Dr. Harry M. Tiebout, a psychiatrist, was an early pioneer in coupling the principles and philosophy of Alcoholics Anonymous with psychiatric knowledge of alcoholism. A strong supporter of A.A. throughout his life, he consistently worked for acceptance of his views concerning alcoholism the medical and psychiatric professions. He served on the Board of Trustees for A.A. from 1957 to 1966, and was chairman of the National Council on Alcoholism in 1950.
Reprinted from
1953 QUARTERLY JOURNAL OF STUDIES ON ALCOHOL
Vol. 14, pp. 58-68
New Brunswick, N.J. 08903
Printed in the United States of America
The Tiebout Collection consists of four papers written during the 1950s, drawing from ‘personal stories and the author’s vast experience.
First published by Hazelden Foundation 1990, who offer a variety of information on chemical dependency and related areas. This publication does not necessarily represent Hazelden or its programs, nor do they officially speak for any Twelve Step Program. Minor editing has been done to this booklet in accordance with the publishers (Hazelden’s) editorial style and grammatical usage.
Tiebout Collection
By Harry M. Tiebout, M.D.
Dr. Tiebout was an outstanding psychiatrist and pioneer in the field of addictions.
These are 5 of the many papers Harry M. Tiebout, M.D. wrote about ego and alcoholism. Dr. Hawkins is quite familiar with Dr. Tiebout’s work with AA, and has spoken highly of his work regarding the practice of surrender. Since alcoholism is an addiction, and all addictions can be treated similiarly with respect to surrender and the ego* (12 step programs), I have reprinted these articles. Myswizard
*This does not relate to (or is a substitute for) medical advice and/or medications for addictions.
THE ACT OF SURRENDER IN THE THERAPEUTIC PROCESS
by Harry M. Tiebout, M.D
INTRODUCTION:
The Importance of a Positive Attitude
A year and a half ago, I wrote a paper in which I discussed a phenomenon which I labeled “conversion.” In that paper I broadened the concept of conversion to cover any major switch from negative to positive thinking and feeling irrespective of a possible religious component. Two points stood out to me as important: first, the fact that the positive frame of mind could appear under a given set of circumstances without special help, psychiatric or otherwise; and second, that the new state of mind had a decidedly healthier tone to its thinking and feeling than that which prevailed when the negative tone was uppermost. Without saying so, I then believed that the positive frame of mind could become a legitimate aim in therapy as, once it was brought about, the individual’s attitudes and responses were much healthier.
While I no longer believe that therapy is simply a matter of reaching a positive relationship with reality, I remain convinced that the creation of a positive attitude is one of the essential features in a successful therapeutic program, and that any experience that brings about such an attitude or frame of mind deserves careful study for the light it may throw on treatment in general. Consequently, I continued my observations on the conversion experience and have arrived at the conclusion that the key to an understanding of that experience may be found in the act of surrender which, in my opinion, sets in motion the conversion switch. My paper will therefore consist of (1) a discussion of the act of surrender, and (2) an endeavor to relate it to the therapeutic process as a whole.
Before I go ahead, it may be wise to recapitulate the contents of my previous paper. In it I described how, with the conversion switch, many aspects of the patient’s attitudes underwent profound and often remarkable alterations. I pointed out how, in eight major ways, the individual switched or changed. Rather than go through the whole list again, I can sum up these changes briefly by saying that the person who has achieved the positive frame of mind has lost his or her tense, aggressive, demanding, conscience-ridden self that feels isolated and at odds with the world and has become a relaxed, natural, more realistic individual who can dwell in the world on a Live and Let Live basis. The difference in the before and after state of these people is very real and represents, I believe, a fundamental psychic occurrence.
The Act of Surrender
With respect to the act of surrender, let me emphasize this point: it is an unconscious event, not willed by the patient even if he or she should desire to do so. It can occur only when an individual with certain traits in his or her unconscious mind becomes involved in a certain set of circumstances. Then the act of surrender can be anticipated with considerable accuracy, as I shall soon show. It cannot be defined in direct conscious terminology but must be understood in all its unconscious ramifications before its true inner meaning can be glimpsed. The simplest way to picture what is involved in the act of surrender is to present a case in which there was a conversion experience that seemed to follow an act of surrender..
One Man’s Story
The patient is a man in his early fifties, very successful in business, and referred to by his associates as Napoleon because of his autocratic methods when he was stirred up. For years, heavy drinking to the point of frequent intoxication was present, interfering to some extent with his efficiency, but never to the degree that his business really suffered. My first contact came some six or seven years ago when he came to Blythewood to dry out. Pursuant to our policy of trying slowly and from time to time to educate patients about the danger of their condition, we permitted this man to remain just for the drying out, at the same time telling him that, in our eyes, he was headed for trouble if he continued on his present trend. Without putting any pressure on him and thus arousing his resistance, we placed the facts before him and let it go.
We continued the policy of letting him come and go pretty much as he pleased, always, however, keeping uppermost before him the need to do something about his drinking, and always making it evident that we were not interested in drying him out, but in the real problem of helping him stop his drinking. Later on and in retrospect, the patient, in referring to these tactics, said, “I used to like to come here; you didn’t always argue with me. I always knew just where you stood and knew I wasn’t fooling you any.”
