By Dr. Brendan Adams

                                                                                                                           The Doctor’s Opinion

     “We of Alcoholics Anonymous believe that the reader will be interested in the medical estimate of the plan of recovery described in this book.” Those fateful words from Dr. Silkworth began the physician’s section in the greatest recovery book ever written – The Big Book of Alcoholics Anonymous. The intertwining of medicine with the powerful firsthand stories of people in recovery has formed the basis of a collaboration going back almost a hundred years that’s responsible for saving the lives of countless alcoholics, now more accurately referred to as “people with the disease of dependency.” (I will employ the term “alcoholic” in this segment because Dale chooses to use it.)
     When Dale asked me to critique his manuscript – and perhaps write an endorsement – I was troubled by a deeper sense that more was required of me than the standard comments requested. Yet, ever mindful of AA’s profound admonition – “principles before personalities” – was I letting my ego run away with me, just as Dale had pondered his own motivations in writing this book you now hold? The words of one of my heroes, Sir William Osler, whispered in response, “Listen to your patient; he’s telling you the diagnosis.” With that I realized I could shine an interpretive light on Dale’s courageous narrative – and if that helped one person, it would honour Dale’s risk in sharing so openly, and it would be worth it.
     My purpose, then, is not to teach the science or medicine of addiction here, nor to expound on any school of thought, but, like an interpreter, to illuminate for the reader the meaning behind Dale’s narrative as seen through the eyes of a physician who listens to and has treated this disease on a daily basis for the past thirty years. My challenge is to stay out of Dale’s way and let him tell his story the way it makes sense to him – no over-interpretation or interference. In my opinion, it’s all here in this book: the problem ... and the solution. I am specifically addressing my remarks to those who still suffer – and their families – for it has been my experience that people with this disease are desperately seeking a way out, and they inevitably start by reading everything they can get their hands on – even if only to prove to themselves that they are different, that they aren’t like THAT.
     Addiction, more properly called “substance use disorder” in the Diagnostic and Statistical Manual edition 5, has been extensively studied. In more recent years, this has culminated in a new specialty, termed “addiction medicine,” the kind of medicine I practise. The foundational text of this specialty, Principles of Addiction Medicine, published by the American Society of Addiction Medicine, runs to some 1,852 pages – and it is only an overview. While there are many different theories, mainstream addiction medicine views this as a primary brain disease – that is, it is not “due to something else.” It is strongly genetically influenced, as Dale observes in chapter two, and also influenced by environmental factors, most notably how much one drinks and how young one starts – the so-called “epigenetic factors” to which he refers. So it is not nature or nurture – it is nature AND nurture.

Now, on to Dale’s story.

