The Natural History of Alcoholism Revisited (1995) is a book by psychiatrist George E. Vaillant that describes two multi-decade studies of the lives of 600 American males, non-alcoholics at the outset, focusing on their lifelong drinking behaviours. By following the men from youth to old age it was possible to chart their drinking patterns and what factors may have contributed to alcoholism. Another study followed 100 severe alcoholics from a clinic eight years after their detoxification. The National Review hailed the first edition (1983) as "a genuine revolution in the field of alcoholism research" and said that "Vaillant has combined clinical experience with an unprecedented amount of empirical data to produce what may ultimately come to be viewed as the single most important contribution to the literature of alcoholism since the first edition of AA's Big Book."Teachout, 1984 Some of the main conclusions of Vaillant's book are: That alcoholism is as much a social as a medical condition. "Alcoholism can simultaneously reflect both a conditioned habit and a disease."Vaillant 1995, p 376. Factors predicting alcoholism were related to ethnic culture, alcoholism in relatives, and a personality that is antisocial and extroverted. An unhappy childhood predicted mental illness but not alcoholism—unless the family problems were due to alcoholism. That alcoholism was generally the cause of co-occurring depression, anxiety, and sociopathic (delinquent) behaviour, not the result. That even though alcoholism is not solely a medical condition, it is therapeutically effective to explain it as a disease to patients. The disease concept encourages patients to take responsibility for their drinking, without debilitating guilt. That for most alcoholics, attempts at controlled drinking in the long term end in either abstinence or a return to alcoholism. That there is as yet no cure for alcoholism, and that medical treatment can only provide short-term crisis intervention. Achieving long-term sobriety usually involves (1) a less harmful, substitute dependency; (2) new relationships; (3) sources of inspiration and hope; and (4) experiencing negative consequences of drinking.Vaillant 1995, p 241-244
Background
Study Samples Core City: In 1940, Sheldon and Eleanour Glueck of Harvard began a major study of juvenile delinquency in teens from Boston — mostly poor kids in tenements, half without a bathtub in their homes.Goodwin 1984 The control group for the study comprised 456 boys who were assessed as non-delinquent. In 1974 this control group, which Vaillant referred to as the Core City sample, was turned over to him to continue research. The Core City group had a mean IQ of 95, and 48% graduated from high school.
College: In 1976 Vaillant inherited another study of more than 200 Harvard sophomores started in 1938—the College sample. The sophomores were white males, selected because they were high achievers and had no known medical or psychological problems. The College sample had a mean IQ of 130, and 76% attended graduate school. Their 1976 mean income was three times that of the Core City group.Vaillant 2003, p 1044.
The research eventually showed that for the Core City sample at age 60, 36% had abused alcohol at some time in their lives; for the College sample at age 70, the figure was 22%.Vaillant 1995, p 131.
The samples were narrow ("male, white, American, and born between 1919 and 1932."Vaillant 1995, p 317) but were followed for a long period. As critics and Vaillant himself pointed out, the samples did not include important segments of the population such as African-Americans and women.Saunders, 1884.Note that in this article alcoholics will be referred to as male to reflect the bias of the samples. Both samples likely excluded those who began abusing alcohol in early adolescence.Vaillant 1995, p 312
The Clinic sample was a group of 100 severe alcoholics who were detoxified at clinic in an urban, municipal hospital (Cambridge Hospital) in Massachusetts during the winter of 1971-1972.Vaillant 1995, p 188 The treatment was carried out under what was known as the CASPAR program—Cambridge-Somerville Program for Alcohol Rehabilitation. This group was followed for 8 years to measure the effectiveness of the treatment.
Timeline
1921: mean birth date of College sample 1929: mean birth date of Core City sample 1938: study on the College sample begins at Harvard 1940: Gluecks begin the Core City study 1971-2: Clinic study begins 1972-4: Vaillant takes over the College and Core City samples. 1983: Vaillant publishes The Natural History of Alcoholism: causes, patterns and paths to recovery. 1995: Vaillant publishes a new edition entitled The Natural History of Alcoholism Revisited, which includes the entire text of the 1983 edition plus new material marked "Revisited." 1996: The 1995 edition is summarized in a paper by Vaillant and Hiller-Sturmhofel entitled “The Natural History of Alcoholism”.Vaillant 1996. 2003: Vaillant brings the studies to a close and summarizes results in a 2003 paper entitled "A 60-year follow-up of alcoholic men".Vaillant 2003
Definitions In the 1983 edition of his book, Vaillant required four positive answers to questions on his Problem Drinking Scale (PDS) to indicate alcohol abuse. To diagnose full-blown alcoholism—i.e. alcohol dependence—he used DSM III, which requires either physical tolerance or physiological withdrawal.Vaillant 1995, p 29 & 32. For the 1995 edition he abandoned the PDS and used the DSM definitions of both abuse and alcoholism.
