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The Ego Factors in Surrender in Alcoholism
Harry M. Tiebout, M.D.
Ego: By Two Definitions
Recognizing Immaturity
Inability to Accept
Frustration
Learning to Live
No Compromise With Ego
Summary
References
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 I.
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,
therefore, I considered a substitute term. That idea was set aside
because, despite possible misinterpretation, the word ego is current
in everyday language in exactly the sense in which it will be
employed in this discussion. The expression, "he has an inflated
ego," is self-explanatory. It evokes the picture of a pompous,
self-important, strutting individual whose inferiorities are masked
by a surface assurance. Such a person appears thick-skinned,
insensitive, nearly impervious to the existence of others, a
completely self-centered individual who plows unthinkingly through
life, intent on gathering unto himself all the comforts and
satisfactions available. He is generally considered the epitome of
selfishness, and there the matter rests.
This popular view of
ego, while it may not have scientific foundation, has one decided
value: it possesses a meaning and can convey a concept which the
average person can grasp. This concept of the inflated ego recognizes
the common ancestor of a whole series of traits, namely, that they
are all manifestations of an underlying feeling state in which
personal considerations are first and foremost.
The existence of this
ego has long been recognized, but a difficulty in terminology still
remains. Part of the difficulty arises from the use of the word ego,
in psychiatric and psychological circles, to designate those elements
of the psyche which are supposed to rule psychic life. Freud divided
mental life into three major subdivisions: the id, the ego and the
superego. The first, he stated, contains the feeling of life on a
deep, instinctual level; the third is occupied by the conscience,
whose function is to put brakes on the impulses arising within the
id. The ego should act as mediator between the demands of the id and
the restraints of the superego, which might be over-zealous and
bigoted. Freud's own research was concerned mainly with the
activities of the id and the superego. The void he left with respect
to the ego is one that his followers are endeavoring to fill, but as
yet with no generally accepted conclusions.
Ego: By Two Definitions
The word ego, however
has been preempted by the psychiatrists and psychologists, although
they do not always agree among themselves about the meaning to be
attached to it. The resulting confusion is the more lamentable
because almost everyone, layman or scientist, would agree on the
concept of the inflated ego. It would be helpful if other terms were
found for the ego concepts about which there are differing views.
The solution for this
dilemma will be to indicate with a capital E the big Ego, and without
a capital to identify the personality aspect which Freud had in mind
when he placed ego between id and superego.
With this disposition
of the problem of terminology, it is now possible to consider the
first issue, namely, the Ego factors in the alcoholic which, through
surrender, become humble. The concept of the enlarged Ego, as noted
previously, is available to common observation. Those who do not
recognize it in themselves can always see it in some member of their
family or among friends and acquaintances -- not to mention patients.
Everyone knows egotistical people and has a perfectly clear idea of
what the word means. Besides egotistical, and the series of words
mentioned earlier, adjectives which help to round out the portrait of
the egotistical person are prideful, arrogant, pushing, dominating,
attention seeking, aggressive, opinionated, headstrong, stubborn,
determined and impatient.
All these terms are
inadequate, however, because they describe only surface features
without conveying any feeling of the inner essence from which the Ego
springs. Unless some appreciation for the source of the Ego is
gained, the dynamic import is lost and the term may seem merely a
form of name calling. It is easy to say someone has a big Ego without
awareness of what is really happening in the deep layers of that
person's mind, without perception of the Ego. Nor is it a matter of
intellect. The need here is to lay hold of the inner feeling elements
upon which the activity of the Ego rests. Only when these elements
become clear can the fundamental basis of the Ego also be clarified.
It is convenient, for
the exposition of this inner functioning, to reverse the usual
sequence and to present a conclusion in advance of the evidence on
which it is based. This is, briefly, that the Ego is made up of the
persisting elements, in the adult psyche, of the original nature of
the child.
