By John W. Meiszner, MD   The Blue Book, Vol. XLVII, 1996 Scottsdale, Arizona   As many times as I have given some version of this talk over the last ten years or so, I never quite know how to begin. I thought I would start by sharing some thoughts that occurred to me as I took a long stroll through the beautiful grounds of the Franciscan Retreat Center after lunch today. It occurred to me that I never cease to be amazed at my Higher Power’s perverse sense of humor. Specifically, last summer when Father Nacius first asked if I would be willing to talk to the NCCA group, my first question was when and where. When he told me it would be in the middle of January in sunny Arizona, I said, “Absolutely! Book me.” When my plane landed yesterday it was raining, even though the flight attendant said that it never rains in Phoenix. When I got up this morning I overheard a man talking to his wife in the lobby of the hotel saying, “Honey, we should go back to Vancouver and warm up.” So much for my plans to get a tan.  When Father Ruddick got in touch with me and told me that the theme for this 47th annual meeting was Spirituality and Recovery, I thought, “Great, no problem.” I had previously given a lecture entitled “Recovery: Life After Death.” And since I had recently read a wonderful book on spirituality, I would use that to update my talk. Well the book I am referring to is The Spirituality of Imperfection. I found out shortly thereafter that the author of that book, Dr. Ernest Kurtz, would be sharing the podium with me. So that plan was ruined. But Father Ruddick was nice enough to let me pick my own topic. It also occurred to me during my walk that I was feeling more than the usual amount of anticipatory anxiety. Some years ago I read a study done by psychologists that the average individual suffers from 1.7 basic fears, such as fear of snakes, fear of heights, fear of close spaces. Well, I have never quite figured out what my .7 is, but I know my 1 is the fear of public speaking. On top of that you need to know that I was taught in grammar school by the BVMs, lovingly called the Black Veiled Monsters, really the Sisters of the Blessed Virgin Mary. In high school I was in the hand of the Vincentians, and from college on through medical school and part of residency I attended Jesuit institutions. When I came down here I realized that there are quite a few Jesuits and Vincentians and maybe even some BVMS here, so my anxiety increased. It reminded me of an experience I had back in 1982 when I was asked to come to Vancouver, British Columbia, to give a presentation to the annual meeting of the IDAA, the International Doctors in Alcoholics Anonymous. Back then I was much less well than I am now and suffered even more from my fear-based terminal self-centeredness. So I went to a dear friend, my mentor, my spiritual advisor who I have since come to call “Mrs. Myagi.” I asked Cecilia, a deeply spiritual woman, to give me some advice. She had at that time over twenty-five years of AA recovery under her belt and had done a fair amount of presenting in public. So I asked her to advise me because I wanted to do a “really good job.” Well I should have known better. Being the good sponsor-type person that she is, she said, “John, I hope for your sake you lay a big egg. You could use the humility.” But she also said that she would talk to Pops, her term for the Man Upstairs, and she would get back to me. Shortly before I left for Vancouver she gave me a sealed envelope and instructed me to not open it until just before it came my turn to speak. I felt surely that the envelope would contain some practical instructions that I could use, be it an opening line or what have you. When I opened it I found this blue card. The card simply said: Matthew 10, verse 19. “When they deliver you up, do not be anxious how you are to speak or what you are to say. For what you are to say will be given to you in that hour. It is not you who speak but the spirit of your Father speaking through you.” So if today’s talk does not go well, you know who is to blame. Of course if it goes well, I am always happy to take all the credit! Further along in my reverie out in the orange groves, I was reminded of an experience I had back in the early ’80s, a time when I was running to every conference, convention, seminar I could find on the topic of alcoholism and addiction and recovery. It was part of my quest to find out what it was really about and how I could cure it. I was returning from a convention in Atlanta, I think it was the annual SECAD Conference. Although I had tried to prepare myself by not getting my hopes up too high, I apparently had expectations because I was once again disillusioned. I was sitting in the airplane wondering if it was worth the time, the effort, and the money when someone tapped me on the shoulder. I looked over and there was this sweet, distinguished looking old gentleman who asked how I enjoyed the convention. I had apparently forgotten to take off my name badge. Trying to be polite I said, “Oh I thought it was just swell.” He said that he enjoyed it thoroughly. By now I was getting annoyed, so I said, “To be honest with you, I was really disappointed. I went there expecting to find some answers, to get some insight, some understanding about alcoholism and I am just as confused, as in the dark as ever.” I asked him what he thought of it. He said he thought it was wonderful. I asked him to elaborate. He said, “Well, I also went there confused and looking for answers.” And I said, “Well, now do you have answers?” He said, “No. I am still confused. But my confusion is of a much higher order.” The lesson to me is the old proverb: If you expect nothing, you have everything.   Expectations   I should like to confess in advance that I do not really know what alcoholism is. In fact, let me share one more plagiarized quote. Actually it is not plagiarism for that is when you quote one person. When you quote more than one, it is called research. This is from the Protestant theologian, Emmett Fox: “Anything that you really understand you can explain in reasonably simple language . . . providing that it lends itself to explanation at all. An air of heavy profundity conveyed in mysterious and vague phraseology is the hallmark of insincerity or of a muddled mind.” If I get into profundity or mysterious phraseology, let me assure you that I am as sincere as I know how to be and, although my Alzheimer’s is progressing, I do not think the problem is a muddled mind. I think that this topic does not lend itself to explanation at all. If in fact I do not know what alcoholism is, then why am I going to spend the next two hours talking to you about it? Probably for the same reason that Scott Peck in his book The Road Less Traveled writes a chapter on love. As I recall, he says early in that chapter that he does not know what love is, he cannot define it, he cannot quantify it, he cannot explain it. Yet, he writes a chapter. The reason is that, although he does not know what love is, he has some good ideas of what it is not.   Alcoholism a Disease?   Maybe we need not go through all this. Let me begin by asking: “How many of you believe that alcoholism/addiction is a disease?” Well, just about every hand went up. There are two or three (probably angry, unhealed co-dependents) who did not raise their hand, but as usual almost everyone raised their hand. Of course you believe it is a disease. Everybody knows it is a disease. Wherever I have asked that question, be it in the community at large, be it in treatment centers, prison populations or institutions of higher learning, 90-100 percent of my audiences have always said that they believe it is a disease. After all, the American Medical Association has defined it as such; the American Psychiatric Association has over a dozen categories in the diagnostic manual; perhaps more importantly, authorities such as Oprah Winfrey, Nancy Reagan, Reader’s Digest, Ladies Home Journal, all say it is a disease. It is downright politically incorrect to say otherwise. So why bother giving this lecture? Maybe we should just adjourn now. But before we leave, let me challenge you with this statement: I do not believe that many of you truly believe that. I am not calling you liars. My experience over the years has been that, although just about everyone says they think it is a disease, they really do not believe it. Let me point out that it is what we believe that determines our actions much more than what we think. Our convictions, not our concepts, determine our behavior. If, in fact, everyone believes that it is a disease, how can it be then that almost every alcoholic and addict that has come to me over the years has been filled with shame, guilt, self-incrimination, and self-loathing? I do not see that with any other disease. I do not see that with the diabetic or with people with heart disease or even people with mental illnesses. There is a contradiction there. If everybody believes it is a disease, how can it be that predictably the significant others, the people around this so-called sick individual, are also filled with shame and blame and guilt and distrust and broken-heartedness. You do not see that in the loved ones of orthopedic patients or surgery patients. Again, although these people will tell you that it is a disease, their emotional reaction suggests otherwise. If, in fact, everyone believes it is a disease, how can it be then that Nancy Reagan, who has gone down in our history books for her leadership role in the fight against this so called disease of addiction, uses the bottom line message, ”Just Say No”? Think about that for a moment! Would it ever occur to you to say that to someone with a brain tumor or someone with a coronary or someone with appendicitis? Of course you would not! Again, there is a contradiction here.   Some More Examples   I am trying to demonstrate to you that there is a need to address this topic. As an aside, I recall many years ago thinking that if I ever again heard someone talk about the “disease concept” I would scream. It seemed to me that everyone already knew that. It was like beating a dead horse. Well here I am, ten or fifteen years later giving that lecture and with a greater sense of conviction and urgency than ever before. Let me go on and share with you a few more “how comes,” a few more sets of facts to demonstrate why it is clear to me that most people do not, in fact, really believe it is a disease. If, in fact, everyone believes it is a disease, how come then that, although the World Health Organization some years ago identified alcoholism as the number three health problem in this country, less money is spent today on alcoholism research than on tooth-decay research? It is estimated that on any given day there are fifteen million active alcoholics in this country. It is a known fact that for every alcoholic there is an average of four people whose lives are directly and painfully affected, be it the spouse, the parents, the offspring, close friends, employer, etc. So, even by conservative estimates, seventy-five million people (or roughly one-fourth of the population) is adversely affected by this so-called disease. Yet, less money is spent on researching it than on dental care. I propose to you again there is a contradiction here. If, in fact, everyone really believes it is a disease, how can it be then that in recent years whenever I call the HMO or managed care company to get permission or to “justify” wanting to treat an alcoholic the response is almost always either “request denied” or “Okay we will give you 2.7 days”? I suggest to you that the people in the