HARRY STACK SULLIVAN AND INTERPERSONAL PSYCHOANALYSIS
It is correct (and a great improvement) to begin to think of the two parties to the interaction as two eyes, each giving a monocular view of what goes on and, together, giving a binocular view in depth. This double view is the relationship.
—Gregory Bateson
Without wearing any mask we are conscious of, we have a special face for each friend.
—Oliver Wendell Holmes, Sr.
Interpersonal psychoanalysis was born in the 1920s in the clinical encounter of the American psychiatrist Harry Stack Sullivan with patients on the extreme end of the mental-health continuum: schizophrenics. Sullivan (1892–1949) grew up in rural Chenango County, in upper New York State. He studied medicine in Chicago, in the days when the pragmatist “Chicago School” dominated American intellectual life, particularly the social sciences. At St. Elizabeths Hospital in Washington, D.C., he worked under William Alanson White, who, along with Adolf Meyer, was a dominant presence in American psychiatry and sparked Sullivan’s early interest in working with schizophrenics.
Freudian psychoanalysis had some presence in the clinical thinking and practice of American psychiatry at that time, but the theoretical system that dominated the field was the traditional psychiatric approach to schizophrenia, fashioned by the German psychiatrist Emil Kraepelin in the late nineteenth and early twentieth centuries. Perhaps the most important distinguishing feature of schizophrenia (Kraepelin’s term was “dementia praecox”) is the disconnection from ordinary channels of relationship with other people. Schizophrenics have disordered thought and live in their own world. They adopt postures (like catatonic stupor) and behaviors (like hebephrenic feces-smearing or paranoid rages) that dramatically discourage any efforts by others to reach them. Kraepelin’s approach cast schizophrenia as a neurophysiological disease, a physically based disorder that worsens inexorably over time and ends in total deterioration.
Sullivan felt that these concepts were strikingly inapplicable to his own experience with schizophrenic patients, whom he found to be extremely sensitive and responsive to their interpersonal environment. Although their communications were often oblique and disguised, they were exquisitely aware, often painfully so, of other people.
The kinds of clinical experiences that led Sullivan to begin to fashion an interpersonal approach to psychological processes were reported four decades later by the British psychiatrist R. D. Laing (together with Aron Esterson), who, like Sullivan, and influenced by Sullivan’s work, had come to doubt the traditional understanding of schizophrenic symptomatology as random sputterings of a deteriorating physiological system.
Laing and Esterson (1970) worked with several regressed schizophrenic patients from the back wards of hospitals who suffered from symptoms thought to be intractable and meaningless indications of their deteriorated physiology. A patient they called Maya Abbott, for example, had auditory hallucinations, felt unreal and detached, wooden and withdrawn; she spoke of experiencing herself as a machine rather than a person, lacking any control of her own mind, with her thoughts and feelings being controlled externally by others. Encountered as an individual, Maya could be persuasively understood to be suffering from a spontaneously arising, completely autonomous, deteriorative internal process. Laing and Esterson brought Maya together with her parents and observed how they interacted.
One small part of family interplay seemed particularly relevant to one of Maya’s psychotic symptoms, characteristic of paranoid schizophrenia, ideas of reference: convictions that things going on around you, unrelated to you, are really about you (for example, that events on a television program are personal messages to you).
An idea of reference that she had was that something she could not fathom was going on between her parents, seemingly about her. Indeed there was. When they were all interviewed together, her mother and father kept exchanging with each other a constant series of nods, winks, gestures, knowing smiles, so obvious to the observer that he commented on them after twenty minutes of the first such interview. They continued, however, unabated and denied. (1970, p. 40)
Laing and Esterson were struck by the mystifying impact of Maya’s parents’ quite public and obvious behaviors, perceived by her, yet denied by them.
Much of what could be taken to be paranoid about Maya arose because she mistrusted her own mistrust. She could not really believe that what she thought she saw going on was going on. Another consequence was that she could not easily discriminate between actions not usually intended or regarded as communications, e.g. taking off spectacles, blinking, rubbing nose, frowning, and so on, and those that are—another aspect of her paranoia. It was just those actions, however, that were used as signals between her parents, as “tests” to see if Maya would pick them up, but an essential part of this game the parents played was that, if commented on, the rejoinder would be an amused, “What do you mean?” “What wink!” and so on. (p. 40)
Maya’s behavior, which seemed clearly bizarre and meaningless when she was encountered as an individual, took on obvious, understandable meaning when she was observed in the original interpersonal context within which that behavior had arisen.
Harry Stack Sullivan’s formative clinical experiences in the 1920s were the same as Laing’s in the 1960s. (Laing, of course, had the benefit of Sullivan’s writings, which he acknowledged as the only helpful work on schizophrenia he had found.) To understand psychopathology, Sullivan became increasingly convinced, the individual is simply not the unit to study. Human beings are inseparable, always and inevitably, from their interpersonal field. The individual’s personality takes shape in an environment composed of other people. The individual is in continual interaction with other people. The personality or self is not something that resides “inside” the individual, but rather something that appears in interactions with others. “Personality . . . is made manifest in interpersonal situations and not otherwise” (1938, p. 32), Sullivan suggested. Personality is “the relatively enduring pattern of recurrent interpersonal situations which characterize a human life” (1940, p. xi).
