Healing Alcoholism

by Claude Steiner PhD

Introduction 

Return to home? 

 Since becoming an "alcohologist" (that's what we experts in alcoholism are called, I am not sure I'm flattered) I have noticed that alcoholism affects an amazing number of people in the USA. Every so often l randomly ask someone I meet whether their lives have been touched by alcoholism. The proportion of those who answer yes is truly amazing: between 80 and 90 percent. "My father, (mother, uncle, sister, brother) is (was) an alcoholic" is the most frequent reply. 

 Neighbors, business partners, and coworkers are often mentioned. Occasionally someone will report having been victimized by alcohol, as in the case of the woman whose husband was killed in a head-on collision with an alcoholic driving the wrong way on a one-way street. By the time a person has reached middle age, it is almost inevitable that he or she will have had at least one serious brush with alcoholism. Many will have to deal with it oftener and earlier in their lives, some will be born into it. And wherever alcoholism touches people’s lives it is a horrifying scourge as it destroys families, victimizes children and robs them of their health, their wealth, and often their lives. My experience is in the United States; I assume that what I found here is true in Russia for which this book is being specially edited. 

 It seems that we all have had that sudden recognition that someone we knew was crossing that nebulous line between a little too much drinking and alcoholism. We have all watched with horror the dilapidating alcoholic condition of a relative or coworker, witnessed the dreadful binges ending in hospitalization or experienced the sinking feeling of seeing a recovered alcoholic begin the slow but steady return into alcoholic hell. Or we may ourselves suddenly have the shocking realization that our once-easygoing drinking has become tough going, and that we have lost control over alcohol and feel powerless to do anything about it. 

Alcoholism is pervasive; but when we look at it from a certain perspective, we notice that alcoholism is just one component of a pattern of addiction to chemicals. Alcoholism is just the most prevalent and deadly such addiction, a case of untold million people's impotence in the face of a single powerful substance. The power of alcohol is awesome not only in numbers of people affected but also in the grip it has on individuals. It isn't unusual for an alcoholic who has been sober for ten or more years to return to his previous alcoholic state, as if no healing or improvement had occurred. For Alcoholics Anonymous this is taken as evidence that alcoholism is incurable; it is a disease that may go into remission, but which continues to develop and is inevitably activated by a single drink. 

 Many professionals who are familiar with alcoholism agree that there is no such thing as making a normal drinker out of an alcoholic. The views of A.A. are highly respected in the community, as well they might be; when the criterion is sobriety, AA has achieved more success than any other approach. In addition the AA based, twelve step approach has been adopted by a huge number of member-run support groups for relatives of alcoholics, sex, gambling, narcotics and other addicts which bring relief to a wide range of human misery, free of charge when nothing else that seems to work is available.

  Returning to alcoholism, until the late 1960’s the American Medical Association published a manual on alcoholism (((2))) in which AA's views were echoed. According to this manual, alcoholism is a: 

  “… highly complex illness… characterized by preoccupation with alcohol and loss of control over its consumption such as to lead to intoxication when drinking is begun, by chronicity, by progression and by tendency towards relapse.” 

  In complicated medical language, the above statement claims that alcoholism is not only an illness, but an incurable one. However, the problem with this claim is that the term “illness” has a very specific meaning. Using the medical definition,(((16)))) an illness is: 

    “…an interruption or perversion of function of any of the organs, or an acquired morbid change in any tissue of an organism or throughout an organism, with characteristic symptoms caused by specific micro-organismal alterations.”

   There is no evidence that alcoholism satisfies the definition of an illness. In fact, in the latest version of the DSM-IV Manual of the American Psychiatric Association, alcoholism is defined as:

    "Chronic alcohol abuse, dependence, or addiction; chronic excessive drinking of alcoholic beverages resulting in impairment of health and/or social or occupational functioning, and increasing adaptation to the effects of alcohol requiring increasing doses to achieve and sustain a desired effect; specific signs and symptoms of withdrawal usually are shown upon sudden cessation of such drinking."

  Notice that the reference to illness has been removed. And for good reason; take the example of a thirty-year alcoholic who has been sober for three years. He is in good health and there are no signs or traces in his bodily tissue of any illnes; no "interruption or perversion of the function of any of the organs," no "morbid change" or "micro-organismal alterations." Yet tomorrow he may go down to the corner bar, have a drink, and within a week be on a terrible binge and on the skids again; the alcoholism has returned full blown.

   Where is the evidence that alcoholism is an illness? I have seen none. Decades of scientific search for evidence of it have failed to produce convincing-let alone conclusive-proof. 

 It is an A.A. dogma that alcoholism is a disease; some members insist that it is an allergy. To support their contention, they cite the fact that some people react violently from the very first drink in the same manner in which allergic people react to penicillin, poison oak, or pollen; one sip of the stuff produces a violent response and complete drunkenness follows.

  But the similarity seems overdrawn; the reaction is like no other allergy. Allergies result in a systemic reaction to a minute quantity of the allergen. A minute quantity of alcohol is not likely to produce a reaction in an alcoholic. The incapacity to stop drinking after even one drink could be called a systemic reaction to alcohol, I suppose, but if alcoholism is an allergy, it stands alone among all the others, invented especially to prove that it is a physical illness.

Instead it seems that some people are constitutionally hyper-sensitive to alcohol just as red-haired Caucasians have a genetic sensitivity to the sun. People's reaction to chemicals and drugs are different from each other, and these differences have a genetic component. But who becomes alcoholic and how it happens is not only genetic or purely physical-nor for that matter is it especially just psychological. 

 To say that alcoholism is an illness is to say that it has an exclusively physical basis. In this sense, as Thomas Szasz points out, the word "illness" is used as a metaphor here; such as when the President of the United States says that our economy is ill, or when Martin Luther King said that racism is a disease that infects all of us. It may be beneficial for an alcoholic to be told that he is not a common drunk, but is ill instead. A person would surely prefer to be taken to a hospital to have her illness treated than to be thrown in the drunk tank as a criminal.

In fact, the concept of alcoholism as an illness was introduced partially in the same humanitarian spirit in which the concept of mental illness was invented-as an effort to clean up the public image of the mad and inebriated, and in order to convince the authorities that the treatment they were getting as criminals was inhumane and counterproductive. This was a definite service to those who were plagued by these afflictions. But it is not accurate to call the mad and inebriated ill, for the most part, and therefore only partially helpful because it is only, at best, half true. 

However, not all the motivation for the "medicalization" of alcoholism and emotional disturbance is benign in intent. Another motive is what has been the tendency of the medical industry, strongly backed by pharmaceutical interests, to include more and more aspects of human affliction under its control. Under the influence of this tendency. everything that goes wrong with people-depression, alcoholism, drug abuse, gambling, sexual problems, and unhappiness of all sorts-should be looked after by a physician and treated with drugs. This makes doctors, drug companies, and druggists happy, but it is not so good for the recipients of the treatment because drugs are notoriously ineffective in the treatment of alcoholism. To compound the problem, some of the difficulties which have been taken over by the medical establishment (alcoholism, schizophrenia, depression) have been declared "incurable" because no one (especially not physicians) seems to know what to do about them except to drug their victims for temporary relief. 

Accordingly, the Manual on Alcoholism recommends that it be treated in much the same way as are other chronic and relapsing medical conditions (in which) the aim of treatment is then viewed more as one of control than cure. In plain English: Alcoholism is incurable the best that can be done is to control it and make the patient comfortable. 

Any professional that goes along with this understanding of alcoholism will be badly prepared for dealing with a person who has a drinking problem. What could be more depressing than to treat someone with the mere purpose of control rather than cure? Actually, most professionals shudder at the idea of adding an alcoholic to their clientele. Alcoholics are undisciplined, they don't pay their bills, they call at all hours of the day and night, and are insulting and insensitive to other people’s feelings and needs. They don't listen, they don't follow treatment plans, and they are discouraging and depressing clients.

