Harry M. Tiebout, M.D.


In the past 15 years, my understanding of the nature of alcoholism as a disease has been influenced largely by insight into the mechanisms at work in the Alcoholics Anonymous process. Some years ago I stated that A.A., to succeed, must induce a surrender on the part of the individual. More recently, I discussed the idea of compliance acting as a barrier to that real acceptance which a surrender produces. On this occasion I propose to extend my observations by discussing (a) what factors in the individual must surrender, and (b) how the surrender reaction changes the inner psychic picture.

The first question, what factors in the individual must surrender received passing attention in the article on compliance. There, relative to the difficulty of surrender, I noted that "the presence of an apparently unconquerable ego became evident. It was this ego which had to become humble." The first part of the present communication will be devoted to an elaboration of the nature of this ego factor.

Use of the word "ego" involves always the possibility of confusion of meaning. For a time, therefore, I considered a substitute term. That idea was set aside because, despite possible misinterpretation, the word ego is current in everyday language in exactly the sense in which it will be employed in this discussion. The expression, "he has an inflated ego," is self-explanatory. It evokes the picture of a pompous, self-important, strutting individual whose inferiorities are masked by a surface assurance. Such a person appears thick-skinned, insensitive, nearly impervious to the existence of others, a completely self-centered individual who plows unthinkingly through life, intent on gathering unto himself all the comforts and satisfactions available. He is generally considered the epitome of selfishness, and there the matter rests.

This popular view of ego, while it may not have scientific foundation, has one decided value: it possesses a meaning and can convey a concept which the average person can grasp. This concept of the inflated ego recognizes the common ancestor of a whole series of traits, namely, that they are all manifestations of an underlying feeling state in which personal considerations are first and foremost.

The existence of this ego has long been recognized, but a difficulty in terminology still remains. Part of the difficulty arises from the use of the word ego, in psychiatric and psychological circles, to designate those elements of the psyche which are supposed to rule psychic life. Freud divided mental life into three major subdivisions: the id, the ego and the superego. The first, he stated, contains the feeling of life on a deep, instinctual level; the third is occupied by the conscience, whose function is to put brakes on the impulses arising within the id. The ego should act as mediator between the demands of the id and the restraints of the superego, which might be over-zealous and bigoted. Freud's own research was concerned mainly with the activities of the id and the superego. The void he left with respect to the ego is one that his followers are endeavoring to fill, but as yet with no generally accepted conclusions.

Ego: By Two Definitions

The word ego, however has been preempted by the psychiatrists and psychologists, although they do not always agree among themselves about the meaning to be attached to it. The resulting confusion is the more lamentable because almost everyone, layman or scientist, would agree on the concept of the inflated ego. It would be helpful if other terms were found for the ego concepts about which there are differing views.

The solution for this dilemma will be to indicate with a capital E the big Ego, and without a capital to identify the personality aspect which Freud had in mind when he placed ego between id and superego.3

With this disposition of the problem of terminology, it is now possible to consider the first issue, namely, the Ego factors in the alcoholic which, through surrender, become humble. The concept of the enlarged Ego, as noted previously, is available to common observation. Those who do not recognize it in themselves can always see it in some member of their family or among friends and acquaintances — not to mention patients. Everyone knows egotistical people and has a perfectly clear idea of what the word means. Besides egotistical, and the series of words mentioned earlier, adjectives which help to round out the portrait of the egotistical person are prideful, arrogant, pushing, dominating, attention seeking, aggressive, opinionated, headstrong, stubborn, determined and impatient.

All these terms are inadequate, however, because they describe only surface features without conveying any feeling of the inner essence from which the Ego springs. Unless some appreciation for the source of the Ego is gained, the dynamic import is lost and the term may seem merely a form of name calling. It is easy to say someone has a big Ego without awareness of what is really happening in the deep layers of that person's mind, without perception of the Ego. Nor is it a matter of intellect. The need here is to lay hold of the inner feeling elements upon which the activity of the Ego rests. Only when these elements become clear can the fundamental basis of the Ego also be clarified.

It is convenient, for the exposition of this inner functioning, to reverse the usual sequence and to present a conclusion in advance of the evidence on which it is based. This is, briefly, that the Ego is made up of the persisting elements, in the adult psyche, of the original nature of the child.

