Prof Peter Collins – Addiction Treatment – Still Hopeful

Prof Peter Collins -Addiction Treatment – Still Hopeful

Appendix to Vol One: Sex and Violence Amongst British Toffs (1945-75)

ADDICTION.

My departure from England for South Africa (where I knew the drink would be cheap) seems as an appropriate point as any at which to try to write an appendix on the subject of my lifelong relation to addiction, in my case addiction to alcohol. There are several reasons for writing such an achronological chapter in this otherwise generally chronological account of my life – so far. One is that addiction to alcohol has been and is so pervasive in my life that I am likely to find myself with three quite different kinds of reader: first, those who know nothing of the shattering, albeit uneven, role that drunkenness has played in my life at every stage of it; second, mainly, my family but also some close friends for whom, my addiction to drink has been by far the most glaringly distressing aspect of my whole life and character; third, those for whom my problems with drink, if they knew about them at all, have been  small ones in my life and certainly have not prevented me from functioning effectively in the variety of environments in which they have encountered me.

I once summed this up by identifying two quite different possible epitaphs for myself. The one read: “Think what such a talented fellow might have achieved had it not been for his ruinous addiction to drink.” The second read: “Isn’t it remarkable how much this fellow did achieve despite his devastating addiction to alcohol.”

Another reason for writing this appendix is that I have increasingly concluded that for those who develop addictions, their drug of choice plays different and interlocking roles in their lives at different stages of those lives and relates to other psychological conditions in different ways, under different circumstances. At least this has been certainly true of me and drink which has sometimes helped me to cope at least temporarily with things like stress, depression loneliness and boredom for which there have been genuine grounds in my real-life circumstances. Mostly, though, it has ended up progressively making bad situations worse. Very obviously, for many people, the benefits of enjoying alcohol (or whatever) even if one is “dependent” on regular indulgence are quite substantial and the self-destructive harms pretty small. Many people I know and, indeed, love “need” to drink regularly more than the recommended dose, for example, to enhance conviviality and overcome shyness, to help deal with the formidable strains of early parenthood, or to mitigate the desuetude of other pleasures like sex and sport which commonly accompanies growing old. For these people, however, whatever the medical downside, it is clear to me that drinking enhances rather than diminishes their ability to enjoy their lives. For others like me, the cost-benefit ratio is mostly reversed. Moreover, the relationship of an addiction to people’s  general psychological make-up is constantly shifting so it has been very difficult for me to get a handle on what drink has done for and to me at any at any particular moment or period of my life: different things were going on at different times and are still doing so. For example, I don’t know how long I shall maintain my present condition of sobriety. It feels to me that I recently made a decisive shutting of the gate but experience tells me I have thought that many times before: I hope that, this time, finally writing about all this may itself be therapeutically helpful but who knows?  I also hope that in writing about what has seemed to me to be the phenomenology of my addiction, I shall render this apparently insane behaviour a bit more explicable to myself and others though not, therefore, more excusable in terms of all the hurt I have caused all round.

When I was recently going through one of the worst periods of my entire life in terms of depression – literally paralysed by a fear that there may be no point in continuing to live – I identified three sources of emptiness which I would have to fill, if I were not to die, not so much of alcohol poisoning, but of despair. I mention these not only to illuminate something about my own case but also because it seems to me that these feelings of emptiness are already quite widespread in the way we live now and are certainly a part of the escalating problems of being retired, whose social and psychological dimension, I suspect, will greatly outweigh the impacts on public finances which is all that current public debate focuses on in discussions of the problems of “ageing populations.” The feelings of emptiness I identified connect a sense of the pointlessness of life now with being in a condition of severe isolation from a real circle of friends and having no engagement with concrete and constructive activities capable of absorbing whatever productive enthusiasms and capacities I still possess.

The largest and most terrifying source of emptiness was the feeling that there was no longer anybody for me to be. I felt I had gone from being a modest hero to an absolute zero in a single fell swoop. This meant if I were to reacquire a genuine reason to go on living there must be somebody for me to be. When so many of us have been forced by retirement to recognise that we are now nobody – or nobody very much – then for this void to be filled we need to recover a sense of having a real identity which persuades us that our lives still really matter, not just to members of our families who may still care about us, but because of who we now are and what we can still do. The second sense of emptiness comes with the reality of isolation and sheer loneliness. It’s not that there aren’t still plenty of people in my life whom I enjoy visiting or otherwise meeting and who seem to be pleased to see me when we do meet. But that’s the point: it is always the case of visiting. This is not the same as belonging to a community or group, of which for most people the workplace, the family and the local community are paradigms, where we can routinely have a normal, conversational social life. When, as for me, the workplace ceases to be a major source of interaction with others, and additionally one lives alone as I do, in the largely anomic towns and cities which seem to me especially characteristic of contemporary England, it is quite easy to go for several days at a time literally without speaking to anyone.  The final void I identified was not an absence of people but an absence of anything I really wanted to do. What I needed, therefore, was to find something I believed to be truly worth doing – a projet – and to which I felt I could still make a useful and substantial, rather than a mere token contribution.