During all this time, however, I was working on his life situation so that ultimately it would provide the necessary dynamite to jar him loose from his whirl of self-centeredness. Gradually, his wife gave up her protectiveness and, before the time of this last admission nearly two years ago, she had determined to leave him if his drinking continued. Moreover, as a result of some discussion with me, his business partner had decided that he, with several key members of the firm, would tender their resignations if the patient did not make a real effort to mend his ways.
After a particularly severe bout, the patient was induced again to enter Blythewood. This time, however, I told him flatly that he would sign himself in for thirty days or he would go elsewhere; we were through with him running his case once and for all. He looked startled, picked up his hat, fiddled with it, and then put it on his head, saying, “Where’s your pen? I’ll go to Hilltop where I belong,” referring to the cottage where he had dried out on previous occasions. Within three or four days he was off the liquor and thinking reasonably straight. He was then informed of his wife’s decision and, instead of ranting around and making it clear where she could go, he discussed for the first time the real hell he had put her through and really seemed regretful. By the end of the first week, quite prepared for trouble, the partner told him of the pending resignations if the drinking persisted, only to be surprised and pleased with the patient’s quiet acceptance of their decision and an acknowledgment of his own real wish to be different. He soon joined A.A. and is now an active member of that organization in his home community. The patient has stayed sober.
What Happened ?
Recently in discussing his experience the man in the story explained, “You did something to me when you made me sign that card. I knew you meant business. I knew my wife was getting sore and that Bill his partner was fed up, but when you showed me you were through fooling, that was a clincher. I knew I needed help and couldn’t get out of it myself. So I signed the card and felt better right off for doing it. I made up my mind that I wasn’t going to run my own case any longer but was going to take orders. Then later I talked with Chris his wife and learned how she felt, and then Bill came along and I knew deep inside my heart they were right. But, I didn’t mind. I didn’t get angry and want to argue like I used to. I kind of surprised myself by agreeing with them. It sure was nice not to have to fight. I felt calmer and quieter inside and have ever since, although I know I’m not out of the woods yet.”
Here is the story of a patient who has been through a conversion experience and is still in the positive phase. His own account of what happened stresses the signing of the card as the turning point in his experience, and I am also convinced that he is right. We can sum this man’s experience up by saying that after trying to run his own case to his own ruination, he gave up the battle and surrendered to the need for help, after which he entered a new state of mind that has enabled him to remain sober.
Breaking Down The Act Of Surrender
This man’s experience, which is not limited to alcoholics, raises three questions:
I . What qualities were there in his nature that so long resisted help and finally were forced to give in?
1. What were the circumstances that brought about the final act of surrender?
2. Why does a positive phase follow the surrender experience?
My answers to these questions are derived primarily from my studies of alcoholics, but not entirely, as I have witnessed surrender with a typical aftermath in at least four cases among the students at Sarah Lawrence. I hope through my discussion in reply to these questions not only to define the act of surrender, but also to give you some feeling for it as a psychological entity or event.
Internal Qualities
To turn then to the first question, “What are the qualities in a patient’s nature that make him or her put up such a battle before finally surrendering?” In the alcoholic, my observations have led me to see that the two qualities that Sillman selected as characteristic — defiant individuality and grandiosity — may very well explain that the alcoholic is typically resistant to the point of being unreasonable and stubborn about seeking help or being able to accept help even when he or she seeks it. Defiant individuality and grandiosity operate in the unconscious layers of the mind and their influence must be understood if one is to see what probably goes on at the time of surrender.
Defiance
Defiance may be defined as a quality that permits an individual to snap his fingers in the face of reality and live on unperturbed. It has two special values for handling life situations. In the first place, defiance, certainly with alcoholics, is a surprisingly effective tool for managing anxiety or reality, both of which are so often a source of anxiety. If you defy a fact and say it is not so and can succeed in doing so unconsciously, you can drink to the day of your death, forever denying the imminence of that fate. As one patient phrased it, “My defiance was a cloak of armor.” And so it was a most trustworthy shield against the truth and all its pressures.
In the second place, defiance masquerades as a very real and reliable source of inner strength and self-confidence, since it says in essence, Nothing can happen to me because I can and do defy it.
With people who meet reality on this basis, life is always a battle with the spoils going to the strong. Much can be said in favor of defiance as a method of meeting life. It is the main resource of the chin-up and unafraid type of adjustment and, as a temporary measure, it helps people over many rough spots.
Grandiosity
Grandiosity, the second quality noted by Sillman, permeates widely throughout the reactions of the alcoholic. Differing from defiance — which seems almost uniquely structuralized in the psyche of the alcoholic — grandiosity springs from the persisting infantile ego. As in other neurotic states, grandiosity characteristically fills a person with feelings of omnipotence, demands for direct gratification of wishes, and a proneness to interpret frustration as evidence of rejection and lack of love. The effect of this persistence in the alcoholic is not a bit different from the effect of any other neurotic. Perhaps in the alcoholic the typical arrogance and sense of superior worth are kept nearer the surface by the associated defiance that feeds the childish ego constantly by its succession of victories. By and large, however, there is nothing in the alcoholic’s grandiosity that distinguishes him or her from the neurotic, whose infantile ego survives to become a significant factor in adult life; it is part of the typical egocentricity of that group, and its presence is confirmed by any careful study of them.
