Book Review: Harry Stack Sullivan - Interpersonal theory and psychotherapy

* Harry Stack Sullivan - Interpersonal theory and psychotherapy by F. Barton Evans 111, London and New York, Routledge. 1996 241pp

With the beginnings of a more comprehensive set of writings from existentially oriented theorists in the European tradition (Cohn 1997, Spinelli 1994, van Deurzen-Smith 1997), the arrival of this text outlining Harry Stack Sullivan's work is opportune. Some years ago I tried to read Harry Stack Sullivan but found his writing something what dissembled and not easy to follow or understand. I remember feeling slightly fogged which accompanied other feelings that Sullivan's work was to be noted and that he was communicating something interesting and less clinically sterile than orthodox psychiatry seemed to be.

I therefore was pleased at this opportunity of reviewing this book with the author's stated purpose to 'recollect' Sullivan and 're-introduce' his work to a 'modern audience'. Books surveying the depth and breadth of Sullivan's work are, to my knowledge, few and far between. Barton Evans, indeed, hopes that this book "will serve as a road map to navigate through some of Sullivan's denser ideas, with the hope of bringing good things to light." So, how far does he succeed in this respect ?

The book is organised into 3 parts:

Part 1 entitled 'Historical Perpectives' attempts to establish Sullivan's place in 'modern psychoanalytic theory and psychology". A brief biography of Sullivan is included with an emphasis on the social context of America in which his career, ideas, and personality developed. Sullivan's work of the 1920's-1940's seriously challenged the validity of Freud's structural model - his emphasis on the role of culture and society as determinants of personality development was perceived by mainstream psychoanalytic writers as to totally disregard the intrapsychic. Readers of this journal, however, are likely to find attractive Sullivan's view that human experience

is a dynamically unfolding interaction between environmental influences and the internal meaning system of the individual which modifies perception and responses to these external experiences. Sullivan was interested in the way a person interprets his or her experience i.e. what the experience means to the person. What is of influence are the ways a person comes to know the world, through the formulation of a set of assumptions, ideas, and fantasies about people and the self, which are based on developmental experience; these he termed 'personifications'.

Sullivan believed that there was more than enough to learn from the patient's description of his or her own experience and perception of the world without resorting to speculation about unconscious fantasy. His emphasis was not the individual and the workings of internal psychic mechanisms, but the individual in his or her interpersonal world and the dynamisms of "energy transformations" between persons. It is interesting therefore that the author refers to Sullivan as a "psychodynamic theorist", given that leaning toward an existential/ phenomenological orientation; and this together with Sullivan's own criticism of the tendency in psycho-analysis to rely on interpretive, inferential constructs over the patients experience. He believed that experience is not organised through noetic processes, such as internalization, incorporation and introjection, but through demonstrable, knowable processes. These processes were the processes of human learning. Sullivan was seriously opposed to the idea of the unconscious-as-place with knowable contents, but believed, however, that covert processes eg. "selective inattention", "dissociation" , do exist. These, however, can only be roughly inferred.

Part 2 of the book entitled 'The Interpersonal theory of Psychiatry' outlines Sullivan's developmental theory which comprises six specific epochs of development. Infancy, childhood, juvenile era, pre-adolescence, early adolescence and late adolescence. The author notes that many of Sullivan's observations about child development have considerable accuracy based on the convergence of his work with later child research findings as well as with Bowlby's attachment theory. Sullivan insisted that the infant must form a sense of secure "interpersonal connectedness" or serious problems would ensue. In keeping with a strong emphasis on cognitive development Sullivan reasoned that the infant formed an increasingly complex elaboration of experience in recall and foresight of interpersonal events which he termed 'personifications". This is the essential way the infant comes to interpret the interpersonal world,

through the formulation of a set of internal assumptions, ideas, and fantasies about people and the self based on interpersonal experience: "The self may be said to be made up of reflected appraisals of others " he believed.

Sullivan's focus on the juvenile and adolescent epochs make for fascinating and, certainly for me at least, experience-near reading. The juvenile era - "the years between entrance to and the time when one actually finds a chum"- through preadolescence roughly coincided with the period of Freud's 'latency'. Sullivan, however, saw the juvenile era as anything but latent: " the first developmental stage in which the limitations and peculiarities of the home as a socializing influence begins to be open to change." The lonely child unable to find any group suffered intense experiences of inferiority which led to elaborations of the "self system" to maintain a fragile sense of self worth. Relationships with peers become paramount in pre-adolescence leading to a collision between the needs for lust, security, and intimacy in early adolescence. Throughout, the experience of and learning from anxiety plays a large role in Sullivan's ideas. His concept of "security operations" to reduce anxiety, though reminiscent of defense mechanisms, are rooted in the interpersonal rather than in the intra-psychic.

Sullivan attempted to formulate what lay beyond the complexities of early adolescence. Late adolescence began with "preferred genital activity". Once the adolescent completed the difficult task of forming a relatively clear sexual identity, he or she was free to work on "the establishment of a fully human or mature repertory of interpersonal relations, as permitted by available opportunity, personal or cultural." Sullivan was, however, by his own admission vague about what it meant to be "fully human or mature." This, for me, is not surprising, for a major problem associate to the conceptualizing of any developmental theory is that it has to suppose an almost idealised ultimate aim, place, or goal and perhaps Sullivan was hesitant about this ?

