Journal of Studies on Alcohol, Vol. 36, No. 1, 1975
Multidisciplinary Perspectives on Alcoholism andthe Needfor Integration An HistoricalandProspective Note• Mark Keller Sv•t•tna¾. The history of the recognitionof alcoholismas a multidisciplinary socialproblemfrom the late 19th centurythroughthe evolutionof the Center o[ AlcoholStudiesis described,highlightingthe men who broughtthe field prominence. The nature o/ alcoholism,viewed proman interdisciplinaryperspective,is outlined.
THORITATIVE VOICEShaverecently begunto saythat manysocial problems, or problems of society, requirea
multi- or an interdisciplinary approach.The knowledges of separatedisciplinesand professions are pronouncedinadequatefor understanding and ineffectivein application,needingsomehowto be integrated.The proposalhas been made, and supported,for example,in the editorial columnof Science(1), that for some problems(suchas air pollution,water management, urbanblight) the necessaryintegrationrequiresthe formationof specialmultidisciplinaryproblem-oriented institutes. The surprisingaspectof such statementsis that their authors seemto think they are uttering a new idea. Actually they have only reinventedthe wheel. What is especiallyinterestingis that the need for multidisciplinaryperspectivewas perhapsfirst, and long ago, recognizedwith respectto alcoholism.And, indeed, alcohol-related problemsmay be the ideal model for global,multi• From the Center of Alcohol Studies,Rutgers University, New Brunswick,NJ 089O3.
Presentedat the 30th InternationalCongresson Alcohol and Addictions;Amsterdam, 5 September1972. The text was scheduledfor publicationin a proceedings volumeof the Congressand has been cited as in presstherein.Sinceplans for that volumehave been abandoned,the text is publishedhere with somerevisionsas of Sept. 1974.
Receivedfor publication:1 September1974. 133
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perspectivist, wholisticstudyand action.Moreover,not only is the needfor interdisciplinary approaches in alcoholism an old recognition, but the model interdisciplinary-interprofessional institutefor suchan approachwas alreadycreatedin that field more than 30 yearsago. This is, of course,the Center of Alcohol Studies,first formedat Yale Universitybeginningin 1940-41and subsequently continuedat RutgersUniversity.Still more, the ideologyof this Centerapparentlyinspiredthe formationof otheralcohol-problemsorientedcenters-notimitations,for eachhasits originaland special features,yet undoubtedlystimulatedto somedegreeby the first Center-at least in Canada (the Addiction ResearchFoundation of Ontario) and in Finland (the Finnish Foundationfor Alcohol Studies). It may be that other alcohol-problems-oriented centers are in process of cominginto being.Nowadays,the dramaticintrusion of other-drugproblemsmakesit difficult to be sure what is temporaryand what may becomepermanent. If, then, the recognitionof the need for a multivalentand integrated approachto alcoholismis old hat, and even the formation of instituteswith that ideologyhas alreadytaken place,what remainsto be saidon thissubiect? First,I thinkthat the needhasas yet beenrecognizedonly in ratherlimitedand exceptional circumstances.Inter-, multi- and polydisciplinary make fine-sounding slogansto which lip serviceis readily given. Rarely is the idea concretelysupported.Even morerarely, and not even in the speciallyformedinstitutes,is the idea carriedinto the realmof execution.Thereare difficultiesin the way of conceptualizing the fundamental wholismof alcoholism.Even if one feels, has an awareness, that the problemis multifaceted,the natureof the complexwhole-
nessis not obvious.Partsare moreeasilygrasped.And if the complex perspectivehas evadeda generalelucidation,it is no wonder that the meansof integratingmultidisciplinary study and polyprofessionalaction have likewisefailed to be realized. What, then, is a truly multidisciplinary or wholisticperspective on alcoholism, and how can a multiplicityof disciplinesand professionsbe integratedfor practicalreactionto the problem?In
addressing thesequestions, it seemsthat the necessary beginning is-with the beginning;that is, with an historicalperspective. While the recognition of the multidisciplinary characterof alcoholismis not anythingnew,exactlywhenit beganis uncertain.It would make an interestinghistoricalresearch.But between1893
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and 1905in Americathe Committeeof Fifty evidencedits aware-
nessby the multifaceted studiesit sponsored and published(2); and in Russia,too, between 1898 and 1915 a formal commission
sponsored and publishedstudiesby membersof a varietyof disciplines The and voluminous professions reports (3).2publishedin both Americaand Russia as an outcomeof thosestudiesmake fascinatingreading. At the very least they shouldhave given somedirectionfor actionsto the two societies,and some indication for the needed integration
to whichthesereportsseemto point.It did not work out that way. In Russia,World War I terminatedthe studies,and in the aftermath, the new regimeadoptedthe Engels-Marxistdoctrinairepositionthat alcoholismwas a diseaseof capitalismand hence would naturallywitherawayin the newpolitical-economic order.Nothing couldbe more totalitarianor further from a multidisciplinaryperspective.And in spiteof formalassertions to the contraryby the highestpoliticalauthorityin the SovietUnion, nothingcould be further from what actuallyhappened-asmore recentand realistic statementsfrom that country reveal (5). But in the meantime, duringa 40-year-long darkness, nothingwas to be doneaboutalcoholismin a rapidlyindustrializing and urbanizingsocietywhere the problemcould well have been expectedto intensify, if not increase.
In America too a one-sided rather than a wholistic view came to
prevail at the sametime, the viewpointof the ClassicTemperance Movement,asdescribed by Bacon(6). It wasin fact an antialcohol movement,and its political aim succeeded.During World War I the Nation adoptedProhibitionand next wrote it into the Constitution. Under the circumstances of this teetotalisticsolution,any broad perspectiveon alcoholproblemsseemedirrelevant.And indeedthe notionprevailedthat the problems-especially alcoholism -must wither away.The fact is that duringthe first 10 yearsafter Prohibition, nearlyall the alcoholics I knew-and they weremany-
had becomealcoholics duringProhibition. But exceptin the noisy and noisomepolitical and policerealm, a darknesshad descended
on the subject. • I have found no indicationthat either of thesetemporallyoverlappinggroups ever heardof the other. Whether the presenceof at least one representative from the SovietUnion at this 30th InternationalCongress suggests someimprovedpossibilityof integratingthe researchor meliorativeor preventiveactionsof the same two countries overwhat prevailedbeforeWorld War I is now a politicalquestion(4).
In the restof the world too,for the mostpart, political-economic solutionswere tried, and commonlyfailed, and were abandoned or ultimatelyamended,but with hardly any long-rangeeffect on alcoholism.