The principle that the field, not the individual, is the most meaningful unit of study sounds simple, but it has profound implications for thinking about personality, psychopathology, and psychoanalysis. From the interpersonal perspective, focusing on the individual without considering past and present relationships wrenches the object of study from the context that makes it understandable, like studying animal behavior by observing an animal in a cage rather than its natural habitat. Sullivan came to feel that human activity and human mind are not things that reside in the individual, but rather are generated in interactions among individuals; personalities are shaped to fit interpersonal niches and are not understandable unless that complex, interactive honing process is taken into account.
Although he began his work with schizophrenics, Sullivan came to feel that less disturbed patients are just as embedded in their interpersonal contexts and that to try to understand them outside those contexts is a serious mistake.
For example, Sullivan described a young man whose life had been centered around a series of “grand passions” for women: “he has fallen deeply in love with one woman after another for years and years past but, shockingly enough, nothing has ever come of it” (1956, p. 46). The patient knew something was distinctly wrong with his approach to relationships, but he had no idea of what it was or how it worked. A traditional Freudian psychoanalyst, using the intrapsychic approach, would generate certain kinds of hypotheses about dynamics inside the patient: The ill-fated romances are likely to be entangled with oedipal dynamics, conflictual wishes to win the mother. The kind of data relevant to testing such hypotheses would include the patient’s fantasies about these women and the patient’s fantasies about his mother. The failed romances would be found to both express and preserve the patient’s tie to the oedipal parent.
Sullivan was interested in very different data. He wanted to know what happens between this man and these women: “there must be something in his relationship with these women—something in the pattern of his behavior toward them—that makes each love object unwilling to continue to be a love object” (p. 47). Whereas the Freudian analyst is looking for repressed wishes and fantasies, Sullivan is looking for unattended interactions.
In the classical analytic setup, the analyst waits silently for the hidden wishes to appear in disguised form in uncensored free associations and then interprets them. In Sullivan’s approach, the analyst actively inquires into interactions; the relevant data will not simply appear, because the patient (without awareness) leaves out what is most important. “So we settle down with this patient and want as much as we can get of what he can recall of the current events in his relationship with the love object” (p. 49).
Sullivan went after details: Who is this other person? How was she selected? What happened? Who said what to whom? When precisely did the emotional climate in the relationship change? For Sullivan to get the data he needed, he had to know more than what the patient thought, felt, and fantasized about. He sought details about what actually happened, and it is only that interactional context, Sullivan suggested, that yields an understanding of the ways the patient was re-creating his fate over and over.
In this case, Sullivan found that
this man works so diligently at investing each of his feminine love objects with rare and desirable qualities which she obviously does not have and devotes so much attention to expressing his profound admiration for these qualities which she does not have that she cannot overlook the fact that she is not the person that he is in love with. (p. 49)
It is only through a highly textured exploration of what was said and done in several of these love relationships that the pattern of subtle rejection, under the guise of great passion, emerged.
He has a way of discouraging each love object about any illusions that she may have that she will do, and he fits the practice to the personality. For example, if the woman is very docile and self-effacing, he will find in her the fine aggressive certainty of herself which is so very dear to him. And if she is quite domineering, then he will find in her an extraordinary consideration for other people’s feelings. (pp. 49–50)
Sullivan was also interested in the past, but not primarily the impulses and wishes of the past, which were, he believed, small segments of larger interpersonal configurations; looking at them in isolation entailed a violent decontextualization that destroyed any possibility of meaningfully understanding them. Rather, he looked at the interactions of the past. In this example, Sullivan placed primary emphasis on identifying something important about what was taking place between the patient and women in the present: he approached women by falling in love with inflated misrepresentations of them. Sullivan would next want to understand the origins of that interaction in the patient’s early history: How did he learn to destroy love in this fashion? Was he loved in this fashion? Were significant others in his early life reachable only in this way?
ANXIETY AND MOTIVATION
Sullivan’s study of interpersonal processes increasingly focused on anxiety as the crucial factor determining the way the individual shapes his experience and his interaction with others.
While other features, such as dramatic and disturbing symptoms, can seem more prominent, Sullivan came to feel that they often are distractions from, and techniques for the management of, underlying points of anxiety. Oscar, a man in his mid-thirties, sought treatment because of a chronic dread that he might be gay, which had tortured him since his mid-adolescence. He had been in psychotherapy before and had seen several other symptoms and problems improve, but his agonizing doubts about his sexual orientation had remained. He had a great many relevant notions about his sexuality, his fears of intimacy, and his family dynamics, but they did little to dispel his concerns.