Most people ask these questions in a desultory way after they have retired. The difference in my case was that I was not going to be fobbed off by the usual trivial dismissals: go spend more time with your grandchildren; join a bridge club; travel. I needed real answers in the form of a sense of real purpose. Moreover, my need to know that my life had not finally become pointless was not a function of megalomania. It is a short step from wondering whether your life still matters to wondering whether anybody’s lives really matter since sooner or later they too will come to the condition I was then in; and from there to wondering whether anyone’s life has ever really mattered beyond the daubings and distractions with which they have sought to paper over the triviality and transience of their ultimately pointless existences.

Above all, then, I had to have a real reason for countering these negative and depressive thoughts – not merely a means of shooing them away – and knowing and feeling that my life really mattered – not just to others but to me. Relatedly, I also needed to know that it was possible for me to take part again in a real human community and that I had genuinely useful work to do– not the synthetic kind, invented solely for the purpose of keeping old people mindlessly content. Could I honestly answer these questions as a 68-year-old pensioner living alone in Oxford, learning more and more about ethics, politics and theology but without anyone else having any interest in reading or talking about the things I was thinking about? If not, I saw no alternative to the spurious sense of well-being I got from drinking myself into oblivion each day – something I could go on doing until some disease would kindly or cruelly carry me off. The power of all addictions, I now think, consists in part in the power of drink or drugs or food or sex or work to ward off the depredations of nihilism and its accompanying sense that all existence is pointless and that the deep truth about ourselves is that we and our lives are ultimately worthless.

Failure to understand this central need that addicts have to feel that their lives are not worthless causes confusion and usually much anger especially amongst relatives of addicts – a role which I have also known from the inside. This is because the addict’s sense of worthlessness feels like rejection of the all the love that the addict’s family and friends have shown him or her as well as of all the work they are likely to have done trying to help the addict. It also makes the addict seem indifferent to all the grief they have endured coping with the often devastating consequences for the family and others of the addict’s behaviour. So although in one sense the parents, lovers, children and friends of the addict understand that the addict in the family is sick, they also quite understandably experience the addict’s behaviour as egregiously selfish and ungrateful. They are also driven to a fury of frustration by the addict’s apparent determination to destroy everything that is good in his or her life with no concern for the harm they are causing to others. Consequently, though in part they feel they ought to treat the addict as someone who is seriously sick, another part of them wants to scream at the addict: “Pull yourself together. Look at all the harm you’re doing.” Unfortunately, the whole point about addiction is that addicts can’t “pull themselves together”: that is actually the defining property of being an addict in the first place.

Relatedly, it’s counter-productive to tell addicts they are killing themselves because in the context of feeling that one’s life is not worth living anyway the prospect of death may seem like a potential relief from the endless Sisyphean struggle of carrying on living with all the burdens of responsibility to others that it seems to carry with it. It may also be counter-productive congratulating addicts who have stayed sober on their achievement. In my case receiving such congratulation scares me into thinking: “Oh God! How long am I going to be able to keep this up?” It also suggests to me that all this is dependent on my strength of character which is precisely what is not the case with addictions. Consequently I find it much more encouraging to be told things like: “You’re looking well” or “I really liked what you did or enjoyed what we did together” rather than “I’m so proud of how long you’ve stayed away from the bottle.”

The outline of my drinking career, of which I have given some indication in this first volume and of which I shall give more detail in Volume Two, evolved as a classic descent to “rock bottom” as the need to be drunk for most of everyday increased to the point where my life was indeed, as the first of the twelve steps in the Alcoholics Anonymous (AA) programme puts it, “unmanageable.” At this point I turned to AA (yet again) and finally got completely sober for about two years in 1992. Subsequent to that, however, I have been what I think of as a “chronic relapser” and, for most of that time (until now?) I have been highly “functional”, capable of having literally an occasional – say, one every three months – glass of wine, but also prone to relapses into terrible binges where I do nothing but drink for more or less longish periods – from about 10 days to three or four weeks. During these binges, I cut myself off from everyone as far as I can, cause great alarm, anger and dismay, especially to my children and become incompetent, amnesiac and a thoroughly unpleasant person. After this I have so far been able to get myself back to normal – to detox myself – mainly by gradually recovering my ability to eat and by sleeping a lot, after which it feels as if I have somehow purged a lot of bottled up rage, resentment and sheer evil from my soul and I become a reasonably contented human being again, capable of love and work. Thus since 1992 it seems to me that my life has been far from unmanageable and that I have mostly been highly competent in both my working and personal life. On the other hand, the terrible binges have placed quite unfair and huge burdens, especially on two colleagues who have never ceased to protect me, to care for me and otherwise try to help me and to whom I shall remain eternally grateful, just as I expect to remain ashamed of the harm and hurt I have caused over the years to my family, friends and other colleagues who have also done everything they can think of to help me.

However, the binges have not, as far as I can judge, seriously compromised my ability to work in business, politics and academia at quite a high level and to deliver some quite substantial achievements over quite a long period of time. I may be deceiving myself about this and, actually, my professional achievements may have been more meagre than I am accounting them and the extent of my dysfunctionality much greater than I recognise. I don’t think it really matters which view is the accurate one. The point for me is that there was definitely a radical change in my life as an alcoholic before and after 1992, that I am far from being “cured” now but, for the most part, since 1992 my life has gone well despite the devastations of my chronic relapses. This is actually a very common phenomenon amongst people who break out of a condition of total and daily enslavement to their drug of choice and become chronic relapsers or occasional bingers. This is also, it seems to me, where the development of treatment increasingly needs to focus but just from my personal point of view, what I need to focus on is not trying to get at the truth of what has so far happened in the past but rather on what it’s going to be like from here on in and what I am going to do about drinking today and for however long I have left to live anyway.