Prohibitionwasrescinded in the U.S.A.in 1933.That year,about 10,000 alcoholics-well-confirmed in their disease-were admitted
to one hospitalin New York City: the PsychiatricDivision of ]3ellevueHospital•a teachingand researchdependency of the New York UniversityMedical School.A new servicewas established iust then-a Medical Serviceof the PsychiatricDivision-to care for thosepsychiatricpatientswho had "medical"disorders.A Dr. NormanJolliffewas appointedchief of this Medical Service,and he startedan intensivestudyof the "medical"disorderswhich did not speciallyinterestthe psychiatrists. More thanhalf the patients assigned to his wardswere alcoholics, and they had in abundance all the classicaldiseases associated with prolongedalcoholism. He learnedand taughthis staffhow to treat mostof them successfully -they were mostlynutritionaldiseases. He was a pioneerof the vitamin-therapy era.Oneof thosediseases-which he wasthe first to describe, andhe succeeded in reducingitsmortalityfrom90%to 10% -is now sometimes calledJolliffe'sencephalopathy (7). I watched thisprocess with fascination asI waslearningto asksomepertinent and impertinentquestions while trying to organizethe clinicaland researchdata, and beginningto exploreand systematize and try to connectthe relevantknowledge,includingthat of the past.Then, one day, in a relaxeddiscussion hour, Jolliffe said, "You know, I must be doing the wrong thing. I sendthesepeopleout cured; and the sameoneskeepcomingback in! They go on drinkingthe sameway, and gettingthe samediseases overagain.I know why they are gettingthosediseases. But why are they drinkingthat way? That's the real question.It's the alcoholismwe shouldbe studying!" Soin the nextmonths-thisis in 1935-we designeda grandresearchproiect.It was to take 7 years.In it, and this was Norman Jolliffe'sidea,we wereto usenot iust all sortsof physicians-including psychiatrists-butalso psychologists and public health nurses,and psychiatricsocialworkersand socialscientists,even anthropologists. For,Jolliffehypothesized, if we weregoingto find out why and how thesepeoplebecamealcoholics, we couldnot do it by studyingthemjustin the hospitaland in our laboratories-we
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would have to go into their communitiesand into their homes.A multidisciplinary approach.ThusJolliffehad reinventedthe wheel. This brilliant multidisciplinary idea was so very attractivethat we camewithin a breathof gettinghalf-a-milliondollarsfrom the RockefellerFoundationto carry it out. At the last stage,in 1936, the Foundationchangedits mind. In the meantime,however,Jollille and Dean JohnWyckoffof the Medical Schooland Dr. Karl M. Bowman,the directorof the PsychiatricDivision,had formed a scientificadvisorycommittee,with representatives of many disciplinesand professions, to sponsorthis great research.One member wasDr. HowardW. Haggard,directorof the Yale Laboratory of AppliedPhysiology, wheredistinguished researchon the metabolismof alcoholand someof its effectswas under way. The advisory committeedid not feel like expiringwhen the Rockefeller
Foundation backedout of supporting the Jollifferesearch proiect. Out of this committeeemergedthe ResearchCouncilon Problems of Alcohol,with the specialaim to seekfundsto supportresearch on alcoholproblems. The firstsignificant grantit succeeded in stimulating was$25,000 fromthe CarnegieCorporation for a reviewof the biologicalliterature on alcohol.The grant went to New York UniversityMedical Schoolwith Norman Jolliffe as chief and medical director of the studyandKarl M. Bowmanaspsychiatricdirector.But an executive directorwas needed,and it was then, in 1939,that Jolliffewent up to the WorcesterStateHospitalin Massachusetts to meet with E. M. Jellinek,the chiefbiometricianof Dr. Roy Hoskins'neuro-
endocrine research proiectin schizophrenia. AndJolliffeluredJellinek awayfromschizophrenia into alcohol.We tookofficespacein the New York Academyof Medicine,becausethere we had the neededlibrary resources for the review, and we acquireda staff -a multidisciplinary team representing clinicaland experimental medicine,physiology, both clinicaland experimentalpsychology, both the psychologically and physiologically orientedbranchesof psychiatry,biometrics,and documentation. The review was more or lesscompleted-buthow was it to be published?Howard W. Haggardhad the visionthento foundan interdisciplinary periodical, the QUARTERLY JOURNAL OF STUDIES ON ALCOHOL, and in its firsttwo volumes,in 1940-41and 1941-42,the reviewpaperswere
published. It turnedout that we had reviewednot onlybiological literaturebut-mu]tisinfu]multidisciplinarians that we were-also
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psychological and psychiatricliterature.In fact, we couldnot resist a glanceat somesocial-economic materials.We even lookedat the popularlimericksaboutdrinking,and what that hasto do with biologycan be understood only undera truly wholisticinterpretation of the biological. Our grantwasexhausted, our reviewnot completelywrittenup, and the ResearchCouncil,far from gettinglarger fundsto support researches, was hardly able to raiseenoughmoneyto maintainits organizationaloffice and smallstarryWhat shouldwe do with ourselves? Now HowardW. HaggardinvitedJellinekto cometo Yale, completethe writing of the review, and engagein somefurther related (as well as unrelated) activities.Soon,at least five of the originalreviewstaff were workingat Yale. Alcoholstudiesboomed there.New staff were added-includinga sociologist, an educationist,anda doctorof iurisprudence. What wereall thesepeopledoing in a Laboratoryof AppliedPhysiology, mixed up with the physiologists, pharmacologists and biochemists whomthey now outnumbered?They were trying to find out the facts aboutalcoholuse, alcoholmisuse,and alcoholism,and they were under the spell of the grandconception:interdisciplinary. Of coursethey neededan organizationalformat and a name. Thus the Center of Alcohol Studiescameinto being,with E. M. Jellinekas its first director. How interdisciplinarywere we? A little-but more multi than inter. Jellinek,in the volumein which most of the reportsof the great literature review were collected,trenchantlyrenewed the emphasison the futility of trying to understand-muchlesssolve -alcohol problemsfrom the perspectiveof any one disciplineor profession (8). Underhisingenious leadership the multidisciplinary staff launchedout in many directionsat once,and they did talk to eachother,and in somecasesthere was cross-disciplinary influence. Sometimes the cross-fertilization
was extreme. It was illus-
trated in a funny story: A reportercame to the Center of Alcohol Studiesto learn-the 3The Councilwas disbanded,in 1949, on the initiative of its last president,Dr. Anton J. Carlson (the "grand old man of American physiology"), apparenfiybecauseit had becometoo dependentfor supporton the public-relationsbranchof the alcoholic-beverage industry.This circumstance had previouslycausedHaggard and Jellinekto severthe connectionof the QUART•.R•.¾ JotmNA•.OF STUDIES ON A•.COHO•. with the Councilas its official organ,althoughthe JotmNx•.had never receivedany financial supportfrom the Councfi.
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real causeof alcoholism.As he circulatedthrough the building, the physiologists explainedit to him in termsof sociology, the sociologistsin terms of psychology, the psychologists in terms of anthropology,the anthropologists in terms of biochemistry,the biochemists in termsof psychiatry,the psychiatrists in terms of physiology,and the documentalists in terms of uncertainty. Therewas cross-disciplinary influence,and there was alsosome indifferenceor resistanceto the "other"disciplines.One sectionof the Center was as nearly multi- and interdisciplinary as was humanly possibly:the documentation-and-publications division.We not only insistedon gatheringand processing into bibliographies and abstractsall the reportsfrom all disciplinesand professions, but we tried conscientiously to indexthe informationin suchways that the searcherfor knowledgefrom one disciplineor profession would find what shouldbe helpful, and enrich his perspective, even thoughit came out of an alien sourcewhich he would not ordinarilyhave consulted(9). Stubbornlywe persistedin publishinga QUARTERLY JOURNAL OFSTUDIES ONALCOHOL with articles rangingfrom physiologyto economicsto psychologyto genetics to historyto anthropology to law to educationto neurochemistry to sociologyto therapeutics,and so on without limit. It amused me to seea youngsocialpsychologist giggleas he openeda new issueof the JOURNAL and read the title on the first page-"Alcohol consumption by inbred mousestrains."I knew he would not read the article,but I thoughtit goodfor his soulto stumbleover this title and sufferthe suggestion that there might be a questionfrom a differentperspective.It annoyedme to discoverthat a neurophysiologist neverreadthe tableof contents beyondthe first onethird of the JOURNAL--because he had learnedthat all articlesthat might interesthim would occurin that part. I changedthe order of articlesin the JOtreNAL to a systematic even if seeminglydisorderedcycle.Now let him try to escapeat leaststumblingover thoseothertitles!The suggestion to split the JOURNAL in two--one for biologicalscienceand one for socialscience-hasbeen resisted. The Centerof AlcoholStudieswasmultidisciplinary andto some extent interdisciplinary. It had the ideology,and it was on the track.But it wouldbe an exaggeration to claim anythinglike an interdisciplinary success. For the mostpart the psychologists studied psychological problems,the biochemists biochemical problems, the sociologists sociological problems,and soon. Nevertheless there
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was one positivegain: Many-a-time,even if not every time, the kindsof questions the staff askedtendedto be deeperand richer becauseof the broaderand deeperperspectivederivedfrom interactionwith and criticismfrom membersof other disciplines;the designof studiesand interpretationof findingsoften showedthis enrichment. 4
In the realm of action,however,the multi- and interdisciplinary perspective wasemphatically manifestand beneficent.The Center of AlcoholStudiesfoundedthe first outpatientalcoholismclinics in whichmultidisciplinary teamswere to treat alcoholics with va-
rietiesof individuallysuitedtechniques, andwhereinterdisciplinary researchon alcoholismwas to be attempted.The Center founded the first SummerSchoolof AlcoholStudies,where all the disciplines and professions, none excepted,and includingAlcoholicsAnonymous,participatedin educatinga cadreof future researchers and activists.The Centersponsored, and in its early yearssupported, an interdiscipline-inspired organizationfor public education-what developedinto the National Council on Alcoholism.The Center
launcheda broad-perspective critiqueof existingschooleducational materialsand stimulatedtheir reform,partly by helpingto form an organizationof educators,the AmericanAssociationfor Instructionon Alcoholand Narcotics.The Centerinitiateda widely hailed industryprogramfor treating employedalcoholics-staff from at least five disciplinesand professions participatedin meetings to plan phasesof this activity. We had, then, someinterdisciplinarycollaborationon the actionsfront.But did we have a clearpositiveconception-interdisciplinary, broad, global,wholisticin perspective-ofthe nature of alcoholism? I think not. We knew that narrow conceptionswere untenable.When new etiologicaltheorieswere enunciated-and we publishedthem-that it was endocrinological, or allergic,or neurohumoral, or nutritional,or genetic,or genetotrophic, or metabolic, or psychogenic, or economic,or sociocultural, or behavioral, or existential, we privatelyfelt confidentin pooh-poohing eachone. From the same perspective,when new treatmentsor cures that were to be universallysuccessful were announcedfrom time to time, we similarlysmiledknowingly,and our skepticismwas invariablyiustifiedby experience. • More than this I will not claim, for I have been an insider, and the final judgment has to come from a less biased observer.