Defiance and Grandiosity at Work in the Alcoholic
We are now in a position to discuss how these qualities operate in alcoholics. On the one side, the defiance says, It is not true that I can’t manage drinking . On the other side, the facts speak loudly and with increasing insistence to the contrary. Again, on the one side, grandiosity claims, there is nothing I cannot master and control, and on the other side, the facts demonstrate unmistakably the opposite. The dilemma of the alcoholic is now obvious: the unconscious mind rejects — through its capacity for defiance and grandiosity — what the conscious mind perceives. Hence, realistically, the individual is frightened by his or her drinking and at the same time is prevented from doing anything about It by the unconscious activity that can and does ignore or override the conscious mind.
Let us see how this clash between the conscious and unconscious response manifests itself in the clinical setting. A stimulus from reality, such as a recognition of the downhill pattern of the drinking, impinges upon the conscious mind and creates acute anxiety which, for the moment, dominates the conscious processes and is recorded as worry, distress, fear, and concern. The patient, in this state, is fired with a desire to quit and eagerly grabs at any kind of help. He or she is in a state of crisis and suffering.
In the meantime, however, the stimulus of reality is hitting the unconscious layers of the mind and is stirring up the reactions of defiance and grandiosity. Since, characteristically, it takes a certain amount of time before the unconscious responses are sufficiently mobilized to influence conscious mental activity, there is always an appreciable lag before the conscious mind evidences signs of the underlying unconscious activity. Then slowly and gradually these attitudes supervene. Patients express less concern about their drinking, complain that they were rushed into seeking help, that they’re no worse than anybody else, and that the worry of others is silly and a gratuitous invasion of their rights. Finally, the memory of their own acute period of anxiety is swallowed up by the defiance and grandiosity. Thus the patient loses the effectiveness of the anxiety as a stimulus to create suffering and a desire for change. This cycle will go on repeating itself as long as the defiance and the grandiosity continue to function with unimpaired vigor.
External Circumstances
We now come to the second question: “What were the circumstances that made that patient give in and sign that card?” Let me review them for you briefly. He had been drinking for years, and he knew his drinking was getting worse in the eyes of family and friends. However, he knew that his condition had reached the point where both his wife and his business associates were leaving him and thereby withdrawing their support and protection. He was threatened with the task of managing himself and his condition entirely on his own, so he sought my help and protection to dry him out and thus allow him once more to resume his role of successful defiance and grandiosity. This time, however, I refused to follow my previous role. I had established myself as not arbitrary, not willing to fit what he needed. But when I asked him to sign the card, I knew that his other circumstances were different and that I represented the one way for him. When I told him, in essence, that he was not running his case or me anymore, his last prop was thus removed. He had no place to take his defiance and his grandiosity; nor could he become defiant with me: someone who stood for his last bit of hope and who actually had become established as an ultimate resource when he was in difficulty. So he staged a brief inward debate and then signed the card.
In short, the patient signed the card, first, when all support was withdrawn; second, when he could not in anger defy those who withdrew their support because he knew they had been patient and long-suffering; and third, when he found himself desperately needing help and had no grandiose ideas left about being able to drink like non-alcoholics. He had neither unconscious defiance nor grandiosity left to fight with. He was licked, and he both knew it and felt it.
The Positive Phase
We now reach the third question, “Why does the positive phase follow?” Here, we frankly reach speculation. I know the positive phase comes, but not just why. Surrender means cessation of a fight, and cessation of a fight seems logically to be followed by internal peace and quiet. That point seems fairly obvious, but why the whole feeling tone switches from negative to positive without all the concomitant changes is not so clear. Nevertheless, despite my inability to explain the phenomenon, there is no question that the changes do take place and that they may be initiated by an act of surrender.
THE DIFFERENCE BETWEEN SUBMISSION AND SURRENDER
One fact must be kept in mind, namely, the need to distinguish between submission and surrender . In submission, an individual accepts reality consciously, but not unconsciously. He or she accepts as a practical fact that he or she cannot at that moment lick reality, but lurking in the unconscious is the feeling, there’ll come a day , which implies no real acceptance and demonstrates conclusively that the struggle is still on. With submission, which at best is a superficial yielding, tension continues.
When an individual surrenders, the ability to accept reality functions on the unconscious level, and there is no residual of battle; relaxation with freedom from strain and conflict ensues. In fact, it is perfectly possible to ascertain how much acceptance of reality is on the unconscious level by the degree of relaxation that develops. The greater the relaxation, the greater the inner acceptance of reality.
We can now be more precise in our definition of an act of surrender. It is to be viewed as a moment when the unconscious forces of defiance and grandiosity actually cease to function effectively. When that happens, the individual is wide open to reality; he or she can listen and learn without conflict and fighting back. He or she is receptive to life, not antagonistic. The person senses a feeling of relatedness and at-oneness that becomes the source of an inner peace and serenity, the possession of which frees the individual from the compulsion to drink. In other words, an act of surrender is an occasion wherein the individual no longer fights life, but accepts it.
Having defined an act of surrender as a moment of accepting reality on the unconscious level, it is now possible to define the emotional state of surrender as a state in which there is a persisting capacity to accept reality. In this definition, the capacity to accept reality must not be conceived of in a passive sense, but in the active sense of reality being a place where one can live and function as a person acknowledging one’s responsibilities and feeling free to make that reality more livable for oneself and others. There is no sense of “must”; nor is there any sense of fatalism. With true unconscious surrender, the acceptance of reality means the individual can work in it and with it. The state of surrender is really positive and creative.