The interpersonal analyst became interested in the last time these thoughts had arisen. Oscar had spent the previous weekend with an old girlfriend. The first night, they had made passionate love; the next morning, he approached her sexually again and she declined. “How about a blow job then?” was his response, and she became angry. He explained that oral sex had long-standing political dimensions between the two of them. She considered his request a demand for submission. He felt his support of feminism and her interests in general were above reproach and sex should be something free and open between them, without concerns of political correctness. He became depressed at the rapid resurgence of their old sexual/political struggle and withdrew. He found himself wondering about a man he had seen the day before at the office. If he were in a sexual situation with this man, would he get aroused? He pictured the man naked and felt a mild degree of excitement. That alarmed him in the now familiar way, and he became caught up in a tense, ruminative preoccupation about whether he was gay and whether he would ever be happy in an intimate relationship with a woman.
From an interpersonal point of view, what is important about this sequence of events is not the sexual content per se, but the way mental content (sexual and otherwise) is moved around in the service of managing anxiety. Upon inquiry, the analyst and Oscar learned that he had felt both elated and anxious following the previous evening’s sexual encounter. Things going well with this woman frightened and confused him. What would happen? Would this mean a commitment he felt ill-prepared to make? In reflecting on his request the next morning for oral sex, it became clear to Oscar that there was an absolute certainty his girlfriend would be antagonized and that their characteristic political debate would follow. The purpose of his request seemed not to draw them closer or obtain sex; the purpose of the request was to create distance. He had been anxious about their intimacy; he was seeking the familiar ground of their distancing conflict. Similarly, he knew that he was capable of being excited by both women and men, and that if he evoked the image of the man and imagined a sexual situation, he would feel a mild degree of arousal. He knew further that that arousal would serve as the basis for self-torture and the by now comfortable confusion he lived in most of the time. The sense of power and success he had felt after the sexual intimacy with his girlfriend had frightened him. His provocative request the following morning helped him rid himself of the anxiety connected to intimacy and potency, and the homosexual reverie further established him securely (even if also anxiously) as unmanly and deferential. Rather than being the causal motivating factor, sexuality seemed rather a means for managing anxiety about closeness and distance, novelty and familiarity.
How do anxiety and its management come to play such a central role in psychopathology? Sullivan introduced a developmental theory in which anxiety is the key pathological factor in shaping the self and regulating interactions with others.
Sullivan portrayed the newborn as oscillating between a state of more or less complete comfort and a state of tension in which needs of various sorts are demanding attention. Most of the tensions that arise for the newborn are not problematic, as long as a reasonably responsive caregiver is present. The baby’s needs are matched by complementary responses in the caregiver. The expression of physical needs for food, warmth, absence of irritation; emotional needs for safety and tenderness; intellectual needs for play and stimulation—all these tend to call out a satisfying reciprocal response in the caregiver, thereby reducing the tension.
Sullivan called these needs integrating tendencies because their essential nature is to draw people together in mutually satisfying ways. The nursing interaction between baby and mother is the most vivid example of the complementarity of integrating tendencies. The baby is hungry and needs to feed. The breasts of the lactating mother are full of milk—she needs to nurse. They are drawn together in a mutually gratifying integration.
These needs for satisfaction generate reciprocity with others not just for the newborn but all throughout life, Sullivan believed; various needs in adults tend to evoke complementary needs in other adults. Given a reasonable amount of patience, flexibility, and tact, various emotional, physical, sexual, and intellectual needs can generate mutually satisfying integrations with others.
In contrast to Freud, Sullivan envisioned human needs as unproblematic in themselves. We are not born with asocial, bestial impulses needing to be tamed and socialized only through great threat and effort, Sullivan argued; rather, we have evolved into social creatures who are wired in a way that draws us into interactions with others.
But if needs for satisfaction operate so smoothly as integrating tendencies, why then are human interactions so filled with dissatisfactions, conflicts, clashes? As Sullivan saw it, the fly in the ointment of nearly all human endeavors is anxiety. Needs for satisfaction arise spontaneously within the baby, but anxiety is something visited upon the baby from the outside.
Sullivan distinguished between fear and anxiety. If a loud noise occurs, if hunger is unaddressed, if tensions of any sort increase, the baby becomes afraid. Fear actually operates as an integrating tendency; as it is expressed in crying and agitation, it draws the caregiver into an interaction that will soothe the baby and address the problem. Anxiety, in contrast, has no focus and does not arise from increasing tension in the baby herself. Anxiety is picked up from other people.
Feeling states are contagious. Someone who is jittery tends to make other people jittery; someone who is sexy tends to evoke sexual feelings in others, and so on. Babies are particularly sensitive to other people’s feeling states, Sullivan believed. Their own state is greatly affected by the emotional tone of the people around them. Sullivan termed this contagious spread of mood from caregivers to babies the empathic linkage.
If the caregiver is relaxed and comfortable, the baby oscillates gently between a euphoric ease and states of tension generated by arising needs, which are more or less smoothly responded to. But what if the caregiver is anxious?
Sullivan believed that anxiety in the caregiver is picked up by the baby and experienced as a formless tension with no focus, no apparent cause. Unlike needs for satisfaction, the tension of anxiety does not serve as an integrating tendency, cannot serve as an integrating tendency, because the potential rescuer from the tension of anxiety is the very person who has caused it in the first place.
