Journal o! Studies on Alcohol, Vol. 37, No. 11, 1976
From Quonset Hut to NavalHospital The Story of an AlcoholismRehabilitationService • Capt.Joseph A. Pursch,MC, USN SUMMAa¾. The historyand treatmentmethodsof the first Navy Alcoholism Rehabilitation Service are described.
ONGSEAFARING MEN, thecustom of drinking is probably asoldasthesailing tradition itself.In theearlydays of the UnitedStatesNavy, it was standardpracticefor everydeparting shipto takeon boardfar morerum thanwater. When Secretary of the Navy Josephus Daniels,in 1913,decreed that the U.S. Navy would henceforthbe "dry," the idiomaticex-
pression "drunkasa sailor" wasreplaced by "drunkin everyport."
For,aseveryskipper of theNavyknows, oncehisshiphitsport, the intoxicated sailorbecomes his majorproblem. While the drinkingof alcoholicbeverages at seadecreased mark-
edlyamongofficersandbecamepractically nonexistent amongenlisted men, the drinking customsand rituals on land became a
stapleof dailylife and an indispensable ingredient of almostall Navysocialfunctions: tellingseastories in a harborsaloon, playing softballat squadron beachparties, bragging at "happyhours," meeting shipmates' familiesbeforedinner,sing-alongs at wetting-down partiesand changeof command ceremonies, all becameunthinkable without alcohol as a central feature. Fair-haired
children of
the Navy family,suchas submariners, developedtheir own particulardrinkingcustoms, for example,"drinkingyour dolphins." In Naval Aviation, we drink accordingto the following customs:
We drinkat happyhours,aftera goodflight,after a bad flight, and after a near mid-air collision.(to calm our nerves).To celebrate our first soloflight we traditionallypresentour instructor with a bottle of his favorite liquor and, if we successfully bail
outof a crippled airplane, we express ourthanksto thelifesaving parachute riggerwitha bottleof hispreferred spirits. We drink • From the Naval RegionalMedical Center, Long Beach, CA 90822. Receivedfor publication:28 January1976. 1655
1656
j.x.
•,v'P, scI-•
whenwe get our wings,when we get promoted(wetting-down parties),whenwe get passedover (to alleviateour depression), at formal dining-ins,changeof commandceremonies,chiefs'initiationsand at "Beef and BurgundyNight." At birthday balls we drink our doorprize if we have the luckyticket.When a diver
inspects the hull of the shipwe givehim medicinalbrandy,and we prescribe the sametreatmentfor "exposure to the elements" if a man falls overboard and is fished out of the Caribbean
on a
hot day in July. A night carrierlandingusuallyrates medicinal
brandy,dispensed by thewell-meaning flightsurgeon. We "hailand farewell"frequently,and the first liquid that wets the bow of any
newbornshipat its christening is champagne. Thus,we drinkfrom enlistmentto retirementand from teenhoodto old age. Sincethe Navy is only a subcultureof Americansocietyitself,
it shouldbe no surprisethat the Navy'sdrinkingcustoms reston suchsolidnationalmythsasthe hard-drinking, two-fisted,pioneering frontiersman; the hard-charging tiger of an aviatorwho can drinkall nightandfly all day;the ruggedness of the guywhocan hold his liquorlike a man;and the notionthat you can'ttrusta man who won't drink.
If thereis any validityto the conceptthat the drinkingpracticesand attitudesof a societyhavesomerelationship to whether
or not a predisposed memberof that society will developalcoholism,then it is likely that a Navy that drinksas our Navy drinkswill generatea high numberof problemdrinkers.Such
indeedappears to be thecase:a survey in 1974revealed that195 of the officersand 375 of the enlistedmenare heavydrinkersand haveserious problems as a result(1).
Perceptive lineofficers aswellasNavylawyers, chaplains and doctorshaveknownthis all along.They haveseenthe drinker's hangovers at Captain's Mast,2hisdeteriorating careerat courtsmartial, his sufferingwife in the confessional, his brokenjaw on the
orthopedic ward,hisbleeding ulcerin theoperating room,and hisshrunken liverat autopsy. But thoughtheseobservers might havebeenperceptive, well-schooled, andof a kindlyspirit,they wereunableto helpthealcoholic. Ourpuritantradition andthe administrative attitudes whichit spawned woulddictatethatthe suffering alcoholic (the onewhohaddrunkwith all the restof us,butwhocouldnolongercontrol it) wouldhaveto be separated • Nonpunitive procedure heldby the sailor'scommanding officerfor the purpose of resolvingminor disciplinaryinfractions.
QUONSETHUT TO NAVAL HOSPITAL
1657
from the Navy administratively or punitively.Thus,the age-old question"what do you do with a drunkensailor"was answered by the administrative fiat "youlet him go downthe tubes,"which meantthat he wouldbe expelledinto the civilianworld. As a result, the alcohol-relateddisordersin the Veterans Administration
hospitals doubledbetween1965and 1969,andmanyof the Navy's bestmembers wereeitherseparated prematurely andpunitivelyor they were nonchalantlyor forciblyretired into invalidism. BAL-•(;BOUND
One suchpersonwas a retired alcoholicCommander,Dick J., from Long Beach, California, who in 1965 was hospitalizedfor the eighth time (this time on the psychiatricward). Again, as during previous hospitalizations, the word alcoholismwas never mentioned,and after
his dischargefrom the hospitalhe was still sick with alcoholism. He finally becameabstinentand recoveredhis mental health through the fellowshipof AlcoholicsAnonymous.It occurredto him that perhaps A.A. meetingscouldbe held at the Long BeachNaval Stationto help thoseshipmateswho were alcoholics.He approachedthe Naval Dispensaryand was directedto the SeniorMedical Officer, Captain J. J. Zuska.Like most medical officers,Captain Zuska had for years been unsuccessful in his efforts to treat alcoholics. He listened to the Com-
mander and became curious. Together they persuadedthe Executive Officer of the Naval Station to let them hold A.A. meetings in the
conference room.Thus,on 20 February1965,the first meetingof A.A. DrydockGroupOne tookplacewith threepeoplein attendance.Meetingscontinued to takeplaceweeklyandthe numberof peopleattending grew.
