VERSUS COMPLIANCE IN THERAPY
- WITH SPECIAL
REFERENCE TO ALCOHOLISM
M. Tiebout, M.D.
A Step Beyond Recognition
Easy Road to Understanding
BECOMING a side-line observer of Alcoholics Anonymous in 1939, my
approach to alcoholism has undergone an almost total reorientation.
For the first time I saw what peace of mind means in the achievement
of sobriety and I began to consider the emotional factors involved
from a very different viewpoint. In A.A. meetings, the role of resentments
was a recurrent theme. This seemed significant. Continuing this
line of observation, I found that another enemy of sobriety was
defiance, which Sillman (1) had already described as "defiant
individuality," a major hallmark of the personality of alcoholics.
significant emphasis in A.A. was humility and "hitting bottom,"
completely new points of emphasis for me. It was clear that if the
individual remained stiff-necked he would continue to drink, but
I could not see why. Finally the presence of an apparently unconquerable
ego became evident. It was this ego which had to become humble.
Then the role of hitting bottom, which means reaching a feeling
of personal helplessness, began to be clear. It was this process
that produced in the ego an awareness of vulnerability, initiating
the positive phase. In hitting bottom the ego becomes tractable
and is ready for humility. The conversion experience (2) has started.
happens in the unconscious at the time of hitting bottom remained
a mystery. The first elucidation came from a patient. Through psychotherapy
she was gradually losing the intractable ego structure and finally,
for rather obscure reasons, she had a minor conversion experience
which brought her relative peace and quiet. During this phase she
began attending various churches in town. One Monday morning she
entered the office, her eyes shining and said at once, "I know
what happened to me. I heard it in a hymn yesterday. I surrendered
when I had that experience." Guided by this clue, I realize
that "hitting bottom" is ineffectual if not followed by
a surrender. Hitting bottom must produce a result, which is surrender.
of my ideas along these lines were incorporated in an article3 on
"the act of surrender" in relation to the therapeutic
process. I now wish to extend these thoughts a step further. The
surrender concept has not generally been well received except by
some A.A.'s who recognize its validity in their own experiences.
One or two psychiatrists have told me they are beginning to see
the usefulness of the concept but no one, to my knowledge, has yet
come forward with a paper supporting the thesis of surrender out
of is own observations.
reason for this lag is the resistance to the idea of surrender.
It seems too completely defeatist. Were I writing that article now
I would change it in this respect so as to discuss the term surrender
in linkage with other, less to-be-shunned concepts. But those links
were discovered only later.
the article on surrender, I said: "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 accepts as a practical fact that he cannot at
that moment conquer reality, but lurking in his unconscious is the
feeling, 'There'll come a day' -- which implies no real acceptance
and demonstrates conclusively that the struggle is still going on.
With submission, which at best is a superficial yielding, tension
continues. When, on the other hand, the ability to accept reality
functions on the unconscious level, there is no residual battle,
and relaxation ensues with freedom from strain and conflict. In
fact, it is perfectly possible to ascertain to what extent the acceptance
of reality is on the unconscious level by the degree of relaxation
which develops. The greater the relaxation, the greater is the inner
acceptance of reality."
that paragraph the words "accept" and "acceptance"
are each used three times. I saw at the time that surrender leads
to acceptance. What I failed to see and emphasize was the very important
relationship between surrender and the capacity for acceptance.
propose, therefore, first, to consider acceptance as a human capacity,
and second, to discuss the blocks to the development of acceptance.
The importance of 61 acceptance" is widely recognized although
often only by indirection. Sometimes the necessity for acceptance
is bluntly stated, as in Grayson's4 recent article on the role of
"acceptance" in physical rehabilitation. Grayson reports
his discovery that the individual who needs rehabilitation remains
a poor prospect until he finally accepts his need for the rehabilitating
procedures. More often the concept of acceptance is dragged in by
the heels with little or no recognition that acceptance itself is
a major psychological step. Two recent illustrations are worthy
of mention. In a summarizing article on Alcoholics Anonymous, in
the Connecticut Review on Alcoholism5, the following statements
appear: "He does not have to fight against ideas which come
from this group, he can accept them." Thus the idea that he
is an alcoholic is acceptable when coming from this group. The need
to avoid the 'first drink' is 44 accepted." Certainly the need
for acceptance is unequivocally stated. And the following statement
is from Kubie's6 book: "The man who is normal can accept the
guidance of reason, reality and common sense" The word "accept"
is scattered throughout the pages of the book but the question of
acceptance is never raised-as if it were something that needs no
first of the Alcoholics Anonymous twelve steps reads: "We admitted
we were powerless over alcohol -- that our lives had become unmanageable."
