The Doctor's Opinion: An Autopsy

I'm doubling up this week with a surprise Big Book reading. The Doctor's Opinion...a great PR resource, a terrible step for medical science. In 1938, on the heels of the Big Book release, Bill W. asked Dr. William D Silkworth—his drunk hospital doctor—to write a letter of recommendation for Alcoholics Anonymous. He happily did, as he was happy with Alcoholics Anonymous's impact on chronic alcoholism. He wrote that a power greater than oneself was his medically educated advice to recovery. His name was not published in the first edition, as he didn't want American medicine boards to see his writing and lose faith in his expertise. But his name was published in the second edition in 1955—four years after Silkworth's death. 

Transcript

SPEAKER_00 0:03

Boy Howdy, welcome to another episode of In Recovery from Alcoholics Anonymous, where crosstalk is welcome. My name is Mary. I won't be crosstalking today, except to myself, because I'm reading the doctor's opinion out of the big book and dissecting the material. So let's get going. The big book is to serve the foundational text for recovering from alcoholism. Bill W. wrote it and it was first published in 1939. And everyone has a big book if they are a member of AA and they go through the big book when they're working on their steps and working with a sponsor. It has the 12 steps and personal stories and the spiritual awakening is in there quite a bit. So yeah, that's the big book. And it was written by Bill W. Bill Wilson, who is the founder of Alcoholics Anonymous. Now, the doctor's opinion on my big book version is on page uh 25. Roman numerals paperback, fourth edition. And they start off saying that we will, as alcoholics, be interested in this chapter, The Doctor's Opinion, because as I quote, convincing testimony must surely come from medical men who had experience with the sufferings of our members and have witnessed our return to health. So really it's a referencing point for them. And it legitimizes Alcoholics Anonymous when they're um nearing their first publishing in 1939 for the big book. And um some history. He was the physician in chief and medical director of the Charles B. Towns Hospital in New York City in the 30s and 40s. I will get into later how Bill W. met him, but Bill W. would go to towns too. He would go to towns to get his treatment. Reading the first letter, it was written in July 1938 and published in 1939, to whom it may concern. I have specialized in the treatment of alcoholism for many years. In late 1934, I attended a patient who, though he had been a competent businessman of good earning capacity, was an alcoholic of a type I had come to regard as hopeless. In the course of his third treatment, he acquired certain ideas concerning a possible means of recovery. As part of his rehabilitation, he commenced to present his conceptions to other alcoholics, impressing upon them that they must do likewise with still others. So when he says certain ideas and commenced to present his conceptions to other alcoholics, he's talking about higher power. Bill brought around a higher power. And when he's writing about how these alcoholics have were impressed upon to deliver likewise with still others, he's talking about essentially sponsorship, paying it forward. Um, it's a very altruistic program, so it's a service for others. Okay, so back to the letter. This man and over 100 others appear to have recovered. And so this was written in July 1938, and Bill W. started his program in 1935. So this is about three years. So that's pretty impressive. I personally know scores of cases who were of the type with whom other methods had failed completely. And that makes sense. I mean, Dr. Silkworth was a physician who studied alcoholism for over 50 years. He was not an alcoholic himself, but he definitely saw the very tragic events that c alcoholism caused, and he treated 40,000 alcoholics in total, and he was considered one of the leading experts of the time. So his um his take is solid ground to stand on with that. These facts appear to be of extreme medical importance because of the extraordinary possibilities of rapid growth inherent in this group. They may mark a new epoch in the annals of alcoholism. Try saying that three times over fast. These men may well have a remedy for thousands of such situations. You may rely on anything they say about themselves. Very truly yours, William D. Silkworth. MD. So he did not, um, not that it matters, but I don't know if that's the case now, if you have to have a PhD. He went to Princeton. But I would say this first letter is nothing specific or medical here. He didn't um go outright and say that the solution is a higher power, but there was smoke and mirrors going on. Um and also in the first edition that was printed, William D. Silkworth's name was not, it was just a doctor. They did not print his name because his letter wasn't aligned with medical scientific backed evidence. Um, his name was restored in 1955 in the second edition. But Dr. Silkworth died in 1951. Um, so I don't know if he had um bla given them his blessing before he died, that his name could appear in the next book, but he did not have his name in the first edition out of concern of the American Medical Association and how they would deem it, how they would approach this letter if he had written it publicly. Fun fact Silk Work died at Charles B. Towns Hospital and of a heart attack. So the same place he worked. Horrible to die at work. So the reason why Bill W. Besides needing credibility in Alcoholics Anonymous, um, he needed funding for his