Of the first 30 members,not a singleone got well. It becameeven more obviouswhat a fatal illnessalcoholismreally was becausesome of them died. The foundersof the groupbecamediscouraged but did not give up. Insteadthey got permission to use an abandonedquonset
hut for their meetingsand addedmedicaltechniques to their rehabilitativeapproach. Sincealcoholism wasa stigmatizing, unmentionable condition,and becausetheir initial operationwas practicallyillegal, they graduallyacquiredmore oppositionthan support. In 1967theywere authorizedby the Bureauof Medicineand Surgery to proceedwith their work as a pilot program;but, symbolically, the authorizationarrived in an envelopemarked"Secret."In spite of official sanction, the pioneeringLong Beachmodelfor treatingalcoholic sailorsand officersremaineda secretscornedoperation-evidencedby the fact that between 1965 and 1973, in spite of repeated invitations,
not a singleNavy doctorfrom Long BeachNaval Hospitalcame to the Alcohol RehabilitationCenter to see what the program was all ab,out.Housedin a dilapidatedWorld War II barracks,it remained
1658
essentiallya bootleg operation,its product more and more widely known but its locationand meansof productionshroudedin a sinister, illicit fog, like a whisky still in a dry county. Gradually a staff was acquiredand severaltreatmentmodalitieswere added. The capacitywas increasedto 65 inpatients,the name was changedto the AlcoholRehabilitationCenter, and it becamethe prototype on which all future Navy alcoholismrehabilitationcenterswere
modeled.In July 1974the Centerwas movedinto the Naval Hospital in Long Beachand becamethe AlcoholRehabilitationService(•s) to give it equal billing with other servicesof the hospitalsuch as the SurgeryService,and to lend palpablecredenceto the philosophythat alcoholism is a disease and should be treated as such. The staff now
includes a psychiatrist,a general practitioner, three part-time psychologists, one socialworker, one nurse and a staff of Navy, Marine Corps and Coast Guard counselors. TP,•ATMENT
I•OCRA•
Rulesand GeneralPhilosophy of the ARS
Whena patientarrives at theLongBeach A•S,hegetsa thorough physical andpsychiatric evaluation, including a batteryof psychological tests.If he is not diagnosed as an alcoholic, he is re-
turnedto duty with an appropriate consultation placedin his healthrecord,or he is transferredto anotherserviceof the hos-
pital for whatevertreatment is indicated. The patientis treatedwith respectanddignityin an environment which is conductedlike any military command(reveille,
uniformof the day,zoneinspections). Thereare no barredwindows,lockeddoorsor any restraintsother than militaryregula-
tions.Thegeneral philosophy isthateverypatient herehasa problem with alcohol.In the ARshe findshimselfin a helping,learning,
problem-solving environment. He hearsnopreaching, theorizing, moralizing, condemning or condoning. Concerning hisdrinking, the
staffattitudesarekindbut firm: we understand whathashappened
to himbut we do not dwellin the past.In the forefrontof all
therapy is theattitude thatalthough hehasa disease, andeven
though wearegoingto helphim,onlyhecanaccept theultimate
responsibility forhisdrinking andforwhathisdrinking will do to him from now on.
How it Works
Duringthe6 to 8 weeks' stayat theARs, thepatientgrows from analcoholically drinking, deiected, resentful, problem-avoiding per-
QUONSET HUT TO NAVALHOSPITAL
1659
son whoselife has becomeunmanageable, to a more confident,
friendlypersonwho hasgonethrougha painfulprocess of selfawareness and who no longertendsto use alcoholto try to solve
hislife problems. Thisis broughtaboutin a drug-free environment throughgroupinvolvement, A.A., education, recreational psychotherapy,psychodrama andfamilytherapy. Introduction
to the ARS
Duringthe first 2 weeksthe patientis in a restrictedstatus. Exceptfor A.A.meetings in the LongBeachareato whichhe is bussed withotherpatients, hecannot leavethehospital compound. Mostpatients resentthisrestriction andaccuse usof nottrusting them. Our answer to that is that we trust them but that we don't
trusttheirdisease. We pointoutthatwehaveseenmanyalcoholic senior officers, career physicians andothertrustworthy individuals of highmoralcaliberwho,although theymadea sincere resolve notto drink,comebackdrunkfromliberty (or werebroughtback in an AWOL a status),mortified,guilt-ridden,unableto compre-
hendhowit couldhavehappened to them.Duringthe initial2 weeks, thepatient is asrapidlyaspossible withdrawn frommedications otherthandisulfiram(Antabuse)andvitamins.Fromthen
onwhenhe getsanxious or depressed weprescribe peopleinstead of pills.
For the first3 daysthepatientis assigned to the intakegroup wherehe is familiarized withthephilosophy of the•a•sandwith
theprinciples ofgroup counseling. Also, hiscurrent stateofphysical fitnessis assessed by usingthe 12-minute runningtest described by Cooper(2). GroupCounseling
Thepatient is nowreadyto be assigned to hisregular group. Thisisanopen-ended group of seven oreightpatients under the leadership of a counselor. Thegroup counselor isthemainstay of the•,Rs.He is anactive-duty recovered alcoholic with2 to 10 years of abstinence whoserves asa rolemodelandasa supportive but firm example for identification.
Thepatients meet ina group session dailyfrom0800to0930hr.
Thethemeofthegroupisthatall members musteventually come Absent without official leave.
