Harry Stack Sullivan

Sullivan was born on 21 February 1892 in Norwich, New York, into a family of Irish Catholic descent, and grew up on a farm near Smyrna in Chenango County. Helen Swick Perry's biography, Psychiatrist of America⁴, describes an isolated boyhood: a Catholic child among Protestant neighbours, with a mother who gave him little warmth. Perry dates to these years his friendship with an older boy, Clarence Bellinger, who also became a psychiatrist. She connects it with the weight Sullivan's theory would later give to the preadolescent friendship with a chum.

He entered Cornell University in 1909 but was suspended. Perry accepts that he went through a schizophrenic episode as a young man, after the suspension. She concludes that he was probably confined at Bellevue, while stating that no record of it has been found. He took his medical degree at the Chicago College of Medicine and Surgery in 1917. Perry presents his career as built on slender formal credentials but sustained by clinical gift (Psychiatrist of America⁴).

Sullivan named three sources for his psychiatry. In the first of the lectures printed as Conceptions of Modern Psychiatry¹ he credits Sigmund Freud, Adolf Meyer and William Alanson White with the move toward a complete psychiatry. From Meyer's psychobiology he took the study of the whole person in a life situation, and in the 1920s he was in close contact with Meyer's circle at Johns Hopkins. He worked under White at St Elizabeths Hospital in Washington in the early 1920s and regarded him as his chief mentor. From Freud he kept the attention to processes outside awareness and to the treatment relationship, but set aside the libido theory (Psychiatrist of America⁴).

His own analysis was with Clara Thompson. After hearing Sándor Ferenczi lecture in New York in 1926, Sullivan urged Thompson to be analysed by him, so that both of them could learn his technique. About two years after her return to New York, in the mid-1930s, she analysed Sullivan himself (Psychiatrist of America⁴).

Perry's portrait is sympathetic but not uncritical, and it records the debts, extravagance and manipulativeness behind his reputation for opportunism. For the last twenty-two years of his life he lived with James Inscoe, some twenty years his junior, and Perry writes about the relationship with discretion.

In 1922 Sullivan moved from St Elizabeths to the Sheppard and Enoch Pratt Hospital in Towson, Maryland. He stayed until 1930, and from 1925 he was its director of clinical research. There he worked out his view of schizophrenia in papers later collected in Schizophrenia as a Human Process⁵. He also set up a special ward for young male patients. It was run apart from the hospital's routine and staffed by attendants he chose himself, which made the relations between patients and staff themselves therapeutic.

He then left the hospital for private practice in New York. Between about 1929 and 1933 he wrote his first systematic book, Personal Psychopathology⁶. On the advice of friends he did not publish it, in part because of its frankness about sexuality. It circulated in manuscript and appeared only in 1972.

In the same years he turned toward the social sciences. From the late 1920s until Sapir's death in 1939 he worked with the linguist Edward Sapir to bring psychiatry and the social sciences into one field of inquiry. He drew on Sapir's view that culture is lived in the relations between particular people. Perry places him in a wider network that also included Ruth Benedict and Harold Lasswell (Psychiatrist of America⁴). In the late 1930s Sullivan, Karen Horney, Thompson and Fromm met in New York as an informal discussion group. They came to be grouped together as the culturalist school, an alliance that broke apart in the early 1940s.

His later career centred on the institutions he built in Washington: the William Alanson White Psychiatric Foundation, the Washington School of Psychiatry, which he led from 1936 to 1947, and the journal Psychiatry. In the autumn of 1939 he gave the first William Alanson White Memorial Lectures, which were printed in Psychiatry in February 1940 and as a book in 1947. From October 1942 to April 1946 he lectured to the staff of Chestnut Lodge, a hospital in Rockville, Maryland, where Fromm-Reichmann worked (Clinical Studies in Psychiatry⁷). His lecture courses at the Washington School of Psychiatry in 1944 and 1945, and in 1946–47, became the basis of The Psychiatric Interview³ and The Interpersonal Theory of Psychiatry². In 1943 he joined Thompson, Fromm and Fromm-Reichmann in founding the New York branch of the Washington School, later the William Alanson White Institute.