 But the confusion about alcoholism is even more serious than that. The opposition to the view that alcoholism can be cured is massive. Denying that there are cures tends to cut off interest in those therapeutic approaches that might work. In addition, there is evidence that when the therapist expects a client to fail in therapy, failure does occur. Frank has demonstrated that expectancy and hope in the therapist, when transmitted to the client, is a powerful factor which determines the outcome of the therapy. Hope as opposed to resignation is a powerful factor in healing. 

I believe that alcoholics are neither incurable nor ill (unless they are in the midst of withdrawal or have liver disease or some other alcohol-related illness), and I say so to the people I work for. This belief is the first in a series of reasons which help me be an effective therapist for alcoholics. In addition to expecting success, I have learned with the help of my clients, colleagues, and friends what to do to help the alcoholic stop being an alcoholic. This book presents views and approaches to the problem, which I have developed over the years. Although the book often speaks of therapy, and could be thought irrelevant to people who are not therapists, I believe that all readers can profit from these insights, which can be applied by therapist and non-therapists alike and will work with alcoholism as well as other emotional problems. 

 

 PART ONE: WHAT IS ALCOHOLISM?

 Chapter 1. The Alcoholic Game

If alcoholism is not a disease, then what is it? I believe that the simplest and yet most valid definition of alcoholism is that it is a very bad habit. The habit of alcoholism can be acquired in a number of deferent ways. Not all alcoholics are the same, and they become alcoholic in different ways and for different reasons. There seem to be three major reasons for alcoholism.  

The first is physical or physiological, based on the fact that alcohol is a very powerful mind-and-body-altering drug, effective in reducing anxiety and generating feelings of well-being but also, most importantly, addictive. Addictive means (a) that, as you drink more and more, you will need more and more alcohol to get the same effect, and (b) that when you get addicted, you will get physically sick (withdrawal sickness) if you stop drinking for any length of time. 

The second reason is social. People become alcoholics because drinking is taught and promoted by parents, relatives, coworkers, advertising and folklore. It is always present when people are having fun and relaxing. It is often required as part of the public-relations aspect of being employed. It is heavily pushed by billions of dollars in the advertising media. It is generally tolerated and even encouraged by the whole society.

Third, people acquire the bad habit of alcoholism for psychological and emotional reasons, because very often drinking is the simplest, most effective solution available for coping with personal problems. People are often confronted with a life situation for which they have literally no visible solution. We do not enjoy the state of powerlessness we experience when we cannot solve our problems; for some, drinking blots out perceptions of powerlessness and anxiety. It gives a sense of well-being, detachment, and power which is, in effect, an excellent short term solution for the situation at hand. 

There are a few other reasons why people drink. When properly prepared, alcohol is a delight to the palate. Alcohol also has some definite, beneficial medical effects. But people who drink for taste or medicine can get just as addicted as those who drink for less wholesome reasons. 

The Alcoholic Game.

People have played "games" for a long time, but Eric Berne was the first to analyze and diagram the games that people play. In his best-seller, Games People Play he described a number of games. Included among them, under the heading of "Life Games" was the game of "Alcoholism." 

A game is a repetitive transaction, with a beginning, middle and end, which has a covert motive, or payoff. Alcoholism, as a game is a repetitive pattern (as we all know) which has identifiable beginning, middle, and end stages, and which is played by the alcoholic for important reasons that are not entirely obvious to himself or the observer. 

A game is a set of transactions between people. The different people who play the game will take roles in the game but for all who play, the payoff is strokes. According to Berne, the roles of Alcoholism are: It (the Alcoholic), the Rescuer, the Persecutor, the Patsy, and the Connection. Berne pointed out that people who play one role in the game will usually take another role sooner or later. It is important to remember that a game is a social event. Accordingly, the alcoholic needs to recruit into his life people who are willing to interact with him so that the game can go through its several stages (the beginning, middle, and end) Without others to play the different roles of the game, the alcoholic could get only to the first transaction and would have to stop. This important concept-that it takes two (or more) to play a game-is one of the contributions of Transactional Analysis game theory to the understanding of human behavior. 

 This is Eric Berne's description, of the game of Alcoholic in Games People Play, (edited and abridged):

  "In game analysis there is no such thing as alcoholism or "an alcoholic" but there is a role called the Alcoholic in a certain type of game. If a biochemical or physiological abnormality is the prime mover in excessive drinking-and that is still open to some question-then its study belongs in the field of internal medicine. Game analysis is interested in something quite different-the kinds of social transactions that are related to such excesses. Hence the game "Alcoholic." 

In its full flower this is a five-handed game, although the roles may be condensed so that it starts off and terminates as a two-handed one. The central role is that of the Alcoholic-the one who is "It". The chief supporting role is that of Persecutor, typically played by a member of the opposite sex, usually the spouse. The third role is that of Rescuer, usually played by someone of the same sex, often the good family doctor who is interested in the patient and also in drinking problems. In the classical situation the doctor successfully rescues the alcoholic from his habit. After the Alcoholic has not taken a drink for six months they congratulate each other. The following day he is found in the gutter. 

The fourth role is that of the Patsy, or Dummy… In literature this is played by the delicatessen man who extends credit or gives him a sandwich on the cuff and perhaps a cup of coffee, without either persecuting him or trying to rescue him. Sometimes the Patsy slides over into another role, which is a helpful but not essential one the Agitator, the "good guy" who offers supplies without even being asked for them. "Come have a drink with me (and you will go downhill faster.)" The ancillary professional in all drinking games is the bartender or liquor clerk. In the game of Alcoholic he plays the fifth role, the Connection, the direct source of supply and the one who, in a way, is the most meaningful person in the life of the addict."

Berne continues:

"In the initial stages of "Alcoholic," the wife may play all three supporting Roles; at midnight the Patsy, undressing him, making him coffee and letting him beat up on her, in the morning the Persecutor, berating him for the evil of his ways, and in the evening the Rescuer, pleading with him to change them. In the later stages, due sometimes to organic deterioration the Persecutor and the Rescuer can be dispensed with, but are tolerated if they are also willing to act as sources of supply. The alcoholic will go to the Mission House and be Rescued if he can get a free meal there, or he will stand for a scolding, amateur or professional, as long as he can get a handout afterward. Present experience indicates that the payoff of "Alcoholic" (as is characteristic of games in general) comes from the aspect to which most investigators pay least attention. In the analysis of this game drinking itself is merely an accidental pleasure having added advantages, the procedure leading up to the real culmination, which is the hangover. It is the same in the game of Schlemiel; the mess-making, which attracts the most attention, is merely a pleasure-giving way for White to lead to the crux, which is obtaining forgiveness from Black. For the Alcoholic the hangover is not as much the physical pain as the psychological torment.

The transactional object of the drinking, aside from the personal pleasures it brings is to set up a situation where the Child can be severely scolded not only by the internal Parent but by any parental figures in the environment who are interested enough to oblige. Hence the therapy of this game should be concentrated not on the drinking but on the morning after, the self-indulgence in self-castigation. There is a type of heavy drinker, however, who does not have hangovers, and such people do not belong in the present category."

In conclusion, Berne writes:

"The psychological cure of an alcoholic also lies in getting him to stop playing the game altogether, rather than simply change from one role to another. In some cases this has been feasible, although it is a difficult task to find something else as interesting to the Alcoholic as continuing his game. Since he is classically afraid of intimacy, the substitute may have to be another game rather than a game-free relationship. Often so-called sober alcoholics are not very stimulating company socially, and possibly they feel a lack of excitement in their lives and are continually tempted to go back to their old ways. The criterion of a true "game cure" is that the former Alcoholic should be able to drink socially without putting himself in jeopardy. The usual "total abstinence" cure will not satisfy the game analyst. 

Nevertheless, Alcoholics Anonymous is still for most people the best initiation into the therapy of over-indulgence.

I have included this long statement for several reasons. I was Berne's disciple and am deeply affected by his point of view. In addition this passage illustrates Berne’s provocative, and at times zany style which made his writing world famous but has also caused transactional analysis to be viewed by some as lacking in rigor and professionalism.

