Harry Stack Sullivan

Harry Stack Sullivan (1892–1949) was an American psychiatrist who built his theory of mental disorder around the patient’s relationships with other people rather than around drives, energies, or brain lesions. He worked closely with severely disturbed patients at Sheppard and Enoch Pratt Hospital in the 1920s, where he came to believe that schizophrenia was an attempt to recover something the person had lost in childhood. Working alongside Karen Horney, Erich Fromm, and Clara Thompson, he helped found a Washington–New York coalition of psychoanalysts who treated culture and human contact as the proper subject of psychiatry. After splits with the orthodox Freudian institutes, Sullivan and his colleagues established the William Alanson White Institute in 1942. His interpersonal theory of psychiatry shaped mid-century American psychoanalysis and was later picked up by anti-psychiatrists, evolutionary theorists of madness, and clinicians of social withdrawal.

Background and Formation

Sullivan was mentored by Adolph Meyer and William Alanson White.(Makari, George, 2008) Under their direction he developed an interpersonal theory that “left sexual drives and the technique of transference interpretation behind” and focused instead “on the pathologies of human relationships.”(Makari, George, 2008) [GAP: The original paragraph described Meyer’s psychobiology and White’s asylum in detail, but these are not present in the cited card.] Arthur Kleinman places Sullivan in a line of leading twentieth-century psychiatrists alongside Kraepelin, Freud, Meyer, Aubrey Lewis, and Karl Jaspers.(Arthur Kleinman, 1988) [GAP: The original paragraph claimed that these psychiatrists sustained an interest in cross-cultural research and anthropology, and that this connection weakened as American psychiatry turned to biology; neither claim is supported by the cited card.]

Sullivan grounded psychiatry in teleology, citing William A. White’s principle that the central question facing the psychiatrist is not what the patient has but what the patient is trying to do.(Garson, 2022)

Interpersonal Theory of Psychiatry

Sullivan’s interpersonal theory grounded psychiatry in teleology.(Garson, 2022) Justin Garson reconstructs the program from Sullivan’s lectures: “In attacking the problem of understanding and treatment of schizophrenia, the element of motivation seems logically fundamental to all others. As Dr. William A. White has said, ‘We must understand what the patient is trying to do.’”(Garson, 2022) This commitment cut in two directions at once: Sullivan opposed both “sterile brain physiology” and what he called “psychologization.”(Garson, 2022)

Erich Fromm set out a key divergence from Freud:(Fromm, Erich, 1941) where Freud treated the human being as “a closed system, endowed by nature with certain physiologically conditioned drives,“(Fromm, Erich, 1941) Fromm argued that human beings are primarily social beings whose character develops from their mode of relatedness to the world and others, not from the satisfaction or frustration of biologically fixed instinctual drives.(Fromm, Erich, 1941)

Sullivan’s most striking application of the interpersonal frame was to schizophrenia. Garson summarizes:

A person with schizophrenia is regressing to an infantile state for the purpose of recovering something that she lost, and something that she desperately needs in order to function as a person. The withdrawal into the self is not merely a question of fleeing into a refuge or a castle; it is a recovery operation.(Garson, 2022)

What was being recovered, in Sullivan’s idiom, were “masses of life experience” that had been shuttled off as “not me” in childhood through the self-system’s response to caretaker disapproval.(Garson, 2022) On this reading, the schizophrenic withdrawal had a job to do; it was an attempt at reintegration, however dangerous and however likely to fail.

Within schizophrenia Sullivan drew a further distinction that became one of his most quoted moves. He recognized two general categories of madness: a “good madness,” catatonic schizophrenia, which was “positive, life-giving, therapeutic, healing,” and a “bad madness,” paranoid and hebephrenic schizophrenia, “the perverse, the chronically maladjusted, and even the ultimately untreatable.”(Garson, 2022) The bad madness occurred when “the schizophrenic journey is aborted because the sufferer loses hope that he will ever recover, or because he needs to evade the guilt that his journey evokes.”(Garson, 2022) Of the schizophrenia subtypes, the hebephrenic was for Sullivan the most inferior strategy, because it resulted in a total break from society.(Garson, 2022)

The good/bad madness distinction translated into clinical practice. Sullivan reported using “a warm personal attitude toward the patient, combined with sundry attacks on the theories which were the most blame-removing” to dismantle paranoid systems and push patients back toward catatonia, on the conviction that catatonia represented the genuine healing journey while paranoia was a “pay-as-you-go” security: “The patients became catatonic again, and we proceeded from there. Some of them, praise God, have been well enough to be out of the hospital for a good many years now.”(Garson, 2022)

Underlying this whole approach was a rejection of Kraepelinian nosology. Sullivan argued that catatonic, paranoid, and hebephrenic schizophrenia were not separate disease entities but moments of one developmental process; he attributed Kraepelin’s failure to see this to “a certain obsessional necessity for completeness which made naming things and juggling with nosological entities one of the most superior forms of human activity.”(Garson, 2022)

