The Act of Surrender in the Therapeutic Process – Harry M. Tiebout, M.D.

The Importance of a Positive Attitude

A year and a half ago, I wrote a paper in which I discussed a phenomenon which I labelled “conversion.” In that paper I broadened the concept of conversion to cover any major switch from negative to positive thinking and feeling irrespective of a possible religious component. Two points stood out to me as important: first, the fact that the positive frame of mind could appear under a given set of circumstances without special help, psychiatric or otherwise; and second, that the new state of mind had a decidedly healthier tone to its thinking and feeling than that which prevailed when the negative tone was uppermost. Without saying so, I then believed that the positive frame of mind could become a legitimate aim in therapy as, once it was brought about, the individual’s attitudes and responses were much healthier.

While I no longer believe that therapy is simply a matter of reaching a positive relationship with reality, I remain convinced that the creation of a positive attitude is one of the essential features in a successful therapeutic program, and that any experience that brings about such an attitude or frame of mind deserves careful study for the light it may throw on treatment in general. Consequently, I continued my observations on the conversion experience and have arrived at the conclusion that the key to an understanding of that experience may be found in the act of surrender which, in my opinion, sets in motion the conversion switch. My paper will therefore consist of (1) a discussion of the act of surrender, and (2) an endeavour to relate it to the therapeutic process as a whole.

Before I go ahead, it may be wise to recapitulate the contents of my previous paper. In it I described how, with the conversion switch, many aspects of the patient’s attitudes underwent profound and often remarkable alterations. I pointed out how, in eight major ways, the individual switched or changed. Rather than go through the whole list again, I can sum up these changes briefly by saying that the person who has achieved the positive frame of mind has lost his or her tense, aggressive, demanding, conscience-ridden self that feels isolated and at odds with the world and has become a relaxed, natural, more realistic individual who can dwell in the world on a Live and Let Live basis. The difference in the before and after state of these people is very real and represents, I believe, a fundamental psychic occurrence.

The Act of Surrender

With respect to the act of surrender let me emphasize this point: it is an unconscious event, not willed by the patient even if he or she should desire to do so. It can occur only when an individual with certain traits in his or her unconscious mind becomes involved in a certain set of circumstances. Then the act of surrender can be anticipated with considerable accuracy, as I shall soon show. It cannot be defined in direct conscious terminology but must be understood in all its unconscious ramifications before its true inner meaning can be glimpsed. The simplest way to picture what is involved in the act of surrender is to present a case in which there was a conversion experience that seemed to follow an act of surrender.

One Man’s Story

The patient is a man in his early fifties, very successful in business, and referred to by his associates as Napoleon because of his autocratic methods when he was stirred up. For years, heavy drinking to the point of frequent intoxication was present, interfering to some extent with his efficiency, but never to the degree that his business really suffered. My first contact came some six or seven years ago when he came to Blythewood to dry out. Pursuant to our policy of trying slowly and from time to time to educate patients about the danger of their condition, we permitted this man to remain just for the drying out, at the same time telling him that, in our eyes, he was headed for trouble if he continued on his present trend. Without putting any pressure on him and thus arousing his resistance, we placed the facts before him and let it go. We continued the policy of letting him come and go pretty much as he pleased, always, however, keeping uppermost before him the need to do something about his drinking, and always making it evident that we were not interested in drying him out, but in the real problem of helping him stop his drinking. Later on and in retrospect, the patient, in referring to these tactics, said, “I used to like to come here; you didn’t always argue with me. I always knew just where you stood and knew I wasn’t fooling you any.” During all this time, however, I was working on his life situation so that ultimately it would provide the necessary dynamite to jar him loose from his whirl of self-centeredness. Gradually, his wife gave up her protectiveness and, before the time of this last admission nearly two years ago, she had determined to leave him if his drinking continued. Moreover, as a result of some discussion with me, his business partner had decided that he, with several key members of the firm, would tender their resignations if the patient did not make a real effort to mend his ways. After a particularly severe bout, the patient was induced again to enter Blythewood. This time, however, I told him flatly that he would sign himself in for thirty days or he would go elsewhere; we were through with him running his case once and for all. He looked startled, picked up his hat, fiddled with it, and then put it on his head, saying, “Where’s your pen? I’ll go to Hilltop where I belong,” referring to the cottage where he had dried out on previous occasions. Within three or four days he was off the liquor and thinking reasonably straight. He was then informed of his wife’s decision and, instead of ranting around and making it clear where she could go, he discussed for the first time the real hell he had put her through and really seemed regretful. By the end of the first week, quite prepared for trouble, the partner told him of the pending resignations if the drinking persisted, only to be surprised and pleased with the patient’s quiet acceptance of their decision and an acknowledgment of his own real wish to be different. He soon joined A.A. and is now an active member of that organization in his home community. The patient has stayed sober. What Happened? Recently in discussing his experience the man in the story explained, “You did something to me when you made me sign that card. I knew you meant business. I knew my wife was getting sore and that Bill his partner was fed up, but when you showed me you were through fooling, that was a clincher. I knew I needed help and couldn’t get out of it myself. So I signed the card and felt better right off for doing it. I made up my mind that I wasn’t going to run my own case any longer but was going to take orders. Then later I talked with Chris his wife and learned how she felt, and then Bill came along and I knew deep inside my heart they were right. But, I didn’t mind. I didn’t get angry and want to argue like I used to. I kind of surprised myself by agreeing with them. It sure was nice not to have to fight. I felt calmer and quieter inside and have ever since, although I know I’m not out of the woods yet.” Here is the story of a patient who has been through a conversion experience and is still in the positive phase. His own account of what happened stresses the signing of the card as the turning point in his experience, and I am also convinced that he is right. We can sum this man’s experience up by saying that after trying to run his own case to his own ruination, he gave up the battle and surrendered to the need for help, after which he entered a new state of mind that has enabled him to remain sober.