Certain aspects of the infant's psyche may be usefully examined. There are three factors which should receive mention. The first is, as Freud observed in his priceless phrase "His Majesty the Baby," that the infant is born ruler of all he surveys. He comes from the Nirvana of the womb, where he is usually the sole occupant, and he clings to that omnipotence with an innocence, yet determination, which baffles parent after parent. The second, stemming directly from the monarch within, is that the infant tolerates frustration poorly and lets the world know it readily. The third significant aspect of the child's original psyche is its tendency to do everything in a hurry. Observe youngsters on the beach: they run rather than walk. Observe them coming on a visit: the younger ones tear from the car while their elder siblings adopt a more leisurely pace. The three-year-olds, and more so the twos, cannot engage in play requiring long periods of concentration. Whatever they are doing must be done quickly. As the same children age, they gradually become able to stick to one activity for longer times.

Thus at the start of life the psyche (1) assumes its own omnipotence, (2) cannot accept frustrations and (3) functions at a tempo allegretto with a good deal of staccato and vivace thrown in.

Now the question is, "If the infantile psyche persists into adult life, how will its presence be manifested?"

In general, when infantile traits continue into adulthood, the person is spoken of as immature, a label often applied with little comprehension of the reason for its accuracy. It is necessary to link these three traits from the original psyche with immaturity and, at the same time, show how they affect the adult psyche. If this is done, not only will the correctness of the appellation "immature" be apparent but, moreover, a feeling for the nature of the unconscious underpinnings of the Ego will have been created.

Recognizing Immaturity

Two steps can aid in recognizing the relationship between immaturity and a continuance of the infantile elements. The first is, by an act of imagination, to set these original traits into an adult unconscious. The validity of this procedure is founded upon modern knowledge of the nature of the forces operating in the unconscious of people of mature age. The second step is to estimate the effect that the prolongation of these infantile qualities will have upon the adult individual.

This attempt should not strain the imagination severely. Take, for instance, the third of the qualities common to the original psychic state, namely, the tendency to act hurriedly. If that tendency prevails in the unconscious, what must the result be? The individual will certainly do everything in a hurry. He will think fast, talk fast and live fast, or he will spend an inordinate amount of time and energy holding his fast-driving proclivities in check.

Often the net result will be an oscillation between periods of speeding ahead followed by periods during which the direction of the force is reversed, the brakes (superego) being applied in equally vigorous fashion. The parallel of this in the behavior of the alcoholic will not be lost on those who have had experience with this class of patients.

Let us take the same trait of doing everything in a hurry and apply it to the word "immature." Few will deny that jumping at conclusions, doing things as speedily as possible, give evidence of immaturity. It is youth that drives fast, thinks fast, feels fast, moves fast, acts hastily in most situations. There can be little question that one of the hallmarks of the immature is the proneness to be under inner pressure for accomplishment. Big plans, big schemes, big hopes abound, unfortunately not matched by an ability to produce. But the effect upon the adult of the persisting infantile quality to do everything in less than sufficient time can now be seen in a clearer light. The adult trait is surely a survival from the original psyche of the infant.

The two other surviving qualities of the infantile psyche similarly contribute to the picture of immaturity and also, indirectly, help to clarify the nature of the Ego with a capital E. The first of these, the feeling of omnipotence, when carried over into adult life, affects the individual in ways easily anticipated. Omnipotence is, of course, associated with royalty, if not divinity. The unconscious result of the persistence of this trait is that its bearer harbors a belief of his own special role and in his own exceptional rights. Such a person finds it well-nigh impossible to function happily on

an ordinary level. Obsessed with divine afflatus, the thought of operating in the lowly and humble areas of life is most distressing to him. The very idea that such a place is all one is capable of occupying is in itself a blow to the Ego, which reacts with a sense of inferiority at its failure to fill a more distinguished position. Moreover, any success becomes merely Ego fodder, boosting the individual's rating of himself to increasingly unrealistic proportions as the king side eagerly drinks in this evidence of special worth.

The ability to administer the affairs of state, both large and small, is taken for granted. The belief that he is a natural executive placed in the wrong job merely confirms his conviction that, at best, he is the victim of lack of appreciation, and at worst, of sabotage by jealous people who set up roadblocks to his progress. The world is inhabited by selfish people, intent only on their own advancement.

The genesis of all this is beyond his perception. To tell him that his reactions spring from the demands of an inner unsatisfied king is to invite incredulity and disbelief, so far from the conscious mind are any such thoughts or feelings. People who openly continue to cling to their claims of divine prerogative usually end up in a world especially constructed for their care. In others, the omnipotence pressures are rather better buried. The individual may admit that, in many ways, he acts like a spoiled brat, but he is scarcely conscious of the extent of the tendency, nor how deeply rooted it may be. He, like most people, resolutely avoids a careful look because the recognition of any such inner attitudes is highly disturbing. The unconscious credence in one's special prerogatives savors too much of straight selfishness to be anything but unpleasant to contemplate.

