In this occasional series we record the views and personal experience of people who have specially contributed to the evolution of ideas in the Journal's field of interest. George Vaillant is an American psychiatrist who has made unique contributions to understanding of substance misuse and recovery within a life-course perspective.
Addiction (A): George, you have made fundamental contributions to understanding of the human life course, so it's natural to start this interview with some questions on your early life and family background.
George Vaillant (GV): I was born in New York City, almost exactly 70 years ago. I spent my first 2 years of life in Mexico, the next 4 in Manhattan, the next 5 in Philadelphia and Peru, and then when I was 10 my father died and we moved to Connecticut. We lived in Connecticut until I was 16 and I went to high school, boarding school in New Hampshire (Exeter). My family then moved to New Hampshire and I went on to Harvard. Since then I have spent most of my life in Cambridge. For the last several years I have lived in America and Australia.
A: So you started off with experience of living in other countries. Was that important? Has it given you an edge of awareness?
GV: It gave me an enormous dislike of America's efforts to try to run other countries and lives. I mean, from age 10 on, I realized that Americans could be enormously unattractive outside their own national boundaries. But I do not think that perspective influenced my professional career.
A: You mentioned briefly your father and he conducted fundamental work on the Aztecs and wrote The Aztecs of Mexico (Vaillant 1940). You must have pride in his accomplishments?
GV: Enormous. In fact, I have been consciously competing with him and marvelling that I have usually got in more royalties from his books than I have from my own.
A: He had a very creative mind, didn’t he?
A: Were you aware of his qualities as a child or have you only later discovered that truth?
GV: He had absolutely wonderful qualities as a friend and as an intellect. He was not a very present father: he regarded young people as rather boring and he was much more interested in people of his own age. He did not even like graduate students much. So as a father he was colourful and he had a sense of humour, but he was waiting for me to grow up and be interesting.
A: Did he introduce you to the Aztecs or was that not something he would talk to you about?
GV: The spring that he died, he was closeted in his study writing a book on Aztecs for young people. He gave me a section to read in draft, saying something like ‘If you read this I’ll give you $2’, but there was no discussion. He would talk to my sister who was smarter than I was.
A: The name Vaillant to people in the addictions world means George Vaillant, but we know there have been other Vaillants before: it is an unusual name—French?
GV: Yes, my great, great grandfather was an impoverished Jacobite who left Normandy in 1848 because he saw the world as going to the dogs. He graduated from the National University of Paris and he was a clever man. He came to Cleveland and taught French and the violin. He and his son worked on the railways and made quite a lot of money. There was enough money for his son, my great uncle, to become an artist, but he certainly did not make a fortune on the scale of other railway entrepreneurs.
‘. . . my great, great grandfather was an impoverished Jacobite who left Normandy in 1848 because he saw the world as going to the dogs.’
GV: I was an enormous failure at boarding school so I did not think anything very dramatically positive was going to happen to me. I did much better at college. My ambition on graduating from medical school was to be a psychiatrist in a community health centre. I certainly did not imagine that I would be a scholar like my father or even have an academic career. In medical school I thought research was rather silly and missed the point of patient care.
A: You went to Exeter, a famous boarding school, and did you then say, I want to go to Harvard and that is that, or was Harvard entrance competitive?
GV: Harvard was the only place I applied. In those days you had to be quite stupid at Exeter not to get into Harvard, Yale or Princeton. But to go to Harvard Medical School was by no means assured. Before entering medical school I had spent 4 years at Harvard majoring in history and literature. So in totality, I spent 8 years at Harvard. I was much more successful at Harvard than I was at boarding school, so that was good in terms of self-esteem, and I was vice president of Lampoon (the humour magazine).
A: Those 4 years at medical school, did you ever think, this is wrong for me, I will go back to epic poetry?
GV: Oh no. It was totally what I wanted. Even when I was studying history and literature, what I wanted to do was medical school, what I wanted was psychiatry.
A: Harvard at that time, was there a peer group to encourage intellectual growth? Was there good afternoon conversation on lawns?
GV: It never quite worked out that way. Everyone was smart and I hung out with bright people, but largely they were not talking about ideas.
PSYCHOANALYSIS FROM THE INSIDE
A: You qualified in medicine in 1959 and then what happened?