To sum up, my observations have led me to conclude that an act of surrender is inevitably followed by a state of surrender that is actually the positive state in the conversion picture. Because of the two always being associated, I believe they represent a single phenomenon to which I attach the term “surrender reaction.”
RELATING THE ACT OF SURRENDER TO THE THERAPEUTIC PROCESS
Having at last made as clear as I could my use of the term “surrender,” I must now try to relate that concept to the therapeutic process. While, a recognition of the dynamic force of the event has proven enlightening in many directions, it has been particularly helpful in understanding the fluctuations in moods of patients and in certain aspects of therapy.
The following patient’s problem took on meaning for me when I grasped the fact that he had experienced an act of surrender at the time he attended his first A.A. meeting. A man in his middle thirties, he tells his story this way:
“I was licked. I’d tried everything, and nothing had worked. My wife was packing to leave me; my job was going to blow up in my face. I was desperate when I went to my first A.A. meeting. When I got there, something happened. I don’t know to this day a year later what it was, but I took a look at the men and women there and I knew they had something I needed, so I said to myself, I’ll listen to what they have to tell me. From that time on, things have been different. I go to meetings, work with other drunks, and study all I can about alcoholism. I know I’m an alcoholic, and I never let that fact escape me.”
Now, if you stop and review this man’s account, you will note the statement, “I’ll listen to what they have to tell me.” In that comment to himself, the patient initiated his act of surrender. There was no lip-service in his willingness to listen; he really wanted help. There was no defiance or grandiosity available at the moment to dilute his listening. He was accepting, without inner reservation or conflict, the reality of his condition and the need for help. And, significantly enough, at this point he goes on to say, “From that time on, things have been different.” Subsequent events clearly indicate that this man did experience the typical change I have been calling conversion , and from that time on “things were different.” His wife, commenting on this change, said feelingly, “It’s the most remarkable thing I ever could imagine. The only trouble is that I still have to keep my fingers crossed because it still doesn’t make any sense to me.”
The patient, however, consulted me because he “didn’t like the way things were going.” By that, he meant that he was finding himself cranky at home and irritable in business, signs that his A.A. experience had taught him were ominous. When I asked him why he gave up drinking, he replied that he had made up his mind to quit so he, did, although he had to admit that A.A. was helpful. A little surprised at this simple assertion and doubting it somewhat, I plied him with further questions and got the real story, which showed to me that he had a typical surrender experience, followed by a typical positive aftermath. But I also saw that the change did not last and that, after several months in which the patient had lived in a state of surrender, he slowly reverted to his former attitudes and ways of feeling. In other words, the surrender reaction did not fix itself into his personality and thus allowed the return of his previous state of mind.
Differing acts of surrender
The fate of the surrender reaction is in itself an interesting study. With some, the surrender experience is the start of genuine growth and maturation. With others, the surrender phase is the only one ever reached, so that they never lose the need to attend meetings and to follow the program assiduously, apparently relying on the constant reminders in their daily existence to supply the necessary impetus to the surrender feeling, at least insofar as alcohol is concerned. For a few, there seems to occur a phenomenon of what might be called selective surrender . After the effects of the initial surrender experience have worn away, the individual returns to pretty much the same person he or she was before, except for the fact that the person doesn’t drink. His surrender is not to life as a person, but to alcohol as an alcoholic. Many other differing aftermaths undoubtedly occur, but a study of any or all of them would, I am sure, disclose the same basic fact: the surrender experience is followed by a phase of positive thinking and feeling that undergoes various vicissitudes before it becomes established in some form or other in the psyche — or it is lost completely, becoming merely a memory and a mirage.
Recognizing the Surrender Reaction
From the standpoint of therapy, recognition of the surrender reaction throws a challenging light upon many clinical phenomena that are generally held to be of significance in the process of getting better. For instance, in catharsis it is not what is revealed but the act of surrender (that preceded and permitted the revealing to come to light) that, in my opinion, produces the characteristic afterglow of positive feeling. It also explains its temporary effect just as with the conversion experience of the alcoholic. Again, the frequent unexpected lifts derived from seemingly ordinary first interviews, while they may be considered transference phenomena, seem to me more in the nature of “surrender reactions” based upon the fact that the client found the interview palatable, and the client made a decision to continue, which by implication means “surrender”, to the psychiatrist. The very decision to come to a psychiatrist, through its surrender significance, often has an ameliorating influence and certainly accounts for the remark of a patient who said, “Once I rang your doorbell, I felt 75 percent better”. The phenomenon of release, which makes people realize that, in losing their lives they are finding them, becomes explicable if one sees that the surrender that preceded the sense of release stills the inner fight and hostility, thus permitting the spontaneous creative elements of the Inner Self outlet for expression.
Resistance
It is in the area of resistance, however, that an understanding of the surrender reaction sheds the greatest light on the therapeutic process. Regularly, therapy goes ahead by fits and starts. For a while there is a period of resistance that is worked through, permitting progress, insight, and awareness of the emotional interplays in the unconscious life. Then another point of resistance is encountered, and again it must be ferreted out and dissolved before further constructive steps may be taken. Meeting resistance and working it through are the everyday tasks of therapy.