The second word is "admitted," which in many ways is a
blood brother of acceptance although many an A.A. meeting has been
devoted to quibbling about the difference between admit and accept.
Time and again slips are explained on the basis that the one who
slips has not truly accepted his alcoholism.
word "accept", thus, appears quite regularly in speech
and writing but never is there much discussion of how acceptance
comes about. The usual explanation is that, if the doctor is accepting,
the patient will be so too; in case of failure, the therapist is
held responsible, just as parents are for their children. To suppose
that acceptance is caught by contagion is a pretty thought. It is
not, however, likely to stimulate much understanding of individual
psychodynamics. It is not enough merely to point the finger elsewhere.
is need, therefore, to discuss the dynamics of acceptance in the
individual. Acceptance appears to be a state of mind in which the
individual accepts rather than rejects or resists: he is able to
take things in, to go along with, to cooperate, to be receptive.
Contrariwise, he is not argumentative, quarrelsome, irritable or
contentious. For the time being, at any rate, the hostile, negative,
aggressive elements are in abeyance, and we have a much pleasanter
human being to deal with. Acceptance as a state of mind has many
highly admirable qualities as well as useful ones. Some measure
of it is greatly to be desired. Its attainment as an inner state
of mind is never easy.
is necessary to point out that no one can tell himself or force
himself wholeheartedly to accept anything. One must have a feeling
-conviction -otherwise' the acceptance is not wholehearted but halfhearted
with a large element of lip service. There is a string of words
which describe halfhearted acceptance: submission, resignation,
yielding, compliance, acknowledgment, concession, and so forth.
With each of these words there is a feeling of reservation, a tug
in the direction of nonacceptance.
people regard nonacceptance as a sign of willful refusal; this bypasses
all current knowledge of the unconscious elements in resistance
and will power. Others, better informed about those attributes,
avoid the use of such a phrase as willful refusal. They know that
it is largely unconscious attitudes and feelings that determine
the conscious thinking and hence do not suppose that resistance
can be given up by an act of will on the part of the conscious mind.
Acceptance: A Step Beyond Recognition
who recognize the role of unconscious forces then take a curious
next step: They talk about undermining the resistance by uncovering
the reasons for the particular series of resistance, as if the unconscious
mind must then accept those reasons-a non sequitur. It is one thing
to see reasons and quite another thing to behave with corresponding
rationality. One patient neatly punctured this assumption. After
8 years of analysis with four therapists of different schools, he
began to get some inkling of acceptance as a state of mind which
he sadly lacked. Finally, in a burst of awareness, he remarked,
"I know all the reasons but I don't know how to be reasonable."
That statement aptly summed up his predicament. His logical mind
could perceive and believe all the factors underlying his difficulties
but he remained cantankerous and unreasonable as far as his feeling
life was concerned. In his head, or conscious mind, he could "accept"
the explanations but deep inside where the heart, or the unconscious,
operates there was no feeling of acceptance. That capacity still
had to be developed. Uncovering reasons for behavior, no matter
how convincing, does not and cannot insure acceptance of those reasons.
Acceptance is a step beyond recognition, a further operation in
the process of therapy. Many therapists have failed to discern this
two-stage process. The clue was my patient's use of the word "reasonable."
He could have said, with accuracy, "reasonable and accepting,"
because he was beginning to appreciate the fact that one's frame
of mind governs one's response to things that are reasonable or,
for that matter, unreasonable.
was not clearly appreciated is the fact that a state of reasonableness
or acceptance or receptivity has an emotional origin which rises
from exactly the same source as does the resistance and the forces
which predominantly contribute to our being willing, namely, the
unconscious. Unless the unconscious has within it the capacity to
accept, the conscious mind can only tell itself that it should accept
but by so doing it cannot bring about acceptance in the unconscious
which continues with its own non-accepting and resenting attitudes.
