Harry Tiebout, a psychiatrist, learned a great deal about A.A. and had some meaningful things to say about the A.A. program of recovery in a series of articles published in the early '50s.
The 12 Steps as Ego Deflating Devices by Doctor Harry Tiebout (circa 1953)
What does Surrender Mean?
For reasons still obscure, the program and the fellowship of AA could cause a surrender which in turn would lead to a period of no drinking. It became ever more apparent that in everyone's psyche there existed an unconquerable ego which bitterly opposed any thought of defeat. Until that ego was somehow reduced or rendered ineffective, no likelihood of surrender could be anticipated.
AA, still very much in its infancy, was celebrating a third or fourth anniversary of one of the groups. The speaker immediately preceding me told in detail of the efforts of his local group—which consisted of two men—to get him to dry up and become its third member. After several months of vain efforts on their part and repeated nose dives on his, the speaker went on to say: "Finally, I got cut down to size and have been sober ever since," a matter of some two or three years. When my turn came to speak, I used his phrase "cut down to size" as a text around which to weave my remarks. Before long, out of the corner of my eye, I became conscious of a disconcerting stare. It was coming from the previous speaker.
It was perfectly clear: He was utterly amazed that he had said anything which made sense to a psychiatrist. The incident showed that two people, one approaching the matter clinically and the other relying on his own intuitive report of what had happened to him, both came up with exactly the same observation: the need for ego reduction. It is common knowledge that a return of the full-fledged ego can happen at any time. Years of sobriety are no insurance against its resurgence. No AA's, regardless of their veteran status, can ever relax their guard against a reviving ego.
The function of surrender in AA is now clear. It produces that stopping by causing the individual to say, "I quit. I give up on my headstrong ways. I've learned my lesson." Very often for the first time in that individual's adult career, he has encountered the necessary discipline that halts him in his headlong pace. Actually, he is lucky to have within him the capacity to surrender. It is that which differentiates him from the wild animals. And this happens because we can surrender and truly feel, "Thy will, not mine, be done."
Unfortunately, that ego will return unless the individual learns to accept a disciplined way of life, which means the tendency toward ego comeback is permanently checked.
This is not news to AA members. They have learned that a single surrender is not enough. Under the wise leadership of the AA "founding fathers" the need for continued endeavor to maintain that miracle has been steadily stressed. The Twelve Steps urge repeated inventories, not just one, and the Twelfth Step is in itself a routine reminder that one must work at preserving sobriety. Moreover, it is referred to as Twelfth Step work—which is exactly what it is. By that time, the miracle is for the other person.
-Dr. Harry M. Tiebout, M.D.
SURRENDER VERSUS COMPLIANCE IN THERAPY
WITH SPECIAL REFERENCE TO ALCOHOLISM
Harry M. Tiebout, M.D.
[A psychiatrist wrote this to his colleagues circa 1952.]
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 article 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 acceptance" is widely recognized although often only by indirection. Sometimes the necessity for acceptance is bluntly stated, as in Grayson's 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 Alcoholism, 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 accepted." Certainly the need for acceptance is unequivocally stated. And the following statement is from Kubie's 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 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.
This article found at www.silkworth.net in August of 2006
DIRECT TREATMENT OF A SYMPTOM
Harry M. Tiebout, M.D.
* The Direct Treatment of a Symptom
* The Individual 's Reaction
* In Conclusion
Therapists with alcoholics have a twofold task. They must treat the disease alcoholism and they must treat the person afflicted with it. Psychiatrists have tended to bypass the disease and treat the individual, but again and again under this approach the patient has proved recalcitrant to all therapeutic endeavor. As a result, alcoholics have been considered very unlikely prospects for therapy of any sort.
The difficulty, of course, was in the main symptom of the disease: the fact that the patient would get drunk, which repeatedly nullified all attempts at assistance. As a consequence, work with the person who drank was stymied by the fact that he drank. In the face of this dilemma, therapists have thrown up their hands in dismay and have turned to greener pastures.
The mistake we made was our failure to recognize that the task was twofold. In rather doctrinaire fashion, we persisted in treating the alcoholism as a symptom which would be cured or arrested if its causes could be favorably altered. The drinking was something to be put up with as best as one could while more fundamental matters were being studied. The result of this procedure was that very few alcoholics were helped. The drinking continued and the symptom remained untouched.