book. So the fellowship was preparing to publish the big book and needed financial backing and medical credibility. So Bill W asked Dr. Silkworth, and he was happy to do it since he saw the great effects of really sick alcoholics finally getting their lives together happier and healthier. Then after that, Bill W. writes that in the statement, we who have suffered alcoholic torture must believe that the body of the alcoholic is quite as abnormal as his mind. It did not satisfy us to be told that we could not control our drinking just because we were maladjusted to life, that we were in full flight from real reality or were outright mental defectives. That is outlining what it was like before Alcoholics Anonymous, where it was just a failing. People could not understand any of it, that people would just keep drinking and be willing to lose it all. There was a huge stigma around alcoholism, and there is today, but back then it was even, you know, tenfold worse. They go on to talk about the doctor's theory that we have an allergy to alcohol interests us. As laymen, our opinion as to its soundness may, of course, mean little, but as the ex-problem drinkers, we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account. I just wrote wrong. It's obviously been debunked a long time ago at this point, but people are still saying it's an allergy in meetings. All you have to do is Google. We have it, Google. It's just downright not an allergy, but that is what Silkworth was trying to drive home at that time. The Medical Rec Record had um published one of uh Silkworth, one of Silkworth's essays titled Alcoholism as a manifestation of allergy in 1937 paper. Um, and it's the basis of doctor's opinion in Alcoholics Anonymous. Silkworth argues that true alcoholism is not a moral failing, a bad habit, or simply a matter of willpower. It's a physical allergic condition. He believed some people have or developed a physiological sensitivity to alcohol that produces a distinct, escalating set of symptoms once triggered. He relates some points in this essay that there's the social drinkers versus the normal drinkers, and most people who drink, even heavily or daily, do so by choice, can stop without much difficulty and show no craving. And these are like the normal or non-allergic drinkers, according to Sookworth. And then that the true alcoholic, at some point, often over a four to six month span, has a shift occur. The person goes from drinking for pleasure to drinking from necessity. Symptoms include morning drinking, hand tremors, irritability, loss of concentration, anxiety, insomnia, and loss of appetite. I do not miss um my using days. My God. And then he makes a defining feature that the drink triggers an uncontrollable craving for more, leading to a prolonged binge in contrast to normal drinkers who can take it or leave it. Um, he also said in this essay that the craving doesn't appear until after the first drink, which also will show up in the big book later. You're powerless after the first drink. Um Silkworth compares the allergy to hay fever. Someone can be exposed for years with no reaction, then gradually develops sensitivity once established, and it's permanent. So abstaining for a year doesn't cure it. One drink brings the whole pattern and routine back to them. He also describes a periodic type, like people who just binge or have like predictable intervals and a manic depressive link type as well. So as constitutional psychopaths who prognosis he is considers poor. So depressing. At the time, he doesn't have any equipment or enough uh resources to prove otherwise. This is what he got. This is what he put together from what he analyzed. Um, he argues that physical treatment must be focused on restoring cell chemistry, while physiological treatment should appeal to intelligence and acceptance of the conditions as a fixed biological fact, not an emotional battle. He promises a follow-up paper on specific therapies. And he also directly says early in his paper in this essay that um we may set it down as a fundamental proposition that alcoholism is not a habit. And then he claims that drunkenness and alcoholism are not synonymous, treating ordinary intoxication as a superficial, non-diagnostic event, quite separate from what he considers true alcoholism. So he's reform framing alcoholism away from a habit or bias and entirely and toward a biological allergic framework, which was a actually very radical in 1937 to say, and became very popular and influential in early AA theories. Like modern medicine today, they don't say it's an allergy and it's not just purely a bad habit either. It's something else completely. Alcoholic use disorder is the more favored term today, is not simply a matter of willpower, and there's a meaningful biological difference between people who develop compulsive escalating use and those who won't. Silkworks intuition proved right, but it's not an allergy. There's no immune system hypersensitivity reaction happening. Silkworks was working before modern neuroscience existed, and allergy was really a placeholder for some people's bodies respond differently to their substance, which I can um, yeah, that's fine. Uh we don't need to be so focused on the words. If that's the placeholder word he used to say, like bodies react weird, that's fine. But people in the rooms do not. And when I say the rooms, I'm talking about AA meanings. People AA members do not use allergy correctly. And they really have taken that word and spun it up, made it its own thing. So it's considered a disorder, not a habit in like the ordinary sense. Like so the