health insurance industry do not really believe that we are talking about a progressive, fatal disease. If, in fact, everyone believes it is a disease, how come there aren’t any doctors here? I recognize that this is a convention of the NCCA, but let me tell you that even when I give this talk in medical centers, rarely do doctors or medical health professionals show up. In my home-base hospital we have over 450 doctors on staff. My guess is that if word got out that there was a good talk being given on HIV infection, every doctor and every nurse would be there. Rightly so; AIDS is a serious illness, it kills a lot of people, and those medical personnel should be there. But alcoholism kills as many people in one day as AIDS does in one year! Dead is dead. If all those people believe it is a disease, why don’t they have an interest in the topic? Closer to home, if everyone truly believes it is a disease, how can it be then that when I am on call in our emergency room as the psychiatrist/addictionologist on duty, I rarely get a call for people suffering from alcoholism. We have one of the busiest private emergency rooms in the Chicagoland area. Several hundred people show up on any given weekend. It is a known fact that 50-80 percent of the people who show up in an emergency room on a weekend are there directly or indirectly because of problems caused by drinking and drug use. Granted, most of those people do not present complaining of “the disease of alcoholism.” Their presenting complaint may well be gastritis or anxiety attacks or depression or insomnia or legal difficulties, but our staff is trained to know that if someone presents with a problem that is caused or aggravated by drinking and drugs, the diagnosis is addiction until proved otherwise. I have spoken to our emergency room staff. They are excellent people. I take my children there. I have given them essentially this same lecture and they all said they believed it was a disease. Yet, how can it be that when 50-80 percent of those hundreds of people who show up there suffer from alcoholism/addiction, I might get, on a busy weekend, two or three calls regarding them. I get a lot of calls for agoraphobia or major depression or post-traumatic stress disorder or whatever happens to be the psychiatric disease of the week, but I get very few for people who suffer from alcoholism. Even the calls that do come have words that may be proper, but the innuendo, the underlying tone of voice, usually sends the message of “How do I get this person out of here without incurring too much liability?” If, in fact, everyone believes it is a disease, how can it be that when so many are painfully afflicted by this progressive and ultimately terminal condition and when treatment is almost universally available, 85-90 percent of these people never accept help. Perhaps more significantly, if everyone believes it is a disease, how can it be that of the 10 or 15 percent who are fortunate enough to make it to a 12‑step path, the majority of them wind up not recovering? How can all these things be?  I will tell you why. Because, although everyone says it is a disease, the fact is that most people do not believe it is a disease, and for good reason. People are not stupid. Maybe we should listen and learn from them.   An Example   To save time: picture in your mind Dr. Smith. Dr. Smith is an emergency room physician. In case you have not been to an emergency room recently, let me describe it to you. On a weekend, especially during the night, it is a very busy, chaotic place. People are there because they are hurting; they are not there for a cup of coffee. They are bleeding, they are suffering, they are in pain, they want help. Although they do not recognize it as such, it is actually the golden opportunity. They are hurting bad enough to be reachable, to be helped. Here is Dr. Smith on duty. The ER is busy; it is two o’clock on a Saturday night. In one gurney, on one cart, there is a little old lady that has suffered a massive coronary. I suggest to you that Dr. Smith approaches this woman in a spirit of concern, compassion, love, and healing. I suspect that it does not even occur to him for one moment to wag his finger in her face and to say, “I told you to just say no.” The issues of disease concept or culpability or reproach just do not arise. He does everything in his power to be an instrument of healing. In another gurney there is a young child that has suffered multiple lacerations. She is bleeding, she is crying, she is in pain. She was involved in a car wreck. I suspect, once again, that the emergency room physician approaches her in the same spirit of compassion and care and concern. As Dr. Smith is working feverishly to help these two sick people, in comes “Charlie.” Charlie suffers from the disease of alcoholism. Charlie presents the way alcoholics tend to present at two o’clock on a Saturday morning. (Now, I will never make fun of an alcoholic, but I certainly have fun with them, so please no one get your nose out of joint.) Picture this: Charlie comes in, bedraggled, loud, abusive, he looks bad, he smells bad, he acts bad. Charlie is annoyed that he cannot have a cigarette, and he wants to know why this old lady really needs oxygen. Then he becomes indignant that he is being kept waiting, after all he was here fifteen minutes before the child from the car wreck and why is she getting stitched up before his needs are met. Already Dr. Smith’s gut reaction to Charlie is somewhat different than to the other two. Then we discover that Charlie is the son of this old woman. She never had the good fortune of finding Al‑Anon so she literally becomes heartbroken whenever Charlie goes on a binge. It appears that Charlie’s toot had a direct bearing on her recent coronary. Then we find out that Charlie was the drunken driver that rear ended this little girl’s station wagon. I think you will agree that Dr. Smith is feeling something less than a “healing spirit.” Then, we pull out the old record and find out that this is the seventh time that Charlie has been here in the last twelve months. Every time Charlie presented in crisis, claiming to have hit bottom and sincerely wanting help. But also every time, forty-eight hours after getting some Librium or Valium or vitamin B complex, he protested that he “now knew what he needed, could do it on his own,” and threatened to sue if he was not allowed to sign out against medical advice. I suggest to you that, even if Dr. Smith is Mother Teresa and Albert Schweitzer rolled into one, he is not likely to embrace Charlie in the same healing spirit as the other two patients. No matter how much he learned in that one hour he had on alcoholism in medical school, even if he heard Dr. Meiszner give the lecture on the disease concept and he agreed with it and he believed it, Dr. Smith, who is human and only has his intellect and his emotions to work with, is not going to be able to be an instrument of healing with the way he feels towards Charlie. To make the point even simpler, my Grandpa Ulmer, although he had very little formal education, had a lot of practical wisdom. Grandpa Ulmer had a saying: “If something looks like a duck, swims like a duck, and quacks like a duck, it is probably a duck.” Now, unless I get some debate from you, I will submit that that is pretty sound philosophy. And, having good genes, I have come to a very similar conclusion: that if that is true (and I think it is), then the converse is equally true. Namely, if something does not look like a duck, and does not quack like a duck, and does not swim like a duck, then maybe it is not a duck. I am here to tell you that alcoholism/addiction does not look like a disease, it does not act like a disease, it does not swim like a disease, it does not quack like a disease. It does not, in fact, meet Koch’s postulates: there is no infectious agent, you cannot reproduce it in a lab, you cannot identify a suspectible host. Although it is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), I can tell you as a board-certified psychiatrist that these people are not crazy, these people are not psychiatrically ill. Although I fully agree with every word in the literature of Alcoholics Anonymous, in the technical sense I do not believe these people are insane. On the contrary, they are probably painfully sane. In case you do not trust my Grandpa Ulmer’s judgment, let me quote some more reputable sources. Oliver Wendall Holmes has said: “The simplicity that precedes complexity is comfortable but worthless. The simplicity that follows complexity is discomforting but priceless.” Or to quote another authority: “In order to speak and hear rightly, false assumptions must be shattered.” That is from Dr. Ernest Kurtz.   Complexity That Follows Simplicity   I propose to you that the statement: “Alcoholism is a disease” is an example of the simplicity that precedes complexity. It is an example of a false assumption that needs to be shattered. It is a duck that does not quack. The fact is, it does not meet the medical model criteria for a disease. It does not meet Koch’s postulates: there is no infectious agent, there is no susceptible host, it is not reproducible in a lab. Even though the American Psychiatric Association lists it as a disease in their DSM-IV, I can tell you that few, if any, of my colleagues truly believe that. At best, they see it as a personality disorder, probably anti-social personality. Although I agree with every word in the 12-step literature and the word “insanity” is used, in the technical, medical model, disease-concept sense, alcoholics and addicts are not insane. If anything they are painfully sane. I suspect that is probably why they drink and why they need to do drugs. Let me emphasize that this is not a theoretical issue. I believe it is a truly vital issue. You see if a person does not believe that they have a disease, chances are they are not going to accept treatment. In like manner, if someone does not truly believe or accept the fact that they are powerless, they will most probably never embrace a 12‑step program.   