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It was a strangeexperienceat times. In spite of the strongly worded assertions by Haggard and ]ellinek-now recognizedthe world over as the {oremostauthoritiesin the field-that only an interdisciplinary perspectivecould have validity (10), one-sided hypothesizing and researches persisted.Thus, suddenly,came the pronouncement from a medicalresearcherthat the causeof alcoholismwas a hormonaldisorder,and he predictedthat within 5 yearsthere would be a chemicalcure which would enable alcoholicsto drink normallyagain.It was especiallyannoyingto me that the authorof this predictionshouldbe occupyingthe position onceheldby Norman]olliffe;andthoughI did notholdmy breath, I did patientlycountoff the years-1, 2, 3, 4 and 5. It is now several times5, but I stoppedcountinglongago.Out of the southwest camethe genetotrophic theory,by a great chemist,and we publishedits first announcement, but shakingour interdiscipline-influenced heads at the unlikelihood of it. From the midwest came a
masked-food-allergy theory, and we publishedthat too-though Jellinekinsistedthen, and again yearslater (11), that he could not even understandit. Our own circle too producedsomeinsufficientlywholistictheorizing-inthe psychogenic and sociocultural lines. Of course,we publishedthose too. Documentalistscould affordto be infinitelyliberal-indeed,we believedourselves bound to be. For we were under no obligationor pressureto formulate theories-onlyto documentthem,and hopethat out of a complete and adequatedocumentation wouldcomethe help, the means,the wholisticfoundationof knowledge,which someingenioussynthesizercouldsomeday useto producethe inspiredwholistictheory. The strangeexperience continues. One-sided, narrowhypotheses, single-discipline or single-profession oriented,continueto be produced.Medicine-oriented theoriesare in conflictwith sociologyorientedones.Thusthe recapitulation of the warningagainstsuch unlikelyeffortsis stillneeded.But the workof Jolliffeand Haggard andJellinekandtheirsuccessors at the formerYaleandnowRutgers Center of AlcoholStudieswas not entirely lost upon the world. For increasinglyoften, over time, we alsohear theorieswhich attempt to integratethe interdisciplinary knowledge,which showthe hallmarksof broaderperspective. • • Particularlynoteworthyis the Report of the CooperativeCommissionon Alcoholism (12) whose work and membershipwere not unconnectedwith the prior historyof the Center of Alcohol Studies.
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If I have thus far given most attentionto the Institutionwith which I was connected,it is not becauseof underestimating the work and contributionsof the other centerswhich I named, but because, owingto the directJolliffe-Haggard-Jellinek earlyinspiration and direction, the Center of Alcohol Studies became and remains a vital model of the sort of institute which can realize the
meaningand effectiveness of an interdisciplinary perspective. What has been outlinedthus far are somehigh pointsfrom a historyof 40 yearsof approaches to an interdisciplinary perspective on alcoholism and otheralcoholproble. ms. The fact that we have not yet solvedthe problem,not yet uncoveredthe truth, should not discourage anyone-noteventhosewho preferto think along monotonic lines.For alcoholism is socomplexthat,not surprisingly, thereis no widespread agreement evenaboutwhat it is descriptively. Thus,if these40 yearsof wanderingin the wildernessof confusionshouldhavejustpartlyliberatedus and partly educatedus in preparationfor new approaches, then progresshas been made toward ultimate goals. But now it seemsappropriateto sum up what I think has been learnedby way of an interdisciplinary-wholistic understanding of alcoholism, and I will try to outlineit. This conception, already suggested manyyearsago (13) but sincethen confirmed by additionalobservations and learning,restsuponthe theoriesand researches of many scientists-and someamateurs-inthe past 40 years,and it is not possible adequatelyto creditall of them. Here,then,is how,at thisstageof our knowledge, I think alcoholismmaybe conceptualized in wholisticperspective:
Thereis a sharplydistinctdifference amongindividuals-possibly amonggroups-indegreeof vulnerability(11). Whetherthe vulnerabilityis to behavioral or affectivedisordergenerally,or to alcoholism in particular,is uncertain. More likely,I think,the for-
mer;thatis,a general vulnerability. To thisvulnerability a genetic factormaywell contribute (14); but it mightbe a negative factor -that is, the geneticfactormay be onethat immunizes or makes the development of alcoholism, or the resortto alcoholism, difficult or unlikely,ratherthanonethatpositively increases vulnerability. Therelativefreedom of theJewsfromalcoholism hasbeenlargely attributed to sociocultural inhibition, but actuallythepossibility of a genetically determined deterrent hasnot beenexcluded by any evidence.
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Whetheror not a geneticsusceptibility or immunityobtains,an infant-rearingand childhood-developmental factorseemsdecidedly to be involvedin laying the groundworkof the ultimate psychologicalvulnerability(15, 16). The formthat thisdevelopment takes may well be that of excessive dependency(17, 18) or dependency conflict (19, 20). The evidencefor that characteror personality trait in alcoholism seemsrather strong,thoughnot yet conclusive or universal,anditsoriginin earlyexperience canhardlybe doubted. Next we havea combinedpersonality and socialdevelopment. Is occursin adolescence. It may be a continuation of maldevelopment in the psychosexual spherethat was initiatedalreadyin infancy or childhood.In somesocieties it may directlyinvolvedrinkingor other deviantbehaviors.Noteworthyis the fact that socialand culturalphenomena beginto play a significantpositivepart here. Thus,wheredrinkingby adolescents is forbiddenor discouraged, the alreadyvulnerableyoungmay now useforbiddendrinkingas a way of counteracting or compensating for the feelingsof inadequacy, or of insecureself-seximage. In that case, if the societal attitudesabout drinkingand drunkenness grant machismo-likeor
heroicrewardsfor outstanding capacityto drink, then thosewho are alreadymostvulnerableare speciallyset up for alcoholism. For in thesecircumstances, not only is heavydrinkingrewarded by peer-groupadmiration,but the heavy-drinking youth experiencesthe proroundest internalrewardfromthe drinking.This oc-
cursbecause of the magicalpharmacological propertyof alcohol: the drunkenpersoncan imaginehimself,feel himself,to be the
manly or womanly,heroicor charming,cleveror sophisticated personthat he thinkshe oughtto be. The insecureadolescent who experiences thismagicaldoublerewardfromdrinkingis likelyto resortto alcoholrepeatedlyin any of the circumstances that are troublousand problematic to the developingadult. And in that caseanotherfactorcomesintoplay: learningor conditioning (16, 21). The individuallearnsor becomesconditionedto resortto al-
cohol,unfailingly andevenreflexively, in amounts sufficient to overcometroublousself-doubts, whenevercertainsortsof problems
arise.Thus,if in theadolescent theywereproblems of relatingto the opposite sex,thenheavydrinkingin sex-related situations could
become theusualreaction. Butthe learned response canequally prevailif theoriginal problems werein general relatingto people, or in copingwith any sortsof practicalproblemsituations. More-
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over,by the rule of generalization, the useof heavydrinkingto relieve,or as an aid in copingwith, one sortof problemwill be followedby its usein meetingotherproblems. The process, and it may be a long process-Jellinek (22) estimatedthat it tookfrom5 to 10 or 12 yearsfor the averagedevelopment of full-blownalcoholism-bywhich an individuallearnsto becomean alcoholic,is itself a complicatedone. It is a reasonable guessthat the morevulnerablean individualwas to beginwith, whethergeneticallyor by childhoodexperienceand adolescent reinforcement, the more likely he is to graspat the glasscrutch and finally to arrive at the stateof helplessaddiction-confirmed alcoholism. We mustassume a rangeof vulnerabilityand reinforcive experience.Similarly,as Jellinekhypothesized(23), there is a rangeof societalpermissiveness, and, as Bacon(24) has hypothesized,environmental encouragement, all contributingto a society's rate of alcoholism. In a societywheremuchand heavydrinkingis accepted,asin France,the lessvulnerablemay developalcoholism and a highrate will result.In a societywhereheavydrinkingand drunkenness are discouraged, as amongthe Jews,only the most vulnerable will "make it" and the rate of alcoholism will be low.