DSM 5, which is the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and which was published in 2013 by the American Psychiatric Association, serves as the standard guidebook and reference tool for mental health professionals in the U.S. to define, classify, and diagnose mental health and behavioral conditions. And also the NIAA, which is the National Institute on Alcohol Abuse and Alcoholism, a U.S. government research agency, they both classify alcohol use disorder, AUD, as a chronic relapsing brain disorder involving disrupted reward, stress, and executive control circuitry, not just a repeated behavior someone could break like nail biting. So it's closer to not a habit position than to the pure habit model, but for like different reasons. It's a neuroadaptation and ultra-brain circuitry rather than an allergic sensation. So I I think the big book has every reason in the world to just update this. Twin and family studies put the air uh heritable component of AUD risk around 50%. And it's not like literally allergic predisposition. Genes affect alcohol metabolism, dopamine signaling, and impulse control, and they all contribute to alcoholism. Environmental trauma, mental health, and repeated exposure interact with that genetic loading as well. It's dimensional and not binary. So current diagnosis frame AUD as a spectrum. So there's mild, moderate, severe, based on number of symptoms rather than the Silkworth, very black and white line between normal drinker and true alcoholic. So overall, this is not an allergy and it's not a simple habit you can just quit if you're really struggling. Um, it's a substance use disorder shaped by genetic vulnerability, learned reward pathways, and environmental factors with real neurological changes that make it categorically different from a habit like biting your nails, but without the immune allergy mechanism Silkworth proposed. They just could add notes at the end saying, hey, by the way, this is what um the medical world has found since 1938 when this was written. That's the first essay, which will be in show notes. Yeah, it's I think eight pages of the easy read. So back to the big book. On page 26, Bill Wilson says, though we work out our solution on the spiritual as well as an altruistic plane, altruistic meaning giving back a service to others, uh, sponsorship, paying it forward. We favor hospitalization for the alcoholic who is very jittery or befogged. This is the doctor's opinion chapter. So I think that's good that they're telling them they need to go to the hospital if they're having tremors or psychosis. So, yes, that's true. And then they say, more often than not, it is imperative that a man's brain be cleared before he is approached, as he has then a better chance of understanding and accepting what we have to offer. So they want the brain clear enough to take in the word of God, the Oxford group theologies, um, and that sort of subject matter. But with my lived experience, I would say someone as fragile and vulnerable as me, just coming out of like a detox or a rehab, and then I'm being fed all this material that I have to follow in order to stay sober or I will die. And it all is around a solution of a higher power or a power greater than myself, is not always the way. It was very confusing and also just stopped me from developing my own critical thinking skills. Um, and I was younger, so my brain wasn't developed yet fully. It was not like I think 25, 24 is when your brain gets developed. So I was just um, I had no resources to protect myself. I just took it in, even though my experience, I uh like religion and all that was just not in my household. I didn't have to like label myself agnostic. I didn't even know what agnostic meant at that time. I didn't think I had to have any focus on labels or any higher power. So it was just a mind fuck for me. And I didn't have any answers. I didn't know what was going on, I just had to accept it as it was. So then Dr. Silkworth wrote a second uh letter of recommendation, basically. So the first one was more, yeah, I uh I endorse this. Oh, sure, I like it. Yeah, it's been going well for Bill W. I'm all in. And then the second statement of Dr. Silkworth was to expand upon his medical views. He gave medical legitimacy after alcoholics were called maladjusted or weak, male moral failure. So it just is way for him to sound more clinically relevant and support the idea that alcoholism is not a moral failing, which is true, I agree. I'm gonna read it. It's the subject presented in this book seems to me to be of paramount importance to those afflicted with alcoholic addiction. I say this after many years' experience as medical director of one of the oldest hospitals in the country treating alcoholic and drug addiction, that is Charles B. Towns Hospital in New York City, as mentioned. Um, and by the way, that hospital closed down in 1965. It was called the Drying Out Hospital. Also sad that it closed down. There was, therefore, a sense of real satisfaction when I was asked to contribute a few words on a subject which is covered in such mash masterly detail in these pages. And I want to add that this was Dr. Silkworth's most notable work was writing the doctor's opinion. So this was his, you look him up and it's gonna come up right away that he was he wrote the doctor's opinion in Alcoholics Anonymous referred to, which is great. We doctors have realized for a long time that some form of moral psychology was of urgent importance to alcoholics, but its application presented difficulties beyond our conception. What with our ultra modern standards, our scientific