And so, for the most part, people remain happily ignorant of the unconscious' drives which push them around. They may wonder why they tend to boil inside and wish they could free themselves from a constant sense of uneasiness and unsettlement. They may recognize that they seem jittery and easily excited and' long for the time when they can meet life more calmly and maturely; they may hate their tendency to become rattled. But their insight into the origin of all this is next to nothing, if not a complete blank. The king lies deep below the surface, far out of sight.

Inability to Accept Frustration

The last trait carried over from infancy is the inability to accept frustration. In an obvious sense, this inability is another aspect of the king within, since one of the prerogatives of royalty is to proceed without interruption. For the king to wait is an affront to the royal rank, a slap at his majesty. The ramifications of this inability to endure frustration are so widespread, and the significance of much that occurs in the behavior of the alcoholic is so far-reaching, that it seems advisable to discuss this trait under a separate heading.

As already indicated, on the surface the inability of the king to accept frustration is absolutely logical. The wish of the king is the law of the land, and especially in the land of infancy. Any frustration is clearly a direct threat to the status of his majesty, whose whole being is challenged by the untoward interruption.

Even more significant is another aspect of this inner imperiousness. Behind it lies the assumption that the individual should not be stopped. Again, this is logical if one considers how an absolute monarch operates. He simply does not expect to be stopped; as he wills, so will he do. This trait, persisting in the unconscious, furnishes a constant pressure driving the individual forward. It says, in essence, "I am unstoppable!"

The unconscious which cannot be stopped views life entirely from the angle of whether or not a stopping is likely, imminent, or not at all in the picture. When a stopping is likely, there is worry and perhaps depression. When it seems imminent, there is anxiety bordering on panic, and when the threat is removed, there is relief and gaiety. Health is equated with a feeling of buoyancy and smooth sailing ahead, a sense of "I feel wonderful!" Sickness, contrariwise, means lacking vim, vigor and vitality, and is burdened with a sense of "I'm not getting anywhere." The need to "get somewhere" to "be on the go," and the consequent suffering from eternal restlessness, is still another direct effect of an inner inability to be stopped or, expressed otherwise, to accept the fact that one is limited. The king not only cannot accept the normal frustrations of life but, because of his inordinate driving ahead, is constantly creating unnecessary roadblocks by virtue of his own insistence on barging ahead, thus causing added trouble for himself.

Of course, on some occasions, the king gets stopped, and stopped totally. Illness, arrest, sometimes the rules and regulations of life, will halt him. Then he marks time, complies if need be, waiting for the return of freedom, which he celebrates in the time-honored fashion if he is an alcoholic: he gets drunk, initiating a phase when there is no stopping him.

The immaturity of such a person is readily evident. He is impatient of delay, can never let matters evolve; he must have a blueprint to follow outlining clearly a path through the jungle of life. The wisdom of the ages is merely shackling tradition which should make way for the freshness, the insouciance of youth. The value of staying where one is, and working out one's destiny in the here and now, is not

suspected. The 24-hour principle would be confining for one whose inner life brooks no confinement. The unstoppable person seeks life, fun, adventure, excitement, and discovers he is on a perpetual whirligig which carries him continuously ahead but, of course, in a circle. The unstoppable person has not time for growth. He must always, inwardly, feel immature.

This, then, is how the carry-over of infantile traits affects the adult so encumbered. He is possessed by an inner king who not only must do things in a hurry, but has no capacity for taking frustration in stride. He seeks a life which will not stop him and finds himself in a ceaseless rat race.

All this is part and parcel of the big Ego. The individual has no choice. He cannot select one characteristic and hang on to that, shedding other more obviously undesirable traits. It is all or nothing. For example, the driving person usually has plenty of energy, sparkle, vivacity. He stands out as a most attractive human being. Clinging to that quality, however, merely insures the continuance of excessive drive and Ego, with all the pains attendant upon a life based on those qualities. The sacrifice of the Ego elements must be total, or they will soon regain their ascendancy.

Learning To Live

Those who view the prospect of life without abundant drive as unutterably dull and boring should examine the life of members of Alcoholics Anonymous who have truly adopted the A.A. program. They will see people who have been stopped — and who, therefore, do not have to go anywhere — but people who are learning, for the first time in their lives, to live. They are neither dull nor wishy-washy. Quite the contrary, they are alive and interested in the realities about them. They see things in the large,are tolerant, open-minded, not close-minded bulling ahead. They are receptive to the wonders in the world about them, including the presence of a Deity who makes all this possible. They are the ones who are really living. The attainment of such a way of life is no mean accomplishment.