Breaking Through Resistance
Where before the patient has been in full resistance — bucking treatment, difficult to manage, getting nowhere — suddenly there is a marked change, almost like the sun bursting through the clouds, bringing everything into focus and making what was once a confused jumble take on form, significance, and meaning. For the time being, the resistances have disappeared and the treatment proceeds apace.
We have been accustomed to saying that the patient has a flash of insight and understanding that brought clarification and a greater awareness of his or her individual emotional makeup. Actually, if you examine the state of mind that breaks through when the resistance melts, you will find it is strikingly parallel to the positive state of mind an individual may have after a conversion experience. In fact, the parallel is so striking that I am more and more becoming convinced that the two are identical. In other words, I now believe that the giving up of resistance during treatment is in reality an act of surrender that typically, as in the conversion experience, is followed by a positive state of mind where elements of resistance are no longer present. This “giving in” may be sudden, causing the patient to enter the positive phase so rapidly as to constitute a sudden turnover with dramatic results. Generally, as in the conversion change, the change is slower, but the alteration is in exactly the same direction.
CONCLUSION
No one recognizes more than I do the sweeping nature of any such observations. No one is more aware than I am of the need to substantiate these observations with clinical material. Someday I may be able to support more conclusively my present hypothesis with case material. I can point out, however, that the positive aftermath of the so-called “successful interpretations” is no more lasting than the positive phase of the so-called “conversion experience”. They are both temporary; they are both slowly supplanted by a new crop of resistances or negative feelings. Also, they both require further change in the unconscious mind before the act of surrender becomes a settled state of surrender in which defiance and grandiosity no longer raise havoc with adjustment, serenity, and the capacity to function as a human being.
To recapitulate, my studies of the conversion experience have led me to see that:
• It is the act of surrender that initiates the switch from negative to positive behavior.
• It occurs when the unconscious defiance and grandiosity are for the time being rendered completely powerless by force of circumstance or reality.
• The act of surrender and the change that follows are inseparable since it is safe to assume that if there is no change, there has been no surrender.
• The positive phase is really a state of surrender that follows the surrender act.
• In several places, as in catharsis, the so-called improvement or feeling better is actually a state of surrender induced by an act of surrender.
• The state of surrender, if maintained, supplies an emotional tone to all thinking and feeling that does insure healthy adjustment.
I have tried in this paper to establish the fact that there is such a psychic event as surrender and that once the fact is appreciated in all its ramifications, it is illuminating clinically and provides a basis for understanding much that goes on in the therapeutic process.
DIRECT TREATMENT OF A SYMPTOM
Harry M. Tiebout, M.D.
Therapists with alcoholics have a twofold task. They must treat the disease alcoholism and they must treat the person afflicted with it. Psychiatrists have tended to bypass the disease and treat the individual, but again and again under this approach the patient has proved recalcitrant to all therapeutic endeavor. As a result, alcoholics have been considered very unlikely prospects for therapy of any sort.
The difficulty, of course, was in the main symptom of the disease: the fact that the patient would get drunk, which repeatedly nullified all attempts at assistance. As a consequence, work with the person who drank was stymied by the fact that he drank. In the face of this dilemma, therapists have thrown up their hands in dismay and have turned to greener pastures.
The mistake we made was our failure to recognize that the task was twofold. In rather doctrinaire fashion, we persisted in treating the alcoholism as a symptom which would be cured or arrested if its causes could be favorably altered. The drinking was something to be put up with as best as one could while more fundamental matters were being studied. The result of this procedure was that very few alcoholics were helped. The drinking continued and the symptom remained untouched.
In other medical treatment this concept of getting at causes is not considered sufficient. No one ignores a cancer, for instance, while searching for its origins. It is cut into or treated with x-ray or radium in the hope that the growth will either be removed or will stop advancing. Once the cancer is detected, the question of etiology is academic.
Exactly the same thinking applies to the treatment of alcoholism. It is a symptom which becomes dangerous in itself. Until it has been effectively stopped, little of real help can be offered. Alcoholics Anonymous stresses the danger of the first drink and Antabus simply stops the ability to take it. Both attack the symptom and both have recorded a substantial measure of success.
The advent of these new tools not only has given us a means of treating the symptom directly, it has focused attention upon a factor whose importance was hitherto insufficiently appreciated. That factor is the significance of the first drink and what it represents to the psyche of the drinker.
Such focusing has two results. First, it directs thought toward the problem of stopping, that is, of not taking the first drink. Second, it leads to a new approach to the understanding of what must transpire in therapy if the alcoholic is to remain sober.
This paper will discuss both those points, namely, the direct treatment of a symptom and the individual’s reaction to such a direct approach.
1. The Direct Treatment of a Symptom
The direct treatment of a symptom is and has been the subject of much controversy. A review of the past is necessary to set the controversy in perspective.
Roughly, we can divide the past into the time before Freud and the time after. Prior to his epoch-making revelations about the unconscious and its controlling influence over behavior, all treatment perforce was direct. If a person was acting in a disturbed manner, he was placed in an institution. If he broke the law, he was imprisoned. A naughty child was spanked. Treatment was aimed at behavior and was essentially disciplinary, the big stick. For the most part, it was applied blindly, woodenly, as the only known means of combating the behaviors being encountered.