The result is a house divided against itself: the conscious mind
sees all the reasons for acceptance while the unconscious mind says,
"But I won't accept!" Wholehearted acceptance under such
conditions is impossible. Experience has proved that in the alcoholic
a halfhearted reaction does not maintain sobriety for very long.
The inner doubts all too soon take over. The alcoholic who stays
"dry" must be wholehearted. Here we meet a complication.
People accept the necessity of being wholehearted about alcoholism
but not about everything else. They are determined to maintain their
capacity for resistance. They fear the fact that if they become
total acceptors they will have no ability whatsoever to resist and
will become "pushovers," complete "Caspar Milquetoasts."
fears of passivity are supported not only by conscious logic but
also by deep unconscious sources which cannot be dealt with in the
present paper. Powerful forces are aligned against acceptance, producing
in the individual extreme conflict which must be resolved if the
capacity for acceptance is ever to develop.
Compliance: Partial Surrender
are thus confronted with the question: What does produce wholehearted
acceptance? My answer is, as before, surrender. But surrender is
a step not easily taken by human beings. In recent years, because
of my special interest in the phenomenon of surrender, I have become
aware of another conscious and unconscious phenomenon, namely compliance
-- which is basically partial acceptance or partial surrender, and
which often serves as a block to surrender. The remainder of this
paper will concern itself with that reaction and how it throws light
on the handling of patients, particularly alcoholics.
needs careful definition. It means agreeing, going along, but in
no way implies enthusiastic, wholehearted assent and approval. There
is a willingness not to argue or resist but the cooperation is a
bit grudging, a little forced; one is not entirely happy about agreeing.
Compliance is, therefore, a word which portrays mixed feelings,
divided sentiments. There is a willingness to go along but at the
same time there are some inner reservations which make that willingness
somewhat thin and watery. It does not take much to overthrow this
kind of willingness. The existence of this attitude will probably
appear as neither strange nor new. Nor is it, until one begins to
see how it operates in the unconscious.
thing must be made absolutely clear: There is a world of difference
between' thinking of compliance in conscious terms and in unconscious
terms. The following discussion is focused wholly on unconscious
reactions and cannot be translated into conscious reactions until
the possible effect of the former upon the latter is appreciated.
An illustration at this point may be helpful. An alcoholic, at the
termination of a long and painful spree, decides that he has had
enough. This decision is announced loudly and vehemently to all
who will listen. His sincerity cannot be questioned. He means every
word of it. Yet he knows, and so do those who hear him, that he
will be singing another tune before many weeks have elapsed. For
the moment he seems to have accepted his alcoholism but it is only
with a skin-deep assurance. He will certainly revert to drinking.
What we see here is compliance in action. During the time when his
memory of the suffering entailed by a spree is acute and painful
he agrees to anything and everything. But deep inside, in his unconscious,
the best he can do is to comply -- which means that, when the reality
of his drinking problem becomes undeniable, he no longer argues
with incontrovertible facts The fight, so to speak, has been knocked
out of him. As time passes and the memory of his suffering weakens,
the need for compliance lessens. As the need diminishes, the half
of compliance which never really accepted begins to stir once more
and soon resumes its way. The need for accepting the illness of
alcoholism is ignored because, after all, deep inside he really
did not mean it, he had only complied. Of course consciously the
victim of all this is completely in the dark. What he gets is messages
from below which slowly bring about a change in conscious attitudes.
For a while drink was anathema but now he begins to toy with the
thought of one drink, and so on, until finally, as the noncooperative
element in compliance takes over, he has his first drink. The other
half of compliance has won out; the alcoholic is the unwitting victim
of his unconscious inclinations.
is the nature of the word to have this two-faced quality of agreeing
and then reneging. It is only by realizing the widespread ramification
of the compliance tendency that its far-flung importance can be
of the first things to recognize is the fact that the presence of
compliance blocks the capacity for true acceptance. Since compliance
is a form of acceptance, every time the individual is faced with
the need to accept something he falls back on compliance, which
serves for the moment -- the individual consciously believing that
he has accepted. But since he has no real capacity to accept, he
is soon swinging in the other direction, his seeming acceptance
a thing of the past. In other words, the best an inwardly complying
person can do toward acceptance is to comply. During treatment the
patient regularly is surprised to learn that his previous tendency
to agree in order to be agreeable was merely a lot of compliance
without any genuine capacity to accept.
unconscious split in the compliance mechanism has deep psychosomatic
reverberations. One patient, who had uncovered a wide streak of
compliance, had a dream in which he placed the two components of
compliance side by side, disclosing their utter incompatibility.