approach to everything, we are scientific approach to everything. That's what Dr. Silkworth had to say, huh? Okay. I wonder if that's why his name wasn't printed on the first edition, because of all that um scientific approach to everything. We are perhaps not well equipped to apply the powers of a good powers of good that lie outside our synthetic knowledge. And I will say this is a time where he thinks they're, you know, have ultra modern standards, but there's also no equipment or tools or not enough advanced studies to get to the core of alcoholism. You know, again, seeing 40,000 different alcoholic patients in his 50-year career and not having a high success rate, Alcoholics Anonymous would turn his head because he's seeing uh more successful outcomes and case studies than he was used to. But again, there wasn't enough evidence to show uh provide he had no evidence to provide that um this was a medical viewpoint of how to cure alcoholism. Many years ago, one of the leading contributors to this book came under our care in the hospital this hospital, and that's Bill Wilson. And while here, he acquired some ideas which he put into practical applications at once. Okay, so Bill W, he had many rock bottoms, and they just kept getting worse and worse and worse. In November 1934, he went to meet up with an old drinking buddy named Ebbie Thatcher in Brooklyn, and they sat at a kitchen and he was like, Oh, we're gonna have a drinking night. I'm gonna have a wild night with Ebbie, and Ebbie would not take a drink. And uh Bill was like, What the heck? Why are you not drinking? And he was like, I found God, I got God on my side, I found God. And so Ebbie was introduced to the Oxford group by Rowland Hazard, who is an Oxford group member, and he helped Ebbie get sober through the this evangelist movement, which is still today around. It's called the Initiatives of Change. So yeah, Ebi introduced the Oxford group to Bill W. And then Bill W went out again. When I say went out, he relapsed, he started drinking, and then landed back into Charles V. Towns and Hospital in December 1934. And then lo and behold, after Ebby visits, and this is a month after they met up, Bill W's ass is in the hospital again, and he says he has a spiritual awakening and sees the white light. Maybe he really did, or maybe he had already started listening, like paying attention to the Oxford group movement. I like to think it's kind of like that John Smith story with the lizard, uh, that like Mormon lore. Honestly, I just don't buy it. I think he had been uh going through one of his drunken stupors again. He was having psychotic. And then, you know, Ebbie showing up with his God stuff, his Oxford movement, all this evangelism. And he was like, oh yeah, I do see a white light. And probably he believes it. I'm not doubting that he didn't believe it, but that's to me more what was hell going on than this white light. I know some of the people who say they have white lights in the meetings. I'm just like, you are full of shit, but it's always the most popular person in the room who's usually the most problematic person in the meeting. So keep that in mind, my friends. All right. Back to reading. Later, he requested the privilege of being allowed to tell his story to other patients here, and with some misgiving, we consented. I wonder what that meant by misgiving. The cases we have followed through have been most interesting. In fact, many of them are amazing. The unselfishness of these men as we have come to know them, the entire absence of profit motive, and their community spirit is indeed inspiring to one who has labored long and warily in this alcoholic field. My sponsor at the time of when I bought this book had me write the feminine spirit. So just interesting. They believe in themselves and still more in the power which pulls chronic alcoholics back from the gates of death. Of course, an alcoholic ought to be freed from his physical craving for liquor. And this often requires a definite hospital procedure before psychological measures can be of maximum benefit. We believe, and so suggested a few years ago, that the action of alcohol on these chronic alcoholics is a manifestation of an allergy, that the phenomenon of craving is limited to this class and never occurs in the average temperament drinker. These allergic types can never safely use alcohol in any form at all. And once having formed the habit and found they cannot break it, once having lost their self-confidence, their reliance upon things human, their problems pile up on them and become astonishingly difficult to solve. So I'm now going to redirect you guys to the second essay that Dr. Silkworth had published in 1937. And this one's called The Reclamation of the Alcoholic, which was a direct follow-up to the allergy paper. It argued that alcoholism is an allergic condition, as we've been talking about. And Silkworth lays out his actual treatment protocol, moving from the theory to clinical practice at Towns Hospital. He claims there's three phases of treatment, like managing the acute crisis for patients who are in grave danger. Like they're in the crisis point of everything. And then the physical normalization and cell revitalization. This phase he considers this like the central one. So once detoxified, the goal is to eliminate cravings by treating the body chemistry itself. And then finally the third one, and that's the mental and moral stabilization. This is the psychological piece. Convincing the patient for their condition is physical, not a moral failing, comparing it explicitly to diabetes as a law of