Longitudinal study A longitudinal study is one that follows test subjects over a long period of time — as opposed to a cross-sectional study, which gives a 'snap-shot' of a group at one point in time. Longitudinal studies tend to examine smaller groups in greater detail, whereas cross-sectional studies are often based on a more representative segment of the population over a short time. The longitudinal method was useful in identifying factors in alcoholism, for instance by investigating whether delinquent behaviour started before or after drinking.
Prospective study A prospective study is forward-looking and includes subjects who did not originally have symptoms of the disease being studied. Many retrospective, or backward-looking, studies might take a group of alcoholics and try to determine what common traits might have caused their alcoholism. A prospective study takes a group of healthy individuals and tries to predict which ones would become alcoholic based on their histories—a much broader technique that often yields surprising results.Goodwin 1894.
Techniques for research on alcoholics Alcoholics present special challenges for researchers because they are good at concealing their drunkenness.Vaillant 1995, p 362 Vaillant asserts that "Alcoholics are expert forgetters,"Vaillant 1995, p 240. have inaccurate memories,Vaillant 1995, p 24. and give persuasive denials that manifest "an extraordinary ability to deny the consequences of their drinking."Vaillant 1995, p 292 For effective interviews, the subject should first be relatively sober. The interviewer should ask non-threatening, non-judgmental questions that do not challenge the alcoholic's right to drinkVaillant 1995, p 33. and that minimise guilt.Vaillant 1995, p 364 (Failure to observe these guidelines by medical professionals has likely contributed to alcoholics’ reputation for denial.Vaillant 1995, p 33) Interviewers should ask for objective evidence. For example, if an alcoholic claims that his divorce led to him drinking, the interviewer could ask if the alcoholic's spouse ever complained of his drinking before they split.Vaillant 1995, p 77. Interviews and questionnaires should always be backed up with interviews with the subject's family, with consultation of medical records, and with searches in public records for evidence of legal problems associated with drinking.
Book summary
Medical or behavioural disorder? A major focus in the book was a comparison of the various definitions of alcoholism: the medical model, which focuses on the individual's physical addiction and on symptoms such as ulcers or cirrhosis of the liver; the behavioural model, which focuses on alcoholism as an individual choice that may be influenced by environmental factors; the sociological model, which focuses on the problems the subject creates in society, such as abuse to family members or arrests for drunk driving; and common sense concepts such as "a person is likely an alcoholic if they admit it and have been diagnosed in a clinic."Vaillant 1995, p 37.
The first interesting observation was that there is no sharp dividing line between alcoholics and non-alcoholics. The number of drinking problems is spread out along a scale, just like IQ and blood pressure; there is not a cluster of alcoholics at the top end of the scale.Vaillant 1995, p 35-36.
Vaillant compiled indicators of alcoholism from many sources, medical and sociological, and applied them to the Core City drinkers. Possible criteria includedVaillant 1995, p 31. frequency of intoxication; binge drinking; complaints from spouses, friends, bosses, or police; accidents and legal problems; attempts at “going on the wagon”; clinical diagnosis; admits problems; the ‘morning shakes’; and health problems. Statistical techniques were used to determine which, if any, of the criteria were the best indicators of alcoholism.Vaillant 1995, p 39-40. Surprisingly, the answer was that all criteria were of roughly equal importance.Vaillant 1995, p 36. No particular indicator or cluster of indicators predominated: it was the number and frequency of problems that best defined alcoholism. More importantly, the medical, sociological, and behavioural criteria were equally reliable (i.e. highly correlated).Vaillant 1995, p 37-39. In other words, it was equally valid to call alcoholism a medical or a behavioural disorder—evidence that doctors and sociologists are indeed talking about the same “unitary disorder”.
There are some grounds, Vaillant argues, for considering alcoholism a medical disease in the most severe cases. As the disorder worsens, conscious choice becomes less and less important and the alcoholic needs medical assistance to detoxify without risk to life (unlike, for example, heroin, which poses less physical danger to addicts going ‘cold turkey’).Vaillant 1995, p 19 In this respect, alcoholism resembles coronary heart disease, which starts as ‘voluntary’, unhealthy behaviours such as poor diet and lack of exercise, but ends in a life-threatening medical condition.
Causes of alcoholism
Public opinion has it that alcoholics drink because they have underlying anxiety, unhappy childhoods, and lack of self-control.O.Reilly 1983. However Vaillant's results indicated that some "obvious" causes of alcoholism such as anxiety or unhappy childhoods, were not significantVaillant 1995, p 47 and that the alcoholic personality—self-centered, immature, dependent, resentful, and irresponsible—was not evident until after the subjects had started to abuse alcoholVaillant 1995, p 51 and 76. The type of personality found most likely to become alcoholic was antisocial and extroverted, although most antisocial behaviour observed was a result of alcoholism. The presence or absence of childhood environmental strengths predicted which of the College men would take tranquilizers or require medicine for physical complaints, but did not predict alcoholism.Vaillant 1995, p 58 and 73 Unhappy family environments caused alcoholism only if the unhappy environments were the result of alcoholism in the first place.Vaillant 1995, p 84, 86-88, and 96-98.