Certain aspects of the
infant's psyche may be usefully examined. There are three factors
which should receive mention. The first is, as Freud observed in his
priceless phrase "His Majesty the Baby," that the infant is
born ruler of all he surveys. He comes from the Nirvana of the womb,
where he is usually the sole occupant, and he clings to that
omnipotence with an innocence, yet determination, which baffles
parent after parent. The second, stemming directly from the monarch
within, is that the infant tolerates frustration poorly and lets the
world know it readily. The third significant aspect of the child's
original psyche is its tendency to do everything in a hurry. Observe
youngsters on the beach: they run rather than walk. Observe them
coming on a visit: the younger ones tear from the car while their
elder siblings adopt a more leisurely pace. The three-year-olds, and
more so the twos, cannot engage in play requiring long periods of
concentration. Whatever they are doing must be done quickly. As the
same children age, they gradually become able to stick to one
activity for longer times.
Thus at the start of
life the psyche (1) assumes its own omnipotence, (2) cannot accept
frustrations and (3) functions at a tempo allegretto with a good deal
of staccato and vivace thrown in.
Now the question is,
"If the infantile psyche persists into adult life, how will its
presence be manifested?"
In general, when
infantile traits continue into adulthood, the person is spoken of as
immature, a label often applied with little comprehension of the
reason for its accuracy. It is necessary to link these three traits
from the original psyche with immaturity and, at the same time, show
how they affect the adult psyche. If this is done, not only will the
correctness of the appellation "immature" be apparent but,
moreover, a feeling for the nature of the unconscious underpinnings
of the Ego will have been created.
Recognizing Immaturity
Two steps can aid in
recognizing the relationship between immaturity and a continuance of
the infantile elements. The first is, by an act of imagination, to
set these original traits into an adult unconscious. The validity of
this procedure is founded upon modern knowledge of the nature of the
forces operating in the unconscious of people of mature age. The
second step is to estimate the effect that the prolongation of these
infantile qualities will have upon the adult individual.
This attempt should not
strain the imagination severely. Take, for instance, the third of the
qualities common to the original psychic state, namely, the tendency
to act hurriedly. If that tendency prevails in the unconscious, what
must the result be? The individual will certainly do everything in a
hurry. He will think fast, talk fast and live fast, or he will spend
an inordinate amount of time and energy holding his fast-driving
proclivities in check.
Often the net result
will be an oscillation between periods of speeding ahead followed by
periods during which the direction of the force is reversed, the
brakes (superego) being applied in equally vigorous fashion. The
parallel of this in the behavior of the alcoholic will not be lost on
those who have had experience with this class of patients.
Let us take the same
trait of doing everything in a hurry and apply it to the word
"immature." Few will deny that jumping at conclusions,
doing things as speedily as possible, give evidence of immaturity. It
is youth that drives fast, thinks fast, feels fast, moves fast, acts
hastily in most situations. There can be little question that one of
the hallmarks of the immature is the proneness to be under inner
pressure for accomplishment. Big plans, big schemes, big hopes
abound, unfortunately not matched by an ability to produce. But the
effect upon the adult of the persisting infantile quality to do
everything in less than sufficient time can now be seen in a clearer
light. The adult trait is surely a survival from the original psyche
of the infant.
The two other surviving
qualities of the infantile psyche similarly contribute to the picture
of immaturity and also, indirectly, help to clarify the nature of the
Ego with a capital E. The first of these, the feeling of omnipotence,
when carried over into adult life, affects the individual in ways
easily anticipated. Omnipotence is, of course, associated with
royalty, if not divinity. The unconscious result of the persistence
of this trait is that its bearer harbors a belief of his own special
role and in his own exceptional rights. Such a person finds it
well-nigh impossible to function happily on an ordinary level.
Obsessed with divine afflatus, the thought of operating in the lowly
and humble areas of life is most distressing to him. The very idea
that such a place is all one is capable of occupying is in itself a
blow to the Ego, which reacts with a sense of inferiority at its
failure to fill a more distinguished position. Moreover, any success
becomes merely Ego fodder, boosting the individual's rating of
himself to increasingly unrealistic proportions as the king side
eagerly drinks in this evidence of special worth.
