The Natural History of Alcoholism Revisited (1995) is a book by psychiatrist George E. Vaillant that describes two multi-decade studies of the lives of 600 American males, non-alcoholics at the outset, focusing on their lifelong drinking behaviours. By following the men from youth to old age it was possible to chart their drinking patterns and what factors may have contributed to alcoholism. Another study followed 100 severe alcoholics from a clinic eight years after their detoxification. The National Review hailed the first edition (1983) as "a genuine revolution in the field of alcoholism research" and said that "Vaillant has combined clinical experience with an unprecedented amount of empirical data to produce what may ultimately come to be viewed as the single most important contribution to the literature of alcoholism since the first edition of AA's Big Book." Some of the main conclusions of Vaillant's book are:
That alcoholism is as much a social as a medical condition. "Alcoholism can simultaneously reflect both a conditioned habit and a disease." Factors predicting alcoholism were related to ethnic culture, alcoholism in relatives, and a personality that is antisocial and extroverted. An unhappy childhood predicted mental illness but not alcoholism—unless the family problems were due to alcoholism. That alcoholism was generally the cause of co-occurring depression, anxiety, and sociopathic (delinquent) behaviour, not the result. That even though alcoholism is not solely a medical condition, it is therapeutically effective to explain it as a disease to patients. The disease concept encourages patients to take responsibility for their drinking, without debilitating guilt. That for most alcoholics, attempts at controlled drinking in the long term end in either abstinence or a return to alcoholism. That there is as yet no cure for alcoholism, and that medical treatment can only provide short-term crisis intervention. Achieving long-term sobriety usually involves (1) a less harmful, substitute dependency; (2) new relationships; (3) sources of inspiration and hope; and (4) experiencing negative consequences of drinking.
Background
Study Samples Core City: In 1940, Sheldon and Eleanour Glueck of Harvard began a major study of juvenile delinquency in teens from Boston — mostly poor kids in tenements, half without a bathtub in their homes. The control group for the study comprised 456 boys who were assessed as non-delinquent. In 1974 this control group, which Vaillant referred to as the Core City sample, was turned over to him to continue research. The Core City group had a mean IQ of 95, and 48% graduated from high school. College: In 1976 Vaillant inherited another study of more than 200 Harvard sophomores started in 1938—the College sample. The sophomores were white males, selected because they were high achievers and had no known medical or psychological problems. The College sample had a mean IQ of 130, and 76% attended graduate school. Their 1976 mean income was three times that of the Core City group. The research eventually showed that for the Core City sample at age 60, 36% had abused alcohol at some time in their lives; for the College sample at age 70, the figure was 22%. The samples were narrow ("male, white, American, and born between 1919 and 1932.") but were followed for a long period. As critics and Vaillant himself pointed out, the samples did not include important segments of the population such as African-Americans and women. Both samples likely excluded those who began abusing alcohol in early adolescence. The Clinic sample was a group of 100 severe alcoholics who were detoxified at clinic in an urban, municipal hospital (Cambridge Hospital) in Massachusetts during the winter of 1971-1972. The treatment was carried out under what was known as the CASPAR program—Cambridge-Somerville Program for Alcohol Rehabilitation. This group was followed for 8 years to measure the effectiveness of the treatment.
Timeline 1921: mean birth date of College sample 1929: mean birth date of Core City sample 1938: study on the College sample begins at Harvard 1940: Gluecks begin the Core City study 1971-2: Clinic study begins 1972-4: Vaillant takes over the College and Core City samples. 1983: Vaillant publishes The Natural History of Alcoholism: causes, patterns and paths to recovery. 1995: Vaillant publishes a new edition entitled The Natural History of Alcoholism Revisited, which includes the entire text of the 1983 edition plus new material marked "Revisited." 1996: The 1995 edition is summarized in a paper by Vaillant and Hiller-Sturmhofel entitled “The Natural History of Alcoholism”. 2003: Vaillant brings the studies to a close and summarizes results in a 2003 paper entitled "A 60-year follow-up of alcoholic men".
Definitions In the 1983 edition of his book, Vaillant required four positive answers to questions on his Problem Drinking Scale (PDS) to indicate alcohol abuse. To diagnose full-blown alcoholism—i.e. alcohol dependence—he used DSM III, which requires either physical tolerance or physiological withdrawal. For the 1995 edition he abandoned the PDS and used the DSM definitions of both abuse and alcoholism.
Longitudinal study A longitudinal study is one that follows test subjects over a long period of time — as opposed to a cross-sectional study, which gives a 'snap-shot' of a group at one point in time. Longitudinal studies tend to examine smaller groups in greater detail, whereas cross-sectional studies are often based on a more representative segment of the population over a short time. The longitudinal method was useful in identifying factors in alcoholism, for instance by investigating whether delinquent behaviour started before or after drinking.
Prospective study A prospective study is forward-looking and includes subjects who did not originally have symptoms of the disease being studied. Many retrospective, or backward-looking, studies might take a group of alcoholics and try to determine what common traits might have caused their alcoholism. A prospective study takes a group of healthy individuals and tries to predict which ones would become alcoholic based on their histories—a much broader technique that often yields surprising results.
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