As I have said I am fully aware of the way I have impaled those who have loved me on the horns of this dilemma between compassion and fury but I have also experienced these frustrations as a parent in relation to my son’s addiction to drugs from which he has made a far more sustained recovery than I have as well as (and perhaps because of) devoting himself with far more dedication than I have been able to muster to helping others over the past 20-odd years. What I learnt in the capacity of responsible parent of an addict has always seemed to me instructive. For many years I tried, as it seemed to me, everything to argue or otherwise induce him to give up drugs, all to no effect. I was also, of course, indirectly funding his habit and paying for the consequences of his addictive behaviour. (He once stole my bank card and found my pin number. When I discovered this, I cut the card up into small pieces and threw the fragments away. He retrieved the fragments, carefully stuck them back together and withdrew more money from my account. More than anything else, I was amazed at his ingenuity and diligence.) Finally, I concluded that I personally could take this no more and so told my son that I could have nothing more to do with him and could not see him again. Only a few weeks after that, he himself finally decided that he now really wanted to stop using drugs and to stay stopped. He meant it and he did it.

In addition to being an addict myself and both the child and the parent of addicts, a consideration that makes me think this appendix worth writing is that I have been something of a student of addiction in both an academic and a practical capacity. In particular, I have run a fairly comprehensive organisation largely concerned with addiction though, in this case, an addiction which holds no attractions for me personally: namely, to gambling. Indeed, I have written “problem gambling” policies for a number of government departments and gambling companies as well as participating in academic discussions of the subject in publications and academic conferences. So I am rather over-qualified to pontificate about addiction from three very different perspectives. I have paid a much higher price than I would have wished to in accumulating all this knowledge and have sometimes wondered whether there has not been something fraudulent about the way I have prescribed for others while remaining “uncured” myself. My conclusion, for what it’s worth, has been to acquit myself of this charge. I don’t think the integrity of my work on gambling addiction has been vitiated by my own continuing struggles with alcohol.

Finally, simply as part of my autobiography I think that though the forms my addiction have taken are unique to me, the same is true for all addicts. It may also be true that almost everybody is to some extent prone to addiction to something so, despite the inevitable uniqueness of my own case, there may be general lessons to be learned from scrutinising my experience as clear-headedly as I am able to.

Ruminating about why I have had the relationship to alcohol that I have had and theorising about addiction in general is something addicts wishing to recover are told they shouldn’t do. Consequently, one particular feature of the way addicts are treated today is that it has become very nearly impossible for addicts to participate in the analysis of their own condition and of the condition of addiction in general. Patients/clients/group-members are typically told that whatever they say about addiction in general or in particular, they are doing no more than showing the extent to which they are in denial, intellectualising, grandstanding, being defiant, and otherwise trying to avoid embracing the path of total abstinence. No doubt, as with any other discussion one may have about matters which are crucial to one’s well-being, it is always possible that the arguments one puts forward about it may be tainted, perhaps irremediably, by rationalisation. But this should not licence a prohibition on reasonable discussion, e.g. of the evidence about what does and doesn’t work, of what the alcoholic or other addict feels that the object of their addiction actually does for them in terms of making them feel good in a way which nothing else can and, above all, of the things they are not powerless about, the respects in which their lives are not unmanageable and the reasonable hopes and fears they may have for the future. In trying to reflect, as rationally as I can, on my own experiences and observations about addiction, my hope is partly that it may prove good for me and partly that others may find something to learn from my reflections. If this results in my being told this is just typical of me – “intellectualising” everything and refusing to accept with adequate humility the hard truths about what I need (and all other addicts need) to do, tant pis: intellectualising is what I do for a living.

The truth is that I think and have always thought that part of the process of managing my addictions involves trying to understand the truth about them in terms of how they relate to my deepest hopes and fears. This is no doubt part of my general tendency to analyse problems and usually put things on paper which is characteristic of my way of dealing with all problems, including, for example, the problems which arise in managing organisations. Moreover, I suspect that those who are disposed to dismiss this “intellectualising” are in part motivated by a recognition that I am likely to win most straightforward intellectual arguments so not unnaturally they don’t wish to fight me on that terrain: they prefer more intuitive and emotional confrontations where I am quite easily cowed.  These critics of intellectualism may also justly point to the fact that for all my intellectualising I don’t seem to have learnt, how to change my behaviour. This is only partly true. I still spend more time being Dr Jekyll than I do as Mr Hyde. Indeed, as I now believe, the sheer strain of trying to be Dr Jekyll to everyone all the time, of saying “yes” to everyone and everything, of feeling responsible for everyone and everything – all these have been a major flaw in my character and therefore part of my problem because it has motivated me to use alcohol as a way of periodic and mostly well-timed escape into anarchic irresponsibility for anyone, including myself. At some profound level I have always believed that I’m not good enough and must try harder. But no matter how hard I try it’s never enough and so eventually I give up and use alcohol, as the addicts say, “to get out of it.”