The ability to
administer the affairs of state, both large and small, is taken for
granted. The belief that he is a natural executive placed in the
wrong job merely confirms his conviction that, at best, he is the
victim of lack of appreciation, and at worst, of sabotage by jealous
people who set up roadblocks to his progress. The world is inhabited
by selfish people, intent only on their own advancement.
The genesis of all this
is beyond his perception. To tell him that his reactions spring from
the demands of an inner unsatisfied king is to invite incredulity and
disbelief, so far from the conscious mind are any such thoughts or
feelings. People who openly continue to cling to their claims of
divine prerogative usually end up in a world especially constructed
for their care. In others, the omnipotence pressures are rather
better buried. The individual may admit that, in many ways, he acts
like a spoiled brat, but he is scarcely conscious of the extent of
the tendency, nor how deeply rooted it may be. He, like most people,
resolutely avoids a careful look because the recognition of any such
inner attitudes is highly disturbing. The unconscious credence in
one's special prerogatives savors too much of straight selfishness to
be anything but unpleasant to contemplate.
And so, for the most
part, people remain happily ignorant of the unconscious' drives which
push them around. They may wonder why they tend to boil inside and
wish they could free themselves from a constant sense of uneasiness
and unsettlement. They may recognize that they seem jittery and
easily excited and' long for the time when they can meet life more
calmly and maturely; they may hate their tendency to become rattled.
But their insight into the origin of all this is next to nothing, if
not a complete blank. The king lies deep below the surface, far out
of sight.
Inability to Accept
Frustration
The last trait carried
over from infancy is the inability to accept frustration. In an
obvious sense, this inability is another aspect of the king within,
since one of the prerogatives of royalty is to proceed without
interruption. For the king to wait is an affront to the royal rank, a
slap at his majesty. The ramifications of this inability to endure
frustration are so widespread, and the significance of much that
occurs in the behavior of the alcoholic is so far-reaching, that it
seems advisable to discuss this trait under a separate heading.
As already indicated,
on the surface the inability of the king to accept frustration is
absolutely logical. The wish of the king is the law of the land, and
especially in the land of infancy. Any frustration is clearly a
direct threat to the status of his majesty, whose whole being is
challenged by the untoward interruption.
Even more significant
is another aspect of this inner imperiousness. Behind it lies the
assumption that the individual should not be stopped. Again, this is
logical if one considers how an absolute monarch operates. He simply
does not expect to be stopped; as he wills, so will he do. This
trait, persisting in the unconscious, furnishes a constant pressure
driving the individual forward. It says, in essence, "I am
unstoppable!"
The unconscious which
cannot be stopped views life entirely from the angle of whether or
not a stopping is likely, imminent, or not at all in the picture.
When a stopping is likely, there is worry and perhaps depression.
When it seems imminent, there is anxiety bordering on panic, and when
the threat is removed, there is relief and gaiety. Health is equated
with a feeling of buoyancy and smooth sailing ahead, a sense of "I
feel wonderful!" Sickness, contrariwise, means lacking vim,
vigor and vitality, and is burdened with a sense of "I'm not
getting anywhere." The need to "get somewhere" to "be
on the go," and the consequent suffering from eternal
restlessness, is still another direct effect of an inner inability to
be stopped or, expressed otherwise, to accept the fact that one is
limited. The king not only cannot accept the normal frustrations of
life but, because of his inordinate driving ahead, is constantly
creating unnecessary roadblocks by virtue of his own insistence on
barging ahead, thus causing added trouble for himself.
Of course, on some
occasions, the king gets stopped, and stopped totally. Illness,
arrest, sometimes the rules and regulations of life, will halt him.
Then he marks time, complies if need be, waiting for the return of
freedom, which he celebrates in the time-honored fashion if he is an
alcoholic: he gets drunk, initiating a phase when there is no
stopping him.
