself a neurosis, offers an unfavorable prognosis through former plans of treatment. Physically science does not know why a man cannot drink in moderation. But through moral psychology—a new interpretation of an old idea—A.A., has been able to solve his former mental obsession. It is the vital principle of A.A., without which A.A. would have failed even as other forms of treatment have failed.
To be sure, A.A. offers a number of highly useful tools or props. Its group therapy is very effective. I have seen countless demonstrations of how well your “24-hour plan” operates. The principle of working with other alcoholics has a sound psychological basis. All these features of the program are important.
But, in my opinion, the key principle which makes A.A. work where other plans have proved inadequate is the way of life it proposes based upon the belief of the individual in a Power greater than himself and faith that this Power is all-sufficient to destroy the obsession which possessed him and was destroying him mentally and physically (2002, p. 191 ff.).”
References to WDS in A.A. and Related Literature
Alcoholics Anonymous Comes of Age (AACA) (1957).
WDS is discussed in Bill Wilson’s history of A.A. First, in an Appendix (E.a.) is a reprint of his 1939 article “A new Approach to Psychotherapy in Chronic Alcoholism.” Second, WDS is cited twice in the section “Landmarks in A.A. History,” the first landmark, his 1934 pronouncement that Bill was a “hopeless alcoholic”, and second the 1945 beginnings of the Knickerbocker Hospital Program WDS started. In the AACA text WDS is referenced more often than any other single individual except Robert Smith, M.D., aka Dr. Bob, the co-founder of A.A. WDS is also described by Bill as a “founder” of A.A. and a continuous “benign” presence in A.A.’s early years.
“As we looked back over those early scenes in New York, we saw often in the midst of them the benign little doctor who loved drunks, William Duncan Silkworth, then Physician-in-Chief of the Charles B. Towns Hospital in New York, a man who was very much a founder of A.A. From him we learned the nature of our illness. He supplied us with the tools with which to puncture the toughest alcoholic ego, those shattering phrases by which he described our illness: the obsession of the mind that compels us to drink and the allergy of the body that condemns us to go mad or die. These were indispensible passwords. “Dr. Silkworth taught us how to till the black soil of hopelessness out of which every single spiritual awakening in our fellowship has since flowered (1957, p.13)” In December, 1934, this man of science had humbly sat by my bed following my own sudden and overwhelming spiritual experience, reassuring me. ‘No, Bill,” he had said, ‘you are not hallucinating. Whatever you have got, you had better hang on to; it is so much better than what you had only an hour ago.’ These were great words for the A.A. to come. Who else could have said them?
When I wanted to go to work with alcoholics, Dr. Silkworth led me to them right there in his hospital, and at great risk to his professional reputation.
After six months of failure on my part to dry up any drunks, he again reminded me of Professor William James’ observation that truly transforming spiritual experiences are nearly always founded in calamity and collapse. ‘Stop preaching at them,’ Dr. Silkworth had said, ‘and give them the hard medical facts first. This may soften them up at depth so that they will be willing to do anything to get well. Then they may accept those spiritual ideas of yours and even a higher power (1957, p.13).”
Throughout AACA, WDS is portrayed as always helpful, whether that is pointing out new “prospects” to Bill at Towns, providing personal financial support for the publication of Alcoholics Anonymous, attending meetings of prominent people to seek support for A.A. and its activities, or providing “the right kind of hospitalization” for alcoholics (1957, p.143). The Knickerbocker Hospital program was held up as an example of what today we would call “best practice (1957, p. 206).” Bill says that the initial A.A. program, the “word-of-mouth-program” owed its origin to the Oxford Groups, William James, and Dr. Silkworth (1957, p. 160). Despite early disputes about emphasis and various spiritual approaches “…all of us, East and West, were placing increasing emphasis on Dr Silkworth’s expression describing the alcoholic’s dilemma: the obsession plus the allergy (1957, p. 161).” WDS’s guidance often turned the direction of internal debates, contributing to the elimination of coercive, third person, language “you must” in Alcoholics Anonymous with more collaborative and supportive language such as “we ought” or “we should (1957, 167 ff.).” Dr Silkworth’s death in 1951, during a period of rapid and successful A.A. development, was noted with that of a helpful Rockefeller confidant who died that same year: “What Willard W. Richardson and William D. Silkworth had left us in pioneering service and in love was a never-to-be-forgotten heritage (1957, p.219).”