The First Step   If it has not occurred to you by now, today’s talk is really a first-step talk. The question: “Is alcoholism a disease?” is no different from the question: “Are alcoholics truly powerless?” As I am sure most of you know, there are over 150 different 12‑step programs. In fact, rumor has it that there is a new 12‑step program for people who have become addicted to 12‑step programs. My opinion is that the 12‑step programs are not only similar, they are in fact identical. They differ only at the portal of entry, the first step. The first step of any 12‑step program says that “we admitted we were powerless” over whatever the object of addiction was: alcohol, drugs, other people, lust, whatever it may be. I believe that the first step is the foundation. It is no different from when you are building a house. No matter how lovely the structure, no matter how grand the decorations, if the house does not sit on a solid, firm foundation it will eventually crumble. In like manner, the foundation of any 12‑step program, of any successful 12‑step recovery path, is a full acceptance of the first step. Even though the AA literature says that the first step is the only one that has to be taken completely, and my experience as a clinician is that most people within the first days or weeks of recovery will tell you that they have mastered the first step, I suspect that the main reason the majority do not accept help or stick with recovery is that they do not truly believe that they are powerless. They do not truly believe that it is a disease. And I think it is really understandable why. Let me postulate a hypothetical individual. We will call him “Joe.” Joe checks into the Betty Ford Center because of his serious drinking problem. Take my word for it when I tell you that Joe is judged to be the “best” patient that has ever checked into this facility. This opinion is formed by staff that are not only formally trained but who have themselves been through the fires of affliction, people who are themselves recovering from alcoholism and addiction. They ascertain that Joe has had a “really low bottom,” he has suffered incredibly. Joe is a constitutionally capable individual, he is introspective, reflective, and sincere. From Dr. Jim W. on down, the staff there feels that Joe’s prognosis is excellent. But Joe is a human being, and like all human beings he essentially has only his intellect and his emotions to work with. Here is the best even Joe can do. Joe has realized three things. Number one: that his drinking and only his drinking has caused him and his loved ones incredible suffering. He no longer wants this pain in his life. Number two: Joe has been taught what he has suspected all along, namely that he must abstain from the first drink. If he does not pick up the first one he will never get drunk, and indeed the first essential requirement for recovery is abstinence. Number three: now that Joe has gotten “really honest” with himself (the most dangerous words in recovery), Joe acknowledges that it was always he who picked up that first drink. No one made him do it. No one ever poured it down his throat. Based on these three realizations, — that drinking has caused him and his loved ones incredible pain, that the first essential requirement is not to pick up the first one, and finally, the honest realization that it was always he himself who had picked up that first one — Joe can reach only one conclusion. That is that he must not, that he can not, and that he will not pick up the first drink. There is no other conclusion that he can reach, no matter how bright, no matter how sincere. The problem with that very reasonable and sincere conclusion is that it is a complete contradiction to what the first step says. The first step says that he is powerless; that (unless some miracle happens) he will drink again! In my work in our rehab (before the HMOs closed it up), I had a reputation as being hard-ass. The word amongst the patients was “Try to avoid Meiszner.” I would like to think that it was not because of my abrasive personality; I would like to think it was because I tried to practice tough love, not only preach it. I was notorious for having “trick questions.” The question I would usually ask the patient before they were discharged is to tell me in their own words what they believed the first step said. A very typical response would be one of relief that they got an easy question, and the person would say, “Oh, that is an easy one. The first step means I can never drink again.” My response would be “Wrong. I think we need to extend your stay. You can drink better than most people I know. In fact, that is why you are here. The first step really says that you cannot not drink.” The response typically would be something like, “Man, you are really messing with my mind. They told me you were tricky.” It is not a trick. The first step says that you will drink again. You by yourself alone, no matter how sincere, no matter how motivated, no matter how strong, how bright you are, you by yourself alone will drink again. Today’s talk is a first-step talk. I am deeply convinced that unless a person embraces the awfulness (and what can be more awful than relinquishing one’s right to oneself) of what the first step says, a person cannot experience the awesomeness of 12-step recovery. Understanding it is not enough. Acceptance has nothing to do with understanding or liking it. When I understand something or like something there is no need for acceptance. I submit to you that just as everyone these days understands or thinks that alcoholism is a disease but does not really believe it, in like manner, the majority of people who say that they have taken the first step do not truly believe that they are powerless. The result is they embrace recovery as a self-improvement kick, as an option, as a way of getting good, and of course, getting good gets boring real quick. I have seen many people over the years who have probably turned their back on recovery because they intuitively sensed the hypocrisy in the statement that alcoholism was a disease. They are too honest, they are too real, to use that as a copout. They truly believe that this is something that they did to themselves and so it is incumbent upon them to undo it. Let me share with you now a paradigm, a way of looking at this thing called alcoholism/addiction that I hope will enable you to more fully embrace, to accept, to truly believe that it is not a disease in the usual sense of the word. In case I have not been clear, I am telling you that in the usual sense of the word disease, alcoholism is not a disease. In the second half of today’s talk I will give you my version of the simplicity that follows complexity. By the way — just as an aside — in my work as a psychiatrist I have found that the paradigm I am about to share with you is applicable not only to addictions but probably to most of the so-called psychological or emotional disturbances.   Simplicity That Follows Complexity   A. A Case Study  A study was done back in the 1950's at McGill University in Canada. In this study the researchers attempted to determine whether DTs (delirium tremens) was in fact an alcohol withdrawal syndrome. In the medical model concept of addiction, one of the essential criteria is to demonstrate physiological withdrawal. So they sought out a group of volunteers and asked them to submit to a structured, controlled environment. Back in those days they were still speculating that DTs were partly due to EEG abnormalities or electrolyte imbalance or neurochemistry imbalance, or what have you. They asked these volunteers to be in a structured environment where all the variables could be held constant with the exception of drinking. In other words, these people were well paid to come to a place where they could drink as much as they could possibly drink without any negative consequences. Now I must tell you it is at this point in the lecture that I usually make my diagnosis of the audience. The alcoholics in the audience usually nod approval, whereas the non-alcoholics shake their head in disgust and disbelief. I must also tell you that for obvious reasons the researchers carefully screened all the volunteers. For obvious reasons they wanted no alcoholics in the study. I do not have time now to go into detail, but take my word for it that they screened them very carefully — psychological profiles, family history, social histories, liver enzymes, etc., etc., etc. For the sake of this discussion, assume that they were not alcoholics.       I will draw for you on the blackboard a diagram of the results of this study.  On these two graphs the horizontal axis represents time. On the lower graph, the vertical axis simply reflects blood alcohol concentration (BAC). On the upper graph, the horizontal axis again represents time, but the vertical axis represents central nervous system or brain activity. Going up on this graph is central nervous system stimulation which the individual experiences as agitation. Going down is central nervous system depression which the individual feels as sedation. Now very quickly and very simply, when these non-alcoholic volunteers drank alcohol obviously their blood alcohol concentration rose until they could not drink anymore, the body metabolized the alcohol and their blood alcohol level dropped. What is reflected on the graph on top is that alcohol produces two effects on the central nervous system simultaneously. On the one hand, it causes central nervous system depression which the individual feels as calming, sleepiness, slurred speech, stumbling, and eventually passing out. When the person stops drinking and the alcohol level drops, the sedation wears off. But notice that at the very same time the alcohol also causes some central nervous system stimulation. The stimulation curve is a lower-amplitude but longer-duration curve, so that once the sedation wears off the stimulation is still operative. Anyone who has ever experienced a hangover can relate to this point.   In the experiment, they had these people drink excessively day after day after day for an extended period, for several months. In fact, they had a bonus clause. If a person drank more than a certain minimum per day, they paid them a bonus. (Many of my patients could have made a fortune. But the screening insured that there were no budding alcoholics in the group.) Every time the person drinks, the blood alcohol level goes up causing both a central nervous system depression (the sedation curve) and at the same time an agitation curve. The next day they drank too much again, again the blood alcohol level goes up, there is sedation, there is agitation. Notice what is happening though. The agitation curve is cumulative because of its longer duration. In other words, if a person drinks too much one night, once the sedative effect wears off the person experiences a certain degree of agitation. If that individual drinks for three or four days straight, once the sedation effect wears off you can see there is considerably more agitation, a very bad hangover. Again, in the experiment, these volunteers drank heavily, daily for many, many days. It was the intent of the experiment to see what would happen when the researchers abruptly cut off the alcohol. These volunteers experienced varying degrees of alcohol withdrawal. A number of them had full blown DTs. Some, for reasons not entirely clear, did not have the convulsions or the hallucinations, but all of them had significant physical discomfort. So the scientists then did what we do in our detox centers — they gave them benzodiazepines and multi-vitamins, and within a week to ten days these volunteers were all satisfactorily detoxed. There was no more withdrawal, no more suffering.   