The reader will note that within the text of this quotation, I have highlighted a sentence which created a veritable furor in the field of alcoholism.

The criterion of a true "game cure" is that the former Alcoholic should be able to drink socially without putting himself in jeopardy

This statement has generated a lot of ill will from people who believe that alcoholism is an incurable disease. It states that alcoholism is a game, not a disease, and that if an alcoholic gave up the game, he would be able to drink socially without putting himself in the danger of reverting to alcoholism. This is a radical statement indeed. To many alcohol workers, especially those who have an allegiance to A.A., this is an extremely alarming point of view. I have debated this issue far and wide, and I find that when I get a thoughtful rather than irrational response the fear is that a person who has attained an uncertain sobriety may hear or read Berne's (or my) statements and derive from them a false hope which could precipitate a binge. I can well understand this concern. It is very valid because that danger is very real. 

 But Berne does not say that alcoholics can continue to drink safely. He is saying that if you give up all the social maneuvers of the game of Alcoholic, you are no longer an alcoholic. There is no suggestion that someone who is still playing the game --could or should be drinking socially or otherwise. 

This is admittedly a self-sealing argument that cannot be disproved. "Alcoholism is a game, if you are not playing the game you are not an alcoholic and you can drink socially." Notice that it is very similar to A.A.’s "alcoholism is a disease if you have the disease you are an alcoholic and cannot drink socially." Neither argument is very convincing.

The phrase "drinking socially" is very important phrase in this discussion. Social drinking is a specific form of drinking. Having a couple of cocktails before dinner, some wine with the meal, and a snifter of after-dinner liqueur does not qualify. Having five or six glasses of vodka at a party or a six-pack of beer during a hot afternoon is not social drinking. Social drinking, I am sure you will agree, is more properly a glass of wine during dinner or a drink before dinner or a couple of beers at a long party or a thimblefuls of liqueur after a hearty meal. Social drinking is done for the taste of the alcohol and for the slight heady feeling that usually accompanies it in small amounts.

What goes under the rubric of social drinking is often self-medication and also the first step-if not a more advanced stage-of alcoholism. 

Finally, Berne's statement does seem to imply that a former alcoholic has to drink socially in order to prove that he's not an alcoholic anymore. Yet, I believe that what he meant was that the only way that an outsider can judge whether an alcoholic is really cured is if the alcoholic is able to drink socially. In this light, therefore, Berne's statement can be rewritten as follows: "Alcoholism is not an incurable illness, but a game, therefore it can be given up. One test of whether a person is no longer an alcoholic is if he drinks socially-that is, ceremonially-without embarking on a new cycle of drunkenness." 

Those are, as best as I can reconstruct them, Berne's views. My views, while based on Berne’s, differ in important ways; "Alcoholism is a game and also a physiological addiction, usually both. The evidence is that some (a few) people who fit the definition of alcoholism are no longer physiologically addicted nor playing the game and have gone back to social drinking while the majority are unable to, or choose not to, return to drinking at any level."

I will elaborate on my views in the next chapter.  

 

  Chapter 2; Can the Alcoholic Return to Social Drinking?  

My answer to this question is less important that it may seem, as you will see as you read on. Yet, it is a question that plagues alcoholics and those around them and I feel obligated to respond to it and put it to rest so we can go on to helping the alcoholic overcome his affliction.

AA's answer the question is a categorical and resounding: "No!" My answer is "Sometimes." The very factors that have made A.A. successful, have also caused it to become a dominating and sometimes overbearing force in the field of alcoholism where its ideology is dominant. Alcoholics who are not attracted to A.A. are lost sheep who have strayed, outcasts from the fold. People who have drinking problems and who come in contact with the courts or other public institutions, but who are not willing to relate to A.A. will have a great deal of difficulty getting help from people who can affect their lives. Alcoholism workers who do not accept A.A.’s total program will find that they have difficulty finding work. Their own ideas or suggestions will not be welcome in clinics or other institutions. People will find it difficult to function effectively as alcohol workers unless they are willing to bend to A.A.’s doctrine. In short, A.A. is an organization which, because of its unequivocal success in working with alcoholics, has unwittingly become a pervasive influence in the field.  

Lately however in the alcohol and other drugs and chemical dependency fields there is a new doctrine taking hold; "harm reduction." This point of view is based on the awareness that the total abstinence approach of A.A. is actually very limited in its success. Long term studies have shown that only between 10% and 20% of alcoholics that pursue sobriety through A.A. maintain it over more than five years. 

Consequently a different new approach is being pursued which seeks to persuade the substance abuser to control drinking by gradually learning  behavior which reduces the harm caused by substance abuse rather than stop all at once. Research done about this approach suggests that controlled drinking has success comparable to A.A.’s and it is therefore being offered as an alternative to A.A.’s. However this has become a political as well as scientific controversy and both sides vehemently question each other’s research. (See Engs, 1990) For me, what is significant is that even the opponents of the harm avoidance approach accept the evidence that a few (about 10%) of confirmed alcoholics return to controlled, long term drinking which undermines the idea that alcoholism is a incurable disease. 

The point of view which I present in this book is different from A.A.’s or harm reduction though it partakes of both.

Almost every alcoholic I have worked with has wanted at some point or another to test his or her ability to drink socially. I have found that some former alcoholics who have remained sober for at least a year while actively involved in therapy with me have been able to go back to social drinking.

After a year or more of sobriety and feeling strong clients have often asked what I think about their trying to drink socially. My usual response is one of great caution. I explain that I believe it is risky, but I cannot say that there is an automatic, inevitable, fatal, consequence from social drinking. That simply does not conform to my experience. Alcoholics who have experimented with drinking after a year of sobriety while in therapy with me have fallen into one of three groups: 

1. This group-the largest by far-discover that they are unable to drink alcohol at any level, and that the inevitable result of having even one drink, is that ultimately their drinking goes out of control and becomes harmful. 

2. People in this group discover, as they experiment with social drinking, that they are uncomfortably drawn to alcohol, that their intake increases slowly and imperceptibly, and that their thoughts become more and more involved with alcohol in that pattern we are all so familiar with. Their drinking becomes "controlled alcoholic drinking." Usually the members of this group decide that drinking is not for them, that it involves too much of a daily struggle and stop drinking without incident or harmful aftereffects. 

3. People in the third and smallest group discover that alcohol is no longer an obsession. It no longer becomes a progressive compulsion and they are able to simply take an occasional, enjoyable, social drink without any dire consequences. My estimate of the size of this group agrees with Armor's findings of between 10 and 20 percent of all alcoholics in treatment. 

 I believe that people who have once been powerless in the face of alcohol can change their lives. Helping them become the kind of people who can look at the forces that affect them and who can decide what they want and don’t want to do, what to put into their mouths, is the aim of my work. I believe that I've been successful in helping many people achieve that goal; a few of them to the point of drinking socially. For some of them this discovery is trivial and no longer holds the fascination it once did. Others in this group are proud of their accomplishment. 

  Most people who have succeeded in becoming ex-alcoholics while working with me have control over alcohol and will not let it destroy their lives. Many of those people discover that even though they haven't had a drink for many years, alcohol continues to hold a strange physical and mental fascination, which increases greatly if they have even one drink. Still they are able to stay away from alcohol without incident or difficulty. 

Past habits are like old ruts on a road, they remain a part of you, and once you fall into them, they are very hard to get out of.  Drinking becomes automatic behavior; once you take step number one, step number two tends to follow, step number three becomes easier, and step number four becomes almost inevitable. 

 In his excellent monograph, The Emergent Comprehensive Concept of Alcoholism James Milam points out that evidence indicates that alcoholics experience certain improvements in mood and mental and motor skills when drinking which are not experienced by non-alcoholics. This effect, combined with the pressures of habit, would make the attempt at social drinking extremely difficult to control; people who were once alcoholics are playing with fire when they try to drink again. 