The immaturity of such
a person is readily evident. He is impatient of delay, can never let
matters evolve; he must have a blueprint to follow outlining clearly
a path through the jungle of life. The wisdom of the ages is merely
shackling tradition which should make way for the freshness, the
insouciance of youth. The value of staying where one is, and working
out one's destiny in the here and now, is not suspected. The 24-hour
principle would be confining for one whose inner life brooks no
confinement. The unstoppable person seeks life, fun, adventure,
excitement, and discovers he is on a perpetual whirligig which
carries him continuously ahead but, of course, in a circle. The
unstoppable person has not time for growth. He must always, inwardly,
feel immature.
This, then, is how the
carry-over of infantile traits affects the adult so encumbered. He is
possessed by an inner king who not only must do things in a hurry,
but has no capacity for taking frustration in stride. He seeks a life
which will not stop him and finds himself in a ceaseless rat race.
All this is part and
parcel of the big Ego. The individual has no choice. He cannot select
one characteristic and hang on to that, shedding other more obviously
undesirable traits. It is all or nothing. For example, the driving
person usually has plenty of energy, sparkle, vivacity. He stands out
as a most attractive human being. Clinging to that quality, however,
merely insures the continuance of excessive drive and Ego, with all
the pains attendant upon a life based on those qualities. The
sacrifice of the Ego elements must be total, or they will soon regain
their ascendancy.
Learning To Live
Those who view the
prospect of life without abundant drive as unutterably dull and
boring should examine the life of members of Alcoholics Anonymous who
have truly adopted the A.A. program. They will see people who have
been stopped -- and who, therefore, do not have to go anywhere -- but
people who are learning, for the first time in their lives, to live.
They are neither dull nor wishy-washy. Quite the contrary, they are
alive and interested in the realities about them. They see things in
the large,are tolerant, open-minded, not close-minded bulling ahead.
They are receptive to the wonders in the world about them, including
the presence of a Deity who makes all this possible. They are the
ones who are really living. The attainment of such a way of life is
no mean accomplishment.
Preliminary to this
discussion, the conclusion was offered that the Ego was a residual of
the initial feeling life of the infant. It should be evident that the
immaturity characteristically found in the make-up of the alcoholic
is a persistence of the original state of the child. In connection
with the description of the manifestations which denote a large and
active Ego, it should be recalled that the presence in the
unconscious of such Ego forces may be quite out of reach of conscious
observation. Only through the acting and feeling of the individual
can their existence be suspected.
Now the answer to the
first question raised herein, namely, what part of the alcoholic must
surrender, is obvious: it is the Ego element.
Life without Ego is no
new conception. Two thousand years ago, Christ preached the necessity
of losing one's life in order to find it again. He did not say Ego,
but that was what he had in mind. The analysts of our time recognize
the same truth; they talk also about ego reduction. Freud saw therapy
as a running battle between the original narcissism of the infant
(his term for Ego) and the therapist whose task it was to reduce that
original state to more manageable proportions. Since Freud could not
conceive of life without some measure of Ego, he never resolved the
riddle of how contentment is achieved; for him, man to the end was
doomed to strife and unhappiness, his dearest desires sure to be
frustrated by an unfriendly world.
In his studies on the
addictions, Rado3 more explicitly asserts that the Ego must be
reduced. He first portrays the Ego as follows: "Once it was a
baby, radiant with self-esteem, full of belief in the omnipotence of
its wishes, of its thoughts, gestures and words." Then, on the
process of Ego-reduction: "But the child's megalomania melted
away under the inexorable pressure of experience. Its sense of its
own sovereignty had to make room for a more modest self evaluation.
This process, first described by Freud, may be designated the
reduction in size of the original ego; it is a painful procedure and
one that is possibly never completely carried out."
No Compromise With Ego
Like Freud, Rado thinks
only in terms of reduction; the need for the complete elimination of
Ego is a stand which they cannot bring themselves to assume. Hence
they unwittingly advocate the retention of some infantile traits,
with no clear awareness that trading with the devil, the Ego, no
matter how carefully safeguarded,' merely keeps him alive and likely
at any occasion to erupt full force into action. There can be no
successful compromise with Ego, a fact not sufficiently appreciated
by many, if not most, therapists.