Keeping these basic facts in mind, I have a question to ask you. Remember that they were not alcoholics at the beginning of this study. Remember also that they drank heavily for many days. When the alcohol was terminated, these people had significant suffering, physical withdrawal symptoms. Now at this point they have all been detoxed and there is no more suffering. They are now comfortable. The researchers first paid them the money. Then they said that they wanted to repeat the study. This time to go through the same procedure but monitor blood sugar levels. I am asking you in the audience, how many of you think that all of them, some of them, or none of them agreed to do the study again? They were not alcoholics at the beginning of the study. They drank heavily for an extended period. As a result of their drinking, they suffered considerably. The question is being asked now, when there is no more pain. How many of you believe all, none, or some? [I should not have asked Dr. Kurtz. I said, “What did you answer?” He says, “Not enough data there.” I knew he would say that.] For those of you listening to me with your heart and not your analytical academic mind, how many of you said some or all would repeat this? It looks to me like about 60 or 70 percent of you, which is lower than usual. What was your reason for saying some or all? Response:  I figure that some liked the experiment and planned to try it again. Response:  The money. There are always one or two that say “for the money.” You must never have had bad DTs or bad withdrawal. It would take a lot of money to go through that again. Response:  They got to like it. Response:  To be honest, I do not think you would have brought it up if no one would have done it again. I think that the alcohol became the thing that made them feel better after they felt bad before. It made them feel better. Any other reasons? Response:  The memory of the good times is better than the memory of the bad times. Any other reasons? Response:  They liked the attention of the doctors and felt they were doing something noble. Any other reasons? I know we are under some time constraint. Let me save a little time. Almost always, wherever I have given this presentation, the majority of the people say some or all. The three major reasons are that they were not initially alcoholics, but because they drank heavily for a long time they had become alcoholics. That is a very common reason. Anybody here think along those lines? Another reason people often give is that they had been hurting but they are not hurting anymore so they forgot the pain. The third reason and the one I am hearing mostly here today is they wanted to recapture the good time. The correct answer is that none, zero, zip agreed to do this again. None, zero, zip. For the following reason: they were not alcoholics before, they are not alcoholics after. Have they become physically addicted? Absolutely. Had the investigators asked during the withdrawal period, “Would you like another drink?,” my guess is that all of them would have said, “Yes, give me another drink, the hair of the dog, to relieve the withdrawal.” But once they were withdrawn, because they did not have alcoholism to begin with, did they become physically addicted? Yes, but if that is all that alcoholism was, if all that addiction was was physical addiction, then I think I could cure every alcoholic by getting them five to seven days of detox, tell them to “just say no,” give them a good kick in the rear for motivation, and we have the cure. But we know that does not work. Did they forget the pain? I suspect so. I think it is human nature to forget unpleasant things rather quickly. So I suspect they did forget the pain. But what good times? I think some of you are hearing this as alcoholics. I believe that non-alcoholics do not feel profoundly better when they drink. I do not have any good definitions. Definitions are limiting. But if I had to give a definition of alcoholism I would simply say: Alcoholics are people who feel profoundly better when they drink. The people in this experiment were not alcoholics. Did they feel different? Yeah. Did they feel drunk? Yeah. Did they feel sedated and pass out? Yes. But they did not feel profoundly better. I remember I gave this talk to a men’s club in my area some years ago. I made the statement that alcoholics are people who feel profoundly better when they drink. I could see them squirming in the chairs. One guy raised his hand and said, “If that is a definition of an alcoholic, half the guys in this room are alcoholic.” I said, “Yes, I have been to New Year’s Eve parties with you.” Many of them are in the program now.   B.  Analysis   So, in this experiment none of them agreed to do it again. There were no alcoholics there. The alcoholism that I understand (or do not understand!) is something that you are probably born with. The alcoholics I have talked to say that from the very first drink they knew this was something very special. Did the disease progress? Yes. Did they develop tolerance? Yes. For obvious reasons you cannot drink as much when you are thirteen as when you are twenty-five. I personally do not understand the concept of a person’s being a social drinker and then a heavy social drinker and then an alcohol abuser and then crossing some invisible line into alcoholism. I do not understand that. To me alcohol abuse is when you take a nice cold six-pack and kick it down the stairs. Now that is abusing alcohol. If alcoholism was not present at the start of the experiment, it was not there at the end. During the withdrawal phase I suspect they all would have said, “Give me another drink.” But once they were detoxed these non-alcoholics said, “No thank you. I am not going to do it again.” Yet, is this not precisely what alcoholics and addicts do? I think so. Again, it is not an explanation, but I think the arrow on the diagram represents graphically what Nancy Reagan and Dr. Smith’s emergency room and all of us see if we are not careful. There are people who do this to themselves, who repeat this experiment over and over and over again, somehow expecting different results. And they are not even paid for it. This represents addiction. That is the vicious cycle of addiction. (See Figure 1) Now what do you do with this? How do you explain this? It seems to me that all of us experts — psychologists, psychiatrists, whatever our particular discipline is — we pretty much approach things via the scientific method. You know, Rene Descartes and deductive reasoning. As I understand it, and I am not an academician or a theoretician, the scientific method really boils down to this: if there is something that pains us, the presumption is that, if we can figure this out, somehow we can fix it. I think this is not only the scientific method; it is the way most of us operate even on a personal level. Francis, have I ever hurt you in anyway? Tell me with conviction that you hate my guts. Francis: I hate your guts! Francis hates my guts. Francis is a man that I have never hurt. I have always done everything in my power to be nice to him, to be decent to him. Let us say he is an old friend. Let us say that he is a patient that I have worked hard for. For whatever reason, he suddenly comes up and says, “Meiszner, I hate your guts.” I feel hurt. I feel pain. What is the first thing I do, without any conscious thought? I say, “Why? Francis, why? Why do you hate me?” Now Francis rattles off thirty-six excellent reasons. Everybody in the room is now thinking, “Oh, I understand why he hates him.” When he is done, do I feel any better? Do I feel any less hurt? No. I will probably say, “Well the first thirty-five reasons I understood, but that thirty-sixth one — could you elaborate some more?” The point is: he could explain logically and give me insight till the cows come home, but it is not going to change how I feel. In like manner, I think that the scientific method falls short. I have in my office a whole wall full of books. Most of them have to do with alcoholism, recovery, addiction, theories of, and so on. I have even read a few of them. All the expert views that I have heard, all the books I have read, when they try logically and scientifically to explain this vicious cycle of addiction, all the explanations basically boil down to two: One is: Alcoholics are incredibly stupid! They are usually not that blunt about it. They say things like “cognitive deficit,” “perceptual deficiency,” etc. But when you read between the lines, go past the 699 pages of psychobabble, and read the conclusion, the bottom line is, “They are stupid.” That would logically explain it. If, in fact, alcoholics and addicts were stupid, could not put two and two together, were too dumb to realize the problems of drinking too much — fall down, throw up, lose the family, lose the job. If these people were stupid, that would give you a good logical explanation. But it does not jive with the facts. I have never met a stupid alcoholic. I have met alcoholics that were brain damaged, I have met alcoholics that were in a ton of denial, I have met alcoholics that were superficially unsavory perhaps, but I have never met a stupid alcoholic. And I am not talking about diplomas on the wall. I am talking about the kind of smarts you see in the twinkle of the eye. You do not have to take my word for it. Look around you at your next AA meeting and show me somebody there that is dull or stupid and I will wonder why they are really there. I will wonder if maybe some misguided therapist did not send a burnt-out, residual schizophrenic to the meeting. There have been many studies of this. I have heard of one study that surveyed physicians who suffer from alcoholism or chemical dependency. The result of this large study was that alcoholic and drug-addicted doctors have an extraordinarily high rate of belonging to Alpha Omega Alpha, AOA, the honor society in medicine. Only the cream of the crop get in. The AOA docs had a four times higher rate than other docs of alcoholism and addiction. So it is not stupidity. Another logical explanation: If they are not stupid, and they are not, the only other explanation that I can see is that they are weak, they are immoral, they are deficient in control. They are lacking moral fiber, they are lacking control. That again would explain (recall the graph) the results. They are smart enough to see the correlation between the devastation in their lives and their addiction. Intellectually, even if they still have a lot of rationalization, at some level they know very well that their life is not going so well because of the drinking or the drugging or the sexual addiction or whatever the addiction may be. So if people are smart enough to put two and two together and they still do it, then it appears that the problem is that they just don’t give a damn. Or if they do give a damn, they just cannot control themselves. Again that would explain it logically, that would make some logical sense out of it. But it does not jive with the facts. Generally speaking, I find that if alcoholics and addicts have anything in common it is that they have an extraordinary degree of control. They tend to be highly controlled people; they are strongly self-willed people. I think it is not a coincidence that, since willingness is the only essential requirement for recovery, that it afflicts these people who are so strong-willed. They are anything but mopes. In clinical practice, if the person I am dealing with is a factory worker, chances are he is the foreman of the factory. If he is a policeman, the commander will tell me he is the best man he has. The neighbors will tell me that when so‑and‑so is not drinking he is the best neighbor they have. Even the spouse will say that when he or she is not drunk he or she is a wonderful parent, a wonderful spouse. There is a program in Atlanta, Dr. Talbot’s program, that has wide renown because of its success with treating the really tough cases. Minimum length of stay is four months — at least it used to be. Not twenty-one days, not four nights a week three hours a night, but four months as the minimum length of stay. Dr. Talbot specializes in the really tough cases: doctors, dentists, nurses. (I even think he lets in a few clergy!) They were people who were tough because they knew, they had answers. They could not be sick, they could not be powerless. I understand in recent years he has really lowered his standards and let a few lawyers in as well. (I hear there is a lawyer here, I apologize.) I am told that Dr. Talbot has graduated two or three Nobel Prize winners from that program. My common sense tells me that you do not get the Nobel Prize in tiddlywinks by being weak or uncontrolled. Abe Lincoln asked 130-140 years ago how it is that this accursed affliction (referring to the habitual drunkards, they did not talk about disease concept back then yet) affects the finest and the warmest in our families? The paradox is that alcoholics are very highly controlled people. In fact, I even have a problem with the definition that alcoholics are people who cannot control their drinking. I heard Stan Gitlow say years ago that the paradox is that only alcoholics can control their drinking. Can you control how many cucumbers that you eat? You probably do not know, you never had to try. It is not an issue, it is not a problem. I think there is a lot of legitimacy to Dr. Gitlow’s statement that there are no pathognomonic tests for alcoholism. But he finds that if the person in question insists, “I can control my drinking,” and secondly if somebody around that person is concerned about that person’s drinking, that is about a 98 percent certainty that you are dealing with alcoholism. The point here is trying to explain this vicious cycle logically, scientifically. Basically all the explanations boil down to 1. they are stupid; or 2. if they are not too stupid, if they are smart enough to see what is happening and still do it, they either do not give a darn or they are deficient in control. Neither reason jibes with the facts. Out of the first seven Nobel Prize winners in literature from America, six of them died from alcoholism — Hemingway, Fitzgerald, O’Neil.   