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THE
ACT OF SURRENDER IN THE THERAPEUTIC PROCESS
-
Harry
M. Tiebout, M.D.
INTRODUCTION:
The
Importance of a Positive Attitude
A
year and a half ago, I wrote a paper in which I discussed
a phenomenon which I labeled "conversion." In
that paper I broadened the concept of conversion to cover
any major switch from negative to positive thinking and
feeling irrespective of a possible religious component.
Two points stood out to me as important: first, the fact
that the positive frame of mind could appear under a given
set of circumstances without special help, psychiatric or
otherwise; and second, that the new state of mind had a
decidedly healthier tone to its thinking and feeling than
that which prevailed when the negative tone was uppermost.
Without saying so, I then believed that the positive frame
of mind could become a legitimate aim in therapy as, once
it was brought about, the individual's attitudes and responses
were much healthier.
While
I no longer believe that therapy is simply a matter of reaching
a positive relationship with reality, I remain convinced
that the creation of a positive attitude is one of the essential
features in a successful therapeutic program, and that any
experience that brings about such an attitude or frame of
mind deserves careful study for the light it may throw on
treatment in general. Consequently, I continued my observations
on the conversion experience and have arrived at the conclusion
that the key to an understanding of that experience may
be found in the act of surrender which, in my opinion, sets
in motion the conversion switch. My paper will therefore
consist of (1) a discussion of the act of surrender, and
(2) an endeavor to relate it to the therapeutic process
as a whole.
Before
I go ahead, it may be wise to recapitulate the contents
of my previous paper. In it I described how, with the conversion
switch, many aspects of the patient's attitudes underwent
profound and often remarkable alterations. I pointed out
how, in eight major ways, the individual switched or changed.
Rather than go through the whole list again, I can sum up
these changes briefly by saying that the person who has
achieved the positive frame of mind has lost his or her
tense, aggressive, demanding, conscience-ridden self that
feels isolated and at odds with the world and has become
a relaxed, natural, more realistic individual who can dwell
in the world on a Live and Let Live basis. The difference
in the before and after state of these people is very real
and represents, I believe, a fundamental psychic occurrence.
The
Act of Surrender
With
respect to the act of surrender, let me emphasize this point:
it is an unconscious event, not willed by the patient even
if he or she should desire to do so. It can occur only when
an individual with certain traits in his or her unconscious
mind becomes involved in a certain set of circumstances.
Then the act of surrender can be anticipated with considerable
accuracy, as I shall soon show. It cannot be defined in
direct conscious terminology but must be understood in all
its unconscious ramifications before its true inner meaning
can be glimpsed. The simplest way to picture what is involved
in the act of surrender is to present a case in which there
was a conversion experience that seemed to follow an act
of surrender..
One Man's Story
The
patient is a man in his early fifties, very successful in
business, and referred to by his associates as Napoleon
because of his autocratic methods when he was stirred up.
For years, heavy drinking to the point of frequent intoxication
was present, interfering to some extent with his efficiency,
but never to the degree that his business really suffered.
My first contact came some six or seven years ago when he
came to Blythewood to dry out. Pursuant to our policy of
trying slowly and from time to time to educate patients
about the danger of their condition, we permitted this man
to remain just for the drying out, at the same time telling
him that, in our eyes, he was headed for trouble if he continued
on his present trend. Without putting any pressure on him
and thus arousing his resistance, we placed the facts before
him and let it go.
We
continued the policy of letting him come and go pretty much
as he pleased, always, however, keeping uppermost before
him the need to do something about his drinking, and always
making it evident that we were not interested in drying
him out, but in the real problem of helping him stop his
drinking. Later on and in retrospect, the patient, in referring
to these tactics, said, "I used to like to come here;
you didn't always argue with me. I always knew just where
you stood and knew I wasn't fooling you any."
During
all this time, however, I was working on his life situation
so that ultimately it would provide the necessary dynamite
to jar him loose from his whirl of self-centeredness. Gradually,
his wife gave up her protectiveness and, before the time
of this last admission nearly two years ago, she had determined
to leave him if his drinking continued. Moreover, as a result
of some discussion with me, his business partner had decided
that he, with several key members of the firm, would tender
their resignations if the patient did not make a real effort
to mend his ways.
After
a particularly severe bout, the patient was induced again
to enter Blythewood. This time, however, I told him flatly
that he would sign himself in for thirty days or he would
go elsewhere; we were through with him running his case
once and for all. He looked startled, picked up his hat,
fiddled with it, and then put it on his head, saying, "Where's
your pen? I'll go to Hilltop where I belong," referring
to the cottage where he had dried out on previous occasions.
Within three or four days he was off the liquor and thinking
reasonably straight. He was then informed of his wife's
decision and, instead of ranting around and making it clear
where she could go, he discussed for the first time the
real hell he had put her through and really seemed regretful.
By the end of the first week, quite prepared for trouble,
the partner told him of the pending resignations if the
drinking persisted, only to be surprised and pleased with
the patient's quiet acceptance of their decision and an
acknowledgment of his own real wish to be different. He
soon joined A.A. and is now an active member of that organization
in his home community. The patient has stayed sober.
What Happened ?
Recently
in discussing his experience the man in the story explained,
"You did something to me when you made me sign that
card. I knew you meant business. I knew my wife was getting
sore and that Bill his partner was fed up,
but when you showed me you were through fooling, that was
a clincher. I knew I needed help and couldn't get out of
it myself. So I signed the card and felt better right off
for doing it. I made up my mind that I wasn't going to run
my own case any longer but was going to take orders. Then
later I talked with Chris his wife and learned
how she felt, and then Bill came along and I knew deep inside
my heart they were right. But, I didn't mind. I didn't get
angry and want to argue like I used to. I kind of surprised
myself by agreeing with them. It sure was nice not to have
to fight. I felt calmer and quieter inside and have ever
since, although I know I'm not out of the woods yet."
Here
is the story of a patient who has been through a conversion
experience and is still in the positive phase. His own account
of what happened stresses the signing of the card as the
turning point in his experience, and I am also convinced
that he is right. We can sum this man's experience up by
saying that after trying to run his own case to his own
ruination, he gave up the battle and surrendered to the
need for help, after which he entered a new state of mind
that has enabled him to remain sober.
Breaking
Down The Act Of Surrender
This
man's experience, which is not limited to alcoholics, raises
three questions:
I . What qualities were there in his nature that so long
resisted help and finally were forced to give in?
- 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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