Then through Freud’s work conduct was recognized as an outgrowth of unconscious functioning, and, before long, the field of psychiatry embraced as one of its major tenets the principle that all behavior sprang from the unconscious, and that therapy, when necessary, had as its goal the determination and elimination of the pathology behind upsetting behavior. The validity of such a shift was indisputable. Since former blind methods could be replaced by much more precise measures, direct treatment of a symptom lost all caste. The day of scientific therapy had arrived.
Strangely, though, a new kind of woodenness then appeared. Anything prior to Freud was out, to be viewed dimly and with alarm.
I, too, was an early believer and expounder of the theory that all behavior was symptomatic. 1, as much as anyone, searched energetically for unconscious forces to help alcoholics, and 1, too, fell flat on my face. It just did not work.
Then, as related elsewhere, Alcoholics Anonymous came along and I saw it succeed not only in arresting the drinking, but in helping a person to mature. All my’ pet assumptions were knocked into a cocked hat (and it took me many a year to realize the full import of what I had seen happen to my patient as she made the grade through Alcoholics Anonymous).
Unconcerned with causes and not bewitched by dogma, the A.A. program was designed to get the individual to stop drinking, and really nothing else. The aspects of personality inventory and of spiritual growth were useful in A.A. chiefly because they tended to insure the individual’s capacity for not taking the first drink. They had nothing to do with causation. The whole program was direct treatment of a symptom.
When this dawned, most of my previous thinking on getting at causes had to be shelved, placed to one side, so that this new fact could be studied open-mindedly.
Antabus came along to confirm the soundness of tackling the symptom, and the need to find an explanation for that heretical fact became more imperative. Finally, the significance of the first drink became apparent, and then the corollary fact that the individual must stop taking even “one”.
With the recognition that total abstinence was the goal of both methods, pre-Freud direct management of symptoms took on a different significance. This, too, was to be seen as an effort to change the individual’s behavior either by putting him in an institution for the mentally ill, or by jailing him, or by inflicting punishment. To be sure, these techniques might be applied without much precision and perhaps too often, but they nevertheless effectively stopped the symptoms, and perhaps that, in and of itself, was not only useful but necessary. Certainly, insofar as helping the alcoholic was concerned, the direct method worked. In my eyes, such treatment had been reestablished as a sound clinical procedure and a valid tool. Hopefully, it could be applied with more skill and finesse now that the Freudian insights were available, but to dismiss it totally would be inexcusable rigidity and evidence of very unscientific dogmatism.
2. The Individual’s Reaction
With the acceptance of the validity of the direct approach, the treatment of the alcoholic individual takes on a new dimension. Instead of determining causes, the therapeutic aim is directed toward helping the patient to utilize available techniques, A.A., Antabus, and/or psychiatry, to aid in his battle to stop drinking. The therapist, so to speak, has his prescription. His job is to sell it to the patient.
At this point, we run into a fundamental issue. Most patients take their doctor’s prescription. Very few alcoholics respond that simply. As a result, the doctor has the task of inducing the patient to take the medicine offered, and it is ‘ here that we must consider the nature of the alcoholic, the individual who balks at taking the remedy suggested. This brings us to our second point, namely, the nature of the individual who so stubbornly refuses to stop drinking.
More accurately, the topic of this section is the nature of the individual’s reaction to direct treatment. The physician for the alcoholic, regardless of his personal inclinations or his theoretical convictions about the function of the therapist, is placed in the role of someone who is trying to stop the patient’s drinking. And although the alcoholic may desperately want help consciously, this does not necessarily overcome his unconscious resistance to such authoritative handling. The therapist inevitably acts as a depriving person.
To try to avoid that role is silly, misleading, and a very poor example. Silly because it denies the obvious, and misleading because it is attempting to sugar-coat an unpalatable truth. A poor example, because the therapist is denying realty-behavior at which the patient is already expert. Fundamental respect can never be established on such a false basis.
As a consequence, the therapist must not fight the patient’s identification of him as a depriving figure. There is no loophole from that position. The only hope is to help the patient learn to accept deprivation and therefore reach a state in which, as a mature person, he will realize that all his wants and demands cannot be satisfied and that there are some things he cannot have.
The therapist must not sidestep his depriving role; instead he must freely acknowledge it and let therapy begin right there. To do so clears the atmosphere and paves the way for establishing a sound working relationship.
The following clinical material shows not only these new tactics which must be adopted but also the patient’s reaction to them. The patient is a man in his middle thirties who, after six years of stumbling success with A.A., decided to try psychiatry because, to quote him, “I’m almost as bad as when I started with A.A. I’ve got to do something.” It was clear that he was strongly motivated, and consequently he was accepted for therapy. The patient was told that his immediate problem was drinking and that it could ruin his chances of profiting from assistance. There would be no insistence on total sobriety, but there would be the following stipulation: if in my opinion his drinking was interfering with therapy, I could require him to take Antabus, which would insure sobriety over a period long enough to settle whether or not he could profit from treatment, so that later on he might be able to get along without the medication.
The patient promptly accepted this proviso, saying it made complete sense to him. On the surface he seemed completely receptive. He remarked in confirmation, “I know when I’m drinking it would be a waste of your time to try to help me; I just wouldn’t get a thing.” No trace of protest could be observed and I am sure none was felt. In fact the patient seemed to welcome a forthright statement of what lay before him. He at least knew where he stood.