But conflictaboutdrinkingwithin a societymay blockthe chances of the vulnerableto escape.For, indeed, not all the vulnerable make it-many sortsof significanteventsmay interveneto save them;and this is a vital consideration for the chancesof planned prevention.
To sumup: Thiscomplexhypothesis of the etiologyof alcoholism incorporatesa geneticor constitutionalfactor which imposesexceptionalsusceptibility or immunity;errorsof infant relationship
or childhood rearingand resultantpsychosexual maldevelopment witha possibly defective, especially hyperdependent or dependencyconflicted,personality trait; furthermisfortunein the form of misdirectedmaturationin the adolescent phase,especially if reinforced by internallywell-rewarded drinkingexperiences; anda subsequent learningor conditioning process,of possiblyyears-longduration, embeddedin culturallyandsocietallydeterminedmoresand conditionsand directions, with a negativebalanceof interpersonal relations;and,finally,the pharmacological properties of alcoholassuming a dominantindispensable rolein the individual's way of life. If the truth is anythingas complicatedas this, then no wonder that peoplein particulardisciplines and professions havemostly
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preferred to concentrate onjusttheirownlimbof thisblind-men's elephant. But if thisbeastis not a productof sheerfantasy-apink elephant-thenit may be an interdisciplinary-wholistic conception of the etiologyof alcoholism. And what, then, is the nature of the beast?What is alcoholism,
underthisconception? In the end,it is surelya disease-ifhelpless addictionto a drugis a disease, as I believe.At an earlierstageit may be the symptomof anotherdisease,if personalitydisorder severeenoughto causefunctionaldisablementis a disease,as I believe.At somestill earlier stage,the heavy drinkingor symptomaticdrinking(or alcoholabuse,if we shouldacceptthat pejorative term) maynot be diagnosable asdisease. Then it hasto be a form of misbehavior,or deviantbehavior,accordingto the perspective from whichone chooses to view it. In that case,we are not talking about alcoholism. Let us at least be clear about that. Alcoholismic
behavioris indicativeof disease(25, pp. xv-xxviii). Misbehavior with alcoholis an elephantof a differentcolor.This simpleclarificationcan help in determiningwhat needsto be doneabout differentpeople,how diverselywe may reactto themand help them in differentstagesof their troubles. What do we gain from a multidisciplinary-wholistic conception of alcoholism?
At a very minimum,the recognitionthat no one profession, no one discipline,no single-minded approach,can hope to deal with this condition.In sayingthis,I am recyclingold truths.But perhapsif we acceptthe underlyingwholisticperspective,we will be able wholeheartedly to resolvethe need for integration.And not onlytheintegration of therapeutic approaches. For toolongwe have paid lip servicealsoto the importanceof prevention,but our actionshavebeenresponsive-for unblamably humanereasons-chiefly to the needsof the catastrophevictims,thosewho are already alcoholics. We have soughtto createmoreand better repair shops, but we have not tried to initiate the era of prevention.And no wonder: we have not known how.
If, however,it is true that somepeople start vulnerable,and thenovera life-historyshowincreasing signsof their vulnerability, finally exhibitingthe prealcoholismic behaviorsof heavy and implicativedrinking (26), then can we not begin to identify the vulnerables-theimplicativedrinkersamong adults, the deviant behaversamongadolescents, perhapsultimatelyeven the uneasy
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and alreadyproblem-beset children?Must we not try to identify them?Isn't that the essenceof the public-healthapproach?And oncewe begin to performthe task of identifyingthe vulnerables, shall we stop short of trying to help them avert the danger?I think that if we try we shallsucceedin findingmeansof helping which will be acceptableto them as well as to the helpers. The interdisciplinary perspective, then,not only allowswholistic understanding but opensa gate to the Ultima Thule, the era of prevention.Too obviousto needelaborationis the fact that all the
disciplines andprofessions mustbe involved,and in an integrated program,both in testingthe parts and the wholenessof the etiologicalhypothesis,and in applyingthe actions,therapeuticand preventive,that its conclusions must invoke. Not enoughhasbeensaidaboutthe necessary integration.Frankly, I do not have a clearconceptionof how the disciplines can be truly integratedin performingthe studiesrequiredto verify the wholisticetiologicalperspective,nor exactlyhow the professions canbe integratedfor the first experimentalprogramsof prevention. ! suggestthat the wider teachingand adoptionof the wholistic perspective, and the better supportof researches and actionsin the truly multidisciplinarycenters,will result in the discoveryand developmentof effectivemeansof integration. REFERENCES
1. LONG,F. A. Interdisciplinaryproblem-orientedresearchin the university. Science 171: 961, 1971. 2. COMMITTEEOF FIFTY FORTHE INVESTIGATION Or THF. L•QuoR PROBLEM.(a) Kor•EN,J. (1899.) Economicaspectsof the liquor problem. (b) W•NES,F. H. and KOREN,J. (1900.) The liquor problem in its legislative aspects. (c) CALKINS,R. (1901.) Substitutesfor the saloon. (d) BILLINGS,J. S., ed. (1903.) Physiologicalaspectsof the liquor problem. ('e) PEABODY, F. G., ed. (1905.) The liquor problem;a sunimaryof investigations conductedby the Committee of Fifty, 1893-1903. Boston; Houghton, Mifflin; 1899-1905. 3. NIZHEGORODTSEV, M. N., ed. Trudy Kommissiipo Voprosuob Alkogolisme,Nos. 1-13. (Studies of the Commissionon the Problem of Alcoholism,Nos. 113.) St. Petersburg; 1898-1915. 4. KELLr.R, M. and ErRON, V. Alcohol problems in Yugoslaviaand Russia; some observations of recent activitiesand concerns.Quart. J. Stud. Alc. 35: 260271, 1974.
5. The Sovietpeople think that the State shouldbe more stringentabout drunkenness.Quart. J. Stud. Alc. 31: 448-450, 1970. 6. BACON,S. D. The classictemperancemovement of the U.S.A.; impact today on attitudes,action and research.Brit. J. Addict. 62: 5-18, 1967. 7. GXANNINI,A. and OGNIBENE, P. P. Su di un casodi encefalopatiadi Jolliffe in alcoolista.Riv. Pat. nerv. ment. 80: 463-466, 1959.
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8. JELLINEK,E. M., ed. Alcohol addiction and chronic alcoholism. (Effects of alcohol on the individual, Vol. 1. ) New Haven; Yale University Press;1942. 9. KELLER,M. A special-libraryinformation-centermodel for a societal-problems field. Proc. int. Conf. Information Sci., pp. 121-129, 1972. 10. Alcohol, scienceand society;twenty-nine lectures with discussionsas given at the Yale Summer Schoolof Alcohol Studies. New Haven; Quarterly Journal of Studieson Alcohol; 1945.