Thomsen’s Biography of Bill Wilson and WDS
Robert Thomsen (1975) worked with Bill Wilson for the last twelve years of his life and published a biography of him four years after Bill’s death in 1971. In the book Bill W., he describes the impact that WDS had on Bill during his four hospitalization at Towns Hospital during 1933-34. He notes that Bill, had his first conversation with WDS on the occasion of his second hospitalization. He felt no condescension from WDS only a straightforward delivery of scientific information about an illness that was an obsession of the mind and an allergy of the body. Thomsen notes that WDS joined with Bill in making the treatment of the illness “their joint responsibility.” He believed that WDS understood him and understood alcoholism. On the occasion of his next hospitalization, WDS told both Lois, Bill’s wife, and Bill, that he was worried that continued drinking would lead to serious brain damage. He warned Lois that to save his life, she might be faced with the need to confine Bill permanently somewhere if he drank again, to save his life. Subsequent to this hospitalization, haunted by WDS’s pronouncement, Bill received a visit from his childhood friend, Ebby Thacher. Ebby was an alcoholic, who was not drinking as a result of his contact with the Oxford Groups and Sam Shoemaker’s Calvary Mission. For a while Bill pursued this path with Ebby but ended up back at Towns Hospital where he was again welcomed by WDS, if somewhat sadly. After detoxification, Bill related that he became deeply depressed, anxious, and fearful. In this state Bill had his dramatic “spiritual experience” after which he felt a growing panic that he was insane. He sought out WDS. After WDS carefully questioned Bill, Thomsen describes the now somewhat familiar intervention, “So… he said, and he looked deeply into Bill’s eyes when he said it, whatever it is you’ve got now, hang on to it, boy. It is so much better than what you had only a couple of hours ago (1975, p.224). During the winter of 1934-35 Bill apparently met frequently with WDS who explained alcoholism and was “a necessary safety valve. He kept bringing Bill down to earth (1975, p.227).” Thomsen says WDS always believed there would be a cure for alcoholism and hoped to contribute to the cure. WDS’s method of treatment was to redirect patients from examination of causes and to attribute the destructive behavior of the alcoholic to the physical illness. He bolstered patients by identifying their strengths for which he apparently had an uncanny eye. Bill described two of WDS’s strengths as his ability to “… engage the confidence of a drunk.” and the “constant reiteration that alcoholism is and illness, an often fatal illness (1975, p. 228).” WDS decided to allow Bill to talk to patients, this was initially quite unsuccessful, until WDS reoriented Bill: “For God’s sake stop preaching… You’ve got the cart before the horse… Tell them about the obsession and the physical sensitivity they are developing that will condemn them to go mad or die. Pour it on. Say it’s as lethal as cancer (1975, p.233 ff).”
WDS in Kurtz’s History of A.A.