Consider a devoted caregiver who is worried about something altogether unrelated to the baby. The baby picks up the anxiety and experiences it as a tension, demanding relief. He cries, in the same way he responds to tensions created by various needs for satisfaction. The caregiver moves toward the baby, concerned and hoping to comfort him. But as she moves closer in her effort to soothe, the caregiver also brings her own anxiety closer to the baby. Most likely she is even more anxious now, precisely because of the baby’s distress. The closer she gets, the more anxious the baby becomes. Unless the caregiver can find a way to pull both herself and the baby out of their anxious state, the baby experiences a snowballing tension with no possible relief.1
In Sullivan’s vision, anxiety becomes a nightmarish condition for the infant that has a profound impact on early experience. Not only is anxiety stressful, frightening, and inescapable in itself, it also operates as a disintegrating tendency with respect to all the infant’s needs for satisfaction. When the infant is anxious, she is unable to feed, to cuddle, to sleep. Anxiety in adults likewise interferes with thinking, communicating, learning, sexual performance, emotional intimacy, and so on. Anxiety, for Sullivan, is the monkey wrench in a complexly evolved, otherwise harmonious system of interpersonal and social mutual regulation.
Because anxiety is so strikingly different from other states, Sullivan believed, the first basic differentiation in the infant’s experience is not between light and dark, or between mother and father, but between anxious states and nonanxious states. Because it is the caregiver who generates the anxiety in the child, Sullivan terms this first distinction “good mother” (nonanxious) states vs. “bad mother” (anxious) states. Experiences with various caregivers (not just the biological mother) when they are anxious are all joined together into the child’s experience of “bad mother”; experiences with various caregivers when they are not anxious (and therefore able to respond effectively to needs for satisfaction) are all joined together into the child’s experience of “good mother.” The fact that these are actually different people is irrelevant to the infant, for whom the only important distinction is between anxious and nonanxious. Similarly, the fact that each of these people is sometimes anxious and sometimes not anxious is irrelevant; the difference in their impact on the child in these two states is so dramatic that they are, as far as the child is concerned, two different people.
Sullivan assumed that the infant originally experiences his states of mind passively; whether “good mother” or “bad mother” reigns, with their enormously different impact on him, is beyond his control. Little by little, however, the infant gains control over his fate. He begins to learn that he can predict whether it is “good mother” or “bad mother” who is approaching. Facial expression, postural tension, vocal intonation become reliable predictors of whether the baby will find himself in the hands of someone who calmly responds to his needs, or at the mercy of someone who draws him into a maelstrom of unrelievable stress.
A second crucial step comes with the child’s discovery that whether “good mother” or “bad mother” appears has something to do with him. He arrives at the startling realization that some of his own activities and gestures make his caregivers anxious, while some of his activities and gestures have a calming effect and elicit approval. Of course, putting a slowly evolving process into language like this is very misleading. Sullivan envisioned a gradual building-up of connections.
Some of the child’s activities (e.g., touching the genitals or fussing) may make a particular caregiver anxious; that anxiety is communicated to the baby, who then begins to connect touching the genitals or fussing with an anxious state of mind. Some of the child’s activities (e.g., resting quietly) may make a particular caregiver relax and generate approval; that approval is likewise communicated to the baby, who then begins to connect resting quietly with a peaceful, approved-of state of mind. In this way, Sullivan speculated, different areas of the child’s experience take on different valences. The activities of the child that tend to generate approval (and therefore, through the empathic linkage, a relaxed state in the child) are organized together under a generally positive valence (“good me”). The activities of the child that tend to generate anxiety (and therefore an anxious state in the child) are organized together under a generally negative valence (“bad me”).
Activities of the child that provoke intense anxiety in the caregivers (and therefore, through the empathic linkage, intense anxiety in the child) are of a different order. Sullivan believed that intense anxiety is extremely disruptive and generates points of amnesia for the experience immediately preceding it. Thus activities that regularly provoke intense anxiety in the particular surrounding adults are not experienced as versions of the child at all—they become “not me,” dissociated states which are not organized into any form that the child, and later the adult, recognizes as himself.
The Self-System
The final and crucial step in the child’s assumption of some degree of control over his own experience comes with the realization that he can shape his own activities in a direction which will make it more likely that “good mother” will appear and less likely that “bad mother” will appear. A more active set of processes (the self-system) develops, allowing access to awareness largely to “good me” and excluding “not me” altogether. The self-system steers activities away from gestures and behaviors associated with rising anxiety in the child’s caregivers (and therefore also in himself) and toward gestures and behaviors associated with decreasing anxiety in his caregivers (and therefore also in himself).
Gradually and incrementally, but inevitably, the self-system shapes the child to fit into the niche supplied by the personalities of his significant others. The myriad potentialities of the child become slowly and inexorably honed down, as he becomes the son of this particular mother, the son of this particular father. The outline of the child’s personality is sharply etched by the acid of the parents’ anxiety.