11. JELLINEK,E. M. The diseaseconceptof alcoholism.Highland Park, NJ; Hillhouse Press; 1960. 12. COOPERATIVE COMMISSIONON THE STUDYOF ALCOHOLISM.Alcohol problems; a report to the nation. (Prepared by T. F. A. PLAUT.) New York; Oxford University Press; 1967. 13. KELLER,M. Cultural aspectsof drinkingand alcoholism.Toronto;United Church of Canada, Commissionon TemperancePolicy and Program; 1958. 14. GOODWIN,O. W. Is alcoholismhereditary?A review and critique. Arch. gen. Psychiat. 25: 545-549, 1971. 15. LOLLX,G. Alcoholismas a disorderof the love disposition.Quart. J. Stud. Alc. 17: 96-107, 1956.
16. BARRY,H., 3d. Psychological factorsin alcoholism.Pp. 53-107. In: KISSIN,B. and BECLEITER, H., eds.The biologyof alcoholism.Vol. 3. Clinical pathology. New York; Plenum; 1974. 17. McCoP•D,W., McCoBx•,J. and GVDEMAN,J. Some current theories of alcoholism; a longitudinalevaluation.Quart. J. Stud. Alc. 20: 727-749, 1959. 18. LEMEXaT,E. M. Dependencyin married alcoholics.Quart. J. Stud. Alc. 23: 590-609, 1962.
19. B,•CON,M. K., BAPm¾, H., 3d and CHILD, I. L. A cross-culturalstudy of drinking. II. Relationsto other featuresof culture.Quart. J. Stud. Alc., Suppl. No. 3, pp. 29-48, 1965.
20. B,•CON,M. K. The dependency-conflict hypothesisand the frequencyof drunkenness;further evidence from a cross-culturalstudy. Quart. J. Stud. Alc. 35: 863-876, 1974.
21. Kn•CH,•M,R. J. Alcoholismand the reinforcementtheory of learning.Quart. J. Stud. Alc. 19: 320-330, 1958. 22. JELLINEK, E. M. Phasesof alcoholaddiction. Quart. J. Stud. Alc. 13: 673-684, 1952.
23. JELLXNEK, E. M. The world and its bottle. World Hlth, Geneva 10 (No. 4): 4-6, 1957.
24. B,•CON,S. D. The processof addictionto alcohol;socialaspects.Quart. J. Stud. Alc. 34: 1-27, 1973. 25. KELLY. R, M. and McComaxcK,M. A dictionary of words about alcohol. New Brunswick, NJ; Rutgers Center of Alcohol Studies; 1968. 26. KELLEa•,M. Definition of alcoholism.Quart. J. Stud. Alc. 21: 125-134, 1960.
Multidisciplinary Perspectives on Alcoholism andthe Needfor Integration An HistoricalandProspective Note• Mark Keller Sv•t•tna¾. The history of the recognitionof alcoholismas a multidisciplinary socialproblemfrom the late 19th centurythroughthe evolutionof the Center o[ AlcoholStudiesis described,highlightingthe men who broughtthe field prominence. The nature o/ alcoholism,viewed proman interdisciplinaryperspective,is outlined.
THORITATIVE VOICEShaverecently begunto saythat manysocial problems, or problems of society, requirea
multi- or an interdisciplinary approach.The knowledges of separatedisciplinesand professions are pronouncedinadequatefor understanding and ineffectivein application,needingsomehowto be integrated.The proposalhas been made, and supported,for example,in the editorial columnof Science(1), that for some problems(suchas air pollution,water management, urbanblight) the necessaryintegrationrequiresthe formationof specialmultidisciplinaryproblem-oriented institutes. The surprisingaspectof such statementsis that their authors seemto think they are uttering a new idea. Actually they have only reinventedthe wheel. What is especiallyinterestingis that the need for multidisciplinaryperspectivewas perhapsfirst, and long ago, recognizedwith respectto alcoholism.And, indeed, alcohol-related problemsmay be the ideal model for global,multi• From the Center of Alcohol Studies,Rutgers University, New Brunswick,NJ 089O3.
Presentedat the 30th InternationalCongresson Alcohol and Addictions;Amsterdam, 5 September1972. The text was scheduledfor publicationin a proceedings volumeof the Congressand has been cited as in presstherein.Sinceplans for that volumehave been abandoned,the text is publishedhere with somerevisionsas of Sept. 1974.
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perspectivist, wholisticstudyand action.Moreover,not only is the needfor interdisciplinary approaches in alcoholism an old recognition, but the model interdisciplinary-interprofessional institutefor suchan approachwas alreadycreatedin that field more than 30 yearsago. This is, of course,the Center of Alcohol Studies,first formedat Yale Universitybeginningin 1940-41and subsequently continuedat RutgersUniversity.Still more, the ideologyof this Centerapparentlyinspiredthe formationof otheralcohol-problemsorientedcenters-notimitations,for eachhasits originaland special features,yet undoubtedlystimulatedto somedegreeby the first Center-at least in Canada (the Addiction ResearchFoundation of Ontario) and in Finland (the Finnish Foundationfor Alcohol Studies). It may be that other alcohol-problems-oriented centers are in process of cominginto being.Nowadays,the dramaticintrusion of other-drugproblemsmakesit difficult to be sure what is temporaryand what may becomepermanent. If, then, the recognitionof the need for a multivalentand integrated approachto alcoholismis old hat, and even the formation of instituteswith that ideologyhas alreadytaken place,what remainsto be saidon thissubiect? First,I thinkthat the needhasas yet beenrecognizedonly in ratherlimitedand exceptional circumstances.Inter-, multi- and polydisciplinary make fine-sounding slogansto which lip serviceis readily given. Rarely is the idea concretelysupported.Even morerarely, and not even in the speciallyformedinstitutes,is the idea carriedinto the realmof execution.Thereare difficultiesin the way of conceptualizing the fundamental wholismof alcoholism.Even if one feels, has an awareness, that the problemis multifaceted,the natureof the complexwhole-
nessis not obvious.Partsare moreeasilygrasped.And if the complex perspectivehas evadeda generalelucidation,it is no wonder that the meansof integratingmultidisciplinary study and polyprofessionalaction have likewisefailed to be realized. What, then, is a truly multidisciplinary or wholisticperspective on alcoholism, and how can a multiplicityof disciplinesand professionsbe integratedfor practicalreactionto the problem?In
addressing thesequestions, it seemsthat the necessary beginning is-with the beginning;that is, with an historicalperspective. While the recognition of the multidisciplinary characterof alcoholismis not anythingnew,exactlywhenit beganis uncertain.It would make an interestinghistoricalresearch.But between1893
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and 1905in Americathe Committeeof Fifty evidencedits aware-
nessby the multifaceted studiesit sponsored and published(2); and in Russia,too, between 1898 and 1915 a formal commission
sponsored and publishedstudiesby membersof a varietyof disciplines The and voluminous professions reports (3).2publishedin both Americaand Russia as an outcomeof thosestudiesmake fascinatingreading. At the very least they shouldhave given somedirectionfor actionsto the two societies,and some indication for the needed integration
to whichthesereportsseemto point.It did not work out that way. In Russia,World War I terminatedthe studies,and in the aftermath, the new regimeadoptedthe Engels-Marxistdoctrinairepositionthat alcoholismwas a diseaseof capitalismand hence would naturallywitherawayin the newpolitical-economic order.Nothing couldbe more totalitarianor further from a multidisciplinaryperspective.And in spiteof formalassertions to the contraryby the highestpoliticalauthorityin the SovietUnion, nothingcould be further from what actuallyhappened-asmore recentand realistic statementsfrom that country reveal (5). But in the meantime, duringa 40-year-long darkness, nothingwas to be doneaboutalcoholismin a rapidlyindustrializing and urbanizingsocietywhere the problemcould well have been expectedto intensify, if not increase.