I can do the psychoanalysis on this and have already mentioned my lifelong sense that I haven’t suffered enough to be worthy of especially my mother’s love and, indeed, that no matter what I do will never be enough to secure for me that sense of being utterly, unconditionally, enduringly and deservedly loved which I have always hankered after. On the other hand, I have also been incredibly lucky that in reality I have in a number of contexts had precisely this sense of being loved in this way so a perduring sense of inadequacy is only actually quite a small part of my story: my sense of being the recipient of much grace in many forms runs far deeper.

I also think the charge that I am over-intellectual about everything – much more so than is good for me – is mistaken even when, as it often isn’t, it is well-meant. Do people who level this charge at people like me really think that being stupid about one’s personal problems  or any other issue, by ignoring evidence, refusing to consider competing explanations, studiously avoiding the critical evaluation of policies and practices, etc is really likely to lead to more effective problem-solving in any area including the three that I have been recently most exercised by, viz. managing human and material resources in business, deciding how best to live in ethics, and figuring out what to do about addictions, either as a public policy issue or as a way of helping people in trouble or as someone afflicted by addiction myself? So I do not propose to stop “intellectualising” and to abandon the search for understanding the truth about my relationship to alcohol or, indeed, about anything else, no matter how unhealthy others may think such searching to be.

This leads me to a certain ambivalence in writing about my own experiences since going public in any form is precisely what the principle of anonymity in AA forbids. The obvious dangers are self-exculpation, self-pity, self-aggrandisement and simply giving hostages to fortune. On the other hand, since the whole point of these memoirs is to try to meet Horace’s classical ideal of being utile dulce or as Boileau put it to “plaire et instruire”, i.e. to write stuff which both entertains and instructs, I feel I can’t avoid trying to tell it like it has been for me with drink and hope I don’t lapse into too much dangerous self-deception.

In writing about my drinking career, these feelings of ambivalence are especially acute in relation to Alcoholics Anonymous itself and its twelve-step programme. On the one hand, I am enormously grateful for AA with whom I began to have a relationship when I was about twenty-five and where I did finally have what I can only describe as an experience of salvation in 1992. I still have many friends in AA and greatly admire the selfless help which many of them continue to offer fellow members, especially “newcomers”.  Moreover, I continue to regard the twelve steps as an excellent recipe for living a comprehensively good and spiritually fulfilling life. This, however, is not surprising since the twelve steps are themselves a distillation of the accumulated wisdom of 2 000 years of Christian spiritual counselling.

I am also not among those who are put off by, or sceptical about the religious element in the AA programme, with its emphasis on the existence of a “higher power” to which each of us can have access, who can “restore us to sanity”, to whom we need to acknowledge our wrongdoings, to whom we can hand over all our worldly concerns, and who can supply us with whatever resources, especially of serenity, courage and wisdom, which we may need to address our worldly concerns. In this context it is worth noting that the programme actually developed, to some extent unconsciously, out of the nineteenth century Anglo-Catholic spiritual teachings of the so-called “Oxford group,” who were seeking to recover the practices of the earliest Christian communities. Moreover, it often seems to me – especially now that I am a theology student – that if you want to understand how the very early Christian church came to develop as it did, there is no better way than to study the history of the early days of Alcoholics Anonymous. At all events, I have certainly known ministers of religion who claim that they have learnt more about Christianity in their twelve step groups than in their churches or theological colleges. For me all this is a turn-on though I recognise that for many religious unbelievers it is the exact reverse.

Finally, I believe that the basic proposition of AA treatment which consists in one alcoholic sharing their “experience, strength and hope” with a fellow alcoholic is an enormously powerful one and I still feel when I am with fellow alcoholics who are otherwise complete strangers to me that here, at last, is someone who actually understands what it’s like to be driven by the same self-destructive compulsions that drive me. It was AA who really pioneered the mutual self-help group which remains, it seems to me, one of the most powerful instruments available to us for relieving the suffering caused to those afflicted – and the relatives of those afflicted – by various kinds of illness as well as affording enormous relief and comfort to individuals suffering particular kinds of distress such as bereavement or divorce. Certainly by now there is great accumulated wisdom inside AA and its now very large number of anonymous sister organisations – the most prominent of which is Narcotics Anonymous.

On the other hand, I no longer accept much of what seems to me to have become AA dogma. In some ways, it seems to me that (like the early Church) AA has declined from being a pragmatic set of responses to human desperation and the longing for love to being a repository of dogma, more interested in whether people’s views are heretical or not than in whether they are actually useful, true and indeed scientifically verifiable. A consequence of this seems to me to be that many claims made by AA are simply either false or not well-supported by the available evidence from medicine, science and indeed honest observation of the ways in which people actually behave. Moreover, as I have indicated, there is no question in my mind that AA does require, whatever its protestations to the contrary, some form of religious commitment and many people simply can’t stomach this.