Sullivan regarded the self-system as conservative but not fixed: As the child develops, the self-system selectively steers experience in the direction of the familiar, the known. Because anxiety in infancy is so nightmarish in its impact, we all become frightened of, phobic about, anxiety itself. If there has been a great deal of anxiety in the first years of life and the self-system has developed rigid controls, genuinely new experience is virtually precluded.
Nevertheless, Sullivan felt, the major developmental epochs of childhood and early adulthood are precipitated by the emergence of a powerful need for a new form of relatedness with others (a new need for satisfaction): the need for peer relations at four or five, replacing the more or less exclusive involvement with adults; the need for a single close friend, the “chum” in preadolescence; and the need for sexual satisfaction and emotional intimacy in adolescence. Each time a new need emerges, the constraints of the self-system are loosened, making possible a new, healthier integration. Old anxieties may be overridden by the force of the new pull toward interpersonal integration on a higher level.
Sullivan never devised a comprehensive theory of development or a theory of healthy functioning. His formulations were explicitly concerned with the development of psychopathology and the response of the self to difficulties in living. Thus his formulations concerning the self all pertain to processes designed to keep anxiety at a minimum. (He termed these antianxiety processes needs for security to distinguish them from needs for satisfaction.) When anxiety is not a threat, the self-system fades into the background; needs for satisfaction emerge and operate as integrating tendencies, drawing the individual into mutually satisfying interactions with others. When anxiety is looming, the self-system dominates: controlling access to awareness, producing interactions that have been successful in minimizing anxiety in the past, selectively shaping the individual’s impressions both of herself and of others she is dealing with.
Like Freud, Sullivan envisioned human experience as playing itself out in a tension between pleasure (Sullivan’s “satisfactions”) and the defensive regulation of wishes for pleasure (Sullivan’s “security”). Yet there are several very basic differences between traditional Freudian theory and Sullivan’s interpersonal approach to motivation, early development, and psychic structure:
Whereas Freud regarded sexuality and aggression as inherently asocial and inevitably conflictual, Sullivan believed that particular areas of experience become conflictual only if they tend to arouse anxiety in significant caretaking others. What is conflictual in one family may work very smoothly to generate mutual satisfaction in another. The source of difficulties is not in the inherent nature of the impulses themselves, but in the response of the human environment.
Whereas Freud regarded the intensity of conflict largely as a property of the impetus behind the drives (the amount of libido or aggression one is born with), Sullivan suggested that levels of anxiety in an individual are a direct product of levels of anxiety in their early environment. The more anxious the caretakers, the more areas of experience become tinged with anxiety for the child (there is more “bad me” and “not me”).
Although there is a marked difference in terminology and sensibility between Sullivan’s work and the tradition of Freudian ego psychology, there is some interesting overlap in the ways these two traditions approached theorizing about mind and development. The ego psychologists, like Sullivan, broadened the framework of analytic concern beyond Freud’s focus on the individual mind and its intrapsychic interior to the interactions between the individual and the environment. The ego psychologists, like Sullivan, regarded the vicissitudes of early caretaking and the relative health or character pathology of the caretakers as crucial to the development of the child. However, the ego psychologists, as we noted in chapter 2, built their concepts alongside of or in conjunction with Freud’s drive theory. They viewed mind as built up from two interpenetrating constituents: constitutional drives and an ego shaped through interaction. Sullivan, on the other hand, envisioned mind as thoroughly social. There may be constitutional differences, but the psychological valences and meanings they accrue are all derived from the way significant others respond to them.
Security Operations and the Point of Anxiety
Sullivan used the term suave to describe the processes of a well-functioning self-system. Each of us moves through life exquisitely sensitive to rising anxiety, developing complex, extremely rapid, covert security operations to steer us from points of anxiety back onto familiar footing. One of the central techniques of the interpersonal psychoanalyst is to increase awareness of the operations of the self-system by asking questions and encouraging self-reflection, so that crucial, rapid sequences can be observed, understood, and, through understanding, gradually altered.
The use of detailed inquiry marks a stark contrast between Sullivan’s clinical methodology and that of Freudian psychoanalysis. In the strictest applications of the classical method, the analyst does not ask questions, and within the logic of the classical model, this is as it should be. The patient’s conflicts emerge within free associations, and free associations need to be uninfluenced by any direction supplied by the analyst. The nondirectedness of the classical method is the central safeguard of the patient’s autonomy and guarantees that the deepest levels of the patient’s conflicts are being accessed. The analyst’s function is to interpret the underlying dynamics embedded in the patient’s free associations, to reveal the latent thoughts hidden therein. Of course, interpretations themselves might be viewed as directives, having an impact on subsequent associations, but it is a clear, intentional and deepening impact, sparse and off-set by long silences, that is clear and intentional. Asking questions gums up and muddies the clarity of the emerging associations without making clearly identifiable interpretive statements.
