- DIRECT
TREATMENT OF A SYMPTOM
- Harry
M. Tiebout, M.D.
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.
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