His public work ranged from psychiatric screening for the Selective Service, which he advised from December 1940 to November 1941, to wartime and postwar efforts for mental health and international understanding (Psychiatrist of America⁴). The closing chapter of The Interpersonal Theory of Psychiatry², drawn from a paper of 1948, calls for a "psychiatry of peoples" that would address tensions between nations. He died in Paris on 14 January 1949.

In Conceptions of Modern Psychiatry¹ Sullivan traces psychiatry's double descent, from medicine and from the social traditions of healers and sages. He defines the field as the study of interpersonal relations, which the psychiatrist can know only as a participant observer. The Interpersonal Theory of Psychiatry² makes personality the relatively enduring pattern of recurrent interpersonal situations that characterise a life. The theory rests on the one-genus postulate, that human beings are far more alike than different. Sullivan's 1946 foreword to the Conceptions attacks what he calls the "delusion of unique individuality".

Conduct, in the Conceptions, is organised around two pursuits: satisfactions, tied to the body, and security, tied to culture. Anxiety, which Sullivan distinguishes from fear and pain, is caught empathically from the start. The infant's needs call out tenderness in the mothering one, while her anxiety reaches the infant through empathy. Avoiding anxiety becomes the mainspring of development (The Interpersonal Theory of Psychiatry²).

Out of approval, disapproval and overwhelming anxiety, the infant forms the personifications good-me, bad-me and not-me. From them grows the self-system, or self-dynamism, which is built from the appraisals of others and controls what enters awareness. What it cannot admit persists as dissociated. Its security operations keep anxiety down at the cost of learning from experience. Chief among them are selective inattention and dissociation (The Interpersonal Theory of Psychiatry²). Clinical Studies in Psychiatry⁷ treats selective inattention, sublimation, dissociation and the paranoid dynamism as the processes by which anxiety is kept out of awareness, and gives selective inattention a chapter of its own.

Experience is organised in three modes. The prototaxic is an undifferentiated flow. The parataxic links what merely occurs together. The syntaxic is consensually validated in shared language (The Interpersonal Theory of Psychiatry²). Parataxic distortion is living a present relationship through illusory figures from the past. Sullivan put the term in place of Freud's transference and widened it to every relationship, not only the patient's relation to the psychiatrist (Conceptions of Modern Psychiatry¹). He illustrated it with a patient who found, after hundreds of hours, that she had been seeing him as a fat old man with white hair.

Sullivan followed development through a series of epochs: infancy, childhood, the juvenile era, preadolescence, and early and late adolescence. A child whose need for tenderness is met with rebuff may come to expect hostility and turn malevolent. The juvenile era teaches competition, compromise and cooperation among peers. In preadolescence the capacity for love first appears, in intimacy with a same-sex chum. This friendship brings consensual validation (Conceptions of Modern Psychiatry¹). Early adolescence brings the lust dynamism and its collisions with the needs for intimacy and security. Personality is not settled in the first years, and each era offers a chance to repair earlier warps (The Interpersonal Theory of Psychiatry²). In Personal Psychopathology⁶ preadolescent friendship is already the first relationship in which another person's well-being matters as much as one's own.

Mental disorders, in this view, are patterns of inadequate or inappropriate interpersonal relations, continuous with ordinary living (The Interpersonal Theory of Psychiatry²). Clinical Studies in Psychiatry⁷ reads hysteria, obsessionalism, hypochondria, manic-depressive psychosis, schizophrenia and paranoid states as patterns of interpersonal living. The schizophrenia papers argue against the Kraepelinian picture of dementia praecox as a fixed organic deterioration. They treat schizophrenia as a human way of meeting a crisis in living, whose strangest thinking and symbols remain within the human range and can be understood with enough contact. The illness typically breaks out in panic, after a collapse of self-esteem before experiences the person cannot integrate. Its early regressive features are conservative, attempts to reintegrate experience through older modes of thought, while its malignant features mark a turn toward lasting dissociation. Some patients come out of an episode more capable than before. Treatment is a psychotherapy modified from psychoanalysis, which lowers anxiety and builds a relationship instead of relying on free association (Schizophrenia as a Human Process⁵). The Conceptions also offers ten developmental syndromes, such as the self-absorbed, the ambition-ridden and the chronically adolescent person, as better guides to a person's future than the categories of mental disease.