Sullivan saw the clinical situation very differently, and this difference reflects important contrasts in understanding the human mind and, particularly, language. In Sullivan’s view, each of us uses language in a largely idiosyncratic fashion. The meaning of words is embedded in the original interpersonal contexts in which they were learned. It takes a long time for one person to understand the real meaning of words used by another person, particularly if what is being discussed involves intensely affective and deeply personal matters. For the analyst to assume she knows what the patient means by the words he is using and to make interpretations based on that assumed understanding is, for Sullivan, to greatly compound confusion and lose any hope of meaningful insight. The only way for the analyst to know what the patient is really talking about is to ask detailed questions. Further, the only way for the analyst to get the relevant information about the situations the patient is describing is to direct the inquiry, at least part of the time. Because of the smoothness through which the self-system steers the person away from the threat of anxiety, a patient can systematically ignore the very details and features of his experience that might be most relevant.
This inattention is clearly evident in Fred, who sought psychoanalysis because he was deeply discontented with his wife; she didn’t seem to understand him, and they fought continually. He thought of her fondly during the day, and would go home from work each evening determined to make his marriage better. Yet despite their best efforts, they would fall into their customary sniping at each other, and Fred soon became discouraged.
The interpersonal analyst would be very interested in the details of what takes place between Fred and his wife. When did the fighting start last night? What does he mean when he speaks of his fondness for her? His discontent? When did Fred notice the change in his attitude toward his wife?
Fred, like most analysands beginning treatment, was a poor observer of his own psychic processes and the full range of his interactions with others. The interpersonal analyst would try to find a way to get Fred interested in those processes and interactions through an individually styled, tactful, detailed inquiry designed to broaden his field of perceptual consciousness.
What happened when he first got home on a particular evening? What sort of mood was he in? How did his wife respond? Who said what to whom? It may take many weeks of detailed inquiry for Fred to become an effective enough observer to be able to pinpoint the crucial moments in their interactions. On the evening in question, Fred and his wife both began with what seemed to be an enthusiasm for each other. She responded to his recounting of his day with an affectionate comment. He noticed the similarity of her comment to her mother’s favorite manner of expressing herself, which he pointed out with some disdain. She backed off and found something critical to say about his family. They were now on familiar ground, settling comfortably into what Sullivan called a hostile integration.
How and why did this shift take place? If one could videotape such an interaction, the camera might pick up a flicker of vulnerability in Fred’s facial expression when his wife responded tenderly to his approach to her, right before he found an opportunity to criticize her. That flicker of vulnerability is a point of anxiety, which, Sullivan suggested, always precedes security operations. Of course, videotapes of family interactions are generally not available to the interpersonal psychoanalyst, so she relies both on the detailed inquiry into outside events and her own experiences in interacting with the patient. The latter (countertransference) would become increasingly important in the interpersonal tradition, as we shall see.
Fred came from a family in which everyone sniped at everyone else from a position of suspicious isolation. He was very comfortable with simmering low-grade hostility. He spent his childhood and adolescence longing for someone he would not fight with, who would understand and accept him. He had many girlfriends, all of whom eventually disappointed him. The early relationship with his wife seemed more promising, but their initial intimacies soon deteriorated into the chronic bickering that drove him into treatment. Moments of tenderness between Fred and his wife make him feel anxious, vulnerable, unprotected. Feelings of tenderness in his original family had been systematically crushed. He had learned to transform any tender impulse (a need for satisfaction) rapidly and unwittingly into a posture of critical superiority, a position from which he felt quite secure and no longer vulnerable.
The interpersonal analyst uses detailed inquiry to slow down and stretch out time. Fred began treatment knowing only that despite his best intentions, he always found himself at odds with his wife. He became aware, little by little, of the way he himself used his critical superiority to push his wife away. He became sensitive to the gradations of his emotional state: his excitement; the way that excitement would turn into an anxious vulnerability; his feeling of security when he arranged things so that he could once again feel comfortably discouraged. The greater awareness of his own security operations made more constructive choices possible.
Sullivan viewed security operations as purchasing a short-term reduction in anxiety at the price of a long-term maintenance of the anxiety-causing situation. Security operations always work. As soon as Fred begins to think his wife is defective, he becomes less anxious; yet in the long run he is stuck with this defective woman. It is their immediate effectiveness that makes security operations so tenacious, amenable to change only through a great deal of hard analytic work. The effectiveness of security operations draws on the same principle as the old joke about the man who snaps his fingers to keep the tigers away. “But there aren’t any tigers around here,” his companion points out. “See how well it works,” answers the omnipotent finger-snapper. Security operations are the self-system’s anxiety-reducing maneuvers for warding off anticipated threats, overgeneralized from earlier interpersonal situations.
The more the patient understands about the workings of the self-system in its efforts to avoid anxiety, the more easily that patient can make different choices, Sullivan believed. The kind of change Sullivan regarded as the goal of treatment has something in common with insight, as Freud understood it. But change for Sullivan was not just conceptual, it was largely perceptual (Bromberg, 1980, 1989), as awareness of both internal processes and also sequences of interpersonal actual events expands. Fred became aware of the ease with which he bailed out of points of intimacy and therefore vulnerability with his wife. To stay in the situation would make him more anxious in the short run but enhanced the chances for resolving his chronic marital unhappiness in the long run. The magic of the finger-snapping (disparagement of his wife), although extremely tempting, came to be understood as a distraction that removed him from the underlying causes of his doubts and unhappiness.