Breaking Down The Act Of Surrender

This man’s experience, which is not limited to alcoholics, raises three questions:

1. What qualities were there in his nature that so long resisted help and finally were forced to give in?
2. What were the circumstances that brought about the final act of surrender?
3. Why does a positive phase follow the surrender experience?

My answers to these questions are derived primarily from my studies of alcoholics, but not entirely, as I have witnessed surrender with a typical aftermath in at least four cases among the students at Sarah Lawrence. I hope through my discussion in reply to these questions not only to define the act of surrender, but also to give you some feeling for it as a psychological entity or event.

Internal Qualities

To turn then to the first question, “What are the qualities in a patient’s nature that make him or her put up such a battle before finally surrendering?” In the alcoholic, my observations have led me to see that the two qualities that Sillman selected as characteristic — defiant individuality and grandiosity — may very well explain that the alcoholic is typically resistant to the point of being unreasonable and stubborn about seeking help or being able to accept help even when he or she seeks it. Defiant individuality and grandiosity operate in the unconscious layers of the mind and their influence must be understood if one is to see what probably goes on at the time of surrender.

Defiance

Defiance may be defined as a quality that permits an individual to snap his fingers in the face of reality and live on unperturbed. It has two special values for handling life situations. In the first place, defiance, certainly with alcoholics, is a surprisingly effective tool for managing anxiety or reality, both of which are so often a source of anxiety. If you defy a fact and say it is not so and can succeed in doing so unconsciously, you can drink to the day of your death, forever denying the imminence of that fate. As one patient phrased it, “My defiance was a cloak of armour.” And so it was a most trustworthy shield against the truth and all its pressures. In the second place, defiance masquerades as a very real and reliable source of inner strength and self-confidence, since it says in essence, nothing can happen to me because I can and do defy it. With people who meet reality on this basis, life is always a battle with the spoils going to the strong. Much can be said in favour of defiance as a method of meeting life. It is the main resource of the chin-up and unafraid type of adjustment and, as a temporary measure; it helps people over many rough spots. Grandiosity Grandiosity, the second quality noted by Sillman, permeates widely throughout the reactions of the alcoholic. Differing from defiance — which seems almost uniquely structuralized in the psyche of the alcoholic — grandiosity springs from the persisting infantile ego. As in other neurotic states, grandiosity characteristically fills a person with feelings of omnipotence, demands for direct gratification of wishes, and a proneness to interpret frustration as evidence of rejection and lack of love. The effect of this persistence in the alcoholic is not a bit different from the effect of any other neurotic. Perhaps in the alcoholic the typical arrogance and sense of superior worth are kept nearer the surface by the associated defiance that feeds the childish ego constantly by its succession of victories. By and large, however, there is nothing in the alcoholic’s grandiosity that distinguishes him or her from the neurotic, whose infantile ego survives to become a significant factor in adult life; it is part of the typical egocentricity of that group, and its presence is confirmed by any careful study of them.