In America too a one-sided rather than a wholistic view came to
prevail at the sametime, the viewpointof the ClassicTemperance Movement,asdescribed by Bacon(6). It wasin fact an antialcohol movement,and its political aim succeeded.During World War I the Nation adoptedProhibitionand next wrote it into the Constitution. Under the circumstances of this teetotalisticsolution,any broad perspectiveon alcoholproblemsseemedirrelevant.And indeedthe notionprevailedthat the problems-especially alcoholism -must wither away.The fact is that duringthe first 10 yearsafter Prohibition, nearlyall the alcoholics I knew-and they weremany-
had becomealcoholics duringProhibition. But exceptin the noisy and noisomepolitical and policerealm, a darknesshad descended
on the subject. • I have found no indicationthat either of thesetemporallyoverlappinggroups ever heardof the other. Whether the presenceof at least one representative from the SovietUnion at this 30th InternationalCongress suggests someimprovedpossibilityof integratingthe researchor meliorativeor preventiveactionsof the same two countries overwhat prevailedbeforeWorld War I is now a politicalquestion(4).
In the restof the world too,for the mostpart, political-economic solutionswere tried, and commonlyfailed, and were abandoned or ultimatelyamended,but with hardly any long-rangeeffect on alcoholism.
Prohibitionwasrescinded in the U.S.A.in 1933.That year,about 10,000 alcoholics-well-confirmed in their disease-were admitted
to one hospitalin New York City: the PsychiatricDivision of ]3ellevueHospital•a teachingand researchdependency of the New York UniversityMedical School.A new servicewas established iust then-a Medical Serviceof the PsychiatricDivision-to care for thosepsychiatricpatientswho had "medical"disorders.A Dr. NormanJolliffewas appointedchief of this Medical Service,and he startedan intensivestudyof the "medical"disorderswhich did not speciallyinterestthe psychiatrists. More thanhalf the patients assigned to his wardswere alcoholics, and they had in abundance all the classicaldiseases associated with prolongedalcoholism. He learnedand taughthis staffhow to treat mostof them successfully -they were mostlynutritionaldiseases. He was a pioneerof the vitamin-therapy era.Oneof thosediseases-which he wasthe first to describe, andhe succeeded in reducingitsmortalityfrom90%to 10% -is now sometimes calledJolliffe'sencephalopathy (7). I watched thisprocess with fascination asI waslearningto asksomepertinent and impertinentquestions while trying to organizethe clinicaland researchdata, and beginningto exploreand systematize and try to connectthe relevantknowledge,includingthat of the past.Then, one day, in a relaxeddiscussion hour, Jolliffe said, "You know, I must be doing the wrong thing. I sendthesepeopleout cured; and the sameoneskeepcomingback in! They go on drinkingthe sameway, and gettingthe samediseases overagain.I know why they are gettingthosediseases. But why are they drinkingthat way? That's the real question.It's the alcoholismwe shouldbe studying!" Soin the nextmonths-thisis in 1935-we designeda grandresearchproiect.It was to take 7 years.In it, and this was Norman Jolliffe'sidea,we wereto usenot iust all sortsof physicians-including psychiatrists-butalso psychologists and public health nurses,and psychiatricsocialworkersand socialscientists,even anthropologists. For,Jolliffehypothesized, if we weregoingto find out why and how thesepeoplebecamealcoholics, we couldnot do it by studyingthemjustin the hospitaland in our laboratories-we
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would have to go into their communitiesand into their homes.A multidisciplinary approach.ThusJolliffehad reinventedthe wheel. This brilliant multidisciplinary idea was so very attractivethat we camewithin a breathof gettinghalf-a-milliondollarsfrom the RockefellerFoundationto carry it out. At the last stage,in 1936, the Foundationchangedits mind. In the meantime,however,Jollille and Dean JohnWyckoffof the Medical Schooland Dr. Karl M. Bowman,the directorof the PsychiatricDivision,had formed a scientificadvisorycommittee,with representatives of many disciplinesand professions, to sponsorthis great research.One member wasDr. HowardW. Haggard,directorof the Yale Laboratory of AppliedPhysiology, wheredistinguished researchon the metabolismof alcoholand someof its effectswas under way. The advisory committeedid not feel like expiringwhen the Rockefeller
Foundation backedout of supporting the Jollifferesearch proiect. Out of this committeeemergedthe ResearchCouncilon Problems of Alcohol,with the specialaim to seekfundsto supportresearch on alcoholproblems. The firstsignificant grantit succeeded in stimulating was$25,000 fromthe CarnegieCorporation for a reviewof the biologicalliterature on alcohol.The grant went to New York UniversityMedical Schoolwith Norman Jolliffe as chief and medical director of the studyandKarl M. Bowmanaspsychiatricdirector.But an executive directorwas needed,and it was then, in 1939,that Jolliffewent up to the WorcesterStateHospitalin Massachusetts to meet with E. M. Jellinek,the chiefbiometricianof Dr. Roy Hoskins'neuro-
endocrine research proiectin schizophrenia. AndJolliffeluredJellinek awayfromschizophrenia into alcohol.We tookofficespacein the New York Academyof Medicine,becausethere we had the neededlibrary resources for the review, and we acquireda staff -a multidisciplinary team representing clinicaland experimental medicine,physiology, both clinicaland experimentalpsychology, both the psychologically and physiologically orientedbranchesof psychiatry,biometrics,and documentation. The review was more or lesscompleted-buthow was it to be published?Howard W. Haggardhad the visionthento foundan interdisciplinary periodical, the QUARTERLY JOURNAL OF STUDIES ON ALCOHOL, and in its firsttwo volumes,in 1940-41and 1941-42,the reviewpaperswere
published. It turnedout that we had reviewednot onlybiological literaturebut-mu]tisinfu]multidisciplinarians that we were-also
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psychological and psychiatricliterature.In fact, we couldnot resist a glanceat somesocial-economic materials.We even lookedat the popularlimericksaboutdrinking,and what that hasto do with biologycan be understood only undera truly wholisticinterpretation of the biological. Our grantwasexhausted, our reviewnot completelywrittenup, and the ResearchCouncil,far from gettinglarger fundsto support researches, was hardly able to raiseenoughmoneyto maintainits organizationaloffice and smallstarryWhat shouldwe do with ourselves? Now HowardW. HaggardinvitedJellinekto cometo Yale, completethe writing of the review, and engagein somefurther related (as well as unrelated) activities.Soon,at least five of the originalreviewstaff were workingat Yale. Alcoholstudiesboomed there.New staff were added-includinga sociologist, an educationist,anda doctorof iurisprudence. What wereall thesepeopledoing in a Laboratoryof AppliedPhysiology, mixed up with the physiologists, pharmacologists and biochemists whomthey now outnumbered?They were trying to find out the facts aboutalcoholuse, alcoholmisuse,and alcoholism,and they were under the spell of the grandconception:interdisciplinary. Of coursethey neededan organizationalformat and a name. Thus the Center of Alcohol Studiescameinto being,with E. M. Jellinekas its first director. How interdisciplinarywere we? A little-but more multi than inter. Jellinek,in the volumein which most of the reportsof the great literature review were collected,trenchantlyrenewed the emphasison the futility of trying to understand-muchlesssolve -alcohol problemsfrom the perspectiveof any one disciplineor profession (8). Underhisingenious leadership the multidisciplinary staff launchedout in many directionsat once,and they did talk to eachother,and in somecasesthere was cross-disciplinary influence. Sometimes the cross-fertilization
was extreme. It was illus-
trated in a funny story: A reportercame to the Center of Alcohol Studiesto learn-the 3The Councilwas disbanded,in 1949, on the initiative of its last president,Dr. Anton J. Carlson (the "grand old man of American physiology"), apparenfiybecauseit had becometoo dependentfor supporton the public-relationsbranchof the alcoholic-beverage industry.This circumstance had previouslycausedHaggard and Jellinekto severthe connectionof the QUART•.R•.¾ JotmNA•.OF STUDIES ON A•.COHO•. with the Councilas its official organ,althoughthe JotmNx•.had never receivedany financial supportfrom the Councfi.