SULLIVAN’S APPROACH TO OBSESSIONALS
Some of Sullivan’s most important contributions were developed in his clinical work with obsessionals, people who tend to be extremely controlling of both themselves and others: stingy, competitive, fastidious, and mired in paralyzing detail. Freud thought about them originally in terms of an anal fixation, as struggling with anal libidinal wishes to mess up, to defy the regimes of toilet training and social cleanliness. He saw their controlling character traits as complex defenses (reaction formations) against, or disguised expressions of, these impulses to mess and defy. Freud later noted the importance of sadism in the dynamics of obsessionalism, and this theme was developed further by Wilhelm Reich. Obsessionals were portrayed as sadistic and power-hungry. Their controlling personality characteristics were understood as an expression of their wish to gain and maintain power over others, or, alternatively, as an expression of efforts to defend against those wishes through deference and obsequiousness.
Sullivan developed a very different understanding. He regarded the obsessional’s need for control not as reflecting anal eroticism, a primary sadism, or concern with power, but rather as a preemptive defense against anticipated humiliation and profound anxiety. Obsessionals, Sullivan found, were raised in families of hypocrites. They were brutalized, either physically or emotionally, while at the same time being told they were loved, that the beating or the humiliation was done for their own good, out of caring for them. Obsessionals, in Sullivan’s view, are deeply confused, mystified. They dread engagements with other people, because they anticipate ending up feeling bad and helpless without understanding why or how. Their power maneuvers are motivated by a need to disarm others, to remove them as threats to their sense of security.
The intrapsychic framework of Freudian psychoanalysis casts the patient as rent by a fierce internal battle. Dangerous impulses are pushing for expression; sturdy defenses are erected against those impulses. The enervating struggle between these internal forces drains energy from possibilities for more satisfying living. The scene of the action is in the patient’s internal world. In Sullivan’s interpersonal framework, the patient is viewed as striving to maintain security in her dealings with others. Past relationships have resulted in deep pain and humiliation; security operations have developed to ward off those dangers in present relationships. The scene of the action is in the patient’s interactions with others.
The analyst’s role, as Sullivan understood it, is to increase the patient’s awareness of her ways of participating in those interactions. The patient begins to notice significant features that she has been studiously avoiding. She comes to appreciate the extent to which her effective efforts to control anxiety in the short run preclude a more satisfying life in the long run. The patient’s relationship with the analyst is often a powerful medium for demonstrating the self-limiting features of characterological security operations. Sullivan pointed to the inevitability of the patient’s enacting important interpersonal patterns in that relationship. But he did not make an exploration of the analytic relationship itself a central feature of his technical approach. That was left to subsequent interpersonal theorists.
The analysis of Emily, an extremely resourceful and extremely obsessional young woman, illustrates how a patient’s pattern of relating can be played out with the analyst. Emily came to treatment because of her difficulties in establishing satisfying relationships with other people, both men and women. She tended to put people off for reasons she did not understand; she found herself irritated and impatient with others. She was talented and successful in many areas of her life, in all of which she worked on her own. She tended to feel that in most of her activities—in her work, around her house, sexually in her bed—she could do it better by herself than relying on others. She was so good at what she did that the wisdom of this approach seemed to be substantiated again and again.
Emily began to pursue the analytic work in her characteristically efficient fashion. She identified problem areas, worked hard to present and explore relevant material, both past and present, and came up with interesting and often helpful insights. The work seemed to be going so well that it took the analyst a while to realize he felt somewhat extraneous to the process, that he felt discouraged by Emily from saying much. When he did speak, Emily would address his contribution and seemed to make good use of it. But he became increasingly aware that he always felt he was interrupting something he perhaps should be staying out of. He became interested in this process and began to pick up the subtle ways Emily managed to convey this impression: the prepared agenda she brought to each session, the focused thoroughness with which she pursued that agenda, the way she eventually worked her responses to the analyst back around to her original concerns.
The analyst asked Emily about her experience at the point at which he began to speak: he had the impression that she always felt somehow interrupted. Emily at first quickly rejected this observation, as if to reassure the analyst that his efforts were appreciated. Eventually Emily was able to reflect more fully on these moments, and she began to realize how at odds she was with herself regarding the analyst’s potential contributions. On the one hand, she came for treatment because she knew she needed help and felt a great regard for the analyst’s professional abilities. On the other hand, she did operate in the analysis as she operated in all interpersonal situations: with a deep conviction that she could do whatever needed to be done better by herself. She did feel that she had been thrown off the track whenever the analyst spoke. As she was talking about her concerns and offering her associations to various topics, it was if she were chugging along productively. When the analyst began to speak, it meant she had to deal with him, his thoughts, which could only be a distraction from her own focus, her own sense of where she needed to go. Of course, she was there because she wanted to know his thoughts, so she made every effort to listen to and consider them. But without really being aware of it, she felt a powerful internal pressure to work herself free of his thoughts as soon as she could so that she could once again make her customary progress on her own.