DEFIANCE AND GRANDIOSITY AT WORK IN THE ALCOHOLIC

We are now in a position to discuss how these qualities operate in alcoholics. On the one side, the defiance says, It is not true that I can’t manage drinking. On the other side, the facts speak loudly and with increasing insistence to the contrary. Again, on the one side, grandiosity claims, there is nothing I cannot master and control, and on the other side, the facts demonstrate unmistakably the opposite. The dilemma of the alcoholic is now obvious: the unconscious mind rejects — through its capacity for defiance and grandiosity — what the conscious mind perceives. Hence, realistically, the individual is frightened by his or her drinking and at the same time is prevented from doing anything about It by the unconscious activity that can and does ignore or override the conscious mind. Let us see how this clash between the conscious and unconscious response manifests itself in the clinical setting. A stimulus from reality, such as recognition of the downhill pattern of the drinking, impinges upon the conscious mind and creates acute anxiety which, for the moment, dominates the conscious processes and is recorded as worry, distress, fear, and concern. The patient, in this state, is fired with a desire to quit and eagerly grabs at any kind of help. He or she is in a state of crisis and suffering. In the meantime, however, the stimulus of reality is hitting the unconscious layers of the mind and is stirring up the reactions of defiance and grandiosity. Since, characteristically, it takes a certain amount of time before the unconscious responses are sufficiently mobilized to influence conscious mental activity, there is always an appreciable lag before the conscious mind evidences signs of the underlying unconscious activity. Then slowly and gradually these attitudes supervene. Patients express less concern about their drinking, complain that they were rushed into seeking help, that they’re no worse than anybody else, and that the worry of others is silly and a gratuitous invasion of their rights. Finally, the memory of their own acute period of anxiety is swallowed up by the defiance and grandiosity. Thus the patient loses the effectiveness of the anxiety as a stimulus to create suffering and a desire for change. This cycle will go on repeating itself as long as the defiance and the grandiosity continue to function with unimpaired vigour.

EXTERNAL CIRCUMSTANCES

We now come to the second question: “What were the circumstances that made that patient give in and sign that card?” Let me review them for you briefly. He had been drinking for years, and he knew his drinking was getting worse in the eyes of family and friends. However, he knew that his condition had reached the point where both his wife and his business associates were leaving him and thereby withdrawing their support and protection. He was threatened with the task of managing himself and his condition entirely on his own, so he sought my help and protection to dry him out and thus allow him once more to resume his role of successful defiance and grandiosity. This time, however, I refused to follow my previous role. I had established myself as not arbitrary, not willing to fit what he needed. But when I asked him to sign the card, I knew that his other circumstances were different and that I represented the one way for him. When I told him, in essence, that he was not running his case or me anymore, his last prop was thus removed. He had no place to take his defiance and his grandiosity; nor could he become defiant with me: someone who stood for his last bit of hope and who actually had become established as an ultimate resource when he was in difficulty. So he staged a brief inward debate and then signed the card. In short, the patient signed the card, first, when all support was withdrawn; second, when he could not in anger defy those who withdrew their support because he knew they had been patient and long-suffering; and third, when he found himself desperately needing help and had no grandiose ideas left about being able to drink like non-alcoholics. He had neither unconscious defiance nor grandiosity left to fight with. He was licked, and he both knew it and felt it. The Positive Phase We now reaches the third question, “Why does the positive phase follow?” Here, we frankly reach speculation. I know the positive phase comes, but not just why. Surrender means cessation of a fight, and cessation of a fight seems logically to be followed by internal peace and quiet. That point seems fairly obvious, but why the whole feeling tone switches from negative to positive without all the concomitant changes is not so clear. Nevertheless, despite my inability to explain the phenomenon, there is no question that the changes do take place and that they may be initiated by an act of surrender.

THE DIFFERENCE BETWEEN SUBMISSION AND SURRENDER

One fact must be kept in mind, namely, the need to distinguish between submission and surrender. In submission, an individual accepts reality consciously, but not unconsciously. He or she accepts as a practical fact that he or she cannot at that moment lick reality, but lurking in the unconscious is the feeling, there’ll come a day, which implies no real acceptance and demonstrates conclusively that the struggle is still on. With submission, which at best is a superficial yielding, tension continues.