Still, without a doubt, occasionally, people who fulfill the definition of alcoholism return to social drinking and continue to do so without incident. This has been amply documented by research. Anyone who wishes to is free to argue that they were not alcoholics to begin with. While that seems a self-sealing argument, it may actually be right in a particular case. It is important to deal with each person's experience with alcohol separately, rather than lumping all alcoholics together. 

I have heard it said repeatedly that by writing and speaking about even the remotest possibility of drinking for former alcoholics, I am endangering the sobriety of the tens of thousands who would go down the drain if they tried this method. I recognize that a person who is an alcoholic and who has been sober for years might pick up this book and after reading it might have a drink, and then go from there into an alcoholic binge. It is not my intention to create that situation, but I must tell the truth as I see it, and that is more important than shielding an unknown human being from the possible potential risk that my ideas might provoke. 

 In the history of ideas, many valid ideas have been considered dangerous. But ideas are primarily correct or erroneous, rather than safe or dangerous. I would like my ideas to have some breathing space next to AA’s ideas.

 That alcoholics can return to social drinking is, however, not my main point. My main point is that alcoholism is not incurable and can be healed and that a person who was once an alcoholic is not permanently tainted for life with a dread disease. 

 Chapter 3: Games and Roles 

 In Games People Play, Eric Berne pointed out that people engage in repetitive, harmful social interactions which he called games. One of the games he described (as shown in Chapter 1 above) is "Alcoholic." Each game has different roles, and he noted that the game of Alcoholic had five: the Alcoholic, the Persecutor, the Rescuer, the Patsy, and the Connection. 

It has become clear, however, that Alcoholic can be best understood in terms of only three, rather than five roles: the Persecutor, the Rescuer, and the Victim. All three roles are alternatingly played by the alcoholic and everyone in his circle.

This very helpful simplification of the game roles was made possible by the theory of the Drama Triangle. Dr Stephen Karpman perceived that of the many roles and switches between roles which are common in games, three main roles and the switches between them are at the root of dramatic developments in life. He arranged the three roles of Rescuer, Persecutor, and Victim in a triangle to symbolize the switching that occurs between them. The drama triangle is a brilliant schematic of the futile and mechanical merry-go-round in which people are trapped when they play games. 

  P R

 

 

V

 

   Figure 1

  The Drama Triangle

 Life can be lived genuinely, or it can be lived as a stage play in which everything is fiction. The three dramatic game roles-the Persecutor, Rescuer, and Victim-are melodramatic simplifications of real life. We see ourselves as generous rescuers of grateful or ungrateful victims. We see ourselves as righteous persecutors of the wicked or as victims of wicked persecutors. Playing any of these roles, we lose perspective of the realities that confront us. We abridge the complexities of real life and like actors on a stage who know that their lives are not real but must pretend that they are, we put on a good show. 

   Especially dramatic are the sudden changes which are caused by the switches between the roles. We never remain long in any of them: the sexual predator falls in love and gets jilted; the loving wife divorces and ruins her insensitive husband, the oppressive boss becomes a downtrodden worker; the doting parent becomes a victim of her children. 

The drama triangle is clearly illustrated in the game of Alcoholism. Consider the following typical case report: 

Intake Interview:  

Mr. S, white, male, 39, married, three children, employed, comes to the alcoholism clinic seeking help. He fears that he is going to lose his job, his wife has threatened to leave him. He has just received a drunk-driving ticket. He is shaky, contrite, tearful, frightened and eager to be helped. He readily agrees that he is an alcoholic, that his drinking is out of control, and that he needs to stop drinking completely. He has tried AA before and found it "too dogmatic." He agrees to attend group therapy sessions once a week and to give AA another try and attend a meeting twice a week. 

Case History:

 At the first group meeting, he discusses his drinking history, describes his relationship with his wife and family and speaks about his work as a draftsman. He says he loves his family and enjoys his job and swears that he has stopped drinking once and for all. At the second meeting, Mr. S is quite changed. He hasn't had anything to drink for ten days, is cheerful and full of confidence. He had his day in court, pled guilty to drunk driving, and was diverted to a treatment program and participate in psychotherapy and attend AA meetings. His job seems secure, and his wife and children are happy with his changes. He thanks the therapist for his help. 

 During the next several group meetings, Mr. S seems to be in very good shape, reports his progress, and has nothing in particular to talk about. He doesn't feel that there is anything worth discussing in his own life at this time but he becomes very active giving advice to another member of the group, Mr. T who is having problems with his wife. Mr. S is convinced that Mrs. T has a drinking problem and urges Mr. T to confront her. 

 After a month of therapy, the therapist becomes a little suspicious of Mr. S's detached behavior and attempts to probe into some of the developments in his life. Is he getting along at work? Is he depressed? How is his family life? Mr. S becomes defensive and says that he is convinced his problem is solved. He is coming to therapy only because it is a condition of probation and because he promised his wife. 

 The next week, Mr. S misses his session. That evening the therapist is awakened at 2.00 A M by an emergency call (relayed by the therapist's answering service) from Mrs. S. Evidently Mr. S has been drinking and has just left the house and driven away after an argument in which she brought up divorce. While Mrs. S is talking on the phone, Mr. S returns and wants to know whom she is speaking to. When he finds out that she is speaking to the therapist, he becomes even angrier. At first he refuses to come to the phone, but eventually does and promises the therapist to stop drinking and go to bed. 

 Just as the therapist is falling asleep the phone rings. Mrs. S, scared and angry, reports that Mr. S has shoved her and has left the house again. She seems to be blaming the therapist for the situation. The therapist tries to smooth the waters and goes back to bed  but can't go to sleep for several hours. The next day at the clinic, Mr. S appears bleary-eyed and shaky; he has missed work for a couple of days and things are worse than when he first came.

This time the therapist notes certain erratic inappropriate affect in Mr. S and comes to the decision that Mr. S 's alcoholism is a cover for a latent psychosis. He refers Mr S. to the clinic's physician, who prescribes Thorazine and Antabuse. Mr. S doesn't want to take Antabuse, but is happy to take Thorazine and to get some vitamin shots. He promises to stop drinking and to come back to the group and resume therapy. 

 At the staff meeting the therapist and the clinic’s physician discuss Mr.S's case. They are both cynical and somewhat bitter. The therapist decides to drop Mr. S from group therapy if he misses any more meetings, and the physician jokes: "Bet you a lunch that his sobriety doesn't last more than two weeks." (He would have won the bet.) 

 This is a typical story, which has surely repeated itself around the world millions of times. It is a melodrama, rather than a drama, because it is suspiciously emotionally overdrawn. Yet, it appears to have all of the characteristics of real life. The roles of Victim, Persecutor, and Rescuer are defined, and Mr. S moves from one to the other with ease; at first, during the intake interview, as the pathetic Victim to the therapist's Rescuer, next, the Rescuer to the therapy group members, the Persecutor who beats his wife and harasses the therapist with midnight emergencies, and then again the hopeless Victim of alcoholism and now of the disappointed staff of the clinic. 

 The therapist is equally involved in the melodrama-first as the helpful Rescuer who takes on Mr. S’s treatment without a clear treatment contract, next as the confused victim in Mr. S's charade, next as the Victim of Mr. and Mrs. S's Persecution, then as the Persecutor when he considers dropping Mr. S from the group. The physician plays his part as the Rescuer and eventually joins the therapist in subtle Persecution as they decide that Mr. S is a hopeless, psychotic case. 

 This decision has dire consequences for Mr. S who now has a new dimension added to his diagnosis. Until his latest bout, his diagnoses was listed as "alcohol dependence (303.90) and alcohol abuse (305.00)" He now has a new number added: (298.90) Psychotic disorder not otherwise specified" To any future health workers looking at his file the fact that there is a psychotic diagnosis means: "Warning!; Psychotic; medicate and don't bother." The major negative consequence of this is that he will not be offered individual psychotherapy any longer (that could actually be a blessing in disguise) and that he will be treated with that special, subtle, Persecutory contempt reserved for those who are labeled psychotic. 