1660
•. A. •,WP, SC•
to termswith their own feelingsand that they must learn drug-
fi'ee,sociallyacceptable waysof releasingthesefeelingsor controllingthem.Honestywith selfandothersis giventhehighestpriority.Rationalization, "cop-outs" andconning areimmediately pointed out anddealtwith. Smoldering resentments, secretfears,childish wishes,defensive grandiosity, immaturetantrums,chronicself-pity and painfulloneliness are exposedas classical reasons for getting drunkand are repeatedlydealt with throughthe groupprocess. If a situationappears "toodeep"or potentiallydestructive for the groupto handle,it is dealtwith in oneor moreindividualsessions by the counselor, psychologist or psychiatrist beforethe subiectis reintroduced intothegroupprocess. Additionally, eachgroupmeets onceor twiceweeklywith a clinicalpsychologist or socialworker. Thishelpsthe counselor to sharpen his clinicalskillsby working closelywith the psychologist and socialworker. Educational
Phase
The educational phaseof the A•s programmostdirectlyspells out the themewhichin oneway or anotherrunsthroughall the A•s activities:that alcoholis a drug,the heavyuseof whichhas
predictable consequences, and that theseconsequences. will becomemanifest in thepatient's physical health,mentalhealth,family life,professional life,social life,legal•life, or financial life.Each morning allpatients attenda 1-hour educational session. Thespeakers(someof whomarerecovered alcoholics) comefromtheworld of medicine,law, industry,showbusiness, the ministry,and the military.They dealwith the medical,physiological, societal and
mentalaspects of drinking. Legalaspects, especially drunken-drivingarrests andalimonyproblems, alwaysprovoke manyquestions. Recovered alcoholics who haveclimbedbackto the top of the ladderpresent a combination "drunkalog" andhowto function as a nondrinker in a drinkingworld.Speakers fromprivateindustry
discuss thealcoholism problem in civilianlife,emphasizing clearly that manycivilianalcoholics wereformerlymilitarypeopleand thattreatmentfor alcoholics in industryis in a way iustas"compul-
sory" asit isin themilitary, because thethreatof ioblossisusedto
coerce patients intotreatment. Chaplains andministers discuss the spiritual aspects of thedisease. Thelectures aresupplemented by paneldiscussions, filmsandvideotapes onalcoholism.
QUONSETHUT TO NAVAL HOSPITAL
1661
AlcoholicsAnonymous
A.A.remains a prominent featureof theAxas program. A.A.literatureisusedandall patients areencouraged to acceptA.A.asa way of attainingand maintaining abstinence. Stepmeetings are held and all patientsare bussedto A.A. meetingsin the Long Beach area5 nightsa week.On Thursday nightstheDrydockGroupOne meeting is heldin the ^xas. It is an openmeetingandis attended by many alumniand friendsof the Navy. A1-Anonand A1-Ateen meetingsare held concurrentlyon the samefloor. Each year an alumnireunionis held to celebratethe anniversaryof Drydock One.
Psychodrama
Thursdayafternoons are devotedentirelyto psychodrama. Introducedinto the •xasseveralyearsagoby professionals, it was initiallyresistedby patientsand staff alikeuntil techniques were masteredby the counselors themselves. The psychodrama is precededby a staff meetingduringwhich possiblethemesor conflictsto be workedon in that day's psychodrama are broughtup. Frequenttopicsare individual(but, nevertheless, common)problems,suchasa certainpatient'sdifficultywith authorityfiguresor father-in-law,how to talk to a womanwithout first usingalcohol as a couragebuilder, how to deal with not drinking when you get back to duty, or how not to reach for the bottle when your wife startsarguingwith you. Every Thursdaya different counseloris the directorof the psychodrama and the entire population (all patients,wives,and staff) participates. Sometimes the subjectfor a psychodrama is an ms community
problem,suchashowthe AXaS as a wholeshoulddealwith weekend drinkingby certainpatients;the problempresented by alcoholicsunder25 yearsof age who want to stay "high"on other drugswhiletheyare patientsin the AXaS; how to deal with the separationanxietyof the entire •a•s when it movesto a new location.
At theconclusion of thepsychodrama thepatients meetin their individualgroups; afterthat the staff'meetsseparately to tie togetherandtherapeutically consolidate whatthe psychodrama produced.Someof the most dramaticand lastingbreakthroughs in
the livesof individualpatientshaveoccurred on Thursdayafternoons.Also,manya community AXaS problemhas been resolved
through psychodrama in a manner farsuperior tosuch time-honored problem-solving methodsasedict,chainof command, consensus or
maiority vote.Patients andstaffalikebelievethatwithoutpsychodrama the ARSwould not be what it is.
Recreational Psychotherapy This new treatmentmodalitywasintroduced because we have become awarethat mostof ourpatients, priorto arrivalat the A•as, hadgradually experienced moreandmorelossof recreational interests. Theirbodies withexcess fat,highresting pulserates,and low pulmonary capacityattestto the fact that they havebecome sedentary, drug-using spectators of life. In orderto restoremuscle tone,a bettercardiopulmonary capacity, and consequent increase in self-respect and senseof well-being,we have introducedthis recreational program.The initial 12-minuterunning-walking test ("howmuchdistancecan you coverin 12 minutes")showseach
patientexactlyin whatphysical shape he is whenhe arrivesat the •as. All patientsand stafflogdailyafterthe morninggroupsand beforetheeducational sessions. Patientprogress ismonitored weekly. Two afternoons per weekeachgroupis involvedin a group sportsuchas swimming, volleyballor basketball, whereplay and counseling arecombined sothattheresistance to therapyanddenial of alcoholism arefurtherloweredandbodilyhealthis improved. In hisfinalweek,eachpatientrepeatsthe 12-mindistance testsothat he canhimselfrecognizewhat he hasachieved.
An athleticprogramof thistype,where"youworkagainstyourselfandmonitoryourownprogress," fits in well with the honesty conceptof A.A. and the •as. It alsohelpsthe patientto identify with hispeersand the •as. Wiveswho go throughrehabilitation with theirhusbands haveioinedthe loggingprogram. Other ARS Tools
Every Monday afternoonthe entire staff in conferencereviews
the progress of everypatient.Suchquestions ashowthe patient's wife canbe gotteninto therapy,whethersheshouldbe in the samegroupasher husband, whetherthe patientis readyfor discharge,how he has benefitedfrom individualcounseling or why he is not responding to therapy,are discussed in detail.Whena patientseems unableto accepthis alcoholism, or is not making sufficient progress, he appears beforethe Counselor's Board.This
QUONSETHUT TO NAVAL HOSPITAL
1663
Boardconsists of a staffphysician, a psychologist, the seniorcounselorandseveralothercounselors, all of whomconfrontthe patient in a closedsessionto break throughhis denial and to ex-
plorewith him alternatewaysof makinghim moreresponsive to the rehabilitation program. The EmpathyBoard,whichconsists of a staffphysician, oneor two counselors andtwo or threeA•spatients, meetsfor the purposeof individually confronting patientswho appearinvolvedin behaviorwhich,althoughit is designedto bolstertheir own denial,
is suchthat it is alsopotentiallyor actuallyharmfulto the A•s process as a whole.For manypatientsthis Boardhaseffecteda breakthrough of theirdenialanda turning-point in theirrecovery.