Need and Control   Any human behavior can be viewed as a combination of need plus control. If a person has great need and/or is deficient in control, you are going to see an exaggerated behavior. We know we are dealing with exaggerated behavior; that is what we are talking about. I have just finished telling you that it is not a matter of deficient control. I am proposing that what we are dealing with here is an exaggerated or increased need of some sort. I am not talking about a want, and I think there is a difference in quality between a want and a need. A want is something conscious; a want is something that you are aware of, that you have full responsibility for. If you are angry at me, you may want to throw that chair at me but you do not need to throw that chair at me. If you do, I will call the police and file a complaint. It is not a psychodynamic event. You may want a new Cadillac, but you do not need a new Cadillac. So I am not talking about a conscious wanting. I am talking about something more fundamental, something inborn, something more basic, an increased need. If I knew exactly what this need is, then I suppose I would get a Nobel Prize in medicine. I do not know exactly what this increased need is. What I do know is that alcoholics and addicts do what they do because they have some sort of an increased need. I have come to believe it has nothing to do with their intelligence, how well informed they are, or their strength of character or deficiency in control. For years I would apologize at this point because I cannot explain what the need is. I would much prefer to have some explanation, to make some logical sense of it. I heard Dr. Gitlow give a talk some years ago. During his presentation he said that in his opinion you cannot talk about alcoholism or addiction without allowing for paradox, without allowing for mystery, without allowing for x-factor. In that context, he said that he believes that the highest level of teaching is metaphor. After all, he said, did not some fellow named Jesus use parables in the New Testament? Parables are metaphors. So all I can offer is certain metaphors for what this increased need is.   Let me go back a little and share an experience that probably took place over a period of months or years. For some reason I recall it as if it happened in one week. Back in the early ’80s I ran to all the conferences I could to find answers to this puzzle. I was treating alcoholics everyday, and I was painfully aware I was not helping them much. I was putting on bandages. I was using what I was taught in medical school and residency and not only was it not doing much good, but I even sensed that many times it was fueling the fire, making things worse.   New Insight   I was at a conference, one of the SECAD conferences as I recall. This conference addressed the question of the disease concept. Some of these conferences go off in all kinds of tangents and talk about the leaves and the twigs. This one talked about the trunk and the roots, the disease concept. Experts from various disciplines addressed this basic question: What is the core issue? What is the common denominator? What makes these people do what they do? I remember hearing somebody whose background was in psychology. (Psychology comes from psyche logos, the logic of the psyche.) The psychologist gave a very eloquent two-hour presentation about his research, about his study, about the things he had written, and concluded with his opinion that the core issue, the common denominator that underlies addiction, is that these people have unresolved, subconscious dependency needs with compensatory, neurotic, oral defense mechanism. Now, people out in the community are usually pretty impressed with that. Some of you obviously have studied psychology. I do not know if that makes sense to you. I know at the time that it made some sense to me. I was familiar with words like “the unconscious” and “dependency needs” and “neurotic defense mechanisms.” I wrote that down, and I was so happy that I had come to this conference because I had an answer; this was something that I could use back in my practice. I went back to my room that night and thought about it. I thought, you know that is pretty good but somehow it does not hit the nail on the head because everybody has unresolved dependency needs. When the doo-doo hits the fan everybody wants to go home, have some chicken noodle soup, curl up in a ball and suck his thumb or whatever. Yet, not everybody is an alcoholic. So that is not quite it. I went back the next day and heard another expert. This one’s background was in sociology (socio logos, the logic of society). The sociologist gave a very eloquent presentation about his research, about his studies and so on. He concluded with something along the lines that he has come to believe that the core issue, the common denominator that underlies all addicted behavior, is that these people experience environmental deprivation during certain formative periods of their life. Again I wrote that down. My left logical mind understood what he said; it made sense to me. I was glad I had an answer. Until I had time to ponder it and realized that there are just as many alkies up in Winnetka, a very affluent suburb north of Chicago, as there are in the inner city. So, environmental deprivation is not really where it is at. I think that influences the expression of the ism. I think that may impact on how it expresses itself, whatever the object of addiction may be, and what a person does under the influence. But clearly there are many people struggling with addiction where there is no apparent environmental deprivation.   Being a bit of a masochist, I went back yet again. This time I heard (and I am on thin ice here) a theologian (theo logos, the logic of God. Is that what theology means? It is almost as crazy as addictionology. I almost cringe when I am introduced as a certified addictionologist because I do not think there is any logic in addiction.) In any event, I heard a theologian give his presentation. He concluded that the problem with these folks, the reason they do what they do, is that they do not belong to the one true Catholic and apostolic Church of Christ. Being a product of the BVMs, Vincentians, and Jesuits I knew I had the answer. It was all those Protestants and Jews out there causing the problem. Until I thought about it and I realized that a lot of the priests and nuns I know go to AA meetings. So that could not be it. I then ran into a man named Father Martin, who I am sure is known to many of you. Father Martin is, of course, not only a Catholic priest, but more importantly he is a recovering alcoholic. I spoke to Father Martin during a coffee break, not when he was on stage. (When you are on stage there is always a temptation to have answers especially when you get paid big bucks; you are not supposed to say, “I do not know.”) I said to him, “Father Martin, you have been here all week, like myself. What am I missing? You have listened to these various speakers with their theories and so on. What do you think the real problem is? What do you think the core issue is?” And he said, “You know, I am not sure I know.” When he said that my ears perked up. When anybody, but certainly a man of his stature and authority, has the courage to say he does not know, I am impressed. It tells me that his mind has not closed yet. He has not become smug yet. He said that it seemed to him that if alcoholics had anything in common, it is an extraordinary soul-hunger. My initial reaction to that was the opposite of what it had been the day before and the day before that. When people talked about unresolved dependency needs and environmental deprivation and having the wrong theology, that made some logical sense to me. Soul-hunger, I do not know what that is. I am at a medical convention. I am a psychiatrist. What am I going to do with “extraordinary soul-hunger”? How am I going to use it back home? Go back to my little office in Orland Park and tell people, “Ah, you suffer extraordinary soul-hunger”? Then what? Prozac, lithium, insight? What do I do with that? So that really disgruntled me. But opposite to the previous days, although my initial reaction was negative because I did not understand it, deep inside it somehow struck a chord. I collared one other man at this convention (again I do not recall whether it was the same convention), a Rev. Hansen. I singled him out because he had given a talk on spirituality. He is the fellow who made the comment, “Look out for the holy ones. When you see the holy ones, grab your wallet, grab your crotch and run.” I knew I would like this man. I collared him and said, “Rev. Hansen, I have been here all week and I just don’t know what I am missing. It just isn’t coming together for me. What do you think?” I recall his answer as something like this: “I have been in the field, I have been working with recovering people for twenty, thirty years,” and he added, “I do not know.” I had a feeling he would say that. He said, “But it seems to me that if alcoholics thirst for anything even more than alcohol, they thirst for God.” Well, I am really annoyed. Soul-hunger, thirst for God. What do I do with that? I do not understand that, but it did not leave me alone. When I got back home, I started listening to the real experts at a different level. By real experts I do not mean the people who are still out there drinking and using. I think those people are doing essentially the same thing that we experts tend to do, trying to make logical sense out of it. When an alcoholic tells you he drinks too much because his boss is a creep, or when a pill abuser tells you she uses pills because her kids are brats, that may not make any sense to you but it may actually be a very sincere heartfelt attempt by that person to make some sense of what they are doing.   