 Mrs. S is involved, too. First she threatens to leave him after months of attempting to Rescue him. Later she becomes the Victim when he is enraged at her and starts drinking again and she believes his denials. Then, when she realizes that he is drinking again, she becomes angry, persecutes him and the therapist, and so on and so forth, endlessly. As easily predicted, everyone in the alcoholic's circle plays one of the three roles sooner or later. 

 Games are dramatizations of life, yet the players of the game roles feel that their roles are real. The Rescuer feels that he is truly helping the alcoholic, and the alcoholic feels that he is a helpless Victim of alcoholism. When either of them becomes a Persecutor, they believe that they have a valid complaint and that their anger is justified. As they play their favorite games, people don't fully see how artificial, temporary, circumstantial their participation is in it. In short, they live their roles as if they were real and truly meaningful at the time. However, if one is not playing the game, one can see that the Victim is not really as helpless as he feels, the Rescuer is not really helping, and the Persecutor does not really have a valid complaint. Thus, the whole melodrama is basically phony-and it is necessary for an observer who wants to understand the situation to know this so as to not get caught up in it. 

 Alcoholism is a harmful game in a pathological life drama. In transactional analysis we call this life long drama the script. Anyone who wishes to really help an alcoholic needs to stay outside the scripted drama. This can be accomplished by refusing to play any of the roles-Rescuer, Persecutor or Victim-and dealing instead with the dreadful realities of alcoholism. 

Why People Play Games.

 Games are played for motives and "payoffs" not readily obvious to most participants or observers. But if what we see isn't the whole story, then what is actually going on?

What is really going on is in the case of Mr. S, as an example, is the he is becoming hopelessly addicted to alcohol and seriously damaging his health, that Mrs. S. is getting fed up and now hates him, that his children are afraid of him, that his boss has decided to fire him, and that his therapist has given up on him. Mr. S is terrified, feels rejected and alone, hurt and angry, and none of this is being acknowledged or discussed. Instead, Mr. S and his social circle play the game of Alcoholic over and over again. 

 But why is this happening? What are the reasons why people play games and stay in their harmful life scripts?

The simple answer is strokes. Let me explain. People need a certain amount of social contact. They want to be with other people. They want to spend time talking to one another. They want to have loving relationships with friends, their children, spouses, or lovers. People are hungry for positive recognition or what Eric Berne called "strokes." 

 A stroke is a unit of human recognition. Human recognition, affection, love, admiration, nurturing, physical contact, are essential for the psychological and physical health and survival of human beings just as is good food, clean air, water, shelter, and all the other basic necessities of life. For reasons I will discuss shortly, there is a scarcity of simple, straightforward human interaction which generates positive recognition. Because of this scarcity, people resort to other less wholesome ways of getting strokes.

We can be given strokes freely, we can obtain them in honest barter, we can buy them or we can coerce them by playing games. Games are devious, subtle manipulations to get the strokes or recognition, affection and attention that people need from each other.  

 When looking at the alcoholic and his circle playing the game, it is important to realize that even though the roles that are being played are constantly changing, one thing remains constant: all of the people in the game are involved in a series of transactions which produce much-needed strokes. 

People’s hunger for strokes causes them to seek positive strokes but it is a feature of human nature that negative strokes will satisfy stroke hunger as well. Unfortunately, games are much more productive of the negative than of the positive. When people play games they are opting for a form of stroke procurement which they are familiar with, but which, after seeming promising at first, ends supplying negative strokes instead. 

Most games are started with the best of intentions. The Alcoholic wants to have some fun, the Rescuer wants to help and trust, and the Persecutor wants to make sure that justice is done. After a few transactions, however, the plot inevitably goes sour and the situation becomes ugly, unpleasant and bitter. 

 Still, interaction does take place, and the players do get something out of the game. Even though the outcome is not as pleasant as it could be, there is a certain amount of human contact and strokes derived that makes playing the game worth the trouble. Because of this, people who don't know how to get strokes in a direct way will repeatedly approach the problem of stroke-hunger by playing games and, unless a direct way is shown and demonstrated to them, they will go back to the game approach because it is better than getting no strokes at all. People want love and warm fuzzies, but if they aren't available people will settle for anything negative strokes, pokes or cold pricklies. 

 Strokes can be compared with food. People who are sufficiently hungry will eat contaminated or spoiled food that they would not normally touch. Likewise, people will settle for the negative strokes of games when they can’t get the positive strokes of genuine interactions. How negative the strokes obtained are varies. 

Berne divided games into three degrees depending on how damaging the game is. First degree games are relatively harmless. Alcoholism is a second or third degree game. When the damage is mostly psychological as in the game "Drunk and Proud" (See Chapter 5)it is second degree, when the game includes tissue damage it is third degree (Wino, Chapter 6). 

Stroke hunger isn’t always obvious when we are on a steady diet of negative game strokes. Similarly, many people are accustomed to a diet of "junk food" which includes lots of sugar and fat. Though they are obese and overeat regularly, they are undernourished. Under these circumstances, they can be constantly hungry and yet, ironically, they will shun truly nourishing and healthful foods, which to them are tasteless and boring.

Similarly, people who are hungry for strokes will continually seek and consume "junk strokes" -- hostile, anxious, negative strokes and will actually refuse the more intimate, direct, loving strokes that might be offered and available to them. Because games, like eating junk food, are essentially bad habits based on poor learning experiences, they can be avoided and replaced with positive intimate interactions.

Intimacy is the most direct, open, sincere, and loving way of exchanging strokes. Even though we fundamentally want these kinds of stroke, we are worried about and afraid of them. We don't easily open up to others for that kind of extremely affectionate interaction and reserve the intimate strokes for our romantic, sexual relationships. Games fend off intimacy and isolate us from the strokes we really want. The pursuit of positive, intimate strokes is the best way to stop playing games.

 Let's look at three alcoholic games: Drunk and Proud, Lush and Wino. 

 

Chapter 4; Drunk and Proud

  As the title of this game implies, the D&P alcoholic is a drinker, and proud of it. For the D&P player, who is most often but by no means always a man, alcoholism is a way of asserting himself, by stimulating people around him who are willing to play along with the game. One way of playing along is as fellow alcoholics who encourage him in his foolishness or as Victims/Patsies (who believe every lie, go along with every absurd proposal, and continually come back for more.) Another way of playing the game is as Persecutors who are angry, mean, intolerant, and demonstrate with their behavior that they are certainly no better than the alcoholic himself. 

 D&P is often played by freewheeling salesmen and business executives with flexible working schedules and by working men of all descriptions, often with their wives (or mothers) as Rescuers and Persecutors. When drunk, a D&P player can make sexy moves with the secretaries, gamble away his paycheck at the poker table, and stay out with the boys without being held accountable. When his wife becomes jealous, nagging and eventually contemptuous he punishes her by getting drunk. The morning after, smiling sheepishly, he apologizes: “Oh boy, I feel terrible about this, honey. I'll try to be good from now on.”  His wife sees only two choices: either she accepts the apology, thereby becoming a dummy (Rescuer/Patsy), or she rejects the apology and becomes merciless and bitchy (Persecutor). Either way she senses that she is only making things worse and she is right. This behavior is called codependency by mental health workers and is recognized as counterproductive. Getting out of the game by refusing to play any of the roles is the only workable choice. Easier said than done; we will explore the options (also called game antitheses) available to the person who does not want to play the game in Chapter 14.

 The D&P player doesn't ordinarily miss any work-at least not more than anybody else does-and manages to keep everything going fairly well. He seldom hangs around the house to get drunk since drinking is just an avenue for misbehavior of another kind. He drinks and drives, drinks and gambles, drinks and cheats on his wife or beats her, drinks and lies. In fact, drinking is the continuous excuse and constant companion for every other form of mischief. If anyone tries to be helpful and speaks to him about his drinking problems he will get angry and defensive, and argue that he drinks for the taste of good liquor, that it is not harming him, that he can stop anytime he wants to, that it is necessary to drink to get ahead in his work, and so on and so forth. In fact, he will give all of the arguments that neutralize the assumption he has a drinking problem. 