In 1979 Kurtz wrote what has become accepted as the standard history of A.A. insightfully titled “Not-God.” Kurtz’s discussions of WDS and his impact rely on Thomsen (1975), Bill’s own history of early A.A. (1957) and add some archival material and interviews with Lois Wilson. As would be expected the picture of WDS and his contribution remains more or less the same. As we know on his second hospitalization at Towns Hospital WDS explained his ideas: alcoholism was an illness, and that an allergy to alcohol led to obsession with drinking. WDS explained the compulsion that resulted from “just one drink,” that this drink got the alcoholic “drunk.” Intoxication led to the compulsive behavior, the loss of control, which only ended when the alcoholic ran out of alcohol or energy. WDS, went on to say that “they” could work together to defeat the obsession and compulsion with proper decisiveness and effort. Ever since his paper on the jungle plant in 1908 WDS focused on the collaborative (i.e., harmonious) relationship with the patient. Since his “Reclamation of the Alcoholic” paper he additionally focused on the need for a decision “in the nature of an inspiration.” Which was a central part of the moral psychology that he believed was required to recover. While Bill took hope from this intervention he was drinking again shortly after his discharge. and WDS told Lois Wilson and eventually Bill that the situation was hopeless and to avoid brain damage Bill would probably have to be locked up. Kurtz notes that the very hopelessness encouraged Bill as he felt that anyone who had received such a prognosis would have to stop drinking, but of course he did not. This notion of clinical explanation, collaborative effort, and the associated “inspiration” on the part of the patient clearly was not enough. The missing element of the “spiritual experience” was just around the corner and it would complete WDS’s and ultimately A.A.’s understanding of the “solution” and “how it works.”
The subsequent period involved the formative intervention by Ebby Thacher, Bill’s exploration of the Oxford Group at Calvary Church and the church’s Bowery mission. Finally, he returns to Towns for his last detoxification during which he has the spiritual experience that frees him from his alcoholism. WDS provides the crucial intervention in this case. As noted earlier rather than dismissing the experience WDS gives his famous, “Whatever it is you’ve got now, hang on to it. Hang on to it, boy. It is so much better than what you had only a couple of hours ago.”
The other important aspect of WDS approach that Kurtz stresses is his redirecting Bill away from preaching at the alcoholics. He urged Bill to emphasize the medical aspects of alcoholism, the illness, the obsession and compulsion, etc. and the hopelessness of their condition. The alcoholic’s sense of hopelessness might create the deflation of ego that leads them to the “essential psychic change” or spiritual experience. This emphasis on hopelessness became a core idea of A.A. WDS did not tell Bill to stop working with the patients but redirected him to create the circumstances that might predispose the patient to listen to the spiritual solution. Again it is worth noting that Kurtz following Thomsen (1975) and Bill himself (1957), emphasizes the consequences of WDS’s two remarkable clinical interventions. The first supporting Bill’s own spiritual experience rather than undercutting it and the second redirecting Bill’s interventions with patients rather than concluding that Bill was a failure as a therapist. It is probably not inaccurate to suggest that these two clinical interventions would contribute to saving the lives of millions of alcoholics and thus may be viewed as two of the most important clinical interventions in history.
WDS in White’s History of Addiction and Recovery in the U.S.
White (1998) supports the significance of WDS’ unremitting advocacy for a disease concept of alcoholism, “…a powerful and guilt-assuaging medical metaphor to understand what had happened to him (1998, p. 129),” and his insightful interpretations of Bill’s spiritual experience remarking “…what Silkworth did not do (provide sedating medication, … offering words not drugs) and did not say are as important… as what he did do and say (1998,p.129, 141).” White also references WDS supervising Bill and encouraging him to stop preaching, but rather to “start confronting the alcoholic’s ego by teaching him about alcoholism. He reminded Bill of what Bill had learned from William James and Carl Jung: “alcoholics must be deflated before they are open to spiritual experience (1998, p.141.)” He also comments on the tremendous numbers of alcoholics, he puts it at 50,000, WDS treated yet, “alcoholics who were cared for by Dr. Silkworth reported that he never seemed to be in a hurry, nor did he respond to his patients with stock answers or formulas. ‘He came to each new case with a wonderfully open mind.’ (1998, p. 141).” In a provocative section attempting to understand WDS’s effectiveness he discusses the “transcendence of contempt.” Referring to several effective alcoholism professionals White quotes Kurtz, “…each, in his own way, had experience tragedy in their lives. They had all known kenosis: they had been emptied out; they had hit bottom… whatever vocabulary you want. They had stared into the abyss. They had lived through the dark night of the soul. Each had encountered and survived tragedy. (1998, p.333)” Finally, White also discusses WDS support for hospitalization and the development of model treatment protocols.