Thus the dilemma
encountered in ego-reduction would be best resolved by recognizing
that the old Ego must go and a new one take its place. Then no issue
would arise about how much of the earliest elements may be retained.
The answer, theoretically, is none. Actually the total banishment of
the initial state is difficult to achieve. Man can only grow in the
direction of its complete elimination. Its final expulsion is a goal
which we can only hope.
The second question
raised here is, "How does the surrender reaction change the
inner psychic picture?" This question is based on a
presupposition, namely that surrender is an emotional step in which
the Ego, at least for the time being, acknowledges that it is no
longer supreme. This acknowledgment is valueless if limited to
consciousness; it must be accompanied by similar feelings in the
unconscious. For the alcoholic, surrender is marked by the admission
of being powerless over alcohol. His sobriety has that quality of
peace and tranquility which makes for a lasting quiet within only if
the surrender is effective in the unconscious and permanent as well.
The effects of
surrender upon the psyche are extremely logical: The traits listed
as characteristic of the Ego influence are canceled out. The
opposite of king is the commoner. Appropriately, Alcoholics Anonymous
stresses humility. The opposite of impatience is the ability to take
things in stride, to make an inner reality of the slogan, "Easy
does it." The opposite of drive is staying in one position where
one can be open-minded, receptive
and responsive.
This picture of the
non-Ego type of person might be amplified in many directions but to
do so would serve no immediate purpose. To have discussed the effect
of the Ego upon behavior, and to have pointed out what may happen
when the Ego is at least temporarily knocked out of action, is
sufficient to, make the point of this communication: It is the Ego
which is the arch-enemy of sobriety, and it is the Ego which must be
disposed of if the individual is to attain a now way of life
Up to this point, no
clinical material has been submitted to confirm the ideas presented.
Their validity will be apparent to many therapists. One brief
citation from clinical experience will be offered, however, in the
hope that it may serve as a concrete illustration of these ideas.
The patient, a man in
his late 30's, had a long history of alcoholism with 7 years of
futile attempts to recover through Alcoholics Anonymous, interspersed
with countless admissions to "drying out" places. Then, for
reasons not totally clear, he decided to take a drastic step. He
determined to enter a sanitorium and place himself in the hands of a
psychiatrist, a hitherto unheard of venom. We planned to arrange for
a limited stay at a sanitarium where he could have regular interviews
with me.
From the outset, he was
undeniably in earnest, although it was only after the first interview
that he really let go and could talk freely about himself and the
things that were going on inside him. After the usual preliminaries,
the first interview started with a discussion of feelings and how
they operate. The patient was questioned about the word Ego as used
at A.A. meetings. He confessed his ignorance of its true meaning and
listened with interest to brief remarks on how it works. Before long,
he was locating in himself some of the Ego forces which hitherto he
had been vigorously denying because they savored too much of vanity
and selfishness with that recognition, the patient made a revealing
remark. He said, in all sincerity, "My goodness, I never knew
that. You don't do your thinking up here (pointing to his head), you
think down here where you feel" placing his hands on his
stomach. He was learning that his feelings had a "mind" of
their own and that unless he heeded what they were saying, he could
easily get into trouble. He was facing the actuality of his Ego as a
feeling element in his life, a step he was able to take because he
was no longer going at full steam ahead. His decision to place
himself under care, a surrender of a sort, had quieted him and made
him receptive, able to observe what was going on in himself. It was
the beginning of a real inventory.