 The D&P player does not believe, and will not admit, that he is an alcoholic. Thus, he almost never finds his way to a psychotherapist's office or AA on his own. When he does, often because his wife has threatened to divorce him, or because he is about to be fired or because a Judge or probation officer sent him there, he is likely to try to engage the therapist or group members as Rescuers Any therapist who misses this point and is willing to undertake therapy with a D&P player, without a contract or clear cut therapy agreement, or thinks that discussing childhood experiences or analyzing dreams will be of any advantage whatsoever, will expose herself to an inevitable and monumental disappointment. 

 Trying to help a reluctant D&P alcoholic with his drinking problem is probably the most frustrating and unrewarding experience that any helpful person could possibly have. It is essentially a hopeless effort, and it is in connection with D&P players that it becomes totally obvious that no therapist should undertake therapy with an alcoholic without an elaborate agreement or contract. I will discuss contracts in detail in Chapter 16. Suffice it to say here that a contract is a mutually agreed upon plan initiated by the alcoholic in which the therapist makes an offer to heal the alcoholic and the alcoholic agrees to participate fully in the process.

To illustrate the frustration of trying to work with a D&P alcoholic without a contract, let me tell you about the case of the Winking Patient. 

 Mr. Lavat, a 36-year-old D&P player, was preceded by his wife who came to see me, wanting to discuss what she could do about him. This was many years ago, in the days when I was still willing to elaborately discuss, with their partners, what could be done to help alcoholics. Nowadays, I know better. If someone who has an alcoholic in her life needs and wants to speak to me, I generally decline any lengthy discussion of what can be done to help the alcoholic, but rather insist that we discuss what can be done to help the advice seeker. With Ms Lavat, I suggested, after some discussion, that she threaten to leave him as a maneuver to get him to come into therapy. 

 She did, and consequently, one sunny morning, I was pleased to have him call me for an appointment. From the beginning, Mr. Lavat dealt with me in a jovial, friendly, “Hi, Doc, how-ya-doing, what's new with you? Can I smoke?” manner. Inexperienced as I was then, I assumed that he was interested in doing something about his alcoholism. After a brief lecture about the dangers, to me, of second-hand smoke we started the usual exploration of the “reasons” for his drinking. He was talkative and interesting, and we worked well together. He stopped drinking and continued to be sober as the weeks passed.

One day as I met him in the waiting room, he added a wink to his usual friendly manner. I noticed this but didn't comment on it, although it gave me a very clear-cut feeling of discomfort. Every week from then on, Mr. Lavat would meet me with a wink. This continued for several months, during which he continued to make "progress.” I never challenged the meaning of his winks or ask him directly if he was maintaining sobriety and continued to “do therapy.” 

 Then quite unexpectedly, I found out that Mr. Lavat had been drinking for several weeks. It turned out that at approximately the same time when he started winking at me, he also began drinking and had continued to drink between appointments. He probably stayed away from alcohol on the day of our meetings to hide the fact that he was drinking. Because of my inexperience, I did not pick up the clues (smell, skin tone, speech) which would not escape me today. Conned in such an obvious way, I felt quite foolish and realized that I had been playing Patsy in the game of Alcoholic. Mr. Lavat never returned for another therapy session, and I learned three important lessons: 

 * Never do therapy without a contract 

 * Inquire regularly about the client's drinking and maintain a reasonable level of suspicion about his sobriety. 

 * Clients who wink and use other subtle humorous gestures are often revealing that the therapist is in danger of becoming a foolish Victim/Patsy. 

 Alcoholics are difficult clients to begin with, even if they really want therapy. D&P alcoholics are usually simply not interested in being therapy clients at all, and most of the therapy done with them is a waste of time. A therapist who finds himself involved with a D&P alcoholic whose involvement he suspects of being insincere should probably take the first opportunity to suggest that therapy be discontinued. 

“Mr. Smith I think you have an alcoholic problem but you don’t agree. I am afraid we are wasting our time in these sessions. Let's plan to stop in a couple of weeks.” 

 If he accepts discontinuation, the situation is clear: the therapy was part of a game which has been stopped. If he becomes unsure and wishes to continue, the next step is making a “no drinking” contract. 

 Whenever a D&P player goes to a physician his attitude is usually ”Boy, I am not feeling well at all. I guess I overdid it a little. Just give me some sleeping pills and I’ll be OK.” This attitude is disconcerting to physicians, who think of alcoholism in terms of illness and fail to understand that alcoholism is a game and that the hangover is just a phase of the game in which the alcoholic is temporarily playing the Victim role. 

 To explain as Berne points out, the hangover, with its agonies, is an essential aspect of the D&P game. In it, the alcoholic believes that his misery absolves him of responsibility for his actions. He is allowed to make demands for remedies for his misery. Any judgmental or disapproving word from a helper will be seen as unfair and probably be answered with hurt indignation. “You call yourself a doctor? I am in pain!” This situation exemplifies the physician's dilemma. He's seems to be left with one of three choices: to be a Persecutor, to be a Rescuer, or, if he is less scrupulous, to simply be a businesslike Connection to drugs. 

 However, D&P alcoholics are seldom interested in hurting themselves irreversibly, since their main payoff comes from the strokes that come with the endless partying, the expression of their anger, and their sexual naughtiness.

When a D&P player begins to feel the ravages of alcoholism, he or she often stops drinking. This may take a number of years involving a series of unsuccessful attempts, but there are many people who were once alcoholics who have sobered up and haven't been drunk or had a drink or even drink socially for many, many years. They probably were D&P alcoholics who eventually decided to stop expressing their rebellious angry and sexual impulses via alcohol. It is as if D&P alcoholism is a behavior pattern of the impulsive, younger years, which, as the person becomes more mature is likely to be given up because of its ineffectiveness. This is what distinguishes D&P from the game of Lush, which will be discussed in the next chapter 

 D&P is a game of rebellion. It is one of a family of games, played on different territories, in which people rebel against the judgments of “holier than thou” players  (cleaner than thou, more productive than thou, thinner than thou, etc.) D&P is related to “High and Proud” the game of rebellious students around the world. All the games of this family are manifestations of reaction against oppressive judgments by others, and even though in some of its aspects it may be a self-damaging activity, it can also be an expression of a healthy rebellious aspect of the person.

In order to be helpful to any player in this family of games, it is necessary for the helper to recognize the positive motivation interwoven in the maneuvers of the players. It is useful to remember that positive social movements have developed from this kind of rebelliousness. “Black is beautiful,” “Gay is OK.” the women's movement, the Tianamen square uprising, and one might guess, all of the movements for liberation that began with people who rebelled against an oppressive social system. This rebellion which may be quite justified can also be impulsive, irrational and self-damaging, or destructive of others. 

 The DP player's anger and rebellion is somewhat justified. He is angry at being encouraged to drink on one hand and being judged for his drinking on the other, at being treated in a condescending manner and at having his addiction exploited by bar and liquor store owners and the alcohol industry. Like every other person a D&P player wants to be able to be proud of himself. The problem is that he is choosing drinking as a subject of his pride. To be adequately helpful, it is important to understand, and identify with, his desire for pride. The D&P player feels that he is justified and OK in his behavior, and he certainly is not going to listen to anyone who says that he is not.

The therapist's only hope is to agree with the D&P player that he is basically a good person but ask him to examine his drunken misbehavior and recognize how destructive of self and others it is. This is one of the major contributions of TA to psychotherapy; the therapist always approaches the client with the attitude that he is O.K. and that it is his behavior which is being scrutinized (and that only at his invitation.) 

 If al1 of the above seems to imply that I am saying we should not judge alcoholics and leave it up to them to do something about their problem, I am not making myself clear. This is my view only up to the point where the alcoholic hurts no one but himself. When his behavior damages others, it clearly must be responded to. But the response should not be to “do therapy,” unless therapy is requested and a contract is established. The response to irresponsible, destructive behavior should be fair, swift justice through the courts.  When the damage, as is so often the case, results in pain and hardship for relatives, friends, and even strangers, the response should be a fair one-such as rejection, anger, or an ultimatum.  