When an individual surrenders, the ability to accept reality functions on the unconscious level and there is no residual of battle; relaxation with freedom from strain and conflict ensues. In fact, it is perfectly possible to ascertain how much acceptance of reality is on the unconscious level by the degree of relaxation that develops. The greater the relaxation, the greater the inner acceptance of reality. We can now be more precise in our definition of an act of surrender. It is to be viewed as a moment when the unconscious forces of defiance and grandiosity actually cease to function effectively. When that happens, the individual is wide open to reality; he or she can listen and learn without conflict and fighting back. He or she is receptive to life, not antagonistic. The person senses a feeling of relatedness and at-oneness that becomes the source of an inner peace and serenity, the possession of which frees the individual from the compulsion to drink. In other words, an act of surrender is an occasion wherein the individual no longer fights life, but accepts it. Having defined an act of surrender as a moment of accepting reality on the unconscious level, it is now possible to define the emotional state of surrender as a state in which there is a persisting capacity to accept reality. In this definition, the capacity to accept reality must not be conceived of in a passive sense, but in the active sense of reality being a place where one can live and function as a person acknowledging one’s responsibilities and feeling free to make that reality more liveable for oneself and others. There is no sense of “must”; nor is there any sense of fatalism. With true unconscious surrender, the acceptance of reality means the individual can work in it and with it. The state of surrender is really positive and creative. To sum up, my observations have led me to conclude that an act of surrender is inevitably followed by a state of surrender that is actually the positive state in the conversion picture. Because of the two always being associated, I believe they represent a single phenomenon to which I attach the term “surrender reaction.“

RELATING THE ACT OF SURRENDER TO THE THERAPEUTIC PROCESS

Having at last made as clear as I could my use of the term “surrender,” I must now try to relate that concept to the therapeutic process. While, a recognition of the dynamic force of the event has proven enlightening in many directions, it has been particularly helpful in understanding the fluctuations in moods of patients and in certain aspects of therapy. The following patient’s problem took on meaning for me when I grasped the fact that he had experienced an act of surrender at the time he attended his first A.A. meeting. A man in his middle thirties, he tells his story this way: “I was licked. I’d tried everything, and nothing had worked. My wife was packing to leave me; my job was going to blow up in my face. I was desperate when I went to my first A.A. meeting. When I got there, something happened. I don’t know to this day a year later what it was, but I took a look at the men and women there and knew they had something I needed, so I said to myself, I’ll listen to what they have to tell me. From that time on, things have been different. I go to meetings, work with other drunks, and study all I can about alcoholism. I know I’m an alcoholic, and never let that fact escape me.” Now, if you stop and review this man’s account, you will note the statement, “I’ll listen to what they have to tell me.” In that comment to himself, the patient initiated his act of surrender. There was no lip-service in his willingness to listen; he really wanted help. There was no defiance or grandiosity available at the moment to dilute his listening. He was accepting, without inner reservation or conflict, the reality of his condition and the need for help. And, significantly enough, at this point he goes on to say, “From that time on, things have been different.” Subsequent events clearly indicate that this man did experience the typical change I have been calling conversion, and from that time on “things were different.” His wife, commenting on this change, said feelingly, “It’s the most remarkable thing I ever could imagine. The only trouble is that I still have to keep my fingers crossed because it still doesn’t make any sense to me.” The patient, however, consulted me because he “didn’t like the way things were going.” By that, he meant that he was finding himself cranky at home and irritable in business, signs that his A.A. experience had taught him were ominous. When I asked him why he gave up drinking, he replied that he had made up his mind to quit so he, did, although he had to admit that A.A. was helpful. A little surprised at this simple assertion and doubting it somewhat, I plied him with further questions and got the real story, which showed to me that he had a typical surrender experience, followed by a typical positive aftermath. But I also saw that the change did not last and that, after several months in which the patient had lived in a state of surrender, he slowly reverted to his former attitudes and ways of feeling. In other words, the surrender reaction did not fix itself into his personality and thus allowed the return of his previous state of mind. Differing acts of surrender The fate of the surrender reaction is in itself an interesting study. With some, the surrender experience is the start of genuine growth and maturation. With others, the surrender phase is the only one ever reached, so that they never lose the need to attend meetings and to follow the program assiduously, apparently relying on the constant reminders in their daily existence to supply the necessary impetus to the surrender feeling, at least insofar as alcohol is concerned. For a few, there seems to occur a phenomenon of what might be called selective surrender. After the effects of the initial surrender experience has worn away, the individual returns to pretty much the same person he or she was before, except for the fact that the person doesn’t drink. His surrender is not to life as a person, but to alcohol as an alcoholic. Many other differing aftermaths undoubtedly occur, but a study of any or all of them would, I am sure, disclose the same basic fact: the surrender experience is followed by a phase of positive thinking and feeling that undergoes various vicissitudes before it becomes established in some form or other in the psyche — or it is lost completely, becoming merely a memory and a mirage.