Outpatient Consultation, Detoxication, and MedicalEducation Every memberof the staff has had sufficienttrainingso that he canprovidea consultation whenever he is calledon.As a resuit,everypotentialpatientis seenliterallywithinminutesafter he arrivesin thehospital or the A•S.Afterregularworkinghours thisservice isprovided by the24-hour-a-day On BoardDutyCounselor.We find thisto be an especially usefulcapability in a hospital-based alcoholism rehabilitation facilitysuchasoursbecause it enables us to provideimmediate consultation, clarification or disposition ideasto physicians andhospital staff.Whenthedoctor or nurseon duty encounters an alcoholicin the emergency room, or on one of the wards where his alcoholismwas not diagnosed
because he wasbeingtreatedunderanotherdiagnosis, the patient invariablygetsbetter care soonerif the alcoholism counselor is available immediately to assist in interviewing the patientandthe family,and to makerecommendations to the physician. In such situations the alcoholism counselor can function as a teacher to
theprofessional, asa therapist to thepatient, andasa facilitator to the whole health-caredelivery system.
In orderto increase the hospital staffsknowledge aboutthe diagnosis andtreatment of alcoholism, andto makethe staffmore comfortable with the various aspects of alcohol misuse, we have begunto meetin formalteaching sessions with physicians, nurs-
es,medical corpsmen andadministrative personnel. An increased awareness, asevidenced by the risingnumberof requests for consultations we are gettingfrom wardsand from the emergency
room,suggests thatthisapproach is goingto be highlyeffective.
1664
j.x.
•tmscn
Also,an increasing numberof dependents and retiredpersonnel are beingadmittedto the aas for detoxication by the staff physicianswho are on duty in the emergency roomwhen thesepatientsare broughtin by familyor police.Formerly,suchpatients were either given sometranquilizersand senthome "becauseyou don't have the DTs" or they were admittedto the hospitalfor treatment of a related disorder, without alcoholismbeing men-
tioned,andwith no particulareffortmadeto get the patientinto treatment
for alcoholism.
Anotheroutgrowthof our hospitalteachingprogramis an increasing numberof inpatienttransfers. A recentexampleis a 20year-oldmarinewho had shothimselfin the chestin a suicide attempt.After lifesaving surgeryon the ThoracicServicehe was stillsomewhat depressed andwasbeing. readiedfor administrative separation. Fortunately, he gotdrunkwhenonleave,andon closer examination wasdiagnosed as an alcoholic.He wastransferredto the aasandexperienced dramaticchanges in histotalpersonality functioning.He is abstinentand has returnedto full duty with a totally differentkind of motivation.
Anotherexample is a HM14whowason independent dutyon a destroyer andwasadmittedto the neuropsychiatric ward with a diagnosis of depressive reaction.Examination by the neuropsychiatrydepartment revealed alcoholism asthe primarydiagnosis.
Thepatientwasthenseenby usin consultation, andtransferred. Amongthe mostrecenttransfers are two patients with fractured jawsfromthe Oral SurgeryService. Bothare alcoholics and are now in rehabilitation.
A mostimportant phaseof the hospitaleducation programis
training physicians andpsychologists fromotherNavalcommands. Theseprofessionals checkintoourservice for a 2-weektraining period.Theyareassigned to a groupandaretreatedthe same as the patients except for restriction anddisulfiram. Theyalso get didactic lectures on medicalaspects of detoxication, andare takento localcivilianhospitals and rehabilitation facilitiesto givethema broader understanding of the disease. Mostof them haveundergone profound changes in theirattitudeaboutalcoholismand two of them voluntarilychangedtheir statusfrom
visitorto patient.They underwent rehabilitation and are now among the48 recovered alcoholic NavyMedicalDepartment ofHospitalCorpsman,First Class.
QUONSETHUT TO NAVALHOSPITAL
1665
ricerswho are abstinentand functioningon duty in the Navy. We have noticedthat the presenceof thesevisitingphysicians stimulates the staff of our own hospitalto look into the disease process in moredetail.During resultantinformaldiscussion some membersof the hospitalstaff are becomingmore aware of the fact that theyhavetendedto diagnose onlythe physiological complications of alcoholism, and that in the absence of complications they have completelyignoredor missedthe sociopsychological aspects of the disease by usingthe diagnosis "simpleintoxication" or "acutebrain syndrome."
The process of bringingthe hospital's staff and the alcoholics togetherto enlighteneachother abouttheir blind spotsis probably the mostexcitingand potentiallyfar-reaching differencebetween the •a•sand other Navy alcoholismtreatmentcenters.Unfortunately,the averagedoctortodayrecognizes only the medical, surgical andorthopedic complications of alcoholism andis inclined to consider themasseparate disease entities,apartfromalcoholism itself.Sincehe knowsnothingaboutthe sociopsychological aspects of the disease,and becauseof his pessimism aboutthe potential benefitsof treatment,he tendsto patchup the complications, en-
ablingthe patientto go out and get moreserious complications withouttheprimarycondition everbeingtreateduntilit istoolate. Oursis a health-oriented society,and the availabilityof healthcare servicesis increasing. All alcoholics sooneror later develop
medicalcomplications whichbringthemfaceto facewith the
health-care deliverer. Education of health-care deliverers will en-
ablethem to makethe diagnosis of alcoholism and to get the patient into treatment sooner.Eventually, emergencyroom treatment
and medicaldetoxication of alcoholics will be lookeduponnot so
muchastherapybut ratherasa means of referralfor treatment. To thatend,ourhospital staffsneedto be educated. In addition to rehabilitating alcoholics, we at LongBeach^Rsconsider the trainingof medicalstaffsand otherprofessionals our mostimportantbusiness. REFERENCES
1. CAHALAN, D. and CISIN,I. H. Final reporton a service-wide surveyof attitudesand behaviorof Naval personnelconcerning alcoholand problem drinking. (Rep.No.AD-AO13-236;NIAAA/NCALI-75/15.) Springfield, VA; U.S. Nat. Tech. Inform. Serv.; 1975.