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real causeof alcoholism.As he circulatedthrough the building, the physiologists explainedit to him in termsof sociology, the sociologistsin terms of psychology, the psychologists in terms of anthropology,the anthropologists in terms of biochemistry,the biochemists in termsof psychiatry,the psychiatrists in terms of physiology,and the documentalists in terms of uncertainty. Therewas cross-disciplinary influence,and there was alsosome indifferenceor resistanceto the "other"disciplines.One sectionof the Center was as nearly multi- and interdisciplinary as was humanly possibly:the documentation-and-publications division.We not only insistedon gatheringand processing into bibliographies and abstractsall the reportsfrom all disciplinesand professions, but we tried conscientiously to indexthe informationin suchways that the searcherfor knowledgefrom one disciplineor profession would find what shouldbe helpful, and enrich his perspective, even thoughit came out of an alien sourcewhich he would not ordinarilyhave consulted(9). Stubbornlywe persistedin publishinga QUARTERLY JOURNAL OFSTUDIES ONALCOHOL with articles rangingfrom physiologyto economicsto psychologyto genetics to historyto anthropology to law to educationto neurochemistry to sociologyto therapeutics,and so on without limit. It amused me to seea youngsocialpsychologist giggleas he openeda new issueof the JOURNAL and read the title on the first page-"Alcohol consumption by inbred mousestrains."I knew he would not read the article,but I thoughtit goodfor his soulto stumbleover this title and sufferthe suggestion that there might be a questionfrom a differentperspective.It annoyedme to discoverthat a neurophysiologist neverreadthe tableof contents beyondthe first onethird of the JOURNAL--because he had learnedthat all articlesthat might interesthim would occurin that part. I changedthe order of articlesin the JOtreNAL to a systematic even if seeminglydisorderedcycle.Now let him try to escapeat leaststumblingover thoseothertitles!The suggestion to split the JOURNAL in two--one for biologicalscienceand one for socialscience-hasbeen resisted. The Centerof AlcoholStudieswasmultidisciplinary andto some extent interdisciplinary. It had the ideology,and it was on the track.But it wouldbe an exaggeration to claim anythinglike an interdisciplinary success. For the mostpart the psychologists studied psychological problems,the biochemists biochemical problems, the sociologists sociological problems,and soon. Nevertheless there
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was one positivegain: Many-a-time,even if not every time, the kindsof questions the staff askedtendedto be deeperand richer becauseof the broaderand deeperperspectivederivedfrom interactionwith and criticismfrom membersof other disciplines;the designof studiesand interpretationof findingsoften showedthis enrichment. 4
In the realm of action,however,the multi- and interdisciplinary perspective wasemphatically manifestand beneficent.The Center of AlcoholStudiesfoundedthe first outpatientalcoholismclinics in whichmultidisciplinary teamswere to treat alcoholics with va-
rietiesof individuallysuitedtechniques, andwhereinterdisciplinary researchon alcoholismwas to be attempted.The Center founded the first SummerSchoolof AlcoholStudies,where all the disciplines and professions, none excepted,and includingAlcoholicsAnonymous,participatedin educatinga cadreof future researchers and activists.The Centersponsored, and in its early yearssupported, an interdiscipline-inspired organizationfor public education-what developedinto the National Council on Alcoholism.The Center
launcheda broad-perspective critiqueof existingschooleducational materialsand stimulatedtheir reform,partly by helpingto form an organizationof educators,the AmericanAssociationfor Instructionon Alcoholand Narcotics.The Centerinitiateda widely hailed industryprogramfor treating employedalcoholics-staff from at least five disciplinesand professions participatedin meetings to plan phasesof this activity. We had, then, someinterdisciplinarycollaborationon the actionsfront.But did we have a clearpositiveconception-interdisciplinary, broad, global,wholisticin perspective-ofthe nature of alcoholism? I think not. We knew that narrow conceptionswere untenable.When new etiologicaltheorieswere enunciated-and we publishedthem-that it was endocrinological, or allergic,or neurohumoral, or nutritional,or genetic,or genetotrophic, or metabolic, or psychogenic, or economic,or sociocultural, or behavioral, or existential, we privatelyfelt confidentin pooh-poohing eachone. From the same perspective,when new treatmentsor cures that were to be universallysuccessful were announcedfrom time to time, we similarlysmiledknowingly,and our skepticismwas invariablyiustifiedby experience. • More than this I will not claim, for I have been an insider, and the final judgment has to come from a less biased observer.
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It was a strangeexperienceat times. In spite of the strongly worded assertions by Haggard and ]ellinek-now recognizedthe world over as the {oremostauthoritiesin the field-that only an interdisciplinary perspectivecould have validity (10), one-sided hypothesizing and researches persisted.Thus, suddenly,came the pronouncement from a medicalresearcherthat the causeof alcoholismwas a hormonaldisorder,and he predictedthat within 5 yearsthere would be a chemicalcure which would enable alcoholicsto drink normallyagain.It was especiallyannoyingto me that the authorof this predictionshouldbe occupyingthe position onceheldby Norman]olliffe;andthoughI did notholdmy breath, I did patientlycountoff the years-1, 2, 3, 4 and 5. It is now several times5, but I stoppedcountinglongago.Out of the southwest camethe genetotrophic theory,by a great chemist,and we publishedits first announcement, but shakingour interdiscipline-influenced heads at the unlikelihood of it. From the midwest came a
masked-food-allergy theory, and we publishedthat too-though Jellinekinsistedthen, and again yearslater (11), that he could not even understandit. Our own circle too producedsomeinsufficientlywholistictheorizing-inthe psychogenic and sociocultural lines. Of course,we publishedthose too. Documentalistscould affordto be infinitelyliberal-indeed,we believedourselves bound to be. For we were under no obligationor pressureto formulate theories-onlyto documentthem,and hopethat out of a complete and adequatedocumentation wouldcomethe help, the means,the wholisticfoundationof knowledge,which someingenioussynthesizercouldsomeday useto producethe inspiredwholistictheory. The strangeexperience continues. One-sided, narrowhypotheses, single-discipline or single-profession oriented,continueto be produced.Medicine-oriented theoriesare in conflictwith sociologyorientedones.Thusthe recapitulation of the warningagainstsuch unlikelyeffortsis stillneeded.But the workof Jolliffeand Haggard andJellinekandtheirsuccessors at the formerYaleandnowRutgers Center of AlcoholStudieswas not entirely lost upon the world. For increasinglyoften, over time, we alsohear theorieswhich attempt to integratethe interdisciplinary knowledge,which showthe hallmarksof broaderperspective. • • Particularlynoteworthyis the Report of the CooperativeCommissionon Alcoholism (12) whose work and membershipwere not unconnectedwith the prior historyof the Center of Alcohol Studies.
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If I have thus far given most attentionto the Institutionwith which I was connected,it is not becauseof underestimating the work and contributionsof the other centerswhich I named, but because, owingto the directJolliffe-Haggard-Jellinek earlyinspiration and direction, the Center of Alcohol Studies became and remains a vital model of the sort of institute which can realize the
meaningand effectiveness of an interdisciplinary perspective. What has been outlinedthus far are somehigh pointsfrom a historyof 40 yearsof approaches to an interdisciplinary perspective on alcoholism and otheralcoholproble. ms. The fact that we have not yet solvedthe problem,not yet uncoveredthe truth, should not discourage anyone-noteventhosewho preferto think along monotonic lines.For alcoholism is socomplexthat,not surprisingly, thereis no widespread agreement evenaboutwhat it is descriptively. Thus,if these40 yearsof wanderingin the wildernessof confusionshouldhavejustpartlyliberatedus and partly educatedus in preparationfor new approaches, then progresshas been made toward ultimate goals. But now it seemsappropriateto sum up what I think has been learnedby way of an interdisciplinary-wholistic understanding of alcoholism, and I will try to outlineit. This conception, already suggested manyyearsago (13) but sincethen confirmed by additionalobservations and learning,restsuponthe theoriesand researches of many scientists-and someamateurs-inthe past 40 years,and it is not possible adequatelyto creditall of them. Here,then,is how,at thisstageof our knowledge, I think alcoholismmaybe conceptualized in wholisticperspective:
Thereis a sharplydistinctdifference amongindividuals-possibly amonggroups-indegreeof vulnerability(11). Whetherthe vulnerabilityis to behavioral or affectivedisordergenerally,or to alcoholism in particular,is uncertain. More likely,I think,the for-
mer;thatis,a general vulnerability. To thisvulnerability a genetic factormaywell contribute (14); but it mightbe a negative factor -that is, the geneticfactormay be onethat immunizes or makes the development of alcoholism, or the resortto alcoholism, difficult or unlikely,ratherthanonethatpositively increases vulnerability. Therelativefreedom of theJewsfromalcoholism hasbeenlargely attributed to sociocultural inhibition, but actuallythepossibility of a genetically determined deterrent hasnot beenexcluded by any evidence.