RECOGNIZING THE SURRENDER REACTION FROM THE STANDPOINT OF THERAPY

Recognition of the surrender reaction throws a challenging light upon many clinical phenomena that are generally held to be of significance in the process of getting better. For instance, in catharsis it is not what is revealed but the act of surrender (that preceded and permitted the revealing to come to light) that, in my opinion, produces the characteristic afterglow of positive feeling? It also explains its temporary effect just as with the conversion experience of the alcoholic. Again, the frequent unexpected lifts derived from seemingly ordinary first interviews, while they may be considered transference phenomena, seem to me more in the nature of “surrender reactions” based upon the fact that the client found the interview palatable, and the client made a decision to continue, which by implication means “surrender”, to the psychiatrist. The very decision to come to a psychiatrist, through its surrender significance, often has an ameliorating influence and certainly accounts for the remark of a patient who said, “Once I rang your doorbell, I felt 75 percent better”. The phenomenon of release, which makes people realize that, in losing their lives they are finding them, becomes explicable if one sees that the surrender that preceded the sense of release stills the inner fight and hostility, thus permitting the spontaneous creative elements of the Inner Self outlet for expression. Resistance It is in the area of resistance, however, that an understanding of the surrender reaction sheds the greatest light on the therapeutic process. Regularly, therapy goes ahead by fits and starts. For a while there is a period of resistance that is worked through, permitting progress, insight, and awareness of the emotional interplays in the unconscious life. Then another point of resistance is encountered, and again it must be ferreted out and dissolved before further constructive steps may be taken. Meeting resistance and working it through are the everyday tasks of therapy. Breaking Through Resistance Where before the patient has been in full resistance — bucking treatment, difficult to manage, getting nowhere — suddenly there is a marked change, almost like the sun bursting through the clouds, bringing everything into focus and making what was once a confused jumble takes on form, significance, and meaning. For the time being, the resistances have disappeared and the treatment proceeds apace. We have been accustomed to saying that the patient has a flash of insight and understanding that brought clarification and a greater awareness of his or her individual emotional makeup. Actually, if you examine the state of mind that breaks through when the resistance melts, you will find it is strikingly parallel to the positive state of mind an individual may have after a conversion experience. In fact, the parallel is so striking that I am more and more becoming convinced that the two are identical. In other words, I now believe that the giving up of resistance during treatment is in reality an act of surrender that typically, as in the conversion experience, is followed by a positive state of mind where elements of resistance are no longer present. This “giving in” may be sudden, causing the patient to enter the positive phase so rapidly as to constitute a sudden turnover with dramatic results. Generally, as in the conversion change, the change is slower, but the alteration is in exactly the same direction.

CONCLUSION

No one recognizes more than I do the sweeping nature of any such observations. No one is more aware than I am of the need to substantiate these observations with clinical material. Someday I may be able to support more conclusively my present hypothesis with case material. I can point out, however, that the positive aftermath of the so-called “successful interpretations” is no more lasting than the positive phase of the so-called “conversion experience“. They are both temporary; they are both slowly supplanted by a new crop of resistances or negative feelings. Also, they both require further change in the unconscious mind before the act of surrender becomes a settled state of surrender in which defiance and grandiosity no longer raise havoc with adjustment, serenity, and the capacity to function as a human being. To recapitulate, my studies of the conversion experience have led me to see that:

• It is the act of surrender that initiates the switch from negative to positive behaviour.
• It occurs when the unconscious defiance and grandiosity are for the time being rendered completely powerless by force of circumstance or reality.
• The act of surrender and the change that follows are inseparable since it is safe to assume that if there is no change, there has been no surrender.
• The positive phase is really a state of surrender that follows the surrender act.
• In several places, as in catharsis, the so-called improvement or feeling better is actually a state of surrender induced by an act of surrender.
• The state of surrender, if maintained, supplies an emotional tone to all thinking and feeling that does insure healthy adjustment.

I have tried in this paper to establish the fact that there is such a psychic event as surrender and that once the fact is appreciated in all its ramifications, it is illuminating clinically and provides a basis for understanding much that goes on in the therapeutic process.