In other medical treatment this concept of getting at causes is not considered sufficient. No one ignores a cancer, for instance, while searching for its origins. It is cut into or treated with x-ray or radium in the hope that the growth will either be removed or will stop advancing. Once the cancer is detected, the question of etiology is academic.
Exactly the same thinking applies to the treatment of alcoholism. It is a symptom which becomes dangerous in itself. Until it has been effectively stopped, little of real help can be offered. Alcoholics Anonymous stresses the danger of the first drink and Antabus simply stops the ability to take it. Both attack the symptom and both have recorded a substantial measure of success.
The advent of these new tools not only has given us a means of treating the symptom directly, it has focused attention upon a factor whose importance was hitherto insufficiently appreciated. That factor is the significance of the first drink and what it represents to the psyche of the drinker.
Such focusing has two results. First, it directs thought toward the problem of stopping, that is, of not taking the first drink. Second, it leads to a new approach to the understanding of what must transpire in therapy if the alcoholic is to remain sober.
This paper will discuss both those points, namely, the direct treatment of a symptom and the individual's reaction to such a direct approach.
1. The Direct Treatment of a Symptom
The direct treatment of a symptom is and has been the subject of much controversy. A review of the past is necessary to set the controversy in perspective.
Roughly, we can divide the past into the time before Freud and the time after. Prior to his epoch-making revelations about the unconscious and its controlling influence over behavior, all treatment perforce was direct. If a person was acting in a disturbed manner, he was placed in an institution. If he broke the law, he was imprisoned. A naughty child was spanked. Treatment was aimed at behavior and was essentially disciplinary, the big stick. For the most part, it was applied blindly, woodenly, as the only known means of combating the behaviors being encountered.
Then through Freud's work conduct was recognized as an outgrowth of unconscious functioning, and, before long, the field of psychiatry embraced as one of its major tenets the principle that all behavior sprang from the unconscious, and that therapy, when necessary, had as its goal the determination and elimination of the pathology behind upsetting behavior. The validity of such a shift was indisputable. Since former blind methods could be replaced by much more precise measures, direct treatment of a symptom lost all caste. The day of scientific therapy had arrived.
Strangely, though, a new kind of woodenness then appeared. Anything prior to Freud was out, to be viewed dimly and with alarm.
I, too, was an early believer and expounder of the theory that all behavior was symptomatic. 1, as much as anyone, searched energetically for unconscious forces to help alcoholics, and 1, too, fell flat on my face. It just did not work.
Then, as related elsewhere, Alcoholics Anonymous came along and I saw it succeed not only in arresting the drinking, but in helping a person to mature. All my' pet assumptions were knocked into a cocked hat (and it took me many a year to realize the full import of what I had seen happen to my patient as she made the grade through Alcoholics Anonymous).
Unconcerned with causes and not bewitched by dogma, the A.A. program was designed to get the individual to stop drinking, and really nothing else. The aspects of personality inventory and of spiritual growth were useful in A.A. chiefly because they tended to insure the individual's capacity for not taking the first drink. They had nothing to do with causation. The whole program was direct treatment of a symptom.
When this dawned, most of my previous thinking on getting at causes had to be shelved, placed to one side, so that this new fact could be studied open-mindedly.
Antabus came along to confirm the soundness of tackling the symptom, and the need to find an explanation for that heretical fact became more imperative. Finally, the significance of the first drink became apparent, and then the corollary fact that the individual must stop taking even "one".
With the recognition that total abstinence was the goal of both methods, pre-Freud direct management of symptoms took on a different significance. This, too, was to be seen as an effort to change the individual's behavior either by putting him in an institution for the mentally ill, or by jailing him, or by inflicting punishment. To be sure, these techniques might be applied without much precision and perhaps too often, but they nevertheless effectively stopped the symptoms, and perhaps that, in and of itself, was not only useful but necessary. Certainly, insofar as helping the alcoholic was concerned, the direct method worked. In my eyes, such treatment had been reestablished as a sound clinical procedure and a valid tool. Hopefully, it could be applied with more skill and finesse now that the Freudian insights were available, but to dismiss it totally would be inexcusable rigidity and evidence of very unscientific dogmatism.
