- SURRENDER
VERSUS COMPLIANCE IN THERAPY
- WITH
SPECIAL REFERENCE TO ALCOHOLISM
- Harry
M. Tiebout, M.D.
Introduction:
SINCE
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.
Another
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.
What
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.
Most
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.
One
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.
In
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."
Understanding
Acceptance
In
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.
I
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 discussion.
The
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.
The
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.
There
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.
It
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.
Most
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
Those
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.
What
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."
Such
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
We
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.
Compliance
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.
One
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.
It
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 appreciated.
One
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.
This
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."
Compliance
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
It
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.
The
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.
After
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 then."
Obviously
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.
It
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.
Enough
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
Some
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.
The
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.
This
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.
Reference:
1.
Sillman, L.R. Chronic alcoholism. J. nerv. ment. Dis.
107: 127-149,1948.
2. Tiebout, H.M.
Therapeutic mechanisms of Alcoholics Anonymous. Amer.
J Psychiat. 100:468-473,1944.
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 3-.39--40,1952.
6. Kubie, L.S.
Practical and Theoretical Aspects of Psychoanalysis.
New York; International Universities Press; 1950.
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