Part 3 of the book, entitled 'Applications' outlines, firstly, Sullivan's reflections on 'Mental disorder' where he emphasised interpersonal processes rather than symptoms and syndromes. He believed that anxiety, the experience of interpersonal insecurity, and loneliness were the primary cause of "inadequate or inappropriate patterns of interpersonal relations." An excessive experience of anxiety damaged the person's ability to develop a positive "self-concept"" and to anticipate positive co-operation with others. A second chapter, 'Psychiatric Interview and interpersonal psychotherapy' outlines

Sullivan's work on psychotherapy. He developed an approach to psychotherapy that grew directly out of his theories of personality and mental disorder: " a treatment approach which challenged, and deviated markedly from, basic tenets of Freud's psychoanalytic method." The author comments on how Sullivan's fundamental principles about the nature of psychotherapy were not clearly stated (reminiscent of RD Laing) though it must be understood, however, from the vantage point of interpersonal relations.

For Sullivan, psychotherapy was a special instance of interpersonal relationship with the client ( the term Sullivan preferred ) seeking help in altering "inadequate or inappropriate patterns of interpersonal relations, patterns shaped by underlying experiences of anxiety and interpersonal insecurity." In order for interpersonal learning (the goal of psychotherapy as he saw it) to occur, the client needed to be secure in the therapeutic relationship. This could be achieved through "respectful empathic listening" or what he termed "respectful seriousness". He, however, started with the "existential assumption about the general inaccessibility of any personality other than our own... the psychotherapist could never have as direct a knowledge of the client as the psychotherapist with his or her own experience... knowledge of this reality could provide a safeguard against assuming that the therapist's experience was identical to the client's... Sullivan believed strongly that it was more important to understand what an individual's actions and thoughts were intended for, rather than what the observer speculated them to mean."

The author maintains that Sullivan saw the therapeutic relationship as "intersubjective", the therapist's role being one of participant - observation. The presence of the therapist was to be taken into account - the 'objectivity' or 'neutrality' of the therapist was a fundamental misconception and fundamentally Unempathic as it led to a perception of the client as an object to be studied, analysed, and treated by a therapist who lacked the same processes as the client. Of particular importance to Sullivan was the therapist's understanding and management of the client's anxiety, present in the form of the client's expectation and fear of the therapist's disapproval, and interpersonal operations designed to avoid this insecurity. The therapist had an ongoing responsibility for what Sullivan called "integrating the situation", that is, joining with the client to assure, through skilful handling of the relationship, an atmosphere of interpersonal security. His stance alternated between respectful listening and skillful questioning. The therapist should be empathic, respectful, interpersonal and engaged, with all interpretations made

by the client and the therapist being subjected to systematic enquiry and "consensual validation". Sullivan never presented empathy as a technique or even discussed it in much of his writing on psychotherapy. His "empathic connectedness" to his clients "grew more from an existential position arising from his belief that we are simpler ply more human than otherwise and that we shared the same existential conditions of anxiety and isolation in our interpersonal relations." For Sullivan, empathy was a state of being with the client.

What this book portrays well is that Sullivan's theory and work embraced several different approaches at the same time. Could it be said, therefore, that he was the original 'integrative' therapist? Though whilst incorporating an existential/ phenomenological approach towards the meeting with and experience encountered by the client, he was, in a sense, also psychodynamic' in terms of his perception of a self process which he termed the "self system" with covert processes eg. "selective inattention" and "dissociation", which are reminiscent of Spinelli (1994) in his existential/ phenomenological approach to psychotherapy. And further, Sullivan's emphasis on cognitive learning and goal oriented therapy resonates with the currently popular cognitive analytic and behavioural therapy, and also pre-empted the current fashion for short-term counselling and psychotherapy.

It has to be remembered that Sullivan was working some 60 to 70 years ago at the same time as Freud - when a climate of emphasis on natural science prevailed. It is interesting to find Sullivan referenced both by Medard Boss, somewhat dismissively, in 'Psycho-analysis and Daseinsanalysis' and 'Existential Foundations of Medicine & Psychology', and more favourably by R.D. Laing in 'The Divided Self' and 'The Self and Others'. This book, then, arrives at a time of flux when the various schools of psychotherapy are juggling for position and place in a lead up to the statutory registration of therapists. It seems to me that Sullivan's work clearly throws up for us the salient and crucial question of whether the existential/ phenomenological orientation hinged to the philosophical notion of 'intersubjectivity' with a focus on the 'between', can be reconciled with an approach that posits covert inner processes in an individual, even if contingent upon interpersonal experience ? It is of concern to some writers (Cohn 1997) that the words 'existential' and 'intersubjective' are being divorced from their philosophical roots and ultimately are being rendered diluted and meaningless. This needed debate has been explored by Diamond (1996).

As to why Sullivan has been so very much neglected begs many interpretations. This book has certainly provoked me to think and I have found it to be the "road map" that the author hoped it to be. I wholeheartedly recommend it as an essential reader for any one interested in the practice of psychotherapy.

Nick Zinovieff

References

Spinelli, E (1994) Demystifying Therapy, Constable, London.

Cohn, H. W. (1997) Existential Thought and Therapeutic Practice, Sage, London.

van Deurzen-Smith, E. (1997) Everyday Mysteries, Routledge, London.

Diamond, N. (1996) Can We Speak of Internal and External Reality? Group Analysis Vol 29, Sage, London.