GV: I did a year's internship and 3 years as a registrar in psychiatry and that was fun. My co-residents included Eric Kandel, Joe Schildkrout, Alan Hobson, Judy Rappaport and Paul Wender: all people who later achieved academic distinction. I never took a course in psychology or sociology. Perhaps it was an advantage that I did not know how to act like a well-trained social scientist. In the evenings a brilliant cardiologist named Mark Altschule taught us biological psychiatry. It was an underground effort. There was psychoanalytical dominance at our hospital. If you gave a drug to a schizophrenic, that was almost seen as a personal failure.
A: Did you in any way lose faith at some point in the world-view of psychoanalysis?
GV: I thought that if I was going to criticize analysis I had to do it from the inside and I saw that world as having much to teach me. It was easy for me to think biologically, but harder to think psychologically. Fifty per cent of psychoanalysis might have seemed like rubbish, but the other half was very valuable. After 50 years I am still trying to encourage Michael Rutter to believe in the importance of defence mechanisms.
A: Can you give me a brief encapsulation of what it is about psychoanalysis which in your judgement can specially enhance our understanding of the human play?
GV: I think it is defence mechanisms, that a great deal of what people do is defensive and interferes with them seeing reality. This is the same thing that fascinates me about alcoholism. If you can see beneath the surface you see a great deal about what is highly relevant but invisible to most doctors.
A: You are thoroughly trained in psychoanalysis. Your research has often dealt with personality. Do you feel that psychodynamic theory has contributed to your understanding of alcoholism?
GV: Ha. I want to say in capital letters, NO! I think psychoanalysis has contributed enormously to my education and to human knowledge about human beings. I think almost everything psychoanalysis has said about alcoholism has been (180 degrees) wrong. That was another thing that I discovered in my research. I had earlier assumed that the reason that alcoholics always found the side of the street with the biggest puddles to fall down in, reflecting the self-destructiveness of the person, but then came to realize that it was a result of the booze.
‘. . . almost everything psychoanalysis has said about alcoholism has been (180 degrees) wrong.’
A: What about personality and personality disorder?
GV: Anything that involves brain disease, any toxicity, severe fatigue, intoxication or early Alzheimer’s, drives defences in the direction of personality disorder (Vaillant & Perry 1980). So there is no question that alcoholism makes defences less mature; but there is no evidence that alcoholics are different than non-alcoholics before they develop alcohol dependence. From a scientific point of view I think the caveat is that if you are an antisocial adolescent you are going to have both immature defences and alcoholism. But if you are an alcoholic you are at increased risk for having alcoholic parents, which can mess up your childhood so you will continue to use immature defences as a psychological result of your parent's alcoholism and a biological result of your alcoholism. Intoxication, however, is the one defence mechanism that you can deploy consciously. In general, psychoanalysis does not provide an understanding of alcoholism.
A: How much do you attribute to the addictive nature of alcohol?
GV: The short answer is, a great deal. The longer answer is that I really like the Diagnostic and Statistical Manual version III (DSM-III) distinction not because there is a black-and-white difference between alcohol abuse and alcohol dependence; but alcohol dependence, as Edwards & Gross (1976) suggest, is on a continuum and the abuse/dependence distinction does divide alcoholism into the top half or the bottom half (in terms of severity). And I think that probably as soon as the person has taken a few drinks the dependence syndrome starts; many social drinkers are a little bit dependent and social drinking to dependence is a smooth continuum. We want our Alcohol Use Disorders Identification Test (AUDIT) score or Michigan Alcohol Screening Test (MAST) score to make cutting points between health and illness, but that is no more possible than it is with blood pressure. But I really do think it makes a big difference whether someone is a little bit dependent or a lot dependent. The two most important reasons are if you are just a little dependent you have a sporting chance to remain or to again become a social drinker. If you are a lot dependent you are not going to do so, but you may be severe enough to stop drinking forever. If you are mid-range dependent, so that it translates into ‘DSM-III alcohol abuse’, you are not dependent enough to make it worthwhile to stop and you are too dependent to either return to social drinking or to be much fun for your health or family.
A: So come 1962, you finished your residency.
THE LEXINGTON EXPERIENCE
GV: Yes, my idea was to avoid the draft and go to NIMH (National Institute on Mental Health), but the government's view was that they had better people to work in their laboratories than George Vaillant so I was consigned to the prison service in Oklahoma. I went back and said again, I want to go to NIMH—that is what you promised me when you had me sign up. The compromise was that I would go to Lexington. At that point I knew nothing about addiction so I saw Lexington as an opportunity to understand psychopaths rather than to understand addiction. In residency training we did not admit alcoholics or discuss their treatment, and in 1962 heroin addiction had not arrived in Boston.