WDS in Hartigan’s Biography of Bill Wilson
Hartigan (2000) notes in his biography Bill W that WDS was the first person Bill had ever met who believed alcoholism was an illness and who could offer a neat scientific explanation (p. 50 ff). All Bill had to do to avoid the obsessive and compulsive drinking, the terrible drinking sprees, and their awful consequences was to avoid alcohol altogether because it was that first drink that created the vicious cycle. Science had an explanation. The treatment was simple: avoid that first drink that would trigger the allergic reaction. This explanation gave Bill extraordinary hope. (No non-recovering person could understand this hopefulness given Bill’s history, nor the fact that there was no method proposed to accomplish this uncharacteristic behavior.) Bill was drunk again within a month. On his next hospitalization at Towns several months later, as we have seen, WDS was considerably less hopeful and worried about alcohol having had a permanent effect on Bill’s brain. Although Lois would not commit Bill, Bill was very frightened by these possible consequences. During his fourth hospitalization Bill had the spiritual experience that frees him from drinking and Hartigan notes that WDS advises Bill to stop trying to understand what happened, just hang onto what the experience had given him. Hartigan says that Charles B. Towns and WDS “were so impressed with his recovery” that they let him work with patients at Towns. He further notes that WDS, noting Bill’s many failures with the prospects he found in the hospital, told him to stop talking “at” patients and start talking “with” patients, “Let them know that you know what their going through.” Bill does this in early summer of 1935 during his first meeting with Robert Smith, M.D. Hartigan also mentions WDS attendance at the Rockefeller dinner and the medical support for A.A. he provided by writing the “Doctor’s Opinion” chapter in Alcoholics Anonymous.
WDS in Cheever’s Biography of Bill Wilson
Cheever (2004) in a very nuanced biography of Bill Wilson confirms WDS’s impact on Bill through his identification of alcoholism as a disease, an allergy that created the phenomenon of craving, and that as an illness it was no more responsive to willpower than tuberculosis. The solution was simple. Don’t take that first drink. But despite his empathic support, despite his willingness to join with Lois and Bill, WDS was not able to provide a method to accomplish this end. After Bill had his spiritual experience, WDS did, of course, support Bill’s experience, support his sanity, and explain that such spiritual experiences had historically cured alcoholism. He supported Bill’s studies of William James’s Varieties of Religious Experience and he supported Bill and A.A. throughout his life. But by reflecting on WDS writings in 1939 and thereafter (2002) the observer can see clearly that WDS “came to understand” the spiritual part of the A.A. program, but in his earlier 1937 “Reclamation of the Alcoholic” (p. 149 ff) WDS emphasized “reasoning” in the discussion of the psychotherapeutic approach, and even the notion of “inspiration” in the brief, subsequent moral psychology section indicated he was not quite there yet. He could offer Bill the disease concept but not a methodology to treat the disease.
WDS in the official A.A. Biography of Bill Wilson
In 1984, AA published its own biography of Bill Wilson Pass It On. The first mention of WDS in the book quotes Bill, “As I came out of the fog that first time, I saw him sitting by the bedside. A great warm current of kindness and understanding seemed to flow out of him. I could deeply feel this at once, though he said scarcely a word. He was very slight of figure and then pushing 60, I should say. His compassionate blue eyes took me in at a glance. A shock of pure white hair gave him a kind of other-worldly look. At once befuddled as I was, I could sense he knew what ailed me (p. 99).” WDS thus enters Bill’s life as a compassionate clinician imbued with remarkable empathy.