What he saw was that his wish to be cooperative and well liked while
yet maintaining his ego intact meant certain conflict, with other
people whose very existence was a threat to his own ego. He was
torn by the dilemma of being nice and pleasant or being a man and
holding his own. His next dream contained a busy ferry-boat plying
back and forth across a river. As the patient watched, it went faster
and faster and faster, the patient following its motion closely.
Soon it seemed as if he were following the flight of a tennis ball
while sitting at the net, his head turning more and more rapidly
until finally he became giddy and woke up feeling dizzy. When the
patient, and physician, saw the connection between this dream and
the dilemma of his preceding dream, he laughed and remarked, "You
know, I have been doctoring for many years and have heard all about
this psychosomatic business, but I never thought I would learn about
it from myself."
creates other problems for the individual. Since it says "yes"
on the surface and "no" inside, it contributes to the
sense of guilt. The person who says yes and feels the opposite has
an inward realization that he is a two-faced liar; this stirs up
his conscience and evokes a feeling of guilt. Compliance also adds
mightily to the problems of inferiority. The guilt reaction increases
the sense of inferiority but the compliance response engrafts it
even more. The unconscious situation can be outlined thus: Compliance
is a form of agreeing, of never standing up for one-self. When that
response is automatic, routine and unvarying, the individual gets
a feeling that he cannot stand up for himself; this inevitably augments
his inferiority problems.
Compliance and Alcoholism
is now possible to link compliance with the problem of alcoholism
and also to the theory of surrender. The link between alcoholism
and compliance has already been shown in the alcoholic's repeated
vows that he would never take another drink, vows which go by the
board because of the inner inability to do more than comply. The
presence of a strong vein of unconscious compliance in the alcoholic
can be demonstrated in other ways. Alcoholics are a notably pleasant
and agreeable group with a marked tendency to say yes when approached
directly. They claim they want to be well liked -- hence their willingness
to promise anything. Yet -- and here the other side of the compliance
reaction is manifest -- they balk at the showdown and are' ever
likely to renege on their original promises. As another illustration,
they are keen to go to a show, buy tickets in advance, and then
on the night of the performance wish they had never had the idea.
Characteristically, one man always calls up at the last moment for
a date, knowing that if he had made the engagement in advance his
present wish would later appear as a "must" which he had
to live up to. He, like so many of his kind, has to do things on
the spur of the moment. Otherwise, the contrary half gets into action
and the project is opposed and quashed. A favorite remark, "Let's
have some fun," must mean immediately: the desire evaporates
if there is any planning to be done. Often alcoholics go downtown
merely looking for fun with not a thought of a drink on their minds
-- in fact, quite "compliant" to the need for sobriety.
When they find the fun, however, the chances are that they will
be in trouble before, the night is over. Undoubtedly the initial
restlessness which stimulated the need for some fun had its origin
in the early rumblings of the noncompliance elements. Much of the
apparent dual personality of alcoholics becomes understandable if
their behavior is seen in the light of conflicting trends.
next point, the relationship between compliance and surrender, has
already been intimated in the remark that compliance blocks the
capacity to surrender. The inability to surrender may seem a small
loss until the matter is studied more thoughtfully.
an act of surrender, the individual reports a sense of unity, of
ended struggles, of no longer divided inner counsel. He knows the
meaning of inner wholeness and, what is more, he knows from immediate
experience the feeling of being wholehearted about anything. He
recognizes for the first time how insincere his previous protestations
actually were. If he is a member of Alcoholics Anonymous, he travels
around to meetings proclaiming the need for honesty -- usually,
at the start of his pilgrimage, with a certain amount of surprise
and wonder in his voice. Quite frankly, before he was able to embrace
the program, he had no idea he was a liar, dishonest in his thoughts;
but now that A.A. is making sense -- that is, he is accepting A.A.