A: How did Lexington turn out for you?
GV: Lexington was exciting. There was an extraordinary group of doctors coming through, people such as Herb Kleber, Everett Ellingwood and Jerry Levine; and Harris Isbell was there, someone who could see addiction from many different viewpoints. One would have lunch with him and try to learn.
A: Did you have contact with Abe Wickler?
GV: Abe was terribly full of himself. He had read everything and had all sorts of notions. I learnt from him something about conditioning theories. He was not in Isbell's league for me in terms of being a hero or a role model.
A: You had patient responsibilities at Lexington?
GV: My job was to run a small psychiatric unit where addicts who had psychiatric breakdowns were sent, and chronic schizophrenics who had been transferred from St Elizabeth. I came to think that it would be terribly interesting to find out what happened to addicts 10 years later on.
FALLING TOWARD THE LIFE-COURSE PERSPECTIVE
A: And that was how you came to set up an absolutely seminal study (Vaillant, 1966a, b, c, d) in the long-term outcome for Lexington opiate addicts?
GV: Yes, I did not have line responsibility for treating addicts, but that is when I set up the study.
A: Seems to me that you were at that moment moving in a highly George Vaillant direction. You were launched at that moment; in intellectual terms, you became you.
GV: When I was an intern I had a patient who had been called a hysteric, and had been studied by all of the great medical scientists in Boston to find out what was wrong with her and nobody had found an answer. I put together 20 years of her records and although that was never published, it sort of prepared me. I suddenly saw long-term follow-up as science, and no one else was undertaking it. The idea of using a telescope, not a microscope, seemed to me wonderful. It was a kind of effortless way to have people say nice things about one and have one's papers published. Although I was not a trained scientist, I was reinforced by having my first paper accepted without revision (Vaillant, 1962). When my papers on schizophrenia were accepted (Vaillant, 1962, 1964a), it was a way of writing and being a detective.
A: Few people have approached alcoholism from the life history perspective. What does that add to our understanding of alcoholism?
GV: By learning longitudinal research you understood development. Alcoholics do not become alcoholics overnight. So, by being interested in cumulative records, which was a way of studying drug use over time, and being interested in life history, it turned out to be a very useful way to study patterns of relapse, recovery and also discovering what really happened over time. It turns out to be quite useful for the study of alcoholism. I think one of the great surprises of longitudinal research is you discover that people recover. When I first published that heroin addicts recovered in the New England Journal of Medicine (Vaillant 1966b), people wrote me that they just could not believe what I had said. The addicts who recovered did not recover because of treatment, they recovered due to other factors.
A: Does treatment have a role and is it in any way similar to what Alcoholics Anonymous does?
GV: Treatment has a very important role but it is probably not the role that many of the treaters think they have. Griffith Edwards once asked me: ‘Your research shows that it doesn’t make any difference. How do you reconcile that?’. I think my reconciliation is really epitomized by this. ‘If you want to treat an illness that has no easy cure, first of all treat them with hope.
‘If you want to treat an illness that has no easy cure, first of all treat them with hope.’
A: Pause there for a moment. Was having studied English literature or history at all relevant to this choice of research direction, or was that an entirely separate world of thought?
GV: Oh, probably history did affect my thinking. The first paper I wrote (Vaillant 1962) used tuberculosis as analogy to schizophrenia and suggested that 19th-century views towards tuberculosis had the same kinds of errors as our present views on schizophrenia.
A: Remind me, where did you publish the results of your Lexington follow-up of narcotic addicts?
GV: One paper was in the New England Journal (Vaillant 1966b), one was in the Archives of General Psychiatry (Vaillant 1966c). There were 100 patients in the study. One core conclusion was that heroin addicts could make stable recoveries, and a second conclusion was that if you had a replacement for the addiction and some external coercion, those seem to be very necessary factors for recovery to take place (Vaillant 1966d). Many years later I summarized my findings in Addiction (Vaillant 1988).
A: On leaving Lexington, you picked up on the Gleuck & Gleuck control group, a sample of inner-city Boston lads, and you also secured access to the information that Harvard gathered on its students of the Kennedy generation at the time they commenced their studies. How did you achieve these coups?