2. The Individual's Reaction
With the acceptance of the validity of the direct approach, the treatment of the alcoholic individual takes on a new dimension. Instead of determining causes, the therapeutic aim is directed toward helping the patient to utilize available techniques, A.A., Antabus, and/or psychiatry, to aid in his battle to stop drinking. The therapist, so to speak, has his prescription. His job is to sell it to the patient.
At this point, we run into a fundamental issue. Most patients take their doctor's prescription. Very few alcoholics respond that simply. As a result, the doctor has the task of inducing the patient to take the medicine offered, and it is ' here that we must consider the nature of the alcoholic, the individual who balks at taking the remedy suggested. This brings us to our second point, namely, the nature of the individual who so stubbornly refuses to stop drinking.
More accurately, the topic of this section is the nature of the individual's reaction to direct treatment. The physician for the alcoholic, regardless of his personal inclinations or his theoretical convictions about the function of the therapist, is placed in the role of someone who is trying to stop the patient's drinking. And although the alcoholic may desperately want help consciously, this does not necessarily overcome his unconscious resistance to such authoritative handling. The therapist inevitably acts as a depriving person.
To try to avoid that role is silly, misleading, and a very poor example. Silly because it denies the obvious, and misleading because it is attempting to sugar-coat an unpalatable truth. A poor example, because the therapist is denying realty-behavior at which the patient is already expert. Fundamental respect can never be established on such a false basis.
As a consequence, the therapist must not fight the patient's identification of him as a depriving figure. There is no loophole from that position. The only hope is to help the patient learn to accept deprivation and therefore reach a state in which, as a mature person, he will realize that all his wants and demands cannot be satisfied and that there are some things he cannot have.
The therapist must not sidestep his depriving role; instead he must freely acknowledge it and let therapy begin right there. To do so clears the atmosphere and paves the way for establishing a sound working relationship.
The following clinical material shows not only these new tactics which must be adopted but also the patient's reaction to them. The patient is a man in his middle thirties who, after six years of stumbling success with A.A., decided to try psychiatry because, to quote him, "I'm almost as bad as when I started with A.A. I've got to do something." It was clear that he was strongly motivated, and consequently he was accepted for therapy. The patient was told that his immediate problem was drinking and that it could ruin his chances of profiting from assistance. There would be no insistence on total sobriety, but there would be the following stipulation: if in my opinion his drinking was interfering with therapy, I could require him to take Antabus, which would insure sobriety over a period long enough to settle whether or not he could profit from treatment, so that later on he might be able to get along without the medication.
The patient promptly accepted this proviso, saying it made complete sense to him. On the surface he seemed completely receptive. He remarked in confirmation, "I know when I'm drinking it would be a waste of your time to try to help me; I just wouldn't get a thing." No trace of protest could be observed and I am sure none was felt. In fact the patient seemed to welcome a forthright statement of what lay before him. He at least knew where he stood.
Also during the first interview the patient was asked to record his dreams. At the next session, he reported the following:
I . Irritated and teased pet bird.
2. Vaguely remember X.Y. Think was drinking with him.
3. Accidentally pulled all the tail feathers out of pet bird.
The first dream he then expanded, adding, "the pet bird was mine and it was caged and visibly annoyed." Little imagination is required to read the unconscious thoughts at this point. Birds stand for freedom, i.e., "free as a bird." A caged bird is not free and, therefore, is "irritated" and "visibly annoyed," feelings which every freedom loving person would show if caged. And no one would deny that a caged bird was a stopped one. The first dream pinpoints the fact that therapy was designed to stop drinking.
The next dream finds the patient drinking with a boon companion, a person he was prone to turn to after sobriety had begun to pall. In this dream, quite literally, the bird becomes the patient, escaped from the cage, and the cage which has been escaped from is the knowledge about the danger of the first drink.
The report of the third dream also received interesting amplification. The patient volunteered that the bird flew by him and that, as it did, he grabbed at it and "pulled every last tail feather off, and all that was left was a bare little butt end." Again the message of the dream is clear. The free bird, again in the picture, presents its butt end to the world, an unequivocal gesture of defiance.