nature. And I think that's a better comparison, like diabetes instead of say an allergy. The key distinction is a decision versus a resolution. He argues resolutions fail because willpower alone can't outlast temptation, while a true decision, once cravings is medically resolved and removes the temptation itself. He describes patients who, after treatment, spontaneously want to help other alcoholics form mutual support groups under moral psychology. This is his like seed of what AA's 12 Steps and Live Fellowship program is. He had some case studies in this essay as well, and they were really brief. But like he has a businessman who successfully detoxed and stabilized a returning traveler whose tremors resolved with the colloidal treatment, a young migraine sufferer who improved dramatically, and two men, a disgraced businessman and a broke former broker who fully rebuilt their lives and became group leaders helping other alcoholics. I'm pretty sure that the broker in this is Bill W because he was a stock analyst and investor. He describes how he lost it all in the 1920s markets uh crash, and his wife Lois had to support him. And this is case five, by the way, um case study five. And the case five arrives, carrying with him two books on philosophy, from which he hoped to get a new inspiration. This mirrors Wilson's own well-documented spiritual search around the time of his final hospitalization at Towns in December 1934, which included exposure to William James's The Varieties of Religious Experience and his sudden white light spiritual experience while a patient there. Again, wild that he had a white light experience with all this fun um literature surrounding him. And then also case five eventually becomes a director in a large corporation and gets back part of his income to help other alcoholics and gathers a group of over 50 men free from their former alcoholism language that maps closely onto the founding of Alcoholics Anonymous in 1935. So, yeah, Sookworth, who diagnosed case study five with the allergy plus obsession framework, whiles and later credited as pivotal. So I think it is obvious that case study five is LW. It was like a precursor to writing uh the doctor's opinion. He was just, you know, working on those uh writing muscles. Back to reading. We are on page 28 of the paperback fourth edition. Frothy emotional appeal seldom suffices the message which can interest and hold these alcoholic people, must have death and weight. In nearly all cases, these ideals must be grounded in a power greater than themselves if they are to recreate their lives. So before he was hinting at certain ideas and uh conceptions, and now he just said power greater than himself. So he's gotten us there slowly. If they are to recreate their lives. He's saying that a higher power can cure alcoholism, which is very manipulative. He's a doctor, so people are supposed to trust him. If any feel that as psychiatrists directing a hospital for alcoholics, we appear somewhat sentimental. Let them stand with us uh us a while on the firing line, see the tragedies, the despairing wives, the little children. Ooh, he's the little children card. Let the solving of these problems become a part of their daily work and even of their sleeping moments, and the most cynical will not wonder what we have accepted and encouraged this movement. We feel after many years of experience that we have found nothing which has contributed more to the rehabilitation of these men than the altruistic movement now growing up among them. So again, altruistic, so removing the ego. And I find it highly manipulative that he's saying, Well, if you um think we're being sentimental, let me just use the fireline examples, like the little children and then the despairing wives. That doesn't make up for the lack of science and medical backing. It is really bizarre. I don't think I really took in anything when I was uh reading the big book for the first, second, third, fourth time. I was just like, okay, just go with the movements and this way I'll stay sober and not die and not disappoint my family and friends. Men and women drink essentially because they like the effect produced by alcohol. The sensation is so elusive that while they admit it is injurious, they cannot after time differentiate the true from the false. To them, their alcoholic life seems the only normal one. They are restless, irritable, and discontent, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks, drinks which they see others taking with impunity. The restless, irritable, and discontent is a very common slogan you constantly hear in uh meetings, through sponsors, through readings. It's always like the if they're having a bad day, it's because they're restless, irritable, discontent. I've really grown to be, oh dear God, resentful with that phrase because it develops a person's experience. They aren't feeling certain ways, like restless, irritable, or discontent simply because of their alcoholism. It's a default slogan applied way too often out of context. Um I may be irritable because I need some alone time, not because I have missed the meaning. Maybe I just need to get away from people. Maybe I'm restless because I um am very anxious about my dog's health. It's something like that. There's not always just because I'm an alcoholic or I have a history of alcoholism. Um, but they always use that to apply for anything. If you're like, I have been told, like, been rude to a guy who was 13 stepping me, and he just said it was restless, irritable, and discontent. You can fuck off right there. What's that? Fucking gaslighting shit.