More generally, I’m very unsure to what extent and in what form it makes sense to think of addiction in terms of a “disease,” let alone an incurable one. There certainly is a neurophysiology of addiction and we are slowly beginning to understand how it works and how we might medicate for it: medications are already available (anti-opioids and other drugs) which mitigate the overwhelming power of addictive cravings and which do not play a much larger part in treatment because a) they are expensive and b) most doctors don’t know about them. Nevertheless, subjectively, addiction feels to me much more like a condition of psychological enslavement akin to being hopelessly and helplessly in love with someone who constantly betrays and abuses one, who affords one moments of great happiness despite being mostly an overwhelmingly destructive force in one’s life and whom one simply can’t stop loving and going back to. There also seems to me to be merit in relating addiction to a proper understanding of the old – and now almost completely misunderstood – concept of sin – sinfulness being that part of our human nature which shapes our behaviour so that “the good that we would we do not, and the evil that we would not, that we do.” Even the most hardened secularists need to acknowledge that there is something very strange and very profound about the sheer self-destructiveness of addictive behaviours.

There are other aspects of AA dogma which I have come to doubt. These mostly relate to what happens to people who do get sober through AA whether they remain total abstainers or become relapsers or revert completely to their old, full-blown addictive behaviours. It was Freud who said that the most effective therapy consists in a change in the reality situation. What too often happens now is that people are fine while they are safely locked away in a rehab or while they are in the first full flush of enthusiasm for their new-found sobriety. But the fact is that if people are simply put back in the same situation that encouraged them to turn to drink or drugs in the first place, without any change in their working conditions or personal lives, they are virtually certain to relapse.

To this day I regret my failure to recognise this, as it now seems to me, fairly obvious truth in a particular case in the 1990s. The vicar in charge of the (very Anglo-Catholic) church I used to attend in Cape Town was a very good friend of mine, David Binns, whom I had known through a mutual friend for many years  before and after he took up the post of rector of St Michael’s, Observatory. He was highly intelligent and a much loved custodian of traditional Anglo-Catholic practices. He also had a very original mind and was extremely witty. He consequently had many friends who loved him as well as admirers. However, he was gay but thought it would be wrong to be anything but celibate. He was, therefore, prone to considerable loneliness. Moreover, both his parents appear to have been quite seriously depressive people. David dealt with the loneliness by drinking and it became increasingly clear that he was descending to the point where he would be drunk in Church – to say nothing of drinking the Communion wine by the bottleful. I had been in AA for about a year and, indeed, had recently made full formal confession, including about my drinking, to David in his capacity as my priest. It was consequently fairly easy for him to talk about his problems to me and I eventually suggested he go for the standard treatment – which had recently worked for my son – offered at the local residential rehabilitation centre. He duly went and completed the course. Soon after he had returned to work, however, he began to relapse as well as being obviously still vulnerable to depression. The result was that one Sunday when he didn’t pitch up for the usual service I was deputed to find him and eventually did find him in his garage where he had connected the exhaust to a hosepipe inserted into the car, swallowed pills and wine and then committed suicide by starting the engine. David had always seemed to me to be something of a suicide risk but I had had a long conversation about many things the day before and he seemed to me to be in better shape than he had been in for a long time. I was therefore astonished by his apparently sudden suicide. On reflection, however, it seemed to me that it should have been obvious that David needed not only to get off the bottle: he actually needed to change his whole way of life and particularly to address the problems of loneliness. I don’t especially beat myself up for not realising this at the time but it has convinced me ever since that real freedom from addiction requires an often quite radical transformation in people’s actual circumstances.

This relates to another phenomenon I have observed amongst those who find sobriety through AA. Quite often, unless they have a strategy of their own devising for reintegrating themselves into real life, they may well end up with nothing much to live for outside the often very extensive work they do within AA, especially sponsoring people and speaking at large numbers of meetings. This exchange of roles from “victim” to “rescuer” – as Eric Berne describes it – is often quite productive from the point of view of the rescuer and the many people he or she may now help. There are dangers in this, however, most notably that when there’s no-one left to rescue the meaning evaporates from their lives. Another friend from AA days who had run the Cape Town office for many years was eventually (and quite spuriously) persuaded to retire whereafter he found his life had suddenly become pointless and he too committed suicide.

A much more sinister phenomenon also sometimes co-occurs when people get sober through a twelve-step programme and become total abstainers. Most people who stop being alcoholics or drug addicts, say, tend to become workaholics and this is often quite productive though, as the name suggests, the excessive commitment to working all the time may well be damaging to their personal lives with others and their own moral or spiritual development. In other cases, however, the lives of ex-addicts become devoted to the ruthless pursuit of other, much more destructive satisfactions of which the pursuit of money and, even worse, the pursuit of power over other people are the most pernicious. The most truly shocking cases of this phenomenon that I have witnessed have manifested themselves when ex-addicts decide themselves to go into the addiction-curing business and set up their own rehabs or addiction counselling consultancies, usually preying on the vulnerability of recent clients whom they employ as counsellors and pay (and otherwise treat) very badly.  I relate this phenomenon to the New Testament parable of the man who having exorcised one demon from his house found that there were seven much more ferocious demons, who seeing that the house was now empty, decided themselves to take up residence so “the last state of that house was worse than the first.” I think on the whole I prefer – i.e. morally prefer – practising addicts to avaricious fraudsters and brutal bullies.