The next insight he
uncovered was even more startling. He had been requested routinely to
report any dreams he would have. Much to his surprise, they appeared
regularly during the period of contact. In his fifth dream, the
patient found himself locked up in an institution because of his
drinking. The interpretation offered, based upon relevant materials,
was that the patient equated any kind of stopping with being locked
up; that his real difficulty lay in the fact that he could not
tolerate being stopped, and abstaining was merely another stopping he
could not take. The patient's reaction to the interpretation was most
significant. He remained silent for some little time; then he began
to talk, saying, "I tell you, Doc, it was like this. I'd get
drunk, maybe stay on it 2 or 3 days, then I'd go into one of those
drying out places where I'd stay 5 or 6 days and I'd be all over
wanting a drink. Then I'd come out and stay sober, maybe a week,
'maybe a month, but pretty soon the thought would come into my mind,
I want to drink! Maybe I'd go into a tavern and maybe not, but sooner
or later I'd go and I'd order a drink, but I wouldn't drink it right
off. I'd put it on the bar and I'd look at it and I'd think and then
I'd look and think: King for a day!" The connection between Ego
and his own conduct had become explicit, as well as the relationship
between not being stopped and Ego. He saw clearly that when he took
that drink, he was the boss once more. Any previous reduction of Ego
had been only temporary.
In treatment, the
problem is to make that reduction permanent. Therapy is centered on
the ways and means, first, of bringing the Ego to earth, and second,
keeping it there. The discussion of this methodology would be out of
place here, but it is relevant to emphasize one point, namely the
astonishing capacity of the Ego to pass out of the picture and then
reenter it, blithe and intact. A patient's dream neatly depicted this
quality. This patient dreamt that he was on the twelfth floor balcony
of a New York hotel. He threw a rubber ball to the pavement below and
saw it rebound to the level of the balcony. Much to his amazement,
the ball again dropped and again rebounded to the same height. This
continued for an indefinite period and, as he was watching, a clock
in a neighboring church spire struck nine. Like the cat with nine
lives, the Ego has a marvelous capacity to scramble back to safety --
a little ruffled, perhaps, but soon operating with all its former
aplomb, convinced once more that now it, the Ego, can master all
events and push on ahead.
The capacity of the Ego
to bypass experience is astounding and would be humorous were it not
so tragic in its consequences. Cutting the individual down to size
and making the results last is a task never completely accomplished.
The possibility of a return of his Ego must be faced by every
alcoholic. If it does return, he may refrain from drinking, but he
will surely go on a "dry drunk," with all the old feelings
and attitudes once more asserting themselves and making sobriety a
shambles of discontent and restlessness. Not until the ego is
decisively retired can peace and quiet again prevail. As one sees
this struggle in process, the need for the helping hand of a Deity
becomes clearer. Mere man alone all too often seems powerless to stay
the force of his Ego. He needs assistance and needs it urgently.
Summary
In the process of
surrender which the alcoholic necessarily undergoes before his
alcoholism can be arrested, the part of the personality which must
surrender is the inflated Ego. This aspect of personality was
identified as immature traits carried over from infancy into
adulthood, specifically, a feeling of omnipotence, inability to
tolerate frustration, and excessive drive, exhibited in the need to
do all things precipitously. The manner in which surrender affects
the Ego was discussed and illustrated briefly from clinical
experience. The object of therapy is to permanently replace the old
Ego and its activity.
References:
Tiebout, H.M. "The
Act of Surrender in the Therapeutic Process." With special
reference to alcoholism. Quart. J. Stud. Aic. 10: 48-58, 1949.
Tiebout, H.M.
"Surrender Versus Compliance in Therapy". With special
reference to alcoholism. Quart. J. Stud. Aic. 14: 58-68,1953.
Rado, S. "The
Psychoanalysis of Pharmachothymia (drug addiction). The clinical
picture." Psychoanal. Quart. 2: 1-23, 1933.
The Act of Surrender in the Therapeutic Process
Harry M. Tiebout, M.D.
The Importance of a
Positive Attitude
The Act of Surrender
One Man's Story
What Happened ?
Breaking Down The Act
Of Surrender
Internal Qualities
Defiance
Grandiosity
Defiance and
Grandiosity at Work in the Alcoholic
External Circumstances
The Positive Phase
The Difference Between
Submission and Surrender
Relating The Act Of
Surrender To The Therapeutic Process
Differing acts of
surrender
Recognizing the
Surrender Reaction
Resistance
Breaking through
resistance
Conclusion
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.
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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:
What qualities were
there in his nature that so long resisted help and finally were
forced to give in?
What were the
circumstances that brought about the final act of surrender?
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.
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