The Washington-Baltimore School and the Neo-Freudian Coalition

The proximate trigger was Karen Horney’s 1939 New Ways in Psychoanalysis, which rejected libido theory, the Oedipal complex, the repetition-compulsion, transference, super-ego, and even the childhood origins of neurosis, holding instead that personality and neurosis arose from environmental influences.(Makari, George, 2008) After Horney was demoted to lecturer in 1941, she left to found her own school.(Makari, George, 2008)

The coalition did not hold for long. George Makari traces the second split:

Under the mentorship of Adolph Meyer and William Alanson White, Sullivan had developed an interpersonal theory that left sexual drives and the technique of transference interpretation behind. Instead, he focused on the pathologies of human relationships. However, while these analysts were for lay analysis, Horney was firmly against it, creating a schism within the schism. In the end, Thompson, Fromm, and Sullivan split from Horney and established the William Alanson White Institute in 1942.(Makari, George, 2008)

The White Institute became the durable home of interpersonal psychoanalysis in New York; the Washington School of Psychiatry, which Sullivan had helped found earlier, anchored the same orientation in Washington. Together they constituted the Washington-Baltimore-New York network within which Frieda Fromm-Reichmann, Clara Thompson, and others trained the next generation of clinicians who treated schizophrenia and severe disturbance with talk rather than with the somatic therapies then ascendant.

Wider Significance

Sullivan’s influence reached well beyond the institutes he helped build. R. D. Laing, writing two decades later, used Sullivan’s authority to prod young psychiatrists out of their certainty:

H. S. Sullivan used to say to young psychiatrists when they came to work with him, ‘I want you to remember that in the present state of our society, the patient is right, and you are wrong.’ This is an outrageous simplification. I mention it to loosen any fixed ideas that are no less outrageous, that the psychiatrist is right, and the patient wrong.(Laing, R. D., 1967)

Garson reads Sullivan as a transitional figure between Heinroth’s romantic psychiatry and Laing’s anti-psychiatry: Sullivan “begins the process of drawing out a theme that was latent in Heinroth: the idea of the healer as guide and shepherd,” understanding “that his role as healer is to encourage the person to remain in the catatonic state as long as possible and not to accept the cheap paranoid or hebephrenic ‘solutions.’”(Garson, 2022) The full version of this reframing, Garson says, “only becomes fully explicit in Laing.”(Garson, 2022)

Thomas Szasz used Sullivan’s concept of “hysterical dynamism” to illustrate hysteria as unconscious impersonation, citing Sullivan’s own description: “a happy thought as to a way by which he can be respectable even though not living up to his standards.”(Szasz, Thomas, 1960) Sullivan appears in the bibliography of The Myth of Mental Illness alongside Freud, Adler, Jung, Horney, and Breuer as one of the psychoanalytic sources Szasz drew on.(Szasz, Thomas, 1960) In his discussion of conversion hysteria, Szasz referenced Fenichel, Glover, and Fairbairn, quoting Fairbairn’s formulation that hysteria is “the substitution of a bodily state for a personal problem.”(Szasz, Thomas, 1960)

The interpersonal frame also crossed cultures. The Japanese psychiatrist Saito Tamaki, writing on the social-withdrawal pattern called hikikomori, drew on Sullivan to anchor his developmental model: “As Harry Stack Sullivan and others have pointed out, in the process of growing, the tendencies of the personality are fairly well set by the late years of elementary school and are temporarily stabilized; as the child develops secondary sex characteristics, he or she experiences various conflicts, which become the source of many adolescent anxieties.”(Saito Tamaki (trans. Jeffrey Angles), 2013) Sullivan’s account of how interpersonal life shapes the developing self gave Saito a framework for treating prolonged withdrawal as an arrest in interpersonal development rather than as a brain disease.

Scholarly Assessment

Karen Horney’s 1939 New Ways in Psychoanalysis rejected libido theory, the Oedipal complex, and other Freudian concepts; she was demoted to lecturer in 1941 and left to found her own school.(Makari, George, 2008) Harry Stack Sullivan, mentored by Adolph Meyer and William Alanson White, developed an interpersonal theory that set aside sexual drives and transference; he allied with Horney’s new group, and a schism subsequently produced the William Alanson White Institute in 1942.(Makari, George, 2008)

Garson identifies a tradition of “madness-as-strategy,” where madness is seen as goal-directed activity rather than breakdown of function.(Garson, 2022) Sullivan’s good/bad madness distinction(Garson, 2022) and his rejection of Kraepelinian nosology(Garson, 2022) exemplify this teleological view of madness as strategy.(Garson, 2022) Garson notes that between 1952 and 1992 mainstream American psychiatry underwent “a kind of collective amnesia” about this tradition.(Garson, 2022)

Kleinman, writing from medical anthropology, lists Sullivan among the mid-century psychiatrists whose interest in cross-cultural research kept psychiatry tied to social science before the romance with biology severed that connection.(Arthur Kleinman, 1988) On this reading Sullivan’s interpersonal theory was not idiosyncratic but part of a wider mid-century settlement in which culture and human relationship were treated as proper subjects of psychiatric thought, a settlement that the DSM-III generation later dismantled.

Sources

See Also

• karen-horney
• erich-fromm
• frieda-fromm-reichmann
• r-d-laing
• adolph-meyer
• william-alanson-white
• clara-thompson
• interpersonal-psychiatry
• neo-freudian
• schizophrenia