Preliminary to this discussion, the conclusion was offered that the Ego was a residual of the initial feeling life of the infant. It should be evident that the immaturity characteristically found in the make-up of the alcoholic is a persistence of the original state of the child. In connection with the description of the manifestations which denote a large and active Ego, it should be recalled that the presence in the unconscious of such Ego forces may be quite out of reach of conscious observation. Only through the acting and feeling of the individual can their existence be suspected.

Now the answer to the first question raised herein, namely, what part of the alcoholic must surrender, is obvious: it is the Ego element.

Life without Ego is no new conception. Two thousand years ago, Christ preached the necessity of losing one's life in order to find it again. He did not say Ego, but that was what he had in mind. The analysts of our time recognize the same truth; they talk also about ego reduction. Freud saw therapy as a running battle between the original narcissism of the infant (his term for Ego) and the therapist whose task it was to reduce that original state to more manageable proportions. Since Freud could not conceive of life without some measure of Ego, he never resolved the riddle of how contentment is achieved; for him, man to the end was doomed to strife and unhappiness, his dearest desires sure to be frustrated by an unfriendly world.

In his studies on the addictions, Rado3 more explicitly asserts that the Ego must be reduced. He first portrays the Ego as follows: "Once it was a baby, radiant with self-esteem, full of belief in the omnipotence of its wishes, of its thoughts, gestures and words." Then, on the process of Ego-reduction: "But the child's megalomania melted away under the inexorable pressure of experience. Its sense of its own sovereignty had to make room for a more modest self evaluation. This process, first described by Freud, may be designated the reduction in size of the original ego; it is a painful procedure and one that is possibly never completely carried out."

No Compromise With Ego

Like Freud, Rado thinks only in terms of reduction; the need for the complete elimination of Ego is a stand which they cannot bring themselves to assume. Hence they unwittingly advocate the retention of some infantile traits, with no clear awareness that trading with the devil, the Ego, no matter how carefully safeguarded,' merely keeps him alive and likely at any occasion to erupt full force into action. There can be no successful compromise with Ego, a fact not sufficiently appreciated by many, if not most, therapists.

Thus the dilemma encountered in ego-reduction would be best resolved by recognizing that the old Ego must go and a new one take its place. Then no issue would arise about how much of the earliest elements may be retained. The answer, theoretically, is none. Actually the total banishment of the initial state is difficult to achieve. Man can only grow in the direction of its complete elimination. Its final expulsion is a goal which we can only hope.

The second question raised here is, "How does the surrender reaction change the inner psychic picture?" This question is based on a presupposition, namely that surrender is an emotional step in which the Ego, at least for the time being, acknowledges that it is no longer supreme. This acknowledgment is valueless if limited to consciousness; it must be accompanied by similar feelings in the unconscious. For the alcoholic, surrender is marked by the admission of being powerless over alcohol. His sobriety has that quality of peace and tranquility which makes for a lasting quiet within only if the surrender is effective in the unconscious and permanent as well.

The effects of surrender upon the psyche are extremely logical: The traits listed as~
characteristic of the Ego influence are canceled out. The opposite of king is the
commoner. Appropriately, Alcoholics Anonymous stresses humility. The opposite of
impatience is the ability to take things in stride, to make an inner reality of the slogan,
"Easy does it." The opposite of drive is staying in one position where one can be
open-minded, receptive and responsive.

This picture of the non-Ego type of person might be amplified in many directions but to do so would serve no immediate purpose. To have discussed the effect of the Ego upon behavior, and to have pointed out what may happen when the Ego is at least temporarily knocked out of action, is sufficient to, make the point of this communication: It is the Ego which is the arch-enemy of sobriety, and it is the Ego which must be disposed of if the individual is to attain a now way of life

Up to this point, no clinical material has been submitted to confirm the ideas presented. Their validity will be apparent to many therapists. One brief citation from clinical experience will be offered, however, in the hope that it may serve as a concrete illustration of these ideas.

The patient, a man in his late 30's, had a long history of alcoholism with 7 years of futile attempts to recover through Alcoholics Anonymous, interspersed with countless admissions to "drying out" places. Then, for reasons not totally clear, he decided to take a drastic step. He determined to enter a sanitorium and place himself in the hands of a psychiatrist, a hitherto unheard of venom. We planned to arrange for a limited stay at a sanitarium where he could have regular interviews with me.

