The Interpersonal Theory of Psychiatry

Harry Stack Sullivan, Harry Stack Sullivan

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136439360
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1955 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

Part I Introductory Concepts

Chapter 1 The Meaning of the Developmental Approach

DOI: 10.4324/9781315014029-1

After A good many years of effort at teaching psychiatry I have concluded that either certain appraisals of myself as a good teacher are entirely unfounded or the teaching of psychiatry is extremely difficult; and I think quite possibly both are the case. But the fabulous difficulty of teaching psychiatry, as I have seen it over the years, is that it is quite easy to learn certain things—that is, to get so you can talk about them—but it is extremely difficult to get any two people to mean just the same thing when they talk about what they have supposedly learned.

This difficulty is a result of the fact that psychiatry deals with living and that everybody has a great deal of experience in living. But no one lives in anything like the highest style of the art; and it is very disconcerting to notice how badly one lives in the sense of the extent to which fatigue and other discomforts are connected with one’s most important dealings with other people. So it is not very easy to develop that type of objectivity about the subject matter of psychiatry which one can acquire about the works of a clock or the principles of physics or even the phenomena of quantum meruit in law.

We interpret everything that we hear in this field of psychiatry on a double basis and, unhappily, neither of the bases is very helpful: first, on the basis of what one presumes the data mean in terms of what one knows already, or half-knows; and secondly, on the basis of how this can be interpreted so that it does not increase one’s feeling of discomfort and inadequacy in living—one’s anxiety, an extremely important term which I shall later define.

Some psychiatrists have had a great deal of training in the area in which psychiatry can perhaps be most easily taught; namely, in the area of describing, as if they were museum pieces, those people who have such great difficulties in living that their situation would be apparent to all. This is the psychiatry of mental disorders; and what one learns about mental disorders by way of descriptive psychiatry is not very meaningful. It does of course provide the psychiatrist with justification for making a living; and he has a feeling of being worth while because he knows a good deal about what these un-understood beings are apt to look like for a long time to come. If the patients manage to change for the better, everybody is so pleased that no one wastes much time condemning the psychiatrist for his mistakes in prognosis.

But the kind of psychiatry I am talking about attempts to explain serious mental disorders; and it also is of some use in living in general. How to communicate this particular theory of psychiatry has puzzled and harassed me for a great many years, and I have finally come to the decision that the only approach is by the developmental route. In other words, if we go with almost microscopic care over how everybody comes to be what he is at chronologic adulthood, then perhaps we can learn a good deal of what is highly probable about living and difficulties in living. The success of this kind of teaching has not been impressively great. It has taken the collaborative work of a group of extraordinarily gifted people, including some of my most distinguished colleagues in the Washington and New York areas, to arrive at something of a consensus about one of the central theoretical formulations in the type of psychiatry that I am attempting to teach.

In understanding what I am trying to say you will have to discard the notion that it is something you have known all the time, which just happened to get well formulated or peculiarly formulated by me. We are really up against one of the most difficult of human performances—organizing thought about oneself and others, not on the basis of the unique individual me that is perhaps one’s most valuable possession, but on the basis of one’s common humanity.

Briefly, I shall proceed by examining one hypothesis after another, selecting those which seem to be the best theoretical formulations now available as to how, from birth onward, a very capable animal becomes a person—something very different from an animal; and as to how this transformation of a very gifted animal—who is always there but who cannot be defined because he is constantly being transformed—is brought about, step by step, from very, very early in life, through the influence of other people, and solely for the purpose of living with other people in some sort of social organization.

No matter what kind of social organization there is, everyone who is born into it will, in certain ways, be adapted or adjusted to living in it. If the person is very fortunate, he will be pretty well adapted to living in that social organization. If he is extremely fortunate, he may come to know almost by intuition, you might say—which simply means that it isn’t clearly formulated—so much about living itself that he can move into a quite different social organization; and fairly rapidly—but by no means immediately—he may learn to live quite successfully in this new social organization. That sort of transfer is practically out of the question for a great many of the people that psychiatrists see as patients. They are not quite able to live adequately as people in the social organization that they have been trained to live in.