 Alcoholism is not an illness or a crime, but it can lead to both. When it includes illness, it should be referred to a physician for treatment of that illness. When it includes crime, it should be referred to the courts. When it includes neither, which is most often the case, it should be left to the alcoholic himself to choose what to do. The only thing we can do to help is not to allow ourselves to play the game as Victims, Rescuers, or Persecutors and to be honest and straightforward instead. How this is done will be explained in Part Three of this book.

Who is an alcoholic?

 One of the difficult questions in the therapy of alcoholism is whether any one player is in fact an alcoholic. D&P players, especially, hotly deny that they are alcoholics, and often take offense when the suggestion is made.  

 The following are typical examples of conversations with D&P players. Each one represents a failed attempt to make the point that he is an alcoholic. 

  The Blunt Approach: “Mr. Smith, as far as I'm concerned, you're an alcoholic.” “Well, that may be so. I've often wondered about it. Sometimes I think I am, but actually, I don't think so.” 

   The Sly Approach: “Mr. Smith, do you think you're an alcoholic?” (Implying that he is.) “No, actually, I don't think so. An alcoholic is somebody who can't control his drinking. But I control my drinking. I never drink before noon, and I can stop anytime. I never get a hangover. I'm a heavy drinker, but I hold my liquor very well, and I don't have a problem with it.” 

 The Argumentative Approach” “Yes, but last weekend you had a drink at 8AM Saturday morning.” 

“Yes but that was just because it was so hot and I needed a cold beer.” 

“Yes, but you looked pretty sick to me Monday morning.” 

“Yes, but that's because I had the beginning of the flu. Actually, I had a large glass of lemon juice with cayenne and vodka, which is the perfect remedy for colds.” 

“Yes, but you were staggering pretty badly when you came out of the party the other day.” 

“Yes, but a cup of coffee sobered me right up. I got home okay, didn't I?” 

 These examples are given to show that as long as one tries to prove the alcoholic wrong, very little will be accomplished. 

 The point is not to prove that he is an alcoholic, but to enlist him in a serious examination of the destructive aspects of his drinking. And that, of course, cannot be done unless the alcoholic asks for help, at which time he may be ready to examine his behavior carefully. If he asks the question, "Am I an alcoholic?”  my answer is, “If you really want to know, I'm going to ask you two questions. If you answer either of them “Yes,” then I believe you are an alcoholic. Do you want to try?" 

 I always make sure not to ask the questions unless the person is genuinely interested and I feel that the answers are going to be honest and clear. 

My first question is: “Do you suspect that you have lost control over your drinking? For instance, do you sometimes drink more than you want to, or do you sometimes drink at times when you don't want to drink? If the answer is yes, then you are an alcoholic." 

The second question is: “Do you feel that your drinking is harming you in any way? At work? Financially? In your relationships? In any other way?” “If so, you are an alcoholic. How severe an alcoholic depends on how out of control and damaging your drinking is, but if the answer is ‘yes,’ to either question then you are somewhere on the road from mild to severe alcoholism.” 

 I am very earnest about not diagnosing alcoholism except in this way. I'm not in the business of telling people that they are this, that, or the other thing. I have never been able to help anyone who didn't sincerely ask for help and who wasn't willing to recognize and analyze his own behavior honestly. Nowhere is the necessity to enlist the client's sincere involvement more important than in the therapy of alcoholism and other drug and chemical abuse.  

 Chapter 5: Lush 

The D&P player seeks strokes for his rebellious and angry behavior. The Lush player is depressed and needy; he seeks strokes by being a Victim.

Before I describe the game of Lush, I want to explain that I divide the alcoholic game into different sub-games in order to point out that all alcoholic behavior is not one and the same; all alcoholism does not come from the same personal motivation or historical origins. I believe that the distinctions between the three alcoholic games represent real and important differences in alcoholic behavior, and that they are useful in understanding alcoholism and not just catchy labels.

However I shudder when I hear people discuss other human beings with the easy abandon that is possible when using TA (or any other) labels. If you are going to use these ideas, please use them thoughtfully, respectfully, and, above all, don't use them as clubs with which to accuse others of "gamey" behavior or as amateur-shrinks-with-the-latest-word. 

 Even though they are different the game of Lush has the same basic motivation as D&P or any other drug-abuse game. It is an attempt to solve the difficulties of living through the use of a chemical. In the case of Lush, however, the specific feeling of the player is one of depression rather than one of rebellion, as is characteristic of D&P. I have observed that Lush is most often played by middle-aged suburban wives, or downtrodden, hard-working, white-collar employees. It is also played by socially anxious people, aging male homosexuals, by native Americans, and, in general, by people who, for one reason or another, are under a heavy load of oppression or difficult circumstances to which they have resigned themselves. 

 The despair and hopelessness associated with their condition is dealt with by using alcohol as a sedative and mood elevator which gets them high, helps them forget their troubles, and makes life's daily difficulties bearable. Whenever Lush is played, it is played in response to some sort of deficit whether it be sexual deprivation, chronic anxiety, loneliness, hunger, joblessness, or some other kind of hardship. 

 In its white, middle-class, North American version, Lush is often played by a housewife with a partner (usually a man) who has problems giving strokes. The alcoholic's continual drinking is to the partner's advantage, since as long as the drinking continues, his own emotional deficiencies and incapacities to be loving-which are his contribution to the game-will not be exposed. As long as the alcoholic drinks, the partner preserves the appearance of blamelessness, while both know that this is not true. Characteristically, the husband of a Lush player comes home late from work, anxious and drained, and avoids loving and sexual intimacy with the alcoholic though he may demand sex. In order to get some attention, the Lush player uses a common maneuver in such cases: making a mess of some sort. 

 There are a number of other games, all of which share making a mess in order to get some strokes. Often the disinterested, unloving partner comes home to a drunken wife who has not cleaned the house and failed to prepare dinner. He may try to ignore her drunkenness, but this can be done only for so long. Sooner or later he will fall into the Persecuting role, calling her names, perhaps going out to eat alone, cheating on her or even beating her. Or he may become the Rescuer, have long discussions with her about her drinking problem, take her out to dinner, or perform some other "helpful" maneuver, which he hopes will change the situation. But either way, the facts of his unloving behavior and the dreariness of her life continue, and the reasons for the drinking remain. 

When any kind of therapy or helping effort begins the Lush player will often stop drinking and make considerable progress . Whether it be Alcoholics Anonymous, a sympathetic physician, a brand-new friendship or a psychotherapist, almost any kind of change will bring about a temporary, apparent improvement in the Lush's drinking. This improvement is a response to the increased strokes that come with a new relationship. However the improvement is likely to be temporary and last only as long as the novelty of the new- found strokes continues. 

In the case of psychotherapy, the progress may be cut short just as the therapist thinks the client is well enough to leave therapy. Since the progress was based on getting strokes it becomes important to keep the therapy going-something that can easily be accomplished by going back to drinking. Therefore, a therapist who is unaware of this pattern, will be caught in a situation where basically he is replacing, usually for a fee, and usually not in a wholly satisfying way, strokes that the client is not getting in his or her personal relationships. For a therapist the initial phase in which the Lush stops drinking and seems to be making brilliant progress is a thrilling experience which motivates his interest and causes increased positive stroking interaction. In time the situation may become commonplace and the strokes may diminish. Commonly, at this point, the therapist will experience an intensified demand for strokes, on the one hand, and a relapse of the drinking every time the strokes are either withdrawn or not forthcoming in the amounts needed by the client. The same seesaw of improvement and relapse characterizes the relationships of Lush alcoholics with friends and relatives. 

 While D&P is a gregarious game, Lush is a solitary one. Often the Lush player drinks at home. However, on occasion, once under the influence of alcohol, the Lush player will leave the house to find a sexual contact wherever available. This is a shocking experience to the Lush's partner, since often a middle-class woman will go to a working-class bar where she hooks up, and sleeps, with an unknown truck driver.  The woman who would never consider having sex with a stranger while she was sober, is so hungry for strokes that she does so under the obliterating influence of alcohol.