Also during the first interview the patient was asked to record his dreams. At the next session, he reported the following:
1. Irritated and teased pet bird.
2. Vaguely remember X.Y. Think was drinking with him.
3. Accidentally pulled all the tail feathers out of pet bird.
The first dream he then expanded, adding, “the pet bird was mine and it was caged and visibly annoyed.” Little imagination is required to read the unconscious thoughts at this point. Birds stand for freedom, i.e., “free as a bird.” A caged bird is not free and, therefore, is “irritated” and “visibly annoyed,” feelings which every freedom loving person would show if caged. And no one would deny that a caged bird was a stopped one. The first dream pinpoints the fact that therapy was designed to stop drinking.
The next dream finds the patient drinking with a boon companion, a person he was prone to turn to after sobriety had begun to pall. In this dream, quite literally, the bird becomes the patient, escaped from the cage, and the cage which has been escaped from is the knowledge about the danger of the first drink.
The report of the third dream also received interesting amplification. The patient volunteered that the bird flew by him and that, as it did, he grabbed at it and “pulled every last tail feather off, and all that was left was a bare little butt end.” Again the message of the dream is clear. The free bird, again in the picture, presents its butt end to the world, an unequivocal gesture of defiance.
The story that these dreams have to tell seems unambiguous. The patient is coming for help about his alcoholism, which he knows can be treated only by his not taking the first drink. The symbol of the caged and annoyed bird is a brilliant condensation of three aspects of his own self as it reacts to his new situation. First, the bird is a symbol of freedom; second, it represents the sense of restriction which is the cage; and third, it shows the “visible annoyance” and “frustration” which the bird feels as it is confronted by the fact that it is not at liberty. In the second dream the patient is no longer stopped. The third dream reveals this clearly as a defiant response to the therapy.
No doubt other interpretations with which I would have no dispute may be offered for these dreams. The point is, however, that the theme of stopping is also unmistakably present in the patient’s unconscious which shows a completely understandable reaction to the idea of being stopped and frustrated.
Despite the note of defiance on which they end, these dreams actually started therapy off on a good sound basis. First and foremost, the patient learned that he had unconscious attitudes. Although he protested vigorously that he had no feeling of defiance toward either the doctor or the treatment, he knew that on many occasions he had shown and felt just such inner attitudes. He could now appreciate that defiance was in his system even contrary to his desires and in spite of his failure to be aware of it. From now on, he would have to recognize the presence of an inner-feeling life which psychiatry might help him reach and learn to handle better. Any lurking misgivings regarding psychiatry were to some extent lessened.
In addition, the patient had to face his inner demand to be free and that inside he balked at any curbing. Recognition of this fact was comforting, for it gave him a belief that further insights might be forthcoming and that the possibility of help might exist.
Still a third advantage to his start sprang from the discussion of defiance and the insistence upon freedom. The patient’s immediate reaction was to scold himself for acting that way and to feel guilty that he had allowed such attitudes to persist. When he could realize that these forces were deep-seated and real, he could drop his punitive reactions of guilt and focus upon the more important issue of how he could rid himself of his tendency to defy and his desire to cherish his freedom at the expense of his sanity. The burden of guilt could be lifted and with it the tensions which contributed so much to his drinking. Therapy was obviously under way.
As this example shows, the patient’s negative responses to the direct approach need not be feared, because they can be used to suggest to the patient the idea that their very presence, while easy to comprehend, is an indication of where his trouble lies.
Let me summarize briefly the points made so far. First, the treatment of the alcoholic must initially focus on his drinking. To say this is not to ignore the person or his body. They must always receive attention regardless of the ailment. However, the primary emphasis on the control of the drinking is essential if treatment is to succeed. Second, the patient’s reactions to direct treatment not only do not undermine the therapeutic relationship, but may actually enhance it. As those reactions are discovered and faced, a solid foundation for a good therapeutic experience is created. To act otherwise can only result in confusion.
Before closing, a few comments are in order. First, the importance of timing cannot be overemphasized. The patient who reacted well to an active technique was ripe for the plucking. He wanted to quit and had been trying to for several years. He was a perfect candidate for the direct approach.
Actually he was at the end of a very long trail. It began with his drinking blithely and unconcernedly. It was nearing its conclusion hopefully with his’ earnest desire not to take the first drink. Space limitations prevent my identifying and discussing all the various sections of that trail. Suffice it to say that he could now seek help with no conscious reservations.
Actually, such direct methods can be applied only when the patient is in a receptive frame of mind. A whole paper could be devoted to a discussion of how the patient’s defenses must weaken so that he is willing and able to turn for help. To be direct when it is certain that such an approach will bounce off a shell proof exterior is obviously bad timing. It wastes ammunition which could later be effective. Other measures must be used first in an effort to soften these defenses. The direct approach can be ventured only when the patient is sufficiently vulnerable to make its success likely.
Secondly, what should be the doctor’s attitude toward the patient’s drinking during therapy? In the “platform” placed before the patient, I included a “wait-and-see plank.” This I did for three reasons. In the first place, I did not want to give the impression of acting before I, too, was in possession of the facts about the drinking pattern. If it continued and caused difficulty, here was concrete evidence on which to base a decision about Antabus.
A second reason for a tentative approach was the hope that the usual concept of the disciplinarian as dogmatic and arbitrary could be undercut if I adopted a less adamant program. If later on it became necessary to crack down, the patient would not be justified in claiming that the new tactics were evidence of a hopelessly closed mind toward drinking.