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Whetheror not a geneticsusceptibility or immunityobtains,an infant-rearingand childhood-developmental factorseemsdecidedly to be involvedin laying the groundworkof the ultimate psychologicalvulnerability(15, 16). The formthat thisdevelopment takes may well be that of excessive dependency(17, 18) or dependency conflict (19, 20). The evidencefor that characteror personality trait in alcoholism seemsrather strong,thoughnot yet conclusive or universal,anditsoriginin earlyexperience canhardlybe doubted. Next we havea combinedpersonality and socialdevelopment. Is occursin adolescence. It may be a continuation of maldevelopment in the psychosexual spherethat was initiatedalreadyin infancy or childhood.In somesocieties it may directlyinvolvedrinkingor other deviantbehaviors.Noteworthyis the fact that socialand culturalphenomena beginto play a significantpositivepart here. Thus,wheredrinkingby adolescents is forbiddenor discouraged, the alreadyvulnerableyoungmay now useforbiddendrinkingas a way of counteracting or compensating for the feelingsof inadequacy, or of insecureself-seximage. In that case, if the societal attitudesabout drinkingand drunkenness grant machismo-likeor
heroicrewardsfor outstanding capacityto drink, then thosewho are alreadymostvulnerableare speciallyset up for alcoholism. For in thesecircumstances, not only is heavydrinkingrewarded by peer-groupadmiration,but the heavy-drinking youth experiencesthe proroundest internalrewardfromthe drinking.This oc-
cursbecause of the magicalpharmacological propertyof alcohol: the drunkenpersoncan imaginehimself,feel himself,to be the
manly or womanly,heroicor charming,cleveror sophisticated personthat he thinkshe oughtto be. The insecureadolescent who experiences thismagicaldoublerewardfromdrinkingis likelyto resortto alcoholrepeatedlyin any of the circumstances that are troublousand problematic to the developingadult. And in that caseanotherfactorcomesintoplay: learningor conditioning (16, 21). The individuallearnsor becomesconditionedto resortto al-
cohol,unfailingly andevenreflexively, in amounts sufficient to overcometroublousself-doubts, whenevercertainsortsof problems
arise.Thus,if in theadolescent theywereproblems of relatingto the opposite sex,thenheavydrinkingin sex-related situations could
become theusualreaction. Butthe learned response canequally prevailif theoriginal problems werein general relatingto people, or in copingwith any sortsof practicalproblemsituations. More-
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over,by the rule of generalization, the useof heavydrinkingto relieve,or as an aid in copingwith, one sortof problemwill be followedby its usein meetingotherproblems. The process, and it may be a long process-Jellinek (22) estimatedthat it tookfrom5 to 10 or 12 yearsfor the averagedevelopment of full-blownalcoholism-bywhich an individuallearnsto becomean alcoholic,is itself a complicatedone. It is a reasonable guessthat the morevulnerablean individualwas to beginwith, whethergeneticallyor by childhoodexperienceand adolescent reinforcement, the more likely he is to graspat the glasscrutch and finally to arrive at the stateof helplessaddiction-confirmed alcoholism. We mustassume a rangeof vulnerabilityand reinforcive experience.Similarly,as Jellinekhypothesized(23), there is a rangeof societalpermissiveness, and, as Bacon(24) has hypothesized,environmental encouragement, all contributingto a society's rate of alcoholism. In a societywheremuchand heavydrinkingis accepted,asin France,the lessvulnerablemay developalcoholism and a highrate will result.In a societywhereheavydrinkingand drunkenness are discouraged, as amongthe Jews,only the most vulnerable will "make it" and the rate of alcoholism will be low.
But conflictaboutdrinkingwithin a societymay blockthe chances of the vulnerableto escape.For, indeed, not all the vulnerable make it-many sortsof significanteventsmay interveneto save them;and this is a vital consideration for the chancesof planned prevention.
To sumup: Thiscomplexhypothesis of the etiologyof alcoholism incorporatesa geneticor constitutionalfactor which imposesexceptionalsusceptibility or immunity;errorsof infant relationship
or childhood rearingand resultantpsychosexual maldevelopment witha possibly defective, especially hyperdependent or dependencyconflicted,personality trait; furthermisfortunein the form of misdirectedmaturationin the adolescent phase,especially if reinforced by internallywell-rewarded drinkingexperiences; anda subsequent learningor conditioning process,of possiblyyears-longduration, embeddedin culturallyandsocietallydeterminedmoresand conditionsand directions, with a negativebalanceof interpersonal relations;and,finally,the pharmacological properties of alcoholassuming a dominantindispensable rolein the individual's way of life. If the truth is anythingas complicatedas this, then no wonder that peoplein particulardisciplines and professions havemostly
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preferred to concentrate onjusttheirownlimbof thisblind-men's elephant. But if thisbeastis not a productof sheerfantasy-apink elephant-thenit may be an interdisciplinary-wholistic conception of the etiologyof alcoholism. And what, then, is the nature of the beast?What is alcoholism,
underthisconception? In the end,it is surelya disease-ifhelpless addictionto a drugis a disease, as I believe.At an earlierstageit may be the symptomof anotherdisease,if personalitydisorder severeenoughto causefunctionaldisablementis a disease,as I believe.At somestill earlier stage,the heavy drinkingor symptomaticdrinking(or alcoholabuse,if we shouldacceptthat pejorative term) maynot be diagnosable asdisease. Then it hasto be a form of misbehavior,or deviantbehavior,accordingto the perspective from whichone chooses to view it. In that case,we are not talking about alcoholism. Let us at least be clear about that. Alcoholismic
behavioris indicativeof disease(25, pp. xv-xxviii). Misbehavior with alcoholis an elephantof a differentcolor.This simpleclarificationcan help in determiningwhat needsto be doneabout differentpeople,how diverselywe may reactto themand help them in differentstagesof their troubles. What do we gain from a multidisciplinary-wholistic conception of alcoholism?
At a very minimum,the recognitionthat no one profession, no one discipline,no single-minded approach,can hope to deal with this condition.In sayingthis,I am recyclingold truths.But perhapsif we acceptthe underlyingwholisticperspective,we will be able wholeheartedly to resolvethe need for integration.And not onlytheintegration of therapeutic approaches. For toolongwe have paid lip servicealsoto the importanceof prevention,but our actionshavebeenresponsive-for unblamably humanereasons-chiefly to the needsof the catastrophevictims,thosewho are already alcoholics. We have soughtto createmoreand better repair shops, but we have not tried to initiate the era of prevention.And no wonder: we have not known how.
If, however,it is true that somepeople start vulnerable,and thenovera life-historyshowincreasing signsof their vulnerability, finally exhibitingthe prealcoholismic behaviorsof heavy and implicativedrinking (26), then can we not begin to identify the vulnerables-theimplicativedrinkersamong adults, the deviant behaversamongadolescents, perhapsultimatelyeven the uneasy
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and alreadyproblem-beset children?Must we not try to identify them?Isn't that the essenceof the public-healthapproach?And oncewe begin to performthe task of identifyingthe vulnerables, shall we stop short of trying to help them avert the danger?I think that if we try we shallsucceedin findingmeansof helping which will be acceptableto them as well as to the helpers. The interdisciplinary perspective, then,not only allowswholistic understanding but opensa gate to the Ultima Thule, the era of prevention.Too obviousto needelaborationis the fact that all the
disciplines andprofessions mustbe involved,and in an integrated program,both in testingthe parts and the wholenessof the etiologicalhypothesis,and in applyingthe actions,therapeuticand preventive,that its conclusions must invoke. Not enoughhasbeensaidaboutthe necessary integration.Frankly, I do not have a clearconceptionof how the disciplines can be truly integratedin performingthe studiesrequiredto verify the wholisticetiologicalperspective,nor exactlyhow the professions canbe integratedfor the first experimentalprogramsof prevention. ! suggestthat the wider teachingand adoptionof the wholistic perspective, and the better supportof researches and actionsin the truly multidisciplinarycenters,will result in the discoveryand developmentof effectivemeansof integration. REFERENCES
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