The story that these dreams have to tell seems unambiguous. The patient is coming for help about his alcoholism, which he knows can be treated only by his not taking the first drink. The symbol of the caged and annoyed bird is a brilliant condensation of three aspects of his own self as it reacts to his new situation. First, the bird is a symbol of freedom; second, it represents the sense of restriction which is the cage; and third, it shows the "visible annoyance" and "frustration" which the bird feels as it is confronted by the fact that it is not at liberty. In the second dream the patient is no longer stopped. The third dream reveals this clearly as a defiant response to the therapy.
No doubt other interpretations with which I would have no dispute may be offered for these dreams. The point is, however, that the theme of stopping is also unmistakably present in the patient's unconscious which shows a completely understandable reaction to the idea of being stopped and frustrated.
Despite the note of defiance on which they end, these dreams actually started therapy off on a good sound basis. First and foremost, the patient learned that he had unconscious attitudes. Although he protested vigorously that he had no feeling of defiance toward either the doctor or the treatment, he knew that on many occasions he had shown and felt just such inner attitudes. He could now appreciate that defiance was in his system even contrary to his desires and in spite of his failure to be aware of it. From now on, he would have to recognize the presence of an inner-feeling life which psychiatry might help him reach and learn to handle better. Any lurking misgivings regarding psychiatry were to some extent lessened.
In addition, the patient had to face his inner demand to be free and that inside he balked at any curbing. Recognition of this fact was comforting, for it gave him a belief that further insights might be forthcoming and that the possibility of help might exist.
Still a third advantage to his start sprang from the discussion of defiance and the insistence upon freedom. The patient's immediate reaction was to scold himself for acting that way and to feel guilty that he had allowed such attitudes to persist. When he could realize that these forces were deep-seated and real, he could drop his punitive reactions of guilt and focus upon the more important issue of how he could rid himself of his tendency to defy and his desire to cherish his freedom at the expense of his sanity. The burden of guilt could be lifted and with it the tensions which contributed so much to his drinking. Therapy was obviously under way.
As this example shows, the patient's negative responses to the direct approach need not be feared, because they can be used to suggest to the patient the idea that their very presence, while easy to comprehend, is an indication of where his trouble lies.
Let me summarize briefly the points made so far. First, the treatment of the alcoholic must initially focus on his drinking. To say this is not to ignore the person or his body. They must always receive attention regardless of the ailment. However, the primary emphasis on the control of the drinking is essential if treatment is to succeed. Second, the patient's reactions to direct treatment not only do not undermine the therapeutic relationship, but may actually enhance it. As those reactions are discovered and faced, a solid foundation for a good therapeutic experience is created. To act otherwise can only result in confusion.
Before closing, a few comments are in order. First, the importance of timing cannot be overemphasized. The patient who reacted well to an active technique was ripe for the plucking. He wanted to quit and had been trying to for several years. He was a perfect candidate for the direct approach.
Actually he was at the end of a very long trail. It began with his drinking blithely and unconcernedly. It was nearing its conclusion hopefully with his' earnest desire not to take the first drink. Space limitations prevent my identifying and discussing all the various sections of that trail. Suffice it to say that he could now seek help with no conscious reservations.
Actually, such direct methods can be applied only when the patient is in a receptive frame of mind. A whole paper could be devoted to a discussion of how the patient's defenses must weaken so that he is willing and able to turn for help. To be direct when it is certain that such an approach will bounce off a shell proof exterior is obviously bad timing. It wastes ammunition which could later be effective. Other measures must be used first in an effort to soften these defenses. The direct approach can be ventured only when the patient is sufficiently vulnerable to make its success likely.
Secondly, what should be the doctor's attitude toward the patient's drinking during therapy? In the "platform" placed before the patient, I included a "wait-and-see plank." This I did for three reasons. In the first place, I did not want to give the impression of acting before I, too, was in possession of the facts about the drinking pattern. If it continued and caused difficulty, here was concrete evidence on which to base a decision about Antabus.
A second reason for a tentative approach was the hope that the usual concept of the disciplinarian as dogmatic and arbitrary could be undercut if I adopted a less adamant program. If later on it became necessary to crack down, the patient would not be justified in claiming that the new tactics were evidence of a hopelessly closed mind toward drinking.
One patient tried to puncture that stratagem by ferreting out the reason for the delaying tactics and accusing me of waiting until he had hanged himself. Since that was true, I admitted the charge and went on from there. I told him he still had to look at the fact that he had hanged himself. The focus was kept on the drinking problem; that he still had to face.