GV: Well, what I wanted to do was to follow-up schizophrenics. Addiction was just a passing phase and I wanted to study recovery from schizophrenia, which was why in 1966 I went to Harvard and said, can I look at your 1940 schizophrenic students at their 25th reunion? But they said, back in 1941 Harvard student health did not have a psychiatric health service. They had no records of schizophrenics; but they did have this study—the Grant Study of Adult Development. So I said, OK, I will study them 25 years later. In addition, I have been impressed, both in schizophrenia and in addiction, that employment was terribly important, so I wanted to study the natural history of unemployment. What did people's inability to work mean for them? The Gleucks had been interested in follow-up of delinquents and I went to them and was admiring of them, and they were people who loved admiration. So both the Gleuck sample and the Harvard sample were sort of turned over to me when I was still an assistant professor at Tufts, because nobody at Harvard cared about this material. It all happened rather gradually. I was being a bit like a museum curator admiring a couple of private collections, and that is a fair parallel because my father worked at a Natural History museum and was the curator there. I used ‘natural history’ on as many paper titles as I could, and that would be an unconscious overlap. It took about 5 years for the Grant Study and the Gleuck study to pass into my hands formally. I arrived as the right person at the right time. Or, put differently, I was unbelievably lucky. The Gleucks had gone about their work from the unsophisticated techniques of social work; but they were my kind of people. Untrained in using proper social science, that is how I did it.
A: But then you moved away from studying schizophrenia, away from studying illness, and turned more to the study of normality—is that right?
GV: Yes. That happened gradually, but it started with schizophrenics who recovered, and these people recovered partly because as any good British psychiatrist could have told me, they were in fact suffering from manic depression.
A: But to study the very basics not of disorder, but of how normal people find their way through life, that surely is the background to all else?
GV: Yes, and there were at the time certainly very few people in the United States interested in this kind of approach.
WHAT PRICE ENVIRONMENT?
A: What understanding of the human condition, besides the importance of defence mechanisms, have these enormously long-term studies of yours given to you?
GV: A triumph of the continuance of biology, that the brain continues to evolve and does not stop maturing at age 5, as Freud would have had us believe. Brain development continues throughout adult life. If you think of maturity as the opposite pole from narcissism, then adult development really is a move from narcissism to maturity, as long as nothing goes wrong with the brain, such as alcoholism or Alzheimer’s.
A: Help me with this. How much of what happened to the inner-city lads or to the Harvard graduates was determined not by their brains, but by the state of the environments in which they lived?
GV: I have always had to keep things very simple and one of my ways of keeping things simple is that I regard all sociologists as up to no good, and just trying to confuse people. So the idea of trying to think that people are different in one generation to another is anathema to me, and I know that is wrong; I know that the world consists of Whigs and Tories and they are all honourable men, but I am incapable of doing anything but hope that the Whigs win every argument. When you follow-up a problem long enough, you will find that the sociologists are misleading us. When a friend returned from a year working with alcoholics in France, he said to me, ‘French alcoholics are no different from the Irish alcoholics that we dealt with at Cambridge Hospital’, and I was just so glad to hear that. Alcoholism is alcoholism—male or female, rich or poor, Irish or French.
A: Are you basically pessimistic or optimistic about the human condition?
GV: I am not at all sure that I want to grow up in my grandchildren's world: it will be over-populated and polluted and I shall not like the music. I am not sure that human civilization is advancing, but I think that human beings are basically good: that maturity moves in the direction of greater lovingness and if you can avoid things such as pollution and epidemics and starvation, then human beings are going in the right direction.
A: Now tell me in what year the Natural History of Alcoholism was published?
GV: 1983 (Vaillant 1983).
A: And it immediately received large popular attention as well as professional praise?
GV: That is right. The popular attention arose apparently because Time Magazine gave the book two pages. Public attention really was not something I was expecting, so it was enormously gratifying.
A: How many books have you published?
GV: There have been five (Vaillant 1977, 1983, 1992, 1993, 2002).
A: Which do you like best?
GV: Oh, Adaption to Life (Vaillant 1977), no question about it. Writing is something that I started doing in high school; not writing books at that time, but writing has always been my favourite hobby. But not writing fiction, I am no good at thinking of something without people telling me the plot. As E. M. Forster said, only connect the prose and the passion—both will be exalted. What is wrong with so much academic writing is that it is all prose and no passion, and it is devoid of feelings].
‘What is wrong with so much academic writing is that it is all prose and no passion, and it is devoid of feelings.’
A: What strikes me on reading your work is your very special capacity for compassion.