unknown 31:17

Okay.

SPEAKER_00 31:17

Okay, back to reading. Now we're on page 29. After they have succumbed to the desire again, as so many do, and the phenomenon of craving develops, they pass through the well-known stages of ice pre emerging remorseful with a firm resolution not to drink again. This is repeated over and over. And unless this person can experience an entire psychic change, once again, psychic change, once again, higher power. So it's psychic, psychic change is what he's referring to is a higher power. There's a very little hope of the of his recovery. So basically, if you're born this way, you're spiritual spiritually sick and you really need a god to survive. On the other hand, and strange as they may this may seem to those who do not understand, once a psychic change has occurred, the very same person who seemed doomed, who had so many problems, he despaired of ever solving them, suddenly finds himself easily able to control his desire for alcohol, the only effort necessary being that required to follow a few simple rules. Um, yeah, it's not a few simple rules. The rules start stacking more and more, probably progress more as the years have gone by, and they get more and more stringent. If you do this, then you're then you have a good program. If you don't do it this way, then you're gonna die. It's it becomes that culture really fast. I also think it's funny that Silkworth's as strange as this may seem to those who do not understand, because he is a doctor and he has studied medicine, and he's once again not mentioning having his name printed in the first edition. His name wasn't printed until he was dead, so he wouldn't have to deal with any of the backlash from uh the American Medical Association. Men have cried out to me, and men have cried out to me in sincere and despairing appeal. Doctor, I cannot go on like this. I have everything to live for. I must stop, but I cannot. You must help me. Faced with this problem, if a doctor is honest with himself, he must sometimes feel his own inadequacy. And I think probably Dr. Silkworth did feel this way a lot. He had 40,000 alcoholics and could not find um long-term success in many of them. That would be really hard. Although he gets all of the that is in him, it often is not enough. One that's sad too. One feels that something more than human power is needed to produce the essential psychic change. Okay, now at this point, he just sounds desperate. He couldn't figure it out himself. He's like, well, let's just see this higher power thing that Bill came up with when he had his Oxford group literature and Ebby around. Though the aggregate of recoveries resulting from psychiatric effort is considerable, we physicians must admit that we have made little impression upon the problem as a whole. Many types do not respond to the ordinary psychological approach. I do not hold with those who believe that alcoholism is entirely a problem of mental control. I have had many men who had, for example, worked a period of months on some problem or business deal which was to be settled on a certain date favorably to them. They took a drink a day or so to prov prior to the date, and then the phenomenon of craving at once became paramount to all the interests so that the important appointment was not met. These men were not drinking to escape, they were drinking to overcome a craving beyond their mental control.

unknown 34:36

Okay.