2. CooPv. R, K. H. Aerobics. NewYork;Bantam Books; 1973.
From Quonset Hut to NavalHospital The Story of an AlcoholismRehabilitationService • Capt.Joseph A. Pursch,MC, USN SUMMAa¾. The historyand treatmentmethodsof the first Navy Alcoholism Rehabilitation Service are described.
ONGSEAFARING MEN, thecustom of drinking is probably asoldasthesailing tradition itself.In theearlydays of the UnitedStatesNavy, it was standardpracticefor everydeparting shipto takeon boardfar morerum thanwater. When Secretary of the Navy Josephus Daniels,in 1913,decreed that the U.S. Navy would henceforthbe "dry," the idiomaticex-
pression "drunkasa sailor" wasreplaced by "drunkin everyport."
For,aseveryskipper of theNavyknows, oncehisshiphitsport, the intoxicated sailorbecomes his majorproblem. While the drinkingof alcoholicbeverages at seadecreased mark-
edlyamongofficersandbecamepractically nonexistent amongenlisted men, the drinking customsand rituals on land became a
stapleof dailylife and an indispensable ingredient of almostall Navysocialfunctions: tellingseastories in a harborsaloon, playing softballat squadron beachparties, bragging at "happyhours," meeting shipmates' familiesbeforedinner,sing-alongs at wetting-down partiesand changeof command ceremonies, all becameunthinkable without alcohol as a central feature. Fair-haired
children of
the Navy family,suchas submariners, developedtheir own particulardrinkingcustoms, for example,"drinkingyour dolphins." In Naval Aviation, we drink accordingto the following customs:
We drinkat happyhours,aftera goodflight,after a bad flight, and after a near mid-air collision.(to calm our nerves).To celebrate our first soloflight we traditionallypresentour instructor with a bottle of his favorite liquor and, if we successfully bail
outof a crippled airplane, we express ourthanksto thelifesaving parachute riggerwitha bottleof hispreferred spirits. We drink • From the Naval RegionalMedical Center, Long Beach, CA 90822. Receivedfor publication:28 January1976. 1655
1656
j.x.
•,v'P, scI-•
whenwe get our wings,when we get promoted(wetting-down parties),whenwe get passedover (to alleviateour depression), at formal dining-ins,changeof commandceremonies,chiefs'initiationsand at "Beef and BurgundyNight." At birthday balls we drink our doorprize if we have the luckyticket.When a diver
inspects the hull of the shipwe givehim medicinalbrandy,and we prescribe the sametreatmentfor "exposure to the elements" if a man falls overboard and is fished out of the Caribbean
on a
hot day in July. A night carrierlandingusuallyrates medicinal
brandy,dispensed by thewell-meaning flightsurgeon. We "hailand farewell"frequently,and the first liquid that wets the bow of any
newbornshipat its christening is champagne. Thus,we drinkfrom enlistmentto retirementand from teenhoodto old age. Sincethe Navy is only a subcultureof Americansocietyitself,
it shouldbe no surprisethat the Navy'sdrinkingcustoms reston suchsolidnationalmythsasthe hard-drinking, two-fisted,pioneering frontiersman; the hard-charging tiger of an aviatorwho can drinkall nightandfly all day;the ruggedness of the guywhocan hold his liquorlike a man;and the notionthat you can'ttrusta man who won't drink.
If thereis any validityto the conceptthat the drinkingpracticesand attitudesof a societyhavesomerelationship to whether
or not a predisposed memberof that society will developalcoholism,then it is likely that a Navy that drinksas our Navy drinkswill generatea high numberof problemdrinkers.Such
indeedappears to be thecase:a survey in 1974revealed that195 of the officersand 375 of the enlistedmenare heavydrinkersand haveserious problems as a result(1).
Perceptive lineofficers aswellasNavylawyers, chaplains and doctorshaveknownthis all along.They haveseenthe drinker's hangovers at Captain's Mast,2hisdeteriorating careerat courtsmartial, his sufferingwife in the confessional, his brokenjaw on the
orthopedic ward,hisbleeding ulcerin theoperating room,and hisshrunken liverat autopsy. But thoughtheseobservers might havebeenperceptive, well-schooled, andof a kindlyspirit,they wereunableto helpthealcoholic. Ourpuritantradition andthe administrative attitudes whichit spawned woulddictatethatthe suffering alcoholic (the onewhohaddrunkwith all the restof us,butwhocouldnolongercontrol it) wouldhaveto be separated • Nonpunitive procedure heldby the sailor'scommanding officerfor the purpose of resolvingminor disciplinaryinfractions.
QUONSETHUT TO NAVAL HOSPITAL
1657
from the Navy administratively or punitively.Thus,the age-old question"what do you do with a drunkensailor"was answered by the administrative fiat "youlet him go downthe tubes,"which meantthat he wouldbe expelledinto the civilianworld. As a result, the alcohol-relateddisordersin the Veterans Administration
hospitals doubledbetween1965and 1969,andmanyof the Navy's bestmembers wereeitherseparated prematurely andpunitivelyor they were nonchalantlyor forciblyretired into invalidism. BAL-•(;BOUND
One suchpersonwas a retired alcoholicCommander,Dick J., from Long Beach, California, who in 1965 was hospitalizedfor the eighth time (this time on the psychiatricward). Again, as during previous hospitalizations, the word alcoholismwas never mentioned,and after
his dischargefrom the hospitalhe was still sick with alcoholism. He finally becameabstinentand recoveredhis mental health through the fellowshipof AlcoholicsAnonymous.It occurredto him that perhaps A.A. meetingscouldbe held at the Long BeachNaval Stationto help thoseshipmateswho were alcoholics.He approachedthe Naval Dispensaryand was directedto the SeniorMedical Officer, Captain J. J. Zuska.Like most medical officers,Captain Zuska had for years been unsuccessful in his efforts to treat alcoholics. He listened to the Com-
mander and became curious. Together they persuadedthe Executive Officer of the Naval Station to let them hold A.A. meetings in the
conference room.Thus,on 20 February1965,the first meetingof A.A. DrydockGroupOne tookplacewith threepeoplein attendance.Meetingscontinued to takeplaceweeklyandthe numberof peopleattending grew.