 D&P tends to be a game that involves people as Persecutors, while Lush tends to involve people as Rescuers. But this tendency is deceptive because people who play a game, play all the roles in it, sooner or later. Even though the Lush player tends to seem to be a Victim looking for a Rescuer, he or she will play the Persecutor role and the Rescuer roles eventually as well-if ever so subtly. For example, the Lush may present herself to the therapist as needing help and being powerless and unable to do anything about her drinking. That is the Victim looking for a Rescuer. But if the therapist is inexperienced enough to indulge in a Rescue, this is likely to eventually anger the alcoholic who will feel patronized and ill treated. Then, in time, the alcoholic will Persecute the therapist in some way. One favored way Lush players persecute their therapists is to get drunk thereby proving that the therapist is ineffectual.  

 Of course, the therapist may in fact be ineffectual, but the therapist who in addition is playing the Alcoholic game will feel the brunt of his incompetence hit him over the head because the alcoholic-turned-Persecutor will make sure that it hurts. More subtly, the Lush player will tend to take up more than her share of the time allotted in group, make late night calls to the therapist’s home number, fail to do any work outside of the therapy hour. If pressured to behave more appropriately she will grudgingly comply for a time. This reluctant resistance comes from a sulking resentment against the therapist who is failing to help, and is a subtle form of Persecution. In time the therapist will get fed up and turn from Victim to Persecutor when he becomes unfriendly, irritated and dismissive in group and pretends he is not home when the alcoholic calls him on the phone.  

 Conversely, the Lush will play Rescuer to other group members or other alcoholics in AA or be very solicitous of the therapist, concerned about his health, inquire about his family, and protect him from her own anger and resentment by keeping it covered and underground. All of this will mask the fact that the reason why the Lush drinks has a lot to do with being deprived of strokes. The game, well played, provides the alcoholic with lots of strokes in the only way she knows how to get them; by drinking. And of course every time she plays the game she can say to herself: "Just as I thought. Nobody loves me." As we will see later this thought is the existential payoff of the game which supports the depressing, loveless script.

 

Chapter Six; Wino 

Two major qualities characterize the game of Wino. First:  Wino is an institutional game, involving the institutions of the neighborhood, county, and state. The Wino becomes involved with the police, the courts, the jails, the public health system, and the oppressive crush of the inner city. As a resident of the city slums, he becomes the victim of slumlords and merchants, street crime, and real estate redevelopment schemes. the game is "played for keeps." Second: A person who plays the game of Wino is willing to include, as a part of the game, the destruction of his body tissue; it is part of a self-destructive script.

As a rule Lush is the precursor of Wino. In the game of Wino, the alcoholic gains strokes by making himself into a "third degree," dangerously ill, Victim. He is willing to sacrifice his body integrity to the point of putting his survival on the line, which forces others to take notice, either as Persecutors or Rescuers. Under these circumstances, those who come to his aid as Rescuers basically facilitate his progress toward the soup kitchen or jail, where he will be fed and sheltered, or to a clinic, where he will be given medication and nursing care. The Wino in the active phase of the game is physically devastated thus forcing the government or charitable organizations to offer some kind of help. With every renewed game, the alcoholic obtains the confirmation for his Victim status. It's pretty clear that unless he is at death's door, the Wino player will be Persecuted; mistreated and ignore. Only under the most extreme circumstances can he get any official help.  

 To the Wino this clearly implies that those people who are in positions of strength and power and are supposedly concerned with his well-being are really not-OK. When he is finally so sick and devastated that he comes to the authorities' attention, they become Connections; professional suppliers of needed commodities rather than the source of any real help. Even the policeman who arrests him is really a Connection. A Wino's loud protestations when arrested should not prevent the observer from noticing that the Wino is getting his payoff and is basically pleased. The arresting policeman is just an official link to the hospital or to the jail dining hall. Winos often like to play a pastime called "Ain't it Awful?" and menta1-health workers will be well advised not to go along. That is not to say that mental-health workers should pretend that it isn't awful to be a Wino or that Winos are not mistreated, but that spending a lot of time in the pastime of dicussing how awful things are is not productive. 

 I witnessed and example of the duplicity of the Wino game in the following early-morning scene, at a large city’s court house: 

Wearily eyeing a score of assorted derelicts awaiting sentence, the Judge goes through the following dialogue with Alex: 

 "Alex-drunk and disorderly again…" 

 "No your honor, I wasn't drunk, I was just…" 

 "Okay, Okay, Alex, I know. Three days in the county jail" 

 Alex slams his fist into his hand ("Shit") spins around and winks and smiles at the row of waiting prisoners as he walks back to the jail door. 

 At the social level, it appears that Alex is being punished for breaking the law. In reality, Alex has once again managed to put a roof over his head-with the help of the judge. The judge chooses not to face his complicity and prefers to pretend that he is somehow administering justice, when, in fact, he is actually providing Alex with a secure situation for the next few days. 

 The conviction on the part of "sympathetic" observers of alcoholism; that alcoholics are the helpless victims of a horrible, incurable disease might seem justified to anyone who has witnessed a hard game of Wino. The very idea that such severe self-damage could be called a game brings out cries of protest from well-meaning observers. When transactional analysts claim that alcoholism is a game, we are not denying that it is serious, tragic, dangerous or horrible game. 

 We are saying only that since alcoholism is a game rather than a disease, a person can choose not to play. That may sound simple, but it is not intended to sound easy. Evidence shows that even the most severe Wino player is capable of stopping his self-destruction; the annals of AA and The Salvation Army are full of examples. If one believes that alcoholism is a choice then one can also believe that alcoholics can permanently change their life-for the better. 

 Thus, I recommend that in dealing with alcoholics, someone who wants to help should avoid incautious expressions of pity and sympathy that are more appropriate for the truly, severely ill and replace them with a nurturing, loving, but tough-minded understanding: that the alcoholic chooses his own destiny daily. Not that there aren't enormous and sometimes seemingly insurmountable difficulties for the alcoholic, or any addict but that the way out can be found-especially with the help of a wise therapist and some of the helping institutions, especially AA, which are available to alcoholics. 

 Especially to be avoided by any one who wants to be of help is that indulgent smile of warm understanding often given the alcoholic as he humorously relates his latest escapade. This smile and the merriment that often accompanies alcoholic’s accounts of their misdeeds is called the "gallows transaction" in ransactional analysis and it is an unwitting but powerful reinforcement of the alcoholic's self-destruction, equivalent to helpfully adjusting the noose around his neck.

Often, alcoholic workers feel that the least they can do is to have a sense of humor about the alcoholic tragedy and that a refusal even to smile is simply a lack of sense of humor or friendliness. But the refusal to smile at the alcoholic's tragedy indicates, once again, that the therapist has not resigned herself to considering the alcoholic helpless. This leaves her free to explore what is hopeful and truly worthy of smiles and laughter in the alcoholic's life. 

 I have come across public agencies which claim to use my thinking as a rationale for a tough, rather than nurturing attitude about alcoholism. I am in favor of tough mindedness but want to clarify that what I mean by "tough-minded" is not the same as just "tough." I mean that working with alcoholics requires a clear, objective perception of the facts which at times is tough to maintain. But this needs to be coupled with a nurturing, loving outlook toward human beings-including alcoholics-an outlook without which the worker will be simply a harsh Persecutor in helper's clothing. A similar attitude has been called Tough Love by some. I prefer to call it"Loving Confrontation." 

 True help can be given the Wino, and this should take the form of alcohol-free, decent housing, healthful food, medical care, opportunities for work, social services, A.A., and, if desired, psychotherapy. All of these should be given in a game-free context, as free as possible of Rescues or Persecution and, of course, drinking or any other drugs. When drunk, the Wino should be given a minimum of medical care, consistent with good practice, and complex helping efforts should be focused on the sober alcoholic, rather than the one who is sick from drinking and needs medical treatment.      

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