SPEAKER_00 34:37

He is like challenging the moral failing, which, good on him, it is not a moral failing, it is a disorder. And then he's discussing they were drinking to overcome a craving beyond their mental control, which is a legitimate thing. That's an intense craving. There's people who have binge eating disorders, and that's an intense craving, and it's ravenous, and they can't control it. It's not a choice, and it's highly misunderstood. And it makes me think of the GLP1 pathways and receptors, because GLP1, for those who don't know, is a glucose glucogen-like peptide, a natural gut hormone and metabolic axis. So it regulates blood sugar and appetites, and it binds to receptors in the pancreas and it sends messages to the hypothalamus for fullness. So it tells you when you're full and when you're hungry. And so, in the same nature of alcoholism, people who can drink have drink and know when to stop, they have a receptor telling them you're done. Whereas people with uh alcohol use disorder, they don't have that off button, which to me kind of leans towards a GLP one receptor issue, they're not getting the signal that they need to stop. Many of you have probably already heard of GLP1 antigens like a Zempic or Wigovee, but the thing is that if these sort of hormones could be studied more for alcoholism or substance use disorder, we might have more solutions to drug dependency, alcohol dependency. It's not into like researching some kind of higher power. There is maybe an answer. And when Silkworth is talking about the craving, he could have gotten at that if he were alive today, like a GLP research clinic or whatever possible studies could serve for us. He would have had more resources to explore and not just leave it to Bill W and Oxford Group to piece things together. So that's to me a sign that it was just because of the times. Okay, back to reading page 30 on Roman numerals, page 30, by the way. There are many situations which arise out of the phenomenon of craving, which cause men to make the supreme sacrifice, which means suicide, rather than to continue to fight, which is to them a moral failing. The classification of alcoholics seemed most difficult and in much detail is outside the scope of this book. There are, of course, the psychopaths who are emotionally unstable. We are familiar with this type. They are always going on the wagon for keeps. They are over-remorseful and make many resolutions, but never a decision. Um, again, this was written in 1938. This is completely false. A psychopath has no empathy or guilt. They do not care if they hurt others and they feel no shame for their actions. There is like a superficial charm. They might look friendly on the outside, but they're just trying to trick people. They're liars, um, they're impulsive, and they do not feel genuine remorse or guilt. While they can experience regret over negative personal consequences like getting arrested or losing money, they fundamentally lack the emotional empathy required to feel sorrow for the harm they cause others. So they didn't even understand the psychology of um mood disorders and personality disorders back then, let alone how to deal with alcoholism. Okay, back to reading. There is the type of man who is unwilling to admit that he cannot take a drink. He plans various ways of drinking, he changes his brand or his environment. There's the type who always believes that after being entirely free from alcohol for a period of time, he can take a drink without danger. There is the manic depressive type, who is perhaps the most least the least understood by his friends and about whom a whole chapter could be written. Um, yeah, why didn't he write another chapter though? There's no more expansion on the manic depressive type. I have a family member who was manic depressive. They only drank when they were manic and didn't drink at all when they were having their depressed state. I'm offering one case of what it may have looked like, what he may have been referring to. Then there are types entirely normal in every aspect except in the effect alcohol has upon them. They are often able, intelligent, friendly people. All these and many others have one symptom in common. They cannot start drinking without developing the phenomenon of craving. This phenomena, as we have suggested, may be manifestation of an allergy which differentiates people and sets them apart as a distinct entity. Again, the allergy, I think, just should be replaced with another word, it's a placeholder. It has never been, by any treatment with which we are familiar, permanently eradicated. The only relief we have to suggest is entire abstinence. Substance use disorder has a spectrum. I prefer abstinence as well. Some people focus on abstinence, but the way people in AA see abstinence, if you're not like full if you're not in the spectrum of pure abstinence, it's you're stigmatized and judged. So that's a problem. This immediately precipitates us into a seething cauldron of debate. Much has been written pro and con, but among physicians, the general opinion seems to be that most chronic alcoholics are doomed. What is the solution? Perhaps I can best answer this by relating one of my experiences. About one year prior to this experience, a man was brought in to be treated for chronic alcoholism. He had but partially recovered from a gastric hemorrhage and seemed to be a case of pathological mental deterioration. He had lost everything worthwhile in life and was only living, one might say, to drink. He frankly admitted and believed that for him there was no hope. Following the elimination of alcohol, there was found to be no permanent brain injury. He accepted the plan outlined in this book. One year later, he