Of the first 30 members,not a singleone got well. It becameeven more obviouswhat a fatal illnessalcoholismreally was becausesome of them died. The foundersof the groupbecamediscouraged but did not give up. Insteadthey got permission to use an abandonedquonset
hut for their meetingsand addedmedicaltechniques to their rehabilitativeapproach. Sincealcoholism wasa stigmatizing, unmentionable condition,and becausetheir initial operationwas practicallyillegal, they graduallyacquiredmore oppositionthan support. In 1967theywere authorizedby the Bureauof Medicineand Surgery to proceedwith their work as a pilot program;but, symbolically, the authorizationarrived in an envelopemarked"Secret."In spite of official sanction, the pioneeringLong Beachmodelfor treatingalcoholic sailorsand officersremaineda secretscornedoperation-evidencedby the fact that between 1965 and 1973, in spite of repeated invitations,
not a singleNavy doctorfrom Long BeachNaval Hospitalcame to the Alcohol RehabilitationCenter to see what the program was all ab,out.Housedin a dilapidatedWorld War II barracks,it remained
1658
essentiallya bootleg operation,its product more and more widely known but its locationand meansof productionshroudedin a sinister, illicit fog, like a whisky still in a dry county. Gradually a staff was acquiredand severaltreatmentmodalitieswere added. The capacitywas increasedto 65 inpatients,the name was changedto the AlcoholRehabilitationCenter, and it becamethe prototype on which all future Navy alcoholismrehabilitationcenterswere
modeled.In July 1974the Centerwas movedinto the Naval Hospital in Long Beachand becamethe AlcoholRehabilitationService(•s) to give it equal billing with other servicesof the hospitalsuch as the SurgeryService,and to lend palpablecredenceto the philosophythat alcoholism is a disease and should be treated as such. The staff now
includes a psychiatrist,a general practitioner, three part-time psychologists, one socialworker, one nurse and a staff of Navy, Marine Corps and Coast Guard counselors. TP,•ATMENT
I•OCRA•
Rulesand GeneralPhilosophy of the ARS
Whena patientarrives at theLongBeach A•S,hegetsa thorough physical andpsychiatric evaluation, including a batteryof psychological tests.If he is not diagnosed as an alcoholic, he is re-
turnedto duty with an appropriate consultation placedin his healthrecord,or he is transferredto anotherserviceof the hos-
pital for whatevertreatment is indicated. The patientis treatedwith respectanddignityin an environment which is conductedlike any military command(reveille,
uniformof the day,zoneinspections). Thereare no barredwindows,lockeddoorsor any restraintsother than militaryregula-
tions.Thegeneral philosophy isthateverypatient herehasa problem with alcohol.In the ARshe findshimselfin a helping,learning,
problem-solving environment. He hearsnopreaching, theorizing, moralizing, condemning or condoning. Concerning hisdrinking, the
staffattitudesarekindbut firm: we understand whathashappened
to himbut we do not dwellin the past.In the forefrontof all
therapy is theattitude thatalthough hehasa disease, andeven
though wearegoingto helphim,onlyhecanaccept theultimate
responsibility forhisdrinking andforwhathisdrinking will do to him from now on.
How it Works
Duringthe6 to 8 weeks' stayat theARs, thepatientgrows from analcoholically drinking, deiected, resentful, problem-avoiding per-
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1659
son whoselife has becomeunmanageable, to a more confident,
friendlypersonwho hasgonethrougha painfulprocess of selfawareness and who no longertendsto use alcoholto try to solve
hislife problems. Thisis broughtaboutin a drug-free environment throughgroupinvolvement, A.A., education, recreational psychotherapy,psychodrama andfamilytherapy. Introduction
to the ARS
Duringthe first 2 weeksthe patientis in a restrictedstatus. Exceptfor A.A.meetings in the LongBeachareato whichhe is bussed withotherpatients, hecannot leavethehospital compound. Mostpatients resentthisrestriction andaccuse usof nottrusting them. Our answer to that is that we trust them but that we don't
trusttheirdisease. We pointoutthatwehaveseenmanyalcoholic senior officers, career physicians andothertrustworthy individuals of highmoralcaliberwho,although theymadea sincere resolve notto drink,comebackdrunkfromliberty (or werebroughtback in an AWOL a status),mortified,guilt-ridden,unableto compre-
hendhowit couldhavehappened to them.Duringthe initial2 weeks, thepatient is asrapidlyaspossible withdrawn frommedications otherthandisulfiram(Antabuse)andvitamins.Fromthen
onwhenhe getsanxious or depressed weprescribe peopleinstead of pills.
For the first3 daysthepatientis assigned to the intakegroup wherehe is familiarized withthephilosophy of the•a•sandwith
theprinciples ofgroup counseling. Also, hiscurrent stateofphysical fitnessis assessed by usingthe 12-minute runningtest described by Cooper(2). GroupCounseling
Thepatient is nowreadyto be assigned to hisregular group. Thisisanopen-ended group of seven oreightpatients under the leadership of a counselor. Thegroup counselor isthemainstay of the•,Rs.He is anactive-duty recovered alcoholic with2 to 10 years of abstinence whoserves asa rolemodelandasa supportive but firm example for identification.
Thepatients meet ina group session dailyfrom0800to0930hr.
Thethemeofthegroupisthatall members musteventually come Absent without official leave.