wholeheartedly and without reservations -- he sees that previously
he had never truly accepted anything. The A.A. speaker does not
follow through to state that, formerly, all he had been doing was
complying; but if asked, he nods his head in vigorous assent, saying,
"That's exactly what I was doing." A more articulate individual,
after a little thought, added: "You know, when I think back
on it, that was all I knew how to do. I supposed that was the way
it was with everybody. I could not conceive of really giving up.
The best I could do was comply, which meant I never really wanted
to quit drinking, I can see it all now but I certainly couldn't
this speaker is reporting the loss of his compliant tendencies,
occurring,' let it be noted, when he gave up, surrendered, and thus
was able wholeheartedly to follow the A.A. program. Let it further
be noted that this new honesty arises automatically, spontaneously;
the individual does not have the slightest inkling that this development
is in prospect. It represents a deep unconscious shift in attitude
and one certainly for the better.
is now possible to see the usurping, dog-in-the-manger role of compliance.
As long as compliance is functioning, there is halfway but never
total surrender. But the halfway surrender and acceptance, serving
as it does to quell the fighting temporarily, deceives both the
individual and the onlooker, neither of whom is able to detect the
unconscious compliance in the reaction of apparent yielding. It
is only when a real surrender occurs that compliance is knocked
out of the picture, freeing the individual for a series of wholehearted
responses -- including, in the alcoholic, his acceptance of his
illness and of his need to do something constructive about it.
has been said, it would seem, to show the significance and the importance
of understanding the relationship between compliance and the ability
to surrender and accept. They are in complete opposition. As long
as the former controls reactions, there can be no wholehearted acceptance,
only the halfhearted kind which is admittedly not sufficient. Results
of real value can only come about when the compliant reactions have
been successfully dissipated.
No Easy Road to Understanding
will ask how this can be brought about. The answer, insofar as I
have been able to formulate it, is long, involved and rather hazy.
Experience shows that through psychotherapy the dominance of compliance
over the unconscious can slowly be superseded, and that through
the A.A. experience compliance can be temporarily and sometimes
permanently blotted out. There does not appear to be any easy road
to real understanding of this problem.
preceding materials can now be summed up. It was pointed out that
in an earlier article on the phenomenon of surrender, the tie of
surrender to acceptance had not been sufficiently stressed. It was
also pointed out that the concept of acceptance is freely talked
about but rarely if ever made an object of study. Some observations
regarding the nature of acceptance were reported and it was shown
to contain two possible reactions which we called wholehearted acceptance
and halfhearted. It was then demonstrated how halfheartedness and
compliance were closely allied. The nature of compliance was next
discussed and, lastly, the antipathetic relationship between compliance
on the one hand and surrender and acceptance on the other.
is a long and rather circuitous route to the point of this paper,
namely, that surrender is essential to wholehearted acceptance and
that unconscious compliance, which is a halfway surrender, can be
a vital block to genuine surrender. It was then pointed out that
alcoholics frequently show marked unconscious compliant trends which
not only help to explain some puzzling aspects of their behavior
but also account for their frequent inability to respond meaningfully
to treatment. Since the presence of these trends has been more clearly
recognized, the response of many patients to therapy has been considerably
more satisfactory. These considerations have been presented in the
hope that others also may find that a recognition of the processes
of surrender, acceptance and compliance can be a source of help
in tackling the alcoholic psychotherapeutically.
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2. Tiebout, H.M. Therapeutic
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3. Tiebout, H.M. The act of
surrender in the therapeutic process. With special reference to
alcoholism. Quart. J. Stud. Alc. 10: 48-58, 1949.
4. Grayson, M. Concept of "acceptance"
in physical rehabilitation. J. Amer. med. Ass. 145-.893-896,1951.
5. Alcoholism Treatment Digest.
Alcoholics Anonymous. III. Sociological features. Conn. Rev. Alcsm
6. Kubie, L.S. Practical and
Theoretical Aspects of Psychoanalysis. New York; International Universities