     Dale’s early life in chapter three and his early career in chapter four are, for lack of a better word, normal. There is no horrific trauma, no living on the margins of society, no early signs of a disturbed mind struggling with reality. And so it is with virtually everyone with this disease, as its tendrils first take root. Are there any signs at all? To an addiction physician – yes. Read these chapters carefully – do you feel a little inadequate? I know I do. This is a very high achiever; he takes pains to make us aware of that. He plays to win, and when he competes, he usually does. If you were a commanding officer, would you want this man serving under you, perhaps sorting out some thorny problems? I know I would. High achiever, good people skills, fits in well but also excels. And yet, perhaps there is some fear of not being good enough, of not being liked, not belonging. Alcohol might fix those feelings …
     On life goes, through chapters five and six. Alcohol is now a normal accompaniment to life. It doesn’t seem to be causing any problems, but life without it is unimaginable. Dale is in his mid-twenties and displaying another characteristic of most pilots – the ability to compartmentalize. Horrific accidents are claiming the lives of his friends, but they don’t seem to affect him. He does things that would terrify most of us, yet he continues on, seemingly unfazed. Or so it would seem, outwardly. I speculate that, every once and a while, the compartmentalization and other defence mechanisms might crack a little, permit some of the unacceptable fear to bubble into consciousness before being slammed back down again. A few drinks would help with that …
     The daily drinking is heavier and heavier, yet doesn’t affect the rest of his life. He can still control it, stop even, if the situation demands it. And yet, reading carefully, we see the margins are already getting a little fuzzy. Legalistic interpretations of eight-hour rules, and when that fails, rationalization that others are doing it too, that it didn’t really affect anything. Episodes where heavy drinking meant being unfit for unexpected calls to duty; however, the drinking patterns don’t change. The locus of control is quietly, slowly shifting from Dale being in control to alcohol running the show. In today’s safety lexicon, this would be called “normalization of deviance.” I see this in my early to mid-stage alcoholic pilots all the time. Near misses are treated as if they never happened. “New normals” are constantly being defined – then the goal posts shift yet again. Throughout all this, the alcoholic is utterly unaware that anything insidious is happening – as are most around him.
     Something else is starting to happen. We all have an inner moral compass, things we “would never do,” things we know are wrong. Does Dale strike you as a man with a moral centre, one who has a code he lives by, or is he a slippery, dishonest con man? I’m reading the story of a man of strong convictions and high standards for himself and those around him. In a word, he comes across as a man who has integrity. What is the effect of the constant drinking on this code? The compromising of safe operations and margins for predictable human error are getting thinner as time marches on. How does he deal with his betrayal of his own standards and the resulting guilt? That tiny nagging voice gets louder – but alcohol can help with that …
     Dale’s words describe this beautifully: “Although I continued drinking, I maintained a performance level that kept me in the top ten percent of the squadron pilots as measured by our bombing scores and other markers used to track our performance effectiveness. I competed at that same level at international flying competitions, bringing home a Top Gun award from one of them.” See? Everything is fine – if my drinking was causing a problem, I certainly couldn’t achieve that!
     While the alcoholic is devoting increasing amounts of psychological energy into fooling himself and denying the gathering storm clouds, there is one person, or persons, they will start to fail to deceive in such efforts – their spouse and children. When was the last time your spouse angrily berated you for being such a glutton and eating too much broccoli? Never – because it never happens. Addiction is a family disease, and just as it cancerously erodes the sufferer’s being, so too it eats away at relationships and marriages. This book is not primarily about Dale’s family – he has kept the spotlight firmly on himself, which I will respect – however, a big part of any addiction physician’s practice is dealing with the family. We see ample evidence in Dale’s story of the slowly eroding trust, the fear and frustration every spouse feels as they are dragged deeper into this disease. Their progression mirrors that of the alcoholic – denial that anything is wrong, rationalization that this is all okay, and then increasing secrecy, shame, broken promises and trust, angry denunciations, empty threats to leave and failed efforts at control. The spouse is like a hostage – try as they might, nothing seems to work, at least not for long. The one they love is slowly slipping away and they are powerless to do anything about it.
     By the end of chapter five, Dale is purchasing his own supply, hiding his consumption from extended family who wouldn’t understand, starting to fight with his wife over some excessive drinking sessions and having to make conscious, effort-based decisions about where and when he drinks. We see loss of control and continued drinking despite ever-increasing negative consequences. Another thing is becoming stronger – the thing that will kill most alcoholics unless they dismantle it – the alternate reality they live in that tells them all is well. Doctors call this “the addictive narrative,” the set of falsehoods and distortions every alcoholic must construct in order to keep drinking. It is deep, and impervious to argument or logic – like ink that has seeped into a white tablecloth. After a while, one cannot believe the tablecloth was ever white.
     Dale takes us through the final descent in chapter six. Now the wheels are starting to come off. A dim awareness is punching through the denial – there is a problem here. One thing that people who don’t understand this disease often say, which inevitably makes me laugh out loud, is “alcoholics are weak.” In point of fact, they are among the strongest people I know. They gut this disease out, struggling to control what they ultimately learn is uncontrollable. One airline pilot described it so eloquently: “It was like being in a spiral dive, Doc; the harder I pulled, the worse it got – I tried everything. Nothing worked, and then the wings came off.” We see Dale progress in his airline career, starting to shave the margins even more, flying when he knows he isn’t fit, rationalizing his behaviour and designing his life activities around alcohol. His home life is deteriorating, and he has manipulated his wife into accepting the results of his drinking – and evaded her efforts at policing it by hiding bottles. A dim awareness of the problem is met by the classic airline pilot response: “I can fix this.” But he can’t, try though he might. Silently, it has moved into the left seat of his life. Alcohol is calling the shots.