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•. A. •,WP, SC•
to termswith their own feelingsand that they must learn drug-
fi'ee,sociallyacceptable waysof releasingthesefeelingsor controllingthem.Honestywith selfandothersis giventhehighestpriority.Rationalization, "cop-outs" andconning areimmediately pointed out anddealtwith. Smoldering resentments, secretfears,childish wishes,defensive grandiosity, immaturetantrums,chronicself-pity and painfulloneliness are exposedas classical reasons for getting drunkand are repeatedlydealt with throughthe groupprocess. If a situationappears "toodeep"or potentiallydestructive for the groupto handle,it is dealtwith in oneor moreindividualsessions by the counselor, psychologist or psychiatrist beforethe subiectis reintroduced intothegroupprocess. Additionally, eachgroupmeets onceor twiceweeklywith a clinicalpsychologist or socialworker. Thishelpsthe counselor to sharpen his clinicalskillsby working closelywith the psychologist and socialworker. Educational
Phase
The educational phaseof the A•s programmostdirectlyspells out the themewhichin oneway or anotherrunsthroughall the A•s activities:that alcoholis a drug,the heavyuseof whichhas
predictable consequences, and that theseconsequences. will becomemanifest in thepatient's physical health,mentalhealth,family life,professional life,social life,legal•life, or financial life.Each morning allpatients attenda 1-hour educational session. Thespeakers(someof whomarerecovered alcoholics) comefromtheworld of medicine,law, industry,showbusiness, the ministry,and the military.They dealwith the medical,physiological, societal and
mentalaspects of drinking. Legalaspects, especially drunken-drivingarrests andalimonyproblems, alwaysprovoke manyquestions. Recovered alcoholics who haveclimbedbackto the top of the ladderpresent a combination "drunkalog" andhowto function as a nondrinker in a drinkingworld.Speakers fromprivateindustry
discuss thealcoholism problem in civilianlife,emphasizing clearly that manycivilianalcoholics wereformerlymilitarypeopleand thattreatmentfor alcoholics in industryis in a way iustas"compul-
sory" asit isin themilitary, because thethreatof ioblossisusedto
coerce patients intotreatment. Chaplains andministers discuss the spiritual aspects of thedisease. Thelectures aresupplemented by paneldiscussions, filmsandvideotapes onalcoholism.
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AlcoholicsAnonymous
A.A.remains a prominent featureof theAxas program. A.A.literatureisusedandall patients areencouraged to acceptA.A.asa way of attainingand maintaining abstinence. Stepmeetings are held and all patientsare bussedto A.A. meetingsin the Long Beach area5 nightsa week.On Thursday nightstheDrydockGroupOne meeting is heldin the ^xas. It is an openmeetingandis attended by many alumniand friendsof the Navy. A1-Anonand A1-Ateen meetingsare held concurrentlyon the samefloor. Each year an alumnireunionis held to celebratethe anniversaryof Drydock One.
Psychodrama
Thursdayafternoons are devotedentirelyto psychodrama. Introducedinto the •xasseveralyearsagoby professionals, it was initiallyresistedby patientsand staff alikeuntil techniques were masteredby the counselors themselves. The psychodrama is precededby a staff meetingduringwhich possiblethemesor conflictsto be workedon in that day's psychodrama are broughtup. Frequenttopicsare individual(but, nevertheless, common)problems,suchasa certainpatient'sdifficultywith authorityfiguresor father-in-law,how to talk to a womanwithout first usingalcohol as a couragebuilder, how to deal with not drinking when you get back to duty, or how not to reach for the bottle when your wife startsarguingwith you. Every Thursdaya different counseloris the directorof the psychodrama and the entire population (all patients,wives,and staff) participates. Sometimes the subjectfor a psychodrama is an ms community
problem,suchashowthe AXaS as a wholeshoulddealwith weekend drinkingby certainpatients;the problempresented by alcoholicsunder25 yearsof age who want to stay "high"on other drugswhiletheyare patientsin the AXaS; how to deal with the separationanxietyof the entire •a•s when it movesto a new location.
At theconclusion of thepsychodrama thepatients meetin their individualgroups; afterthat the staff'meetsseparately to tie togetherandtherapeutically consolidate whatthe psychodrama produced.Someof the most dramaticand lastingbreakthroughs in
the livesof individualpatientshaveoccurred on Thursdayafternoons.Also,manya community AXaS problemhas been resolved
through psychodrama in a manner farsuperior tosuch time-honored problem-solving methodsasedict,chainof command, consensus or
maiority vote.Patients andstaffalikebelievethatwithoutpsychodrama the ARSwould not be what it is.
Recreational Psychotherapy This new treatmentmodalitywasintroduced because we have become awarethat mostof ourpatients, priorto arrivalat the A•as, hadgradually experienced moreandmorelossof recreational interests. Theirbodies withexcess fat,highresting pulserates,and low pulmonary capacityattestto the fact that they havebecome sedentary, drug-using spectators of life. In orderto restoremuscle tone,a bettercardiopulmonary capacity, and consequent increase in self-respect and senseof well-being,we have introducedthis recreational program.The initial 12-minuterunning-walking test ("howmuchdistancecan you coverin 12 minutes")showseach
patientexactlyin whatphysical shape he is whenhe arrivesat the •as. All patientsand stafflogdailyafterthe morninggroupsand beforetheeducational sessions. Patientprogress ismonitored weekly. Two afternoons per weekeachgroupis involvedin a group sportsuchas swimming, volleyballor basketball, whereplay and counseling arecombined sothattheresistance to therapyanddenial of alcoholism arefurtherloweredandbodilyhealthis improved. In hisfinalweek,eachpatientrepeatsthe 12-mindistance testsothat he canhimselfrecognizewhat he hasachieved.
An athleticprogramof thistype,where"youworkagainstyourselfandmonitoryourownprogress," fits in well with the honesty conceptof A.A. and the •as. It alsohelpsthe patientto identify with hispeersand the •as. Wiveswho go throughrehabilitation with theirhusbands haveioinedthe loggingprogram. Other ARS Tools
Every Monday afternoonthe entire staff in conferencereviews
the progress of everypatient.Suchquestions ashowthe patient's wife canbe gotteninto therapy,whethersheshouldbe in the samegroupasher husband, whetherthe patientis readyfor discharge,how he has benefitedfrom individualcounseling or why he is not responding to therapy,are discussed in detail.Whena patientseems unableto accepthis alcoholism, or is not making sufficient progress, he appears beforethe Counselor's Board.This
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1663
Boardconsists of a staffphysician, a psychologist, the seniorcounselorandseveralothercounselors, all of whomconfrontthe patient in a closedsessionto break throughhis denial and to ex-
plorewith him alternatewaysof makinghim moreresponsive to the rehabilitation program. The EmpathyBoard,whichconsists of a staffphysician, oneor two counselors andtwo or threeA•spatients, meetsfor the purposeof individually confronting patientswho appearinvolvedin behaviorwhich,althoughit is designedto bolstertheir own denial,
is suchthat it is alsopotentiallyor actuallyharmfulto the A•s process as a whole.For manypatientsthis Boardhaseffecteda breakthrough of theirdenialanda turning-point in theirrecovery.