There is also a wonderful true story about the founding of AA which indicates something that has gone profoundly wrong with the whole twelve-step movement. Shortly after having established the basic principles and practices of the AA programme, its principal and most enthusiastic founder, Bill Wilson, started to make plans to expand AA activities across America by opening AA centres and publishing businesses on a not-for-profit basis. Having worked in Wall Street Bill knew Rockefeller and went to see him with a view to securing financial support for his ambitious plans. Rockefeller said: “I’ll tell you what I’ll do. I’ll host a dinner party for my richest friends who are also philanthropists and you can tell us about what you’re doing and what you’re achieving.” Bill duly went to the dinner and told the assembled company all about the way AA worked and what it had already accomplished for many people previously written off as hopeless and incurable drunks. After this Rockefeller conferred with his friends and then came to see Bill. He said: “Bill, we have discussed everything you’ve told us and we think it’s all truly wonderful. The work you’re doing is amazing but we’re not going to give you any money. This thing is built on love and money would ruin it.” AA has lived exclusively on small voluntary contributions by members ever since. However, something like the ruination Rockefeller foresaw has happened to AA through the commercialisation of the twelve-step programme in expensive and highly profitable private rehabs.

So here’s some advice, especially to parents of young addicts. If you’ve got this problem in your family, don’t waste your money thinking it can be fixed by the courses offered in high-charging, residential rehabs. It may be worth your while spending the money if what you want is simply to know that your child is safe, off the streets, and out of your hair for a few weeks but don’t expect that they will come away “cured”. The “cure” rate amongst those who receive residential treatment, those who are treated as out-patients and those who go to an anonymous group like AA and NA are all about the same: roughly 20% will still be abstinent after two years. The rest will have relapsed to a greater or lesser extent. Moreover, some of those who recover would have recovered anyway because they were highly motivated in the first place and to the extent that others recover it is likely to be because the rehabs make their clients attend AA and NA meetings and engage with twelve-step programmes – which, of course, cost the clinics nothing.

All this I know from personal experience as well as from having studied quite a lot of the literature and been involved in the delivery of charitable addiction treatment programmes myself. If I had a  pound for every penny I have spent on various forms and rehabilitation for drunkenness, I’d be quite rich  – though not as super-rich as those who have spotted this gap in the market and exploited it mercilessly. Their sales techniques combine smooth pseudo-medical marketing with the kind of inducements associated with recruiting members to a cult.

First you will be told that the only hope is absolute abstinence and only by following their fancy-titled programme do you have a reasonable chance of achieving this. This is likely to strike you as not only a dreadful prospect – total abstinence for ever. It also may run counter to some psychological story you have been “exploring” with a therapist over the years about the need to get at the underlying depression which causes you to drink/take drugs etc.

Second, you will be told that all you need to do, is to do as you’re told (accept the Programme). Under no circumstances ask a question. If you do try to ask a question you will be told that the fact of your asking the question is itself a symptom of your disease. You need to be forced to face up to all the shameful truths about yourself and your life before you can hope to become a sober (and docile) patient/client.

Third, you will be told that whatever fate has been prepared for you, it’s for the best. If you have to share with other grown men and make your own bed etc that’s therapeutically indicated (and just happens to save the clinic money as well); if you think variation of routine might be good for you then that’s rebellion. If you think you might be doing better reading a book rather than attending a “meeting” – the entire rehab being movement being parasitic on the many excellencies of twelve-step programmes – then you’re “isolating” etc.

Worst of all, you will be told that, if you relapse, you will need to return to the rehab and go through the whole process again, including, of course, paying the exorbitant fees.

There are, of course, exceptions to this model of the profit-driven rehab but unfortunately they tend to rely on religious indoctrination of the most fundamentalist sort as the necessary condition for cure and this, apart from being extremely unpleasant for the addicts, may well prove counter-productive or damaging to the clients’ mental health in other ways.

And, of course, there are mercifully still some rehabs where the motives of the staff and owners remain authentically idealistic so that at least clients and their parents (typically) know they are dealing with honest and genuinely compassionate people.

In general, however, the current evidence suggests that, while it is much better to seek treatment than not to do so, it doesn’t much matter what form of treatment is sought. At present probably the most cost-effective treatment is a combination of cognitive behavioural therapy and anti-opioid medication. This can bring success rates up to about two thirds, provided, of course, that the crucial condition for all successful psychotherapy is met to which I have already alluded: namely, that the client/patient believes that the therapist really cares about them. There is also a new model of treatment on the market which, as it happens, is being pioneered amongst others by my son, David. This is called life-coaching or in the case of addicts “recovery coaching”. I am naturally very proud of the work my son is doing in this area but I have also studied it objectively and it makes a lot of sense.