     Dale experiences a mystery I have heard time and time again from recovering people. Alcoholics call it “a moment of absolute clarity.” It is often deceptively trivial – a Navy doctor’s lecture in his case, perhaps reading this book for some. It is the moment when the healthy part of a dependent person’s brain screams through the fog, “I’m in trouble. I need help!” It can be a crisis – an alcoholic surgeon told me of his despairing, overwhelming shame as he sat in a jail cell, arrested for intoxicated behaviour. “How has it come to this?” they all ask. Trauma surgeons refer to “the golden half hour,” that precious first thirty minutes in major trauma before the compromised patient crashes irretrievably. This moment of absolute clarity is the equivalent for addiction physicians. The window of opportunity will close quickly as denial slams back down, and we see this in Dale’s story. It would be at least a year between the first realization that he was alcoholic and reaching out for help. But the seed was there.
     Dale tells us about his early recovery – and his working of the twelve steps of Alcoholics Anonymous. I must avoid the temptation to delve into this with the depth and passion I feel for the subject because this is Dale’s story – and he tells it well. I will confine my remarks to some generalities about the program and let Dale’s detailed narrative stand on its own.
     The Big Book was written in 1934 by a pair of white males. Its language is couched in the vernacular of its time and can be off-putting for some. What is easy to miss is that which did not escape Sir Osler: that patients know their own disease. The Big Book has stunned me time and time again with its insight into the condition of addiction – and the solution to that same disease. Without knowing of neurobiology, and having only rudimentary psychology and psychiatry, these lay people (Dr. Bob was a surgeon; however, his medical training was not relevant to the problem of addiction) constructed a program consistent with our modern knowledge of these topics. Thousands of pages have been written on how and why it works – they are widely accessible for anyone interested, and unnecessary to examine here.
     Several points I would draw the reader’s attention to as Dale’s narrative unfolds. Firstly, as he stresses, this program is to be worked by each individual as they – advised by their sponsor – see fit. The founders indeed wrote “this is a suggested program of recovery.” There is no right or wrong way, any more than one way to teach flying skills. However, there are qualities evident in virtually every successful recovery I have witnessed – and the reader will see them in Dale’s story. AA uses the acronym HOW: honesty, openness and willingness. Add to this the Big Book advice of being thorough from the start, and that encompasses all that is necessary, in my experience.
     Secondly, this is a process – not a destination. Dale’s story is rich in self-discoveries – of secondary or underlying addictions, of incomplete understandings – later addressed by repeat trips through the steps, of growth. If you are an aviator, think about your career – your growing understanding and mastery of your machine and its environment. That happened over time, with mentorship and hard lessons provided by experience. There were false paths, and you didn’t know what you didn’t know. So it is with recovery.
     Dale confines his narrative to Alcoholics Anonymous, and for that reason I will only mention this briefly here. What of other paths? SMART, Refuge Recovery, Rational Recovery – and the list goes on. A wry joke in recovery circles has it that “an alcoholic is someone who would complain about the colour of the ambulance that showed up while he was having a heart attack.” In my experience, this topic covers two disparate issues. The first is the standard defence mechanisms of denial and deflection wrapped up in phony righteous indignation (and nobody does righteous indignation as well as an active alcoholic!). The alcoholic, terrified by the loss of his precious elixir of life, flings the life preserver back at the rescuer, loudly proclaiming that he would never embrace a “religious” program (which AA is not) or that it compromised one of his many, suddenly convenient and deeply held principles. Those same principles he wouldn’t hesitate to throw away if a drink were involved. This is just another face of the disease, best handled as the fear-based response that it truly is.
     The second issue is also exceedingly common – one I refer to as “reinventing the wheel.” Many of my patients insist on designing their own unique program from scratch – something that makes as much sense as insisting on getting an aeronautical engineering degree before starting initial ground school. It’s not wrong, but my heavens, is it hard work! And work they do – pilots are not a lazy bunch. On they struggle for months, sometimes years, reading voraciously, researching, writing volumes, only to recreate Alcoholic Anonymous. Granted, their terminology is different, their theories intricate and reasoned, but if the fruits of their labour are dispassionately dissected, at the root are always the principles espoused in the twelve steps – reframed. They did it the hard way – but they did it. Dale is saving you a whole lot of work, but the choice is truly yours.
     And so, we come to the end of my remarks. To those reading these pages, perhaps through the eyes of skeptical denial or, more likely, a growing sense of desperation, I would gently inform you: life does not need to hurt as it does for you. There is a solution. Doctors don’t give many guarantees, but I’m giving you one now. If you follow the simple program Dale has laid out in these pages – in your own way, one that is authentic to you – you will indeed “know a new freedom and happiness.” I know. I’ve seen it daily in my practice. He is not lying to you, nor is he deluded. This works.
     In closing, if I were to be asked “what was the greatest honour of your life?” I know how I would answer, without hesitation. I would respond that it was the privilege of walking the path alongside my addicted patients as they battled their way back from Hell. Each one magnificently unique, each one with their own courage and dignity, each one with their unique set of challenges. To each of them I say from the bottom of my heart, thank you for teaching me … thank you for all of it.

Brendan Adams, MD