From the outset, he was undeniably in earnest, although it was only after the first interview that he really let go and could talk freely about himself and the things that were going on inside him. After the usual preliminaries, the first interview started with a discussion of feelings and how they operate. The patient was questioned about the word Ego as used at A.A. meetings. He confessed his ignorance of its true meaning and listened with interest to brief remarks on how it works. Before long, he was locating in himself some of the Ego forces which hitherto he had been vigorously denying because they savored too much of vanity and selfishness with that recognition, the patient made a revealing remark. He said, in all sincerity, "My goodness, I never knew that. You don't do your thinking up here (pointing to his head), you think down here where you feel" placing his hands on his stomach. He was learning that his feelings had a "mind" of their own and that unless he heeded what they were saying, he could easily get into trouble. He was facing the actuality of his Ego as a feeling element in his life, a step he was able to take because he was no longer going at full steam ahead. His decision to place himself under care, a surrender of a sort, had quieted him and made him receptive, able to observe what was going on in himself. It was the beginning of a real inventory.

The next insight he uncovered was even more startling. He had been requested routinely to report any dreams he would have. Much to his surprise, they appeared regularly during the period of contact. In his fifth dream, the patient found himself locked up in an institution because of his drinking. The interpretation offered, based upon relevant materials, was that the patient equated any kind of stopping with being locked up; that his real difficulty lay in the fact that he could not tolerate being stopped, and abstaining was merely another stopping he could not take. The patient's reaction to the interpretation was most significant. He remained silent for some little time; then he began to talk, saying, "I tell you, Doc, it was like this. I'd get drunk, maybe stay on it 2 or 3 days, then I'd go into one of those drying out places where I'd stay 5 or 6 days and I'd be all over wanting a drink. Then I'd come out and stay sober, maybe a week, 'maybe a month, but pretty soon the thought would come into my mind, I want to drink! Maybe I'd go into a tavern and maybe not, but sooner or later I'd go and I'd order a drink, but I wouldn't drink it right off. I'd put it on the bar and I'd look at it and I'd think and then I'd look and think: King for a day!" The connection between Ego and his own conduct had become explicit, as well as the relationship between not being stopped and Ego. He saw clearly that when he took that drink, he was the boss once more. Any previous reduction of Ego had been only temporary.

In treatment, the problem is to make that reduction permanent. Therapy is centered on the ways and means, first, of bringing the Ego to earth, and second, keeping it there. The discussion of this methodology would be out of place here, but it is relevant to emphasize one point, namely the astonishing capacity of the Ego to pass out of the picture and then reenter it, blithe and intact. A patient's dream neatly depicted this quality. This patient dreamt that he was on the twelfth floor balcony of a New York hotel. He threw a rubber ball to the pavement below and saw it rebound to the level of the balcony. Much to his amazement, the ball again dropped and again rebounded to the same height. This continued for an indefinite period and, as he was watching, a clock in a neighboring church spire struck nine. Like the cat with nine lives, the Ego has a marvelous capacity to scramble back to safety — a little ruffled, perhaps, but soon operating with all its former aplomb, convinced once more that now it, the Ego, can master all events and push on ahead.

The capacity of the Ego to bypass experience is astounding and would be humorous were it not so tragic in its consequences. Cutting the individual down to size and making the results last is a task never completely accomplished. The possibility of a return of his Ego must be faced by every alcoholic. If it does return, he may refrain from drinking, but he will surely go on a "dry drunk," with all the old feelings and attitudes once more asserting themselves and making sobriety a shambles of discontent and restlessness. Not until the ego is decisively retired can peace and quiet again prevail. As one sees this struggle in process, the need for the helping hand of a Deity becomes clearer. Mere man alone all too often seems powerless to stay the force of his Ego. He needs assistance and needs it urgently.


In the process of surrender which the alcoholic necessarily undergoes before his alcoholism can be arrested, the part of the personality which must surrender is the inflated Ego. This aspect of personality was identified as immature traits carried over from infancy into adulthood, specifically, a feeling of omnipotence, inability to tolerate frustration, and excessive drive, exhibited in the need to do all things precipitously. The manner in which surrender affects the Ego was discussed and illustrated briefly from clinical experience. The object of therapy is to permanently replace the old Ego and its activity.


Tiebout, H.M. "The Act of Surrender in the Therapeutic Process." With special reference to alcoholism. Quart. J. Stud. Aic. 10: 48-58, 1949.

Tiebout, H.M. "Surrender Versus Compliance in Therapy". With special reference to alcoholism. Quart. J. Stud. Aic. 14: 58-68,1953.

Rado, S. "The Psychoanalysis of Pharmachothymia (drug addiction). The clinical picture." Psychoanal. Quart. 2: 1-23, 1933.

Last updated 21 May 2005.
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