One patient tried to puncture that stratagem by ferreting out the reason for the delaying tactics and accusing me of waiting until he had hanged himself. Since that was true, I admitted the charge and went on from there. I told him he still had to look at the fact that he had hanged himself. The focus was kept on the drinking problem; that he still had to face.
The third reason for adopting a non-dogmatic policy was to place myself in the position of being able to discuss the problem of the drinking with the patient directly. Generally with such delaying tactics the patient makes an extra effort at control and as a rule succeeds for a while, after which the condition usually takes its course and the patient gets drunk. At that point, it is possible to review with him his hopes of controlling intake and his consequent disillusionment and renewed awareness of his drinking problem. In this manner, the patient’s feeling of need for help is revived and motivation is thereby strengthened. Therapy can thus proceed on a firmer footing.
My third comment opens up a vast area. It has to do with the significance of the direct approach in treating alcoholism or any other condition. The full import of this question can only be hinted, but an effort must be made to point out the far-reaching bearing of the direct approach with its stopping-attribute.
One way to discuss the significance of being direct is to ask the question, “How much of the handling of people is of the direct or stopping-variety?” To my mind the answer is, “Far more than most of us realize or have ever suspected.” As already pointed out, incarceration is a form of direct treatment. It still has its values in certain situations. Its more respectable counterpart, the trip or vacation or residence in a sanitarium, serves much the same purpose, namely that of lifting the individual out of the whirling currents of his everyday existence and depositing him in a setting where he can slow down and stop. One can also wonder at the new therapies. Certainly [electro-] shock gives the body and mind an awful beating which in some obscure fashion perhaps may serve a disciplinary, hence stopping, function. Again the sleep therapies put the patient in an enforced rest and, for the time being, effectively stop him.
Children are told to “cut that out” and know that they are being stopped. While the routine use of such a phrase is severely to be frowned upon, the teacher or person in authority who cannot use that phrase when necessary is badly handicapped in the performance of his job.
Youngsters in the nursery school or kindergarten reveal the need for stopping. Good practice has periods of free play interspersed with times when the children sit and draw or paint or listen to stories or have rest periods. These quiet times are designed to slow the youngsters down. On occasion, particularly with a new and inexperienced teacher, the class gets too keyed up and, since this kind of excitement is infectious, the class goes “wild.” It then must be dismissed for the day. The firm hand of the good teacher was lacking and the children got out of control.
Certainly a lot of preventive mental hygiene is of this same stopping variety. — We sleep, we play, or take holidays to provide a break or a cut in the monotony of continued plugging. We seek avocation interests to change our life pattern. Part of the undoubted value of church attendance arises from the peace and quiet of the religious ceremonies and the soothing atmosphere of the church surroundings.
The list is long and could be expanded almost indefinitely. Most rule-of-thumb therapy is of this sort. To rule directness out because it is not scientific may hamstring our effectiveness as people. Neither was surgery, which is a “cut-it-out” technique, too scientific at the outset, but its value was never doubted, and as it went on, the skill in its application advanced until its use is now routine, always, of course, where it is indicated. Yet, obviously, surgery only tackles a symptom, a resultant of infection or tissue change. The surgeon’s concern with cause does not hinder his taking appropriate action.
Similarly the psychiatrist should not hesitate to cut in. He should not be just a butcher with a knife, but perhaps more than is the custom, the psychiatrist should assume responsibility for things happening to his patient. He must not fall back on the excuse that his patient was uncooperative or poorly motivated; he must do his bit to shift attitudes so that cooperation is obtained. Sometimes a little discipline, artfully applied, works wonders. To discard it entirely may deprive one of a very necessary therapeutic resource.
In Conclusion
Let me repeat what I initially stated, namely that the treatment of the alcoholic must include direct treatment of the symptom. This does not exclude the value of deep insights; it merely rechannels them into an understanding of why the patient blocks from taking the remedy prescribed. The study of causation is shifted from origins to the causes which obstruct the therapy. As they are uncovered and resolved, not only is sobriety attained but the inner changes necessary to a sober existence can be and are developed.
The truth of this last statement I can only vouch for at this time. In a later paper I shall try to prove the validity of this claim. In the meantime, this paper will have served its purpose if it has alerted the reader to the dangers inherent in the rigid application of the concept of symptomatic behavior and has tempered his antagonisms to disciplinary measures when properly applied. If it has, the effort to prepare it has been worth while.
THE EGO FACTORS IN SURRENDER IN ALCOHOLISM
Harry M. Tiebout, M.D.
Introduction:
In the past 15 years, my understanding of the nature of alcoholism as a disease has been influenced largely by insight into the mechanisms at work in the Alcoholics Anonymous process. Some years ago I stated that A.A., to succeed, must induce a surrender on the part of the individual. More recently, I discussed the idea of compliance acting as a barrier to that real acceptance which a surrender produces. On this occasion I propose to extend my observations by discussing (a) what factors in the individual must surrender, and (b) how the surrender reaction changes the inner psychic picture.
The first question, what factors in the individual must surrender received passing attention in the article on compliance. There, relative to the difficulty of surrender, I noted that “the presence of an apparently unconquerable ego became evident. It was this ego which had to become humble.” The first part of the present communication will be devoted to an elaboration of the nature of this ego factor.
Use of the word “ego” involves always the possibility of confusion of meaning. For a time, theref