Bill relates that being the Physician-in-Chief at Towns Hospital was a lucky break for WDS who had like so many others lost his savings and investments in the 1929 market collapse. WDS eventually confided in Bill how hopeless (perhaps WDS understood hopelessness at a personal level) the situation was for most alcoholics, although there were some that showed “hope of recovery” and how in his work at Towns he was trying to develop some method to reverse these terrible outcomes. When WDS explained his “allergy theory” and its corollaries: craving, inability to break the habit themselves, no safe alcohol use, overwhelming “problems.” “Bill listened, entranced, as Silkworth explained his theory. For the first time in his life, Bill was hearing about alcoholism not as a lack of willpower, not as a moral defect, but as a legitimate illness… alcoholism could no more be ‘defeated’ by willpower than could tuberculosis (p. 102).” This intellectual approach and WDS obvious concern and empathy for each patient was very special. In the same breath, however, Bill says, “Not a great M.D., this man, but a very great human being (p. 104).” This is a very awkward characterization and may suggest Bill’s misunderstanding of clinical verses scientific skill. At any rate, Bill and Lois took great hope from his meetings with WDS and left the hospital filled with optimistic belief that with the knowledge he now had, he could remain sober. He did not.
Subsequent visits to Towns and WDS, recall there were four in the period 1933-34, did not end with optimism and enthusiasm. Recall that the third hospitalization resulted in WDS telling Lois that despite his initial optimism that Bill might be “one of the exceptions,” he was now concerned about brain damage and felt Bill would have to be “locked up somewhere.” Bill was temporarily frightened into sobriety and he did stay sober for several months. During this period he reunited with Ebby Thacher and met other Oxford Group members and had his first spiritual experience at the Bowery mission of Sam Shoemakers Calvary Church. At least Bill felt that “something had happened” when he “testified” at the mission (p. 119). (This “small” spiritual experience is often overlooked in discussions of Bill’s spiritual development but is worth noting.) He went back to Towns for the last time and experienced perhaps his deepest depression, “This was the finish, the jumping-off place.” Followed by the dramatic spiritual experience that changed everything. Then WDS provided support and encouragement for whatever it was that had happened in an almost Delphic fashion, “Yes, my boy, you are sane, perfectly sane in my judgment. You have been the subject of some great psychic occurrence, something that I don’t understand. I’ve read of these things in books, but I’ve never seen one myself before. You’ve had some kind of conversion experience.”
WDS in the A.A. Biography of Robert Smith, M.D.
In Robert Smith’s biography released by A.A. in 1980 there is one mention of WDS and that is in the context of Bill speaking to Dr. Bob, a prospect after all, as WDS had instructed him, about the physical aspects of the disease of alcoholism and the hopelessness of the illness (p. 68).
Discussion
During their very first encounter Bill Wilson was impressed by WDS’ assertion that alcoholism was a physical illness with definite symptoms. This legacy, that alcoholism is an illness, endures today. Its repetition in alcoholism recovery circles undercuts the guilt about having the condition, and provides a framework for effective treatment. Bill was hearing this from an experienced physician, a man who had treated tens of thousands of alcoholic patients and who was committed to making a difference in the alcoholism treatment field. Alcoholism, in Bill Wilson’s day, was a hopeless, chronic, illness but in typical clinical style WDS asserted that if “they” (the physician and the patient) worked together “they” might be able to treat it successfully. Here then are three of WDS central contributions to alcoholism treatment: the assertion that alcoholism was an illness; the quietly confident, inspirational guidance of a very experienced doctor; and the joining of patient and practitioner in a clinical collaboration to control the patient’s disease.
WDS was one of those rare physicians who could make hopelessness sound like a challenge. He believed that an “inspired” decision never to drink again coupled with complete abstinence could work. When Bill had his celebrated spiritual experience, WDS recognized it as the spontaneous conversion cure that had occurred throughout history in the face of crushing depression. He did not dismiss it as the ravings of a depressed, detoxifying alcoholic. He supported Bill by referencing these past occurrences and encouraging Bill to “hang on to” whatever had happened. He also appeared to believe that Bill had changed permanently. As proof of this WDS was willing to support and guide Bill’s intense desire to help other alcoholics by giving him opportunities to work with patients at Towns Hospital.
