- SURRENDER VERSUS COMPLIANCE IN THERAPY
- WITH SPECIAL REFERENCE TO ALCOHOLISM
- Harry M. Tiebout, M.D.
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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 acceptance is widely recognized although often only by indirection. Sometimes the necessity for acceptance is bluntly stated, as in Grayson's (4) 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 (5), 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 (6) 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.
Tiebout, H.M. Therapeutic mechanisms of Alcoholics Anonymous. Amer. J Psychiat. 100:468-473,1944.
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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