The essence of this model is to concentrate not on what people have to stop doing because doctors, employers, family members tell them they must but rather on what they really want more generally from their own futures and what they think they can constructively do to secure the kind of future they want. The therapist is not there mainly to prescribe a course of treatment, to offer the kind of advice a counsellor would offer or to act as a mentor teaching people what they are presumed to need to know. The coach is essentially there, as the name suggests, to elicit and hone life-skills which the client already possesses. Unsurprisingly there is a big demand for psychological coaching in business as firms increasingly recognise that, just as they provide gyms and personal trainers to keep their employees physically fit, they need to provide facilities for nurturing psychological fitness and keeping their employees well-motivated, anxiety- and depression-free, and, of course, safe from abuse and reliance on drink and drugs. I have often commented that life coaches seem to do the work of secular chaplains and I continue to think that that is an illuminating analogy for the work of offering people encouragement and compassion, who have no religious beliefs and no interest in religion, but who nevertheless periodically need help from someone they feel they can trust completely in navigating life’s sorrows, disappointments, frustrations and even disasters as well as in nurturing their reasonable hopes and refreshing their self-confidence. I should also stress that what life coaches actually do, in reality, overlaps considerably with what is done in practice by other counsellors and therapists as well as by more traditional religious providers of pastoral care but coaching is distinctive in its focus on future positives rather than past negatives and in its assumption that clients already possess within themselves the resources to solve whatever the problems are which are troubling them.

This brings me to a final observation about addiction in general: we don’t actually know very much about it and so about what’s best to do about it. Moreover, because addicts are still widely despised by the general public, it is has been politically impossible to abandon the “war on drugs” which has been a complete and colossal failure, wasting billions of dollars and exacerbating human misery and corruption to an incalculable extent. While having no positive impact on the incidence or prevalence of addiction. It is also politically impossible to divert public health resources away from more “deserving” sufferers like cancer patients or children in order to supply effective treatment for addicts. In fact, it looks to me as if most people have some addictive tendencies – look at the failure rates for dieting – but they vary greatly in the form they take and, especially, in the harm they do. What we do know is that we live in a world in which all sorts of people get into all sorts of trouble and all sorts of other people have relevant talents and experience in helping people in trouble. One obstacle to more effective treatment, therefore, derives from the excessive concern in our societies with money and status, so that many of those who offer help to those in trouble are doing so as a job and are consequently subject to all the concerns people have about advancing their careers and protecting professional turf. In a more charitable society many different kinds of people would be doing much more, not as a job but as fellow members of the human race, to help people avoid or otherwise deal with their troubles. This is perhaps what is most impressive about the Anonymous movements: health and happiness are secured by unselfishly caring for other people and certainly not by trying to make money from them.

Nevertheless, I don’t want to give the impression that, in my case, alcoholism has been just one more element floating on the general sea of troubles that flesh is heir to. On the contrary, addiction to drink is a particularly nasty addiction, in the destruction it wreaks in the addict’s life and, perhaps worse, the extreme harm and distress that it causes to those who are close to an alcoholic. Moreover, the form of alcoholism from which I suffer is particularly nasty one. This is because, whereas as some drunks become comparatively genial, if usually extremely boring, when they are drunk I become extremely vicious – a genuine Mr Hyde to my more normal Dr Jekyll. In particular I know I cause great upset by the cruelty of the things I say, especially since I typically have no recollection subsequently of what I have actually said. I have never really understood that as long as I am not actually hitting people I cannot be abusing them. This is in part a result of my own experiences of violence as a child but it is a terrible error. To tell people they are much more stupid or boring or self-centred or vain than they think they are is for many people much more painful than any physical abuse, especially if there is some truth in what I say and they can see it is something I have thought all along but bottled up when sober precisely out of a desire not to wound them egregiously. Probably, I should manage my critical sentiments towards others better when sober and not try to be Mr Nice-Guy all the time. In particular I shouldn’t bottle up resentments or even simple irritations to the point where they explode once liquor has removed the inhibitors of cruelty. But the reality of the situation is that my negative sentiments, whatever they are and whether they have some justification or not, are never more than a fraction of the truth about the person who is the object of my withering humiliations: it is quite possible to be perhaps not quite as intelligent or beautiful or whatever as you would like others to think you are, and still be a wonderful human being in all sorts of other ways – kind, funny, brave and still pretty smart and attractive etc. It was certainly this verbal cruelty on my part when drunk that put an end to my second marriage and it has taken great goodness on the part of others to forgive me other drunken outbursts of unalloyed cruelty.  Understandably some never have. All this is quite apart from the huge anger and distress my drunkenness causes to those who care about me by subjecting them to the spectacle of seeing and hearing me being obviously on a binge and expecting to hear at any moment of my death.

I think one of the reasons I cannot answer the question which I have wrestled with all my life: “Why can’t I stop drinking?” is that I have never really found a satisfactory answer to the question: “Why should I stop drinking?”

It is, of some interest to me that when I finally hit rock bottom in 1992, I was living alone; I was on the verge of losing my job; I had been divorced for a second time; I was forbidden to see my young daughters; I was also clearly quite likely to die. All this was down to the fact that I had lost the ability even to get to work without getting drunk first and that, in any domestic context I not only got drunk but also became exceptionally cruel and verbally aggressive. Yet none of this seemed to constitute a good enough reason to stop drinking continuously from first thing in the morning onwards, let alone to seek to give up drink entirely. What finally drove me (back) into the arms of AA was something quite different: I began to realise that I was going mad in the literal sense of not being able to tell the difference between fantasy and reality. I could feel my mind slipping from my grasp as if it were a physical phenomenon. This prospect of losing my reason really frightened me in a way that nothing else had done and I knew I had to stop.