To repeat, no very simple explanation is adequate to communicate some of the instrumentalities that might be useful for improving one’s own life and the life of others. The only way that has occurred to me of providing something more useful is by this careful following of that which is possible and probable from birth onward. When psychiatry is approached that way it does not become simple—far from it. Since we have six or seven, or even more, extremely refined channels of contact with events around us, our experience of various combinations of the functions of these channels becomes pretty complicated. And since most of human life is not by any means concerned merely with events in the physicochemical universe, but is concerned also with matters of cultural definition—values, prejudices, beliefs, and so on—the actual complexity of the field becomes mathematically rather overwhelming. The best that I can hope to present are dependable frames of reference as a guide in exploring this complex field, and the conviction that I have had personally for many years, that the great capabilities of the human animal do not fail to make sense when given an adequate chance.

I would like to say—I think with no material fear of extravagance—that I don’t believe many psychiatrists have a very good theoretic framework for thinking about difficulties in living, their origin, their dependable manifestations, or their fairly certain improvements. I do not mean to imply that most psychiatrists are not useful to people. But I am stressing the need for a genuinely scientific approach to cope with the rapidly multiplying inefficiencies, inadequacies, misfortunes, and miscarriages of life which come to the attention of the psychiatrist. When I talk about a scientific approach I mean something about as far from empiricism as the mind will go—something precise, something capable of formulation, with a varying range of probability. So far as I know, most of the ways in which one goes about being a human being could be very different from anything we have ever heard of. In other words, the human organism is so extraordinarily adaptive that not only could the most fantastic social rules and regulations be lived up to, if they were properly inculcated in the young, but they would seem very natural and proper ways of life and would be almost beyond study. In other words, before speech is learned, every human being, even those in the lower imbecile class, has learned certain gross patterns of relationship with a parent, or with someone who mothers him. Those gross patterns become the utterly buried but quite firm foundations on which a great deal more is superimposed or built.

Sometimes these foundations are so askew from what I would describe as good foundations for living in a particular society that the subsequent development of the person is markedly twisted from conventional development—that is, from the average in the purely statistical sense, from the way in which most people live. In those circumstances we recognize the results as psychoneuroses or psychoses. But to make anything useful in the way of thought about these psychoneuroses and psychoses and to develop any certainly helpful technique for dealing with these ‘warped’ people, your thinking has to reach very much further back than the presenting situation. The great difficulty is that in this reach-back you find that a large part of the person’s living is not particularly different from yours. And this apparent identity between your living and his living confuses the fact that this living, while outwardly identical, may not be at all identical in meaning to you and to him. And so you cannot ignore those aspects of his living that seem quite natural or normal to you.

In attempting to formulate and teach a theoretic framework for psychiatry over the years it has seemed to me necessary to avoid as far as possible psychiatric neologisms. Of course, every science has to have its technical language. But since this is the study of living and since it has the difficulties which I have already stressed, why add to the certainty of confusion and the Tower-of-Babel phenomena by putting in a lot of trick words? For these trick words, so far as I can discover, merely make one a member of a somewhat esoteric union made up of people who certainly can’t talk to anybody outside the union and who only have the illusion that they are talking to one another. Any experiment in the definition of most of the technical terms that have crept into psychiatry shows an extraordinary fringe of difference in meaning. For that reason, I think we should try to pick a word in common usage in talking about living and clarify just what we mean by that word, rather than to set about diligently creating new words by carpentry of Greek and Sanskrit roots.

If I succeed then in communicating my ideas—and to the extent that I succeed—I hope that psychiatrists may derive some benefit in formulating their professional and other dealings with people in rather general terms; such general terms will, I believe, permit further exploration in the direction of getting highly probable statements. There are people who want certainties; they want to be able to distinguish certainly between correct and incorrect propositions. That is a perfectly foredoomed goal in psychiatry. You see, we are not that simple. We have so much spare adjustive equipment that we really live for the most part with only shockingly poor approximations to what might be correct or incorrect.