So when I came back with these soul-hunger and thirst-for-God ideas floating in my head, I started listening — not so much with my left analytical brain but more with my heart. The real experts are not the ones that are still using, nor are they ones who are smugly on the program. By real experts I am talking about people who have been abstinent for a while and have come to the realization that 12‑step recovery is not a feel-good process or a know-a-lot process. People who do not think that the first step is something they dealt with when they first came in. People who are painfully aware after years of recovery that they have alcoholism and not alcohol-wasm. People who have come to realize that the pain of the ism may be God’s finger poking at them. People who have learned to embrace the pain and grow from the pain. People who have come to the realization that it is not so much finding out more answers but learning to live more comfortably with the questions. People who, in my judgment, are truly pursuing the joy of living, are sincerely working a program. From those real experts, when I asked the question “Why do you folks or why do alcoholics do this?”, I learned some of my best metaphors — better than “unresolved dependency needs” or “environmental deprivation.” From those people I heard things like this: Why do they drink? “Because it made me feel better.” Well that is of course too simple. I am looking for indepth explanations. I would say, “Made you feel better? You mean you are an irresponsible hedonist?  Just to have a temporary high, you sacrificed your well-being and your family’s well-being and watched everything go down the drain?” “No,” they would say, “I did not say I wanted to get high. You asked me why I drank, and I told you I drank because I felt better. I felt normal for a while.” Well, I am skeptical and I am not buying this.  “What do you mean, you felt normal?” And time and time again I would hear people tell me that since they have come into 12-step recovery they have come to believe that the ism of their alcoholism was probably there from day one. Well, I still think I am getting bamboozled. What is this ism of the alcoholism? They would tell me, “I do not know, Meiszner; something InSide Myself? There is a feeling since day one that I do not quite fit in.” I would hear people with very little formal education say things like, “I drank because I think I was born with a hole in my soul.” Another person would say, “a God-shaped hole.” It would occur even to me that “God-shaped hole in the soul” is probably not too different than “extraordinary soul-hunger” or “thirst for God.” I asked some of my more intellectual patients, “Why did you drink? When you look back on it, you have been sober for five years, ten years, tell me what was it about? Why would you do what you did?” They would say things like, “I think I suffered from extraordinary existential indigestion.” Never to be outdone I would say, “Is that anything like a metaphysical fart?” But the real experts, people who had been there, people who had hit a bottom, people who were in meaningful recovery, people who were actively working the program, painfully aware they weren’t whole, they weren’t healed yet, would tell me very simple things: that all of their lives they felt like square pegs trying to fit into round holes. They would tell me things like, “I was just born scared.” I would say, “Scared of what?” “Scared of everything and scared of nothing.” Usually they do not look scared because that is all compensatory on the outside. People would say, “I was born with a broken heart” or “I feel like I have a broken heart.”   A Metaphor   Let me use my favorite metaphor. Does anybody here like dogs? I am a dog lover. I am the type of guy that you could take the wife and kids; just leave me my dog, and I will be fine. Right around the time when I was sloshing all this through my head, I had an experience. Like the SECAD conference, this truly happened — except this time it happened in an instant, in a flash of less than a second. As I remember, I had been to these conferences and I was thinking and analyzing and asking a lot of questions, driving people crazy. It was just not coming together for me. I was sitting one day in my study at home feeling about as good as this human being ever feels. It was one of those rare peak days that you have once every ten years or so. Feeling fairly content, feeling fairly at peace, not particularly worried about anything. As I recall my wife was not mad at me, which is kind of unusual; my sons were not in trouble, which is even more unusual; the Bears were winning, and that was before they had Coach Ditka. You get the picture? Lying next to me on the floor is my beagle with the droopy ears and the sad eyes. Her name was Kate. If you are a dog lover, you will understand this. Usually, when I look at my dog I get a warm, contented feeling on the inside. It is almost like a non-chemical Valium. You know when I am sick of humans and I am sick of life and I am sick of my own deep thoughts, I always take a little comfort by just hugging my dog. On this particular day I am feeling reasonably serene and content and grateful. As I look at the beagle laying there, I have a rather unusual reaction, a kind of a twinge of negativity, a kind of a hostile feeling. Being a psychiatrist, of course I immediately get into introspection and self-analysis. What I become conscious of is that I am feeling somewhat jealous. What I am jealous of is that, although I am feeling about as content and serene as I ever feel, one look at this damn dog — she does not have to tell me in words — makes it very evident that she feels more content, more serene, more at peace than I have ever been or ever will be. She is lying there like this (belly up). With three boys bouncing around the house, I do not lie like this on my own bed. I lie with my back against the wall just in case.   So now I have to analyze the situation. Here is what my analysis comes up with: I had steak for dinner, she had Alpo. I am married to a lovely woman, she has been spayed (the dog not the wife). I have a few dollars in the bank, I have some measure of security, she cannot even go tinkle unless I let her out. If anybody in this room should feel content and secure and grateful, it should be me and not her. Then, all of the sudden, the light bulb goes on. All this head noise that has been running about my head blocking out my soul screams (the only original thing I said today), suddenly evaporates and kerplunk! It suddenly hits me like a ton of bricks. What hits me is this, and I will say it six different ways: It dawns on me that the reason for the discrepancy is very simply that she is not afflicted by what I am afflicted with. She has no ism inside herself. She does not have any soul-hunger. She is not tortured by ego, which is nothing more than “conscious awareness of self as separate.” She is not afflicted by the human condition. She does not have any spiritual thirst, any spiritual hunger. All she has is instinct. She is not capable of worrying about “Will they like me or won’t they like me?” When she is hungry, she pushes her dish with her nose. When her bladder is full, she scratches on the door. When she is in season, she says, “Come on over, Rover.” When she is not in season, she bites him. End of story. She is not capable of the introspected anguish that I am (unfortunately or fortunately) capable of. She is not capable of agonizing whether Rover really loves her or just wants a little nookie. She is not capable of agonizing about what a fool she made of herself last week. She is not able to dwell on things like, “Why am I alive? Why am I here? Where am I headed?” I think that this increased need that is the core issue that underlies addictive behavior is a spiritual hunger, a yearning for  at‑one‑ment, for completion, for connectedness. I think maybe it is what the anthropologists are talking about when they point out that humans, as far back as you can go, no matter how small or primitive the tribe, humans and only humans have always demonstrated some sort of God-seeking behaviors. Not dogs, not gorillas, but humans have exhibited some kind of God-seeking behavior. I think that this spiritual hunger, this increased need is the human condition. It is a spiritual brokenness. And I think maybe it is what Bertrand Russell was talking about when he said, “the center of me is always and eternally in terrible pain, a curious wild pain, a searching for something beyond what the world contains.” I think maybe it is what the Old Testament prophet was saying when he said, “I come and I complain to you, O Yahweh. Alas I am so dry, and it is so dark within me.” In Matthew 27, “about the ninth hour Jesus cried with a loud voice . . . ’My God, why hast thou forsaken me?’” is a cry of the spirit. I am not a theologian, but I think that this increased need, this spiritual hunger, this yearning for connectedness, this thing that we have to varying degrees (that my beagle Kate did not have) is what underlies all addiction. Last night when I listened to Father Mike, I was reminded that years ago I used to give a version of this talk in our alcohol rehab program. In hindsight, I almost cringe at how chauvinistic I was then. You know hindsight is insight. When I look back on it, I remember saying that alcoholics are people who are afflicted with this extraordinary soul-hunger, this thirst for God. I suggested in those days that all those other people out there were earth people, beagles on two legs. They did not have this drivenness. I was confronted on several occasions by people in the audience who came up and said something like this, “You know, it is very interesting, but I am really angry with you.” I would say, “Why?” “Well my name is Mrs. Smith and my husband is over in your rehab program and I came in to listen. I really resent the fact that you are telling me that this SOB who has been making my life a living hell for the last twenty years is a God-seeker and soul hungry.” She says, “I am not a beagle, I am not a Gomer Pyle, I experience this, I long to connect, I am lonely, I am yearning but I do not drink.” I would step back and I would say, “Well, first of all, your anger is going to kill you quicker than the booze is going to kill him so I really suggest you to go to Al‑Anon. Secondly, I notice you weigh 350 pounds so maybe you are eating your pain away.” But that kind of feedback really alerted me to the fact that that woman and others made a good point. This increased need, this soul-hunger, this inner churning is not unique to alcoholics. I think it is common to all of us. That may dilute the concept of addiction for some of you. But it also suggests why 12‑step recovery has universal applicability . . . it addresses a universal brokenness, the ism of alcoholism, the ism of humanism.   Spiritual Recovery   What I can tell you as a psychiatrist, is that what I have learned about spiritual recovery from people who are living it — and from my own journey — has more universal applicability than anything I ever learned in medical school or psychiatry school. That is not to diminish it or to bad mouth any of it. Perhaps they did not give much attention to it but it seems to me that traditional, psychological, medical-model psychiatry basically has two things to offer. Basically, what I was trained to do is to relieve pain — whether it is by Valium for anxiety or Dalmane for sleep or Prozac for depression. I was taught if I cannot do that, then shed some light, shed some insight, gain some understanding. Both of those are fine as far as they go. There is certainly nothing wrong with feeling better. There is certainly nothing wrong with understanding better. But it seems to me there is a qualitative difference between feeling better and truly getting well. There is a qualitative difference between insight and understanding “reasons why” and acceptance and living with questions. The traditional, psychological, medical-model approach is to not have a breakdown, to retain your right to yourself, to make the pain go away. A spiritual program teaches us to embrace the pain and grow from the pain. People who have been through extensive therapy often tell me, “At the end of it I had a much clearer understanding of why I tick the way I tick. But I still tick that way.” There is no definitive change. My conviction is that the principles that are learned in a 12-step recovery process (and you cannot learn them from a book) have universal applicability.       