I shall write more fully in my account of my life in South Africa about the multiple circumstances surrounding how I had come to be in this abject condition as well as about its aftermath. These included various attempts at sobriety, one with AA, and one of which lasted for several months. I have also already indicated that it was obvious at least to the college psychiatrist when I was an undergraduate at Oxford that I was an alcoholic – just as it becomes obvious in the best fictional account of alcoholism known to me, viz. Brideshead Revisited that Sebastian doesn’t drink or get drunk in the way other undergraduates do: with him it is compulsive and is clearly compensating for some great sense of void in his life rather than being simply a source of disinhibition and pleasure. I also took myself to a meeting of AA in London when I was twenty-five but was rather rebuffed by the first person I spoke to and concluded that this is not for me. So I have never been in any doubt that there is something seriously wrong with the way I drink. No doubt, there’s a genetic element in all this but that doesn’t seem to me to be relevant to the question: “What should I do?” I suppose I must always have also believed, however irrationally, that there are things drink can do for me which nothing else can and I’m still inclined to think that the key to living sober for me and for other addicts consists in either ceasing to need the psychological satisfactions which drink supplies or to find better ways of securing them.

Meanwhile, I recognise that to many people, especially my friends and family, preferring to go on drinking to losing one’s job, one’s family, one’s health and probably one’s life must itself constitute adequate proof of madness. Conversely, it is a source of immense frustration, resentment and rage to those who love me that the fact that I am so much loved does not by itself provide a sufficient incentive for me to abandon my ugly and clearly self-destructive behaviour. I get this. On me, however, the demand that I stay alive because I am so much loved has, as I suggested earlier, the exact opposite effect to that intended. Typically, I resort to drink to escape what has seemed to me to be a massive – and no doubt exaggerated – burden of responsibility. The demand that I go on living for the sake of those who love me consequently feels to me like yet another demand being made on me to do things for those for whom I am responsible. Consequently, I suspect that, while at one level they see my relapses as part of an illness, they also experience them as a kind of cruel personal rejection of them and their love for me. Obviously, I in turn want to say in these circumstances: “Look, this is not about you: it’s about me and my doubts about what makes my life worth living, other than discharging my responsibilities to Uncle Tom Cobley and all. Maybe it should be enough for me to enjoy the love of family and friends but it just isn’t and I can’t make it so by an act of will.” I hasten to say that this kind of mutual misunderstanding has mostly been fairly short-lived and has not prevented me, when not bingeing, from having mostly very warm and close relationships with family, friends and colleagues, especially for most of the last twenty years. In fact, I consider myself to have been exceptionally and quite undeservedly blessed in the warmth of my relationships with especially my children and now my grandchildren. No doubt that makes everything more distressing for them when I do relapse and turn into Mr Hyde. I am genuinely sorry for the hurt I have caused as Mr Hyde, including for “the sins which I cannot now remember,” to quote the formula for Christian confession and repentance. Nor do I think it constitutes an excuse that I have simply felt helplessness before the onslaught of an evil which AA rightly characterises as “cunning, baffling and powerful.”

For what it’s worth and having thought about this more in writing this appendix than I have ever done before, I’m inclined to attribute the fundamental reason why I drink to a deep-seated sense of failure in relation to what I have always taken to be the one thing that I have always felt since childhood would be really worth doing. This has been my belief that what I was really put on this planet to do was to find the answers to the big questions of philosophy and ethics: “Why are we here?” and “How should we live?” The fact that it was the prospect of going mad that finally made me seek help suggests to me that my drinking somehow, no doubt paradoxically, connects with this sense of vocation which I describe in Chapter One above.

At a deep level my life since leaving Oxford has felt like one of continual failure and of betrayal of my vocation, both through sins of commission and omission on my part, from the sense of having to discharge what has felt like an ever-increasingly burdensome set of distracting responsibilities, and from encountering much substantial rejection and lack of recognition, some of it fair, some not. It may be that my fundamental ambition has always been much larger in scope to the point of absurdity than the aspirations which seem to give most people a purpose in life and grounds more modest and realistic hopes. Even I can see that it must seem pretty daft to hope, let alone to expect to succeed in solving, the riddles of the moral universe. On the other hand, I also think that most people have an often thoroughly well-repressed but ultimately inescapable fear that they are, at the deepest level of their being, not good enough to live up to the demands of whatever it is we think that real goodness in human beings requires. This is why so many of us spend so much time and energy trying to persuade ourselves that we are really pretty decent human beings and certainly quite good enough compared with almost everybody else, thank you very much. Deep down, however, most of us feel that we are not really and never will be “good enough” because as a matter of fact we are not, in fact, good enough to meet the impossible demands living as we believe we really ought to be living. Be that as it may, the overwhelming blessing that drinking to excess confers on me, and I suspect this is true of what other activities do for other kinds of addicts, is to give me the feeling that I really am good enough, after all. Alcohol makes me feel good, no matter how specious and temporary and delusional and counter-factual that feeling may be. A better and more secure way of feeling good is actually to be good and this is, I think, what underpins the success of movements like AA: they teach you how to live a morally much better life – based on honesty, humility, unselfishness, kindliness and courage. At any rate it seems to me that for me and everyone else, if your fundamental problem is, as mine is, that you think you are not good enough there is a simple solution: get better.

So what do I now promise or predict for the future? Nothing. So far, at least, however, I have managed to remain still hopeful.