GV: My first impulse is to say, I learnt it because I was very well treated, but I also learnt it because I was badly treated. It is a mixture of having a childhood with a great deal of care and consideration and one that had isolation in it—it really helps to have both.
A: Your career trajectory in a sense has a life history of its own. In your earlier years you were looking at schizophrenia and drug abuse which were diseases of young people, then you got into alcoholism, a disorder of middle age, and now you are into ageing. In there anything in the process of going through life stages yourself that might influence the things that you find interesting and that you want to devote your intellectual energies to?
GV: I think it had a very powerful effect. As predicted by my ideas about life course, I went from being a researcher and writing papers to being a research director, writing papers with other people, and then being an author because it was good for other people's career. I am now interested in ageing, and what it does for people, but I once thought, getting older, how boring. My latest grant is based on how to preserve the study for the next generation.
LEARNING FROM AA
A: One thing that emerges continually from your research on the natural history of alcoholism and recovery process, is the role of AA. What have you learned about AA over the years?
GV: My first introduction to 12-Step programmes was that I had some relatives who were members of Frank Buchman's moral rearmament and as far as I could see it was a cult, an undemocratic religion. It was not anything I wanted any part of. But I later went to AA meetings, found them constructive and learned from them. As time went on I had more relatives, more friends and more patients who recovered and seemed to benefit from AA. I began to look more closely at it. By then my study had started and it was clear something was going on there. My findings suggested that AA was not just a magical collection of recovering alcoholics but that it embodied certain principles that worked quite separately. I think another aspect was in my own spiritual life. I found that during periods when I had to go to AA as a condition of employment I would stop going to church. Actually, Bill Miller and Scott Tonigan's research as part of Project MATCH (Babor et al. 2003) makes it look as if it is human community rather than spirituality that is the important factor in the success of AA. I still hope that someone will show that spirituality is part of the process.
A: You have had a long relationship with AA and have been appointed to their Board of Trustees.
GV: Oh, I am enormously grateful for that appointment. When I knew I was being put up as a Trustee, I felt I violated the spirit of the programme because it made me feel so proud. I wanted to boast about it rather than being modest and humble. It takes a lot of time and it is enormously enriching. I feel very proud to be an amateur member of the Fellowship.
A: Are there any books or pieces of music which have been particularly important for you?
GV: Probably The Little Prince (de Saint-Exupéry 1943) would be near the top of the list, and also Lee Robins's Deviant Children Grown Up (Robins 1966)—they are very different. Music is not part of my environment.
A: You are a recipient of the Jellinek Award. What has your research done to confirm or disconfirm Jellinek's seminal ideas?
GV: I think the terrible problem in the addictions field is that people become specialist in one facet of the problem. That is certainly true of me and I think it is true of most of the researchers in the field; so that my respect for Jellinek is based on the fact that he was not limited by a narrow focus. I think for his time he was right on everything except that he believed alcoholism was a progressive disease, which I certainly did until I conducted 30-years follow-ups. Alcoholism is very similar to schizophrenia, cigarette smoking and obesity; it progresses for about 5–10 years, but 30-year follow-ups suggest that there is a point where schizophrenia and often alcoholism stop progressing and even become a little better. The only problem is that if you are very far along on alcohol abuse you cannot go back to where it does not cause you any trouble. You need to become abstinent or accept dying prematurely. In that sense it is very similar to cigarette smoking.
A: Are you still changing?
GV: I have taken a much more spiritual stance. My findings in the samples that I have looked at is that increasing spirituality is not part of everybody's vital development; but it certainly is part of my life development and I am interested in writing about spirituality, which is one of the reasons that I feel so privileged to have been allowed to have been a non-alcoholic trustee with AA.
A: Your career has spanned the modern history of alcohol studies. Where do you see yourself in this of growth of understanding about alcoholism?
GV: The short answer to your question is God Bless Senator Hughes. Clearly, my own involvement in the field is entirely a product of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). My own interest in psychiatry has been trying to replace superstition with evidence. If I have made any contribution to this shift from addiction being largely superstition to being increasingly based on science, it is because the use of prospective study methods can help to remove illusion. I have an enormous sense of pleasure in having partially mastered alcoholism and having contributed to studies of alcoholism and defence and normality; it is having undertaken several different things, which is rewarding, the chance to be a little bit creative.
A: What would your advice be to a young person who said, Professor Vaillant, please tell me how I should prepare myself for a career in the addictions field?
GV: I would say, you want to pay attention to time as a dimension rather than see things only as static. Oh yes, and subscribe to Addiction.