All of us are afflicted by the fact that long before we can remember, certainly long before we can make brilliant intellectual formulations, we catch on to a good deal which is presented to us, first, by the mothering one and, then, by other people who have to do with keeping us alive through the period of our utter dependence. Before anyone can remember, except under the most extraordinary circumstances, there appears in every human being a capacity to undergo a very unpleasant experience. This experience is utilized by all cultures, by some a little and by some a great deal, in training the human animal to become a person, more or less according to the prescriptions of the particular culture. The unpleasant experience to which I am referring I call anxiety. And here I am making the first of a long series of references to the basic conception of anxiety, which incidentally I have set forth briefly in my paper, “The Meaning of Anxiety in Psychiatry and in Life.”¹

¹ [Harry Stack Sullivan, “The Meaning of Anxiety in Psychiatry and in Life,” Psychiatry (1948) 11:1–13. Also, see “Towards a Psychiatry of Peoples,” Psychiatry (1948) 11:105–116. And “The Theory of Anxiety and the Nature of Psychotherapy,” Psychiatry (1949) 12:3–12.]

In discussing the concept of anxiety, I am not attempting to give you the last word; it may, within ten years, be demonstrated that this concept is quite inadequate, and a better one will take its place. But this concept of anxiety is absolutely fundamental to your understanding what I shall be trying to lay before you. I want to repeat that, because I don’t know that I can depend on words really to convey the importance of what I am trying to say: Insofar as you grasp the concept of anxiety as I shall be struggling to lay it before you, I believe you will be able to follow, with reasonable success, the rest of this system of psychiatry. Insofar as I fail to get across to you the meaning of anxiety, insofar as you presume that I mean just what you now think anxiety is, I shall have failed to communicate my ideas.

Because a great many phenomena in the whole biological field are easier to understand if you trace them from their beginnings to their most complex manifestations, I would like to describe how I think anxiety begins in the infant. I do not know how early in life anxiety first manifests itself. It is not exactly a field that you can get mothers and children to cooperate in exploring. I have no doubt that as a great many other things vary from person to person, so the precise data which have to do with being anxious vary from infant to infant. It is demonstrable that the human young in the first months of life—and I think it is true of some other young, but it is very conspicuous in the human young—exhibits disturbed performance when the mothering one has an ‘emotional disturbance’—I am using that term quite loosely to mean anything that you think it means. Whatever the infant was doing at the time will be interrupted or handicapped—that is, it will either stop, or it will not progress as efficiently as before anxiety appeared.

Thus anxiety is called out by emotional disturbances of certain types in the significant person—that is, the person with whom the infant is doing something. A classical instance is disturbance of feeding; but all the performances of the infant are equally vulnerable to being arrested or impeded, in direct chronological and otherwise specific relationship to the emotional disturbance of the significant other person. I cannot tell you what anxiety feels like to the infant, but I can make an inference which I believe has very high probability of accuracy—that there is no difference between anxiety and fear so far as the vague mental state of the infant is concerned. Some of you may feel inclined to say, “Well, do infants have fear?” And that, of course, becomes a matter of, “Well what do you mean by fear?” But I would like to point out that if an infant is exposed to a sudden loud noise, he is pretty much upset; certain other experiences of that kind which impinge on his zones of connection with the outside world cause the same kind of upset. Almost anybody watching the infant during these upsets would agree that it didn’t seem to be fun; the infant didn’t enjoy it. There is no doubt that this—whatever you call it—develops, with no break, into manifestations which we in ourselves call fear, and identify in others as fear. I have reason to suppose, then, that a fearlike state can be induced in an infant under two circumstances: one is by the rather violent disturbance of his zones of contact with circumambient reality; and the other is by certain types of emotional disturbance within the mothering one. From the latter grows the whole exceedingly important structure of anxiety, and performances that can be understood only by reference to the conception of anxiety.

In this connection, I will venture to say that the sort of experience which the infant probably has as primitive anxiety, or primitive fear, reappears much later in life under very special circumstances—perhaps in everyone, but certainly in some people. These circumstances are fairly frequent in the earlier stages of what we call the schizophrenic disorders of living. In quite a number of people, they are not too infrequent in so-called dreams at disturbed times of life, perhaps more specifically in the adolescent era. In these circumstances, anything from a hint to perhaps a fairly full-scale revival of the most primitive type of anxiety arouses uncanny emotion.