called to see me and I experienced a very strange sensation. I knew the man by name, and I partly recognized his features, but there all resemblance ended. From a trembling, despairing, nervous wreck had emerged a man brimming over with self-reliance and contentment. I talked with him for some time, but was not able to bring myself to feel that I had known him before. To me, he was a stranger, and so he left me. A long time had passed, has passed with no return to alcohol. When I need a mental uplift, I often think of another case brought in by a physician prominent in New York. The patient had made his own diagnosis and deciding his situation hopeless, had hidden in the deserted barn determined to die. He was rescued by a searching party and in desperate condition brought to me. Following his physical rehabilitation, he had a talk with me, which he frankly stated he thought the treatment a waste of effort, unless I could assure him, which no one ever had, that in the future he would have the willpower to resist the impulse to drink. His alcoholic problem was so complex and his depression so great that we felt his only hope would be through what we would then call moral psychology, and we doubted it even that would have any effect. So it's the moral psychology. However, he did come become sold on the ideas contained in this book. He has not a drink for a great many years. I see him now, and then he is as fine of a specimen of manhood as one could wish to meet. So this is very helpful in that people go to meetings and their sponsor or someone gives them a big book and they read this and they're like, oh my God. So people really do understand what I am going through and what my drinking or using looks like and how messy it is. So I will be safe here. But at the same time, this guy's beaming with a light, and he's got the higher powers and the powers greater than selfs. But there is a blank, uh blind spot. They're not talking about how long depression can last after sobriety. People talk about pink clouds. Some people get a pink cloud because they're so happy to be able to wake up in the morning and feel good. But there's uh other things that follow that are really hard, and that can feel very isolating because then they just tell you you have a bad program, but you did damage to your body, and it's your body, and you're gonna grieve having gone through that too. But it's just not talked about. Okay, last paragraph, page 32, Roman Numerals, the doctor's opinion. I earnestly advise every alcoholic to read this book through and through. And though perhaps he came to scoff, he may remain to pray. Okay, that's pretty fucking he did a little Christian slow walking. He's like, Yeah, no, I'm a doctor. You can trust me. And then, oh, it's an allergy. You can trust me, though. I have had so many alcoholics come to my hospital. I've been dealing with this for 50 years, and then he talks about the power that greater than yourself or the psychic change. And then finally, at the end, he gets to the last sentence's pray. So the newcomer might be confused, but they're just hearing about these really great success stories. And the doctors have said that this works, and he's seen so many bad outcomes, and he's telling you it's not a memorial failing, and your brain is completely fucked after going through a binge of some sort, and you're fragile and sensitive, and just want a community. What are you gonna do? You're gonna just keep reading forward, even if you don't really believe in the prayer or the solution stuff. If you do, that's fine. But if you also don't want being forced some kind of religion on you and being told it's non-denominational, that's gonna be a bit of a mind fuck. I would love to read this with someone who's never read the big book and doesn't have uh any uh substance abuse issues and see their point of view. Because you don't really, I don't know, I personally didn't think too much about it when it happened. So I just think of it as the foot in the door technique. It's a like social psychology turn for getting someone to agree to something that's small first and then makes them far more likely to agree to um to bigger things later. So I feel like the doctor's opinion is kind of the first stepping stone to saying, well, yeah, it's medically proven that if you believe in God, you're gonna have a really great life of sobriety. But the good takeaway is it is not a moral failing, and I like that he reiterated that people do get their lives back in AA. Um, there are success stories, and it seems to me that Alcoholics Anonymous was at the time really a radical experience because you were kind of signed off as uh doomed if you were an alcoholic back then. There was no way to recover, and it was very rare that people did. But also, it's simply there was not enough resources that at that time. I'm very curious. I would love to know what Silkworth would have thought back into. I mean, today, I don't think he would have he would have been written off or maybe disbarred if he did that to this day and age. And maybe it would have happened back then because he did not have his name printed. So that is the doctor's opinion, guys, in the big book. We read it. Woo! I hope you got something out of it. I have show notes which will include Silkworth's essays, and I'll put in the chapter of the doctor's opinion in there as well. For show notes, check out patreon.com slash c slash in recovery. That's patreon.com slash c slash in recovery. Do you have a question or story you want to address on the podcast? Email me at recovery from a pod at pm.me. That's recovery from a pod at pm.me, PM as in penguin, and m as in Mary. And I may read and respond to it in an upcoming episode. Have a good day.