The clinical method follows from the theory. The Psychiatric Interview³ defines the interview as primarily vocal communication between two people on an expert–client basis. Its aim is to clarify the interviewee's characteristic patterns of living, in a way from which he expects to benefit. The psychiatrist is an expert in interpersonal relations and a participant observer, never a neutral mirror, and must stay aware of his own share in the field from which the data arise. Anxiety in both participants is the chief obstacle to learning anything. How things are said, in tone, pauses and digressions, is evidence as much as what is said. Sullivan divides the interview into the formal inception, the reconnaissance, the detailed inquiry and the termination, and uses the developmental history as the frame of reference for the inquiry.

Sullivan's theory reached most readers through editors. Perry and Mary Ladd Gawel edited The Interpersonal Theory of Psychiatry² from recordings of his lectures and from his notebooks, and where a lecture had not been recorded they rebuilt it from his outline. For Clinical Studies in Psychiatry⁷ the editors kept about 130,000 of more than a million words of lectures. Sullivan was himself guarded about parts of the system. In the 1946 foreword to the Conceptions he called the developmental sketch its weakest part, and admitted that his accounts of anxiety, the self and selective inattention were inadequate (Conceptions of Modern Psychiatry¹). In her introduction to the 1953 volume, Mabel Blake Cohen warns that its chapters on infancy are hypotheses about what must happen to every infant, not direct observations.

Within his lifetime his interpersonal approach to schizophrenia shaped the intensive psychotherapy that Fromm-Reichmann practised at Chestnut Lodge. After his death his interpersonal psychiatry was carried forward by Thompson, Fromm and Fromm-Reichmann, and institutionalised at the William Alanson White Institute.

In Object Relations in Psychoanalytic Theory⁸ (1983), Greenberg and Mitchell set Sullivan's interpersonal psychoanalysis beside the British object relations theories of Melanie Klein, Ronald Fairbairn, Donald Winnicott and Harry Guntrip. They presented these as radical alternatives to Freud's drive theory. In their distinction between the drive/structure and relational/structure models, the relational/structure model begins with Sullivan's interpersonal theory and Fairbairn's object relations. Mitchell, who trained at the White Institute, argued in Relational Concepts in Psychoanalysis⁹ (1988) that interpersonal psychoanalysis, object relations theory and self psychology could be joined in a single relational-conflict model. Relational psychoanalysis, which grew from this work, took from the interpersonal tradition its focus on actual interactions and on the analyst's participation. Mitchell and Margaret Black's survey Freud and Beyond¹⁰ (1995) gives Sullivan and interpersonal psychoanalysis a chapter of their own, alongside chapters on ego psychology, the Kleinians and the British object relations school.

Perry's Psychiatrist of America⁴ became the standard life. Reviewers praised its research, though some found it speculative, or more convincing about Sullivan's career than about the man. Personal Psychopathology⁶, because of its candour about sexuality, has been read more than his other writings as a key to his own life.

The only general statement of his theory to appear in Sullivan's lifetime was Conceptions of Modern Psychiatry¹, printed in Psychiatry in 1940 and as a book in 1947 with an exposition by Patrick Mullahy. The rest of his work was published after his death by W. W. Norton. The Interpersonal Theory of Psychiatry² (1953) is the fullest account of his developmental theory, and The Psychiatric Interview³ (1954) the most systematic statement of his clinical method. Clinical Studies in Psychiatry⁷ (1956) collects his lectures at Chestnut Lodge, and Schizophrenia as a Human Process⁵ (1962) gathers his papers of the 1920s and early 1930s, with commentaries by Perry. Personal Psychopathology: Early Formulations⁶ (1972) is the book he wrote around 1930 and withheld. A further collection, The Fusion of Psychiatry and Social Science, gathers his social-scientific essays.