By uncanny emotion—which is just a trick term, since it hasn’t any divine warranties for existing—I refer to an indeterminately large group of feelings of which the most commonly experienced is awe. Perhaps some of you have experienced it on first hearing a huge pipe organ. Many people experience great awe on their first glimpse into the Grand Canyon. Everybody has had some experiences of awe. I couldn’t begin to name all the different sorts of circumstances in which most people experience awe. The rest of the named uncanny emotions are less well known. I would number them as dread—dread in far more than the purely conversational sense—horror, and loathing. All of these uncanny emotions have a sort of shuddery, not-of-this-earth component which is, I believe, a curious survival from very early emotional experience, all of which can be thus characterized. If you think of an occasion in your own early life when you really experienced one of these uncanny feelings, of which, as I say, awe is much the most common, you will realize that it is as if the world were in some way different. If you try to analyze the experience, you may talk about your skin crawling, or this or that; at any rate, you know that it was very curious. I think any of you who recall an awe-inspiring incident will realize it could easily have been terribly unpleasant. True, many of you, perhaps, have never experienced awe to that extent; awe is certainly the mildest of the uncanny emotions. But if there were a great deal more of such emotion, you would be very far from a going concern as long as you had it. That is the nearest I can come to hinting at what I surmise infants undergo when they are severely anxious.

In attempting to outline this whole system of psychiatry, I want to stress from the very beginning the paralyzing power of anxiety. I believe that it is fairly safe to say that anybody and everybody devotes much of his lifetime, a great deal of his energy—talking loosely—and a good part of his effort in dealing with others, to avoiding more anxiety than he already has and, if possible, to getting rid of this anxiety. Many things which seem to be independent entities, processes, or what not, are seen to be, from the standpoint of the theory of anxiety, various techniques for minimizing or avoiding anxiety in living.

For years and years psychiatrists have been struggling to cure this-and-that distortion of living as it came up in patients. Some of these distortions have proven extraordinarily resistant. I am inclined to say, when I don’t feel that too many people are hanging on my words, that some of the cures have probably just been the result of mutual exhaustion. And why has this been so? Well, the present indication is very strongly in the direction of the wrong thing having been tackled. There was nothing particularly wrong with that which was allegedly to be cured. It was a pretty remarkable manifestation of human dexterity in living.

Then what was the trouble? Was it susceptibility, vulnerability to anxiety which called out this alleged symptom? When you begin to loo...

Table of contents

• Cover Page
• Half Title Page
• series Page
• Title Page
• Copyright Page
• Title Page
• Copyright Page
• Contents
• Editors’ Preface
• Introduction, by Mabel Blake Cohen, M.D.
• Part I Introductory Concepts
• 1. The Meaning of the Developmental Approach
• 2. Definitions
• 3. Postulates
• Part II The Developmental Epochs
• 4. Infancy: Beginnings
• 5. Infancy: The Concept of Dynamism—Part 1
• 6. Infancy: The Concept of Dynamism—Part 2
• 7. Infancy: Interpersonal Situations
• 8. The Infant as a Person
• 9. Learning: The Organization of Experience
• 10. Beginnings of the Self-System
• 11. The Transition from Infancy to Childhood: The Acquisition of Speech as Learning
• 12. Childhood
• 13. Malevolence, Hatred, and Isolating Techniques
• 14. From Childhood into the Juvenile Era
• 15. The Juvenile Era
• 16. Preadolescence
• 17. Early Adolescence
• 18. Late Adolescence
• Part III Patterns of Inadequate or Inappropriate Interpersonal Relations
• 19. The Earlier Manifestations of Mental Disorder: Matters Schizoid and Schizophrenic
• 20. Sleep, Dreams, and Myths
• 21. The Later Manifestations of Mental Disorder: Matters Paranoid and Paranoiac
• Part IV Towards a Psychiatry of Peoples
• 22. Towards a Psychiatry of Peoples
• Index