Let me quickly pull it all together for you now with a kind of a “psycho-spiritual paradigm.” Here is the way the vicious cycle of addiction goes. In the beginning is the ism; that is primary, that is number one. I do not think it starts when you have pimples as a teenager or because your mother did not breast feed you. I think in the beginning is the ism; it is inborn; it is uncomfortable. Like all living creatures, we seek relief. Just as a plant grows away from the cold shade towards the sun. Just as the amoeba and paramecium in your high school lab, if you put them in a petri dish and drop some toxin, where do they go? Away from the painful stimulus! So, we humans have this ism from day one; it is inborn, it is primary. Spiritual hunger, whatever it is. We seek relief by pursuing “false gods.” By false gods I mean nothing more, nothing less than whatever “it” is — be it alcohol, drugs, power, another person, our own intellect — that we think is going to fill our voids. There is nothing wrong with any false god per se. There is nothing wrong with alcohol. If I invented alcohol today I would get the Nobel Prize. But if you have alcoholism, it will kill you. There is nothing wrong with money, there is nothing wrong with having somebody in your life, rather it is the nature of the attachment to it that is the difficulty. It is an unholy embrace, it is a “have to” attachment. Anything can be a false god.   False Gods   False gods have three things in common: 1. They make you feel better which is why you pursue them. They give you some relief, they soothe your ism, they give you temporary surcease from yourself. 2. In the process of pursuing them you actually develop ego strength. Ego strengths simply mean coping mechanisms; you get good at stuff. If you have no ego strengths, I guess you are a slug or you are a catatonic schizophrenic. So, in the vicious cycle of addiction people have this ism from the gitgo. I do not know how you measure it, but I would think it exists in varying degrees. I see some people that, before their butt hits the chair, I could sense the ism inside that person. Without being conscious of it, what we have all done for a lifetime is pursue false gods. A false god can be anything. It is not a coincidence that some of our best helping professionals, social workers, doctors, nurses, clergy people, happen to be from dysfunctional families. They are very often the oldest in the dysfunctional family. The dynamic of that simply is that ever since childhood that child learned that by making others okay, by taking care of others and meeting everybody’s expectations, they will be okay, their void will be filled. So it makes them feel better, it gives them a relief from their inner torment at least for a while. In the process they get good at stuff. I cringe when I hear “experts” saying that alcoholics are people who cannot cope with life. My experience is that alcoholics and addicts are the toughest hombres around. If I am ever pinned down in a fox hole under heavy fire, I want an alkie next to me, preferably not drunk. They are doers. They are competent people. They are strong people. Of course towards the end, everything goes down the toilet. I am not talking about the five percent that are in the gutter. I am talking about garden variety suburban alcoholism, the cream of the crop, the toughest of the tough. They drink to escape their own inner torment. It is not life they cannot cope with . . . it is their selves they seek to escape.   When I evaluate somebody in my office, I always ask myself whether an addiction is at play here. I do not base my diagnosis so much on how much they drink. Sometimes I do not even ask that question. Why? Number one, the person is usually so filled with shame and guilt they do not tell me the truth. Even if they try to tell me the truth, they usually do not remember. After five or six drinks, who counts, who keeps track? More importantly, I am not sure that that is a very reliable criterion because I know alcoholics who suffer terribly from their ism, but whose drinking is under some sort of control. I also know others, although not often, who because of cultural factors or whatever drink quite a bit but it is not alcoholism. My grandfather, I am told, drank a liter of wine every day. Not more, not less, one liter of wine. He died at age eighty of stomach cancer. That is not alcoholism. What I look for, instead, are these ego strengths. I remember one of my patients, a sixty-two year old psychiatrist who had gone hither and yon for treatment for his depression and somehow or other wound up at my doorstep. I think it helped that he had been everywhere else. I thought he was alcoholic, although his drinking was still under pretty good control. I think his dry was killing him more than his drinking. To make a long story short, he amazingly accepted my recommendation to go to AA. After about six months he came back shaking his head. When I said, “What’s wrong?” He replied, “You know, it is weird. I am sixty-three years old. I never had any character defects until I got to AA.” He made a very valid point. I think that what the spiritual program of Alcoholics Anonymous identifies as character defects by and large is what the ego and society applauds. You know, beat the other guy out, more for you is less for me, cover your butt, cover all the bases, be competitive, be fierce, be independent, be strong, do not ever think of relinquishing your right to yourself, which of course is the essential task of a recovery program. So when somebody comes to see me with the demeanor of a Gomer Pyle and I say, “Sit down,” and they say, “Okay,” and when I say, “Get up,” they say, “Okay,” when that happens I do not care if that guy has got a half pint in each pocket, it is probably not alcoholism. If on the other hand the person struts in and has real charisma and a firm handshake and within five minutes is conducting the interview and I am feeling intimidated, that is alcoholism.  The pursuit of false gods gives you relief, temporary relief, makes you good at stuff, makes you strong. It is not a coincidence that when you look at the sports pages, it is not your third-string bench sitters that are going into treatment, it is your Dwight Gooden and your Dexter Manley and your Lawrence Taylor and your Lennie Bias and your Miradonna and your Mike Schmidt, etc., etc. Or in the arts and entertainment section, it is not a coincidence that it is your Richard Burton and your Liza Minelli and your Kevin Costner. The creme de la creme. “The warmest and the finest in our families” as Abraham Lincoln observed.   3.  There is a third thing that the pursuit of false gods has in common, inevitable disillusionment. I am running out of time so I just want to use a quick example. Have any of you ever been in love? Three or four, I know you are clergy. Well maybe I am an extraordinary romantic. But when I was in love, I remember it as a profoundly changing experience. When I was in love my whole view changed. Do you remember that? I usually look at life through sort of gray colored glasses, but when I was in love everything had a pink hue to it. I suddenly became very profound and the beloved was an instant soul mate. Suddenly I was six-foot-two, and my biceps were bigger, and . . . I was just bigger all over. It was a metamorphosis. Go to a restaurant sometimes, look across the room, you can spot the lovers a mile away. She spills the salt and he thinks it is profound. Have any of you ever stayed in love? One time a little old guy in the back row kept raising his hand. I said, “Sir, my question is did you stay in love?” As I watched, the lady next to him gave him a poke in the ribs. Being in love is a very real intoxication. I think it is an addictive problem, and God knows I see a lot of people in my office whose lives are falling apart because of their in‑love behavior.  In any event, the vicious cycle goes like this: There is inevitable disillusionment, sooner or later these things do not work for you. They are all fine for a while. As I look back, I think the main reason I made it through medical school (I was not particularly smart and I did not have any real deep motivation about curing mankind of disease) was that one of my false gods was that if I become a doctor, I will be okay. And I was right. I remember graduation. Mom was there, Dad, uncles, aunts, pictures, tears. For at least fifteen minutes I found nirvana, and then the ism kicked back in and said, “Okay, now what?” So, false gods work — but only for a while. There is inevitable disillusionment. Now, if this person happens to have alcoholism and meets alcohol, which he or she inevitably will, here is what happens: The alcohol will do something to this person, and what it does to this person is the same thing it does to the people in the study I mentioned earlier — bad stuff, makes them sick, makes them act stupid, inhibits inhibitions, so that good people act badly. If it stopped there, if the alcohol only did bad stuff to this individual, then I would tend to agree with Nancy Reagan and I would say “Just say no. Are you stupid? What is the matter with you?” If it stopped here, I think we would be talking about the people that you see out on New Year’s Eve. I stopped going out on New Year’s Eve years ago because all the people out there are trying to act like alcoholics. You know the ones I am talking about. The ones who drink those fuzzy drinks with umbrellas and fruit and vegetables in it? They have one or two and they say, “Oh. I am starting to feel it. No more.” And you say, “Now is when you pick it up.” You see, those people get up the next morning and they reflect on what it did to them — they acted badly and they drove carelessly and have a queasy stomach and have bad breath. It did something to them, and it did nothing for them. Just like the people in the study, it did nothing for them. So they do not drink again until next New Year’s Eve. However, if you have the alcohol ism, the alcohol does something for you. And what the alcohol does for the alcoholic is tremendously profound. It is not in the cortex; it is in the old primitive brain. It soothes your ism, it gives you temporary relief from the inner torment. That is much more profound than trivial things like losing your family and losing your car and losing your job. Many, many people in early recovery (you do not go from active alcoholism to joy of living without going through some painful dry times) at times feel like, “Hey, I would settle for a couple of nights in jail or for some vomiting of blood just to get rid of this inner torment of the ism, of being dry.” If a person could stay drunk, then there would be no problem. But for obvious reasons, at some point a person has to quit drinking. The doo-doo hits the fan, you get the pink slip, the divorce, whatever it may be, the liver gives out. At some point a person has to quit drinking. When this individual stops drinking the ism is still there, whatever that inner torment is, that spiritual longing, that yearning for wholeness. Now, in addition, this person has a ton of situational pain: money problems, job problems, marital problems, health problems on top of the ism. And what do you suppose is going to make this person feel better, what is going to give this person some relief? You are darn right: another drink. That is the vicious cycle of alcoholism, that is the arrow that we started with. Now, most people I deal with are not yet