Outpatient Consultation, Detoxication, and MedicalEducation Every memberof the staff has had sufficienttrainingso that he canprovidea consultation whenever he is calledon.As a resuit,everypotentialpatientis seenliterallywithinminutesafter he arrivesin thehospital or the A•S.Afterregularworkinghours thisservice isprovided by the24-hour-a-day On BoardDutyCounselor.We find thisto be an especially usefulcapability in a hospital-based alcoholism rehabilitation facilitysuchasoursbecause it enables us to provideimmediate consultation, clarification or disposition ideasto physicians andhospital staff.Whenthedoctor or nurseon duty encounters an alcoholicin the emergency room, or on one of the wards where his alcoholismwas not diagnosed
because he wasbeingtreatedunderanotherdiagnosis, the patient invariablygetsbetter care soonerif the alcoholism counselor is available immediately to assist in interviewing the patientandthe family,and to makerecommendations to the physician. In such situations the alcoholism counselor can function as a teacher to
theprofessional, asa therapist to thepatient, andasa facilitator to the whole health-caredelivery system.
In orderto increase the hospital staffsknowledge aboutthe diagnosis andtreatment of alcoholism, andto makethe staffmore comfortable with the various aspects of alcohol misuse, we have begunto meetin formalteaching sessions with physicians, nurs-
es,medical corpsmen andadministrative personnel. An increased awareness, asevidenced by the risingnumberof requests for consultations we are gettingfrom wardsand from the emergency
room,suggests thatthisapproach is goingto be highlyeffective.
1664
j.x.
•tmscn
Also,an increasing numberof dependents and retiredpersonnel are beingadmittedto the aas for detoxication by the staff physicianswho are on duty in the emergency roomwhen thesepatientsare broughtin by familyor police.Formerly,suchpatients were either given sometranquilizersand senthome "becauseyou don't have the DTs" or they were admittedto the hospitalfor treatment of a related disorder, without alcoholismbeing men-
tioned,andwith no particulareffortmadeto get the patientinto treatment
for alcoholism.
Anotheroutgrowthof our hospitalteachingprogramis an increasing numberof inpatienttransfers. A recentexampleis a 20year-oldmarinewho had shothimselfin the chestin a suicide attempt.After lifesaving surgeryon the ThoracicServicehe was stillsomewhat depressed andwasbeing. readiedfor administrative separation. Fortunately, he gotdrunkwhenonleave,andon closer examination wasdiagnosed as an alcoholic.He wastransferredto the aasandexperienced dramaticchanges in histotalpersonality functioning.He is abstinentand has returnedto full duty with a totally differentkind of motivation.
Anotherexample is a HM14whowason independent dutyon a destroyer andwasadmittedto the neuropsychiatric ward with a diagnosis of depressive reaction.Examination by the neuropsychiatrydepartment revealed alcoholism asthe primarydiagnosis.
Thepatientwasthenseenby usin consultation, andtransferred. Amongthe mostrecenttransfers are two patients with fractured jawsfromthe Oral SurgeryService. Bothare alcoholics and are now in rehabilitation.
A mostimportant phaseof the hospitaleducation programis
training physicians andpsychologists fromotherNavalcommands. Theseprofessionals checkintoourservice for a 2-weektraining period.Theyareassigned to a groupandaretreatedthe same as the patients except for restriction anddisulfiram. Theyalso get didactic lectures on medicalaspects of detoxication, andare takento localcivilianhospitals and rehabilitation facilitiesto givethema broader understanding of the disease. Mostof them haveundergone profound changes in theirattitudeaboutalcoholismand two of them voluntarilychangedtheir statusfrom
visitorto patient.They underwent rehabilitation and are now among the48 recovered alcoholic NavyMedicalDepartment ofHospitalCorpsman,First Class.
QUONSETHUT TO NAVALHOSPITAL
1665
ricerswho are abstinentand functioningon duty in the Navy. We have noticedthat the presenceof thesevisitingphysicians stimulates the staff of our own hospitalto look into the disease process in moredetail.During resultantinformaldiscussion some membersof the hospitalstaff are becomingmore aware of the fact that theyhavetendedto diagnose onlythe physiological complications of alcoholism, and that in the absence of complications they have completelyignoredor missedthe sociopsychological aspects of the disease by usingthe diagnosis "simpleintoxication" or "acutebrain syndrome."
The process of bringingthe hospital's staff and the alcoholics togetherto enlighteneachother abouttheir blind spotsis probably the mostexcitingand potentiallyfar-reaching differencebetween the •a•sand other Navy alcoholismtreatmentcenters.Unfortunately,the averagedoctortodayrecognizes only the medical, surgical andorthopedic complications of alcoholism andis inclined to consider themasseparate disease entities,apartfromalcoholism itself.Sincehe knowsnothingaboutthe sociopsychological aspects of the disease,and becauseof his pessimism aboutthe potential benefitsof treatment,he tendsto patchup the complications, en-
ablingthe patientto go out and get moreserious complications withouttheprimarycondition everbeingtreateduntilit istoolate. Oursis a health-oriented society,and the availabilityof healthcare servicesis increasing. All alcoholics sooneror later develop
medicalcomplications whichbringthemfaceto facewith the
health-care deliverer. Education of health-care deliverers will en-
ablethem to makethe diagnosis of alcoholism and to get the patient into treatment sooner.Eventually, emergencyroom treatment
and medicaldetoxication of alcoholics will be lookeduponnot so
muchastherapybut ratherasa means of referralfor treatment. To thatend,ourhospital staffsneedto be educated. In addition to rehabilitating alcoholics, we at LongBeach^Rsconsider the trainingof medicalstaffsand otherprofessionals our mostimportantbusiness. REFERENCES
1. CAHALAN, D. and CISIN,I. H. Final reporton a service-wide surveyof attitudesand behaviorof Naval personnelconcerning alcoholand problem drinking. (Rep.No.AD-AO13-236;NIAAA/NCALI-75/15.) Springfield, VA; U.S. Nat. Tech. Inform. Serv.; 1975.
2. CooPv. R, K. H. Aerobics. NewYork;Bantam Books; 1973.