When Bill’s “work” with the patients at Towns was one hundred percent unsuccessful, he was willing to supervise Bill, not cancel his privileges, nor tell Bill to quit and be happy that he himself was cured. WDS offered the sound supervisory advice to “stop preaching” and tell them about the illness, his own experience with alcohol, and the hopeless prognosis. Only then might the patients be crushed enough, hopeless enough, as Bill was, to listen to a spiritual solution. This is an outstanding example of clinical supervision. When this approach began to be successful WDS saw for the first time a systematic method that could work, and began to describe (1937) the method: detoxification and medical stabilization followed by a combination of psychotherapy, moral psychology and longer term rehabilitation. WDS utilized and tweaked the new treatment model at Towns Hospital and later expanded and refined it at Knickerbocker Hospital. He gave the new model of care and particularly A.A. his professional medical backing. During this time period and the next several years, as can be seen in the evolution of his writing and speaking, WDS participated in the clarification of the new method of “moral psychology,” the Twelve Step Program. He explained the success of this new program as a result of: one alcoholic talking to another alcoholic in a unique, direct communion, the shared summary of experience and illness, and the belief in a power greater than the self, a Higher Power.
WDS also addressed what remains a central issue in addiction treatment: relapse. Without judgment he presented it cogently as a failure to comply with the medical regimen prescribed. He addressed the still controversial issue of whether alcoholics started out as “normal” individuals whose co-morbidities and psychopathology were caused by drinking, or whether alcoholics had underlying problems of a unique sort. He came down resoundingly on the first point of view. He was an early and strong advocate for the development of prevention strategies. WDS continued to support new medical developments in alcoholism treatment, just as he had in describing his clinical trials with the “jungle plant” (1908, 1909). Even at the end of his career (1950) he was exploring his theory that salt might prevent craving. At every turn he supported Bill and the other pioneering recovering alcoholics. As Bill pointed out, he “showed up” at all the important and unimportant events in the history of A.A. until his death in 1951.
One might conclude that without WDS, his clinically astute treatment of Bill Wilson, and his support and help for the development of what would become the dominant model of alcoholism treatment, there would today be no A.A. Conversely, if WDS had never encountered Bill Wilson, never given him the compassionate and informed care he did, he would be remembered, if at all, as just another worker, a footnote at best, in the wearisome and frustrating world of alcoholism treatment.
ReferencesAnonymous. (1957) Alcoholics Anonymous Comes of Age. New York: Alcoholics Anonymous World Services, Inc.
Anonymous. (2001) Alcoholics Anonymous. New York: Alcoholics Anonymous World Services, Inc.
Anonymous. (1980) Dr. Bob and the Good Oldtimers. New York: Alcoholics Anonymous World Services, Inc.
Anonymous (1984) Pass It On: The story of Bill Wilson and how the A.A. message reached the world. New York: Alcoholics Anonymous World Services, Inc.
Cheever, S. (2004) My Name Is Bill. New York: Simon and Schuster.
Hartigan, F. (2001) Bill W.: A Biography of Alcoholics Anonymous Cofounder Bill Wilson. New York: Thomas Dunne Books, St. Martin’s Griffin.
Kurtz, E. (1991) Not-God: A History of Alcoholics Anonymous. Center City, MN: Hazelden Educational Materials.
Michel, D. (2002) Silkworth: The Little Doctor Who Loved Drinks. Center City, MN: Hazelden Educational Materials.
Silkworth, W.D., Texon, M. (1950) Chloride levels in the blood of alcoholic patients in relationship to the phenomenon of craving. Quarterly Journal of Studies on Alcohol, 11, 381-384.
Silkworth, W.D. (1909) A further report on the jungle plant (combretum sundiacum) in morphine addiction. New York Medical Journal, 1/16/09, 115-116.
Thomsen, R. (1975) Bill W. New York: Harper and Row.
White, W.L. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Normal, IL, Chestnut Health Systems/ Lighthouse Institute.