daily, in-the-gutter, dead-end, bottom-of-the-line drinkers. Most of the people I have dealt with I imagine are people like yourselves. When the doo‑doo hits the fan and there is a so-called bottom, people usually put the plug in the jug, they quit drinking. To simplify this, I believe that an alcoholic, an addict, has only one of three ways to go — no exceptions. One, is to stay actively addicted. If your way still works for you, whether it is drinking, whatever your way is, stick with it. To me addiction is like a dog chasing his tail. Picture that. When you look at the tip of the nose and the tip of the tail, logic says run just a little bit faster and you will catch it. Right? The paradoxical truth is the faster he runs the behinder he get. Only when he gives up exhausted, spent, surrenders and lays down what happens? The tail comes and lays right on his nose. If your addiction, whatever it is, even if it is a socially acceptable one like workaholism, if it still works for you, stick with it. If it is doing more for you than to you, stick with it. You’d be a fool not to! Choice number two is that if your way is not working any more, whatever your addictive chase-your-tail cycle is, if your false gods are not doing it for you any more, then stop it. Stop chasing your tail. That you can do by yourself. To continue to stay addicted or to stop, you can do either by yourself. But, as an old timer once said, “When I was drinking, my life was all screwed up. When I was not drinking, I was all screwed up.” If you just stop using, drinking, drugging, whatever it may be, things will get better almost right away, but you will not get better. I think we call it “being dry.” My experience has been that being dry in very short order becomes more awful than being drunk. In fact, if drunk or dry were the only two choices, I think I would vote for drunk because dry is horrific. Understand what I am saying? Now drinking and being dry you can do on your own. You do not need anybody’s help for that. But there is a third choice, thank God, and that is sobriety — which has to do with the joy of living, which is much more than just abstinence. I think it is the same difference as reformation and transformation. You can reform yourself, and Nancy Reagan has tried to reform you, and your spouse has tried to reform you. It is like pushing the dirt around, getting “gooder.” But getting good gets boring real quick. Self can reform self, but self cannot transform self. Drinking and being dry have to do with externals, with situational change. True sobriety has to do with innner change. This inner transformation cannot be brought about by the individual, nor can anyone else do it for him/her. It is the inevitable, paradoxical, mysterious by-product of “Working a Program.” For years, I was convinced that I was the only person on the South side of Chicago who did not understand what that meant . . . oh, like everyone else, I pretended to and used the phrase often: “You’re not feeling grateful? You must not be working your program!" Finally, I could not stand my own hypocrisy, so I went around and asked some of more respected AA members in my community, “Excuse me, what do you mean when you say ‘work the program’?” Guess what kind of answers I got . . . “You know, just work the damn program!” I’d respond, “But, what does that mean?” and they would say, “You know, just work the steps” and mumble something about psychiatrists always complicating things. Well, I ask you even now, just how does one “work a step”? With a hammer, a calculator, a crowbar? I have been wrestling with this question for over fifteen years and have yet to hear a simple, practical answer. Although I give a two-hour seminar on “12‑Step Recovery: Life After Death” in which I talk a lot about what it is not about and try to dispel some of the many misconceptions (such as, it is a feel-good program of self-actualization), the best I can do to convey the essence of this process of transformation is to share yet another metaphor, the Karate Kid Story: The Karate Kid asks Mr. Myagi, a humble unassuming janitor, to please teach him karate. What brings the Kid to the Old Man is pain. In his case, it is physical pain. In the case of addicts and alcoholics, it is usually psychic pain. The point is, in both cases it is not a matter of sudden insight or life-long ambition. When the Kid first approaches, he is still a bit of “hot-dog.” He wants to be taught some sexy moves that will make him an instant black-belt. The Old Man, in his wisdom, takes one look and realizes that this boy is nowhere near ready. He still has his own agenda, he thinks he knows what he needs. So, without explanation, he tells him, “I can’t help you. You’re not ready.” So the Kid goes out and continues to do all the things he knows to do . . . he lifts weights, he does push ups, he reads Karate magazines, etc. Things that make good logical sense. He is very sincere and works very hard, but he continues to get whupped by the bad guys who know karate. He cannot transform himself into a champion. One night, the bullies have him cornered and are literally beating him to a pulp. The Old Man comes across the scene, takes one look at the Kid (who is now flat on his back, beaten into submission; no more “cool dude” stuff) and thinks to himself, “Maybe he is ready now.” So he jumps the fence, beats off the bad guys and takes the Kid in. He patches him up, dresses his wounds (detox?) and says, “OK, I think I can help you . . . but there is ONE condition: I teach, you learn.” This time the Kid does not respond with conditions and expectations. He only says, “Okay.” Little does he realize what is ahead. The Old Man is a part-time junkman and says, pointing to some old, rusty jalopies in his yard, “See those cars? I want you to go wash and wax them. When you’re done with that, you can paint my fence. And then you can sand my deck.” This makes no sense to the Kid, but he does not argue. He is in pain, he has been humbled, he knows to the core that his way will not work. So, he goes out and starts washing, waxing, and painting. But, a few days later, his pain has subsided somewhat and he has started THINKING about this. Predictably, he puffs out his chest and confronts the Old Man with: “Who do you think you are? This is not what I need! You don’t understand! I quit!” At that critical juncture, it is important to note that Mr. Myagi does NOT explain (we in the audience can see what is happening, he is learning all the basic karate moves), nor does he force compliance. If he did either of those, the tasks would lose their purpose, then the Kid would just be washing cars and painting fences. Instead, the Old Man says three things: 1. I know these directions do not make sense or appeal to you . . . but if the ways out made sense or appealed to you, you would have made yourself a champion long ago. 2. Why don’t you keep an open mind? I do not expect you understand it or like it, but at least allow for the possibility that things are not what they appear. 3. Remember our deal: I said I can help you IF you take direction. Amazingly, the Kid goes back to his waxing and painting and sanding. It is amazing because from his standpoint these things made no sense. For all he knew, the Old Man was exploiting him. Yet, despite his confusion and misgivings, he continues to do as he is told. The end-result is that he becomes a champion and wins the tournament. What is the point? The point is: 1. The Kid became a champion for one reason and one reason only — he was WILLING to take directions; and 2. he was willing because he had suffered enough pain. The specifics of the directions are not the point. Actually, waxing cars is probably not the most efficient technique for learning Karate, but if the Kid had not waxed every one of those cars he would not have become a winner. It is the willingness that is essential. Willingness is not a feeling. Feelings come and go. If you understand something or like something, there is no need for willingness. Insight and good feelings may be reliable criteria for reformation, but they are only egoistic obstacles to transformation. To become willing two things are required: 1. a certain amount of character (“constitutionally capable,” not entirely sociopathic or alloplastic); and 2. pain — not necessarily situational pain but an inner pain. “Hitting bottom” is an inside job. Let us never be so arrogant as to think we can predict whether a person has hit their bottom. I have seen people who have lost just about everything externally, but are not ready to surrender. Inwardly, they still demand to exercise their “right to themselves.” And, I have seen others who still appear outwardly intact, but they have had enough painful disillusionment. Although they do not feel very lucky, they are indeed blessed in their awful awareness that they cannot fill their own void.   Summary   Allow me to attempt to summarize more succinctly some of the major issues I have attempted to address today.    1. Alcoholism alone, even when narrowly defined, has been recognized as the number three health problem in our society, both in terms of morbidity and mortality. There are approximately fifteen million active alcoholics and an average of four significant others for each of them, for a total of seventy-five million people whose lives are being painfully, destructively affected.   2.  When addiction is viewed in a broader sense, the way we have looked at it today (with the emphasis not on the particular object of addiction but on destructive process itself), the numbers are much higher. In fact, we are dealing with a pandemic.   3. Recovery is not only possible, it is virtually assured if people who suffer from addiction would accept and apply themselves to a 12‑step recovery path. Yet, even though this is common knowledge and recovery programs are universally available, the sad reality is that only a small percentage (10-15 percent) of these “sick” ever enter recovery and an even smaller percentage stick with it.   4. Why?!? There are no doubt many reasons. This clinician’s experience suggests that perhaps the most fundamental reason is a pervasive, fundamental dishonesty: namely, the notion that alcoholism/addiction “is a disease.”   5. Although almost everyone says they believe that, the fact is that very few, if any, really believe it . . . and for good reason: in the usual sense of the word, addiction is not a disease. When it is studied from a scientific (i.e. logical) perspective, the inevitable conclusion is that these people are either stupid (i.e. don’t know any better) or weak (i.e. can’t control themselves).   6. Just as significantly, even those who are knowledgeable about the “disease concept” react to these “sick” people negatively on an emotional level — anger, impatience, disgust, moralism, judgmentalism.   7. This is not just a theoretical issue, it is vital. We humans, be it the addict, significant other or helping professional, do what we do because of our feelings and beliefs rather than because of any scientific or theoretical data. When you feel angry with someone, or pity them, and really believe in your heart that they ought to know better and/or control themselves (i.e. a perfectly human, and predictable reaction), you cannot be a conduit of healing. You are doomed to the oscillations of the co-dependent, going from angry, punitive admonitions to various rescue efforts.   8. Having demonstrated that “alcoholism is a disease” is an example of Oliver W. Holmes’ dictum, “The simplicity that precedes complexity is comfortable but worthless,” we proceeded to suggest a new paradigm, a new way of looking at this disease.