SURRENDER IN ALCOHOLISM *
M. Tiebout, M.D.
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.
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.
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.
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.
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
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.
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.3
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.
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.
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.
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.
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.
the question is, "If the infantile psyche persists
into adult life, how will its presence be manifested?"
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.
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.
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.
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.
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.
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
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
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.
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
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.
to Accept Frustration
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.
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.
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!"
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
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.
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.
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.
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.
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.
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.
the answer to the first question raised herein, namely,
what part of the alcoholic must surrender, is obvious:
it is the Ego element.
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
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
No Compromise With
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.
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.
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.
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.
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
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.
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.
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.
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
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
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.
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.
Tiebout, H.M. "The Act of Surrender in the Therapeutic
Process." With special reference to alcoholism.
Quart. J. Stud. Aic. 10: 48-58, 1949.
H.M. "Surrender Versus Compliance in Therapy".
With special reference to alcoholism. Quart. J. Stud.
Aic. 14: 58-68,1953.
S. "The Psychoanalysis of Pharmachothymia (drug
addiction). The clinical picture." Psychoanal.
Quart. 2: 1-23, 1933.