I The third reason for adopting a non-dogmatic policy was to place myself in the position of being able to discuss the problem of the drinking with the patient directly. Generally with such delaying tactics the patient makes an extra effort at control and as a rule succeeds for a while, after which the condition usually takes its course and the patient gets drunk. At that point, it is possible to review with him his hopes of controlling intake and his consequent disillusionment and renewed awareness of his drinking problem. In this manner, the patient's feeling of need for help is revived and motivation is thereby strengthened. Therapy can thus proceed on a firmer footing.
My third comment opens up a vast area. It has to do with the significance of the direct approach in treating alcoholism or any other condition. The full import of this question can only be hinted, but an effort must be made to point out the far-reaching bearing of the direct approach with its stopping-attribute.
One way to discuss the significance of being direct is to ask the question, "How much of the handling of people is of the direct or stopping-variety?" To my mind the answer is, "Far more than most of us realize or have ever suspected." As already pointed out, incarceration is a form of direct treatment. It still has its values in certain situations. Its more respectable counterpart, the trip or vacation or residence in a sanitarium, serves much the same purpose, namely that of lifting the individual out of the whirling currents of his everyday existence and depositing him in a setting where he can slow down and stop. One can also wonder at the new therapies. Certainly shock gives the body and mind an awful beating which in some obscure fashion perhaps may serve a disciplinary, hence stopping, function. Again the sleep therapies put the patient in an enforced rest and, for the time being, effectively stop him.
Children are told to "cut that out" and know that they are being stopped. While the routine use of such a phrase is severely to be frowned upon, the teacher or person in authority who cannot use that phrase when necessary is badly handicapped in the performance of his job.
Youngsters in the nursery school or kindergarten reveal the need for stopping. Good practice has periods of free play interspersed with times when the children sit and draw or paint or listen to stories or have rest periods. These quiet times are designed to slow the youngsters down. On occasion, particularly with a new and inexperienced teacher, the class gets too keyed up and, since this kind of excitement is infectious, the class goes "wild." It then must be dismissed for the day. The firm hand of the good teacher was lacking and the children got out of control.
Certainly a lot of preventive mental hygiene is of this same stopping variety. -- We sleep, we play, or take holidays to provide a break or a cut in the monotony of continued plugging. We seek avocation interests to change our life pattern. Part of the undoubted value of church attendance arises from the peace and quiet of the religious ceremonies and the soothing atmosphere of the church surroundings.
The list is long and could be expanded almost indefinitely. Most rule-of-thumb therapy is of this sort. To rule directness out because it is not scientific may hamstring our effectiveness as people. Neither was surgery, which is a "cut-it-out" technique, too scientific at the outset, but its value was never doubted, and as it went on, the skill in its application advanced until its use is now routine, always, of course, where it is indicated. Yet, obviously, surgery only tackles a symptom, a resultant of infection or tissue change. The surgeon's concern with cause does not hinder his taking appropriate action.
Similarly the psychiatrist should not hesitate to cut in. He should not be just a butcher with a knife, but perhaps more than is the custom, the psychiatrist should assume responsibility for things happening to his patient. He must not fall back on the excuse that his patient was uncooperative or poorly motivated; he must do his bit to shift attitudes so that cooperation is obtained. Sometimes a little discipline, artfully applied, works wonders. To discard it entirely may deprive one of a very necessary therapeutic resource.
In Conclusion
Let me repeat what I initially stated, namely that the treatment of the alcoholic must include direct treatment of the symptom. This does not exclude the value of deep insights; it merely rechannels them into an understanding of why the patient blocks from taking the remedy prescribed. The study of causation is shifted from origins to the causes which obstruct the therapy. As they are uncovered and resolved, not only is sobriety attained but the inner changes necessary to a sober existence can be and are developed.
The truth of this last statement I can only vouch for at this time. In a later paper I shall try to prove the validity of this claim. In the meantime, this paper will have served its purpose if it has alerted the reader to the dangers inherent in the rigid application of the concept of symptomatic behavior and has tempered his antagonisms to disciplinary measures when properly applied. If it has, the effort to prepare it has been worth while.
Found at www.silkworth.net in July of 2006