What was the paradigm for the security operations Emily and her analyst were delineating in her present patterns of relating? Emily’s parents were both extremely emotional, anxious, intense. The father, a businessman who moved through cycles of great successes and cataclysmic failures, was extremely self-absorbed and had little time to focus on his children. Of Emily’s three siblings, two had gone into the father’s business; their own personal concerns seem to have been swallowed up by the maelstrom generated by the father’s activities and anxieties. Emily’s mother was treated as imbecilic and incompetent. Constantly panicked about the ups and downs of the father’s business activities, from which she was excluded, she continually turned to Emily tearfully for reassurance. Neither parent seemed capable of attending to Emily’s needs; they broke into her world only when they needed something from her.
As these processes in the present and their roots in the past became clearer and more available for Emily to think about, the analyst asked whether she could imagine the possibility that he might introduce a thought that would take her somewhere useful that neither of them had previously envisioned. Of course, Emily could have answered yes reflexively to such a question. But the analytic inquiry into her manner of maintaining security by controlling the access of others to her own thought processes had made her more deeply aware of how she operated. As she thought about that question more reflectively, she became aware of how little she really allowed for the possibility of getting anything terribly useful from anyone else, and of how her self-controlling manner of directing her own experience made such a possibility extremely unlikely. Maintaining security in the present undermined her chances of broadening her security-enhancing network of relationships in the long run.
CONTEMPORARY INTERPERSONAL PSYCHOANALYSIS
The person most responsible for shaping interpersonal psychoanalysis in its contemporary form was Clara Thompson (1893–1958). She had been trained in classical Freudian analysis at the New York Psychoanalytic Institute and had been analyzed in Budapest by Sandor Ferenczi, the most experimental and controversial of the major figures surrounding Freud. Ferenczi broke with Freud over the issue of sexual abuse of children by adults, believing actual incidents to be the cause of neuroses, in contrast to Freud’s emphasis on instinctually based fantasy. Ferenczi also felt the analyst had to be more than a detached observer of the patient’s dynamics; the analyst’s deep and genuine caring was essential to overcome the trauma caused by early abuse.
Thompson found a close compatibility between Ferenczi’s emphasis on the importance of actual relationships, past and present, and Sullivan’s interpersonal theory. To complete the amalgam that Thompson fashioned into her version of interpersonal psychoanalysis she added Erich Fromm’s “humanistic psychoanalysis.” Fromm (1900–1980) had repositioned much of Freud’s account of psychodynamic forces within a broader Marxist conception of history and an existentialist vision of human nature.
Human beings develop different character types at various points in history, Fromm reasoned, because different types of societies require particular types of people to perform specific socioeconomic functions. We are profoundly social creatures who dread isolation above all else; there is thus a tremendous pressure for all people to shape themselves according to social need. The separation of experience into conscious and unconscious realms is determined, therefore, not by the inherent primitivity of instinctual drives, but by the social selection of desirable and undesirable traits from the broad range of human possibilities. In Fromm’s view, the unconscious is a social creation, maintained because of the deep abhorrence each of us has of our own freedom and the social isolation we fear may result from a fuller expression of our authentic, personal experience.2
Thompson wove Sullivan’s interpersonal theory (which he always considered a school of psychiatry, not psychoanalysis) with strands from Ferenczi and Fromm into the loose fabric of interpersonal psychoanalysis, less a comprehensive, integrated theory than a common set of theoretical emphases and a clinical methodology. Two broad developments in the interpersonal tradition from Sullivan’s early contributions to current interpersonal practice greatly reflect the impact of Fromm’s thought.
First, the emphasis has shifted markedly from the past to the present, from the there and then to the here and now. Sullivan placed great importance on the patient’s personal history, suggesting that treatment begin with an exhaustive investigation of the patient’s background and all significant developmental phases. In order to understand what was happening in the current interpersonal field, Sullivan felt, it was necessary for the therapist to have a firm sense of the illusory personifications, shaped in the past, with whom the patient was interacting in the present. A full understanding of a patient’s current security operations depended on the analyst’s knowing how they had come into being in their original interpersonal contexts.
Contemporary interpersonal analysts (like many contemporary Freudians; see chapter 9) have tilted the balance between past and present more toward the present. The concept of “character,” central to the contributions of both Thompson and Fromm, became increasingly important. What mattered was not so much a reconsideration of the patient’s early, formative relationships but the manner in which those relationships shaped an approach to living in the present. The crucial scene of the action was felt to be the patient’s way of integrating relationships with others (and the relationship with the analyst was regarded as the key arena in which this could be observed). A preoccupation with the past was in many cases regarded as a distraction from (sometimes an avoidance of) dealing with real issues taking place in the present between patient and analyst.
In a second and closely related development, the personal experience of the analyst came to be regarded as much more activated by and embedded in the analytic situation; countertransference (the analyst’s personal experience of the patient) was now regarded as a crucial feature of the analytic process.3
Sullivan described the analyst’s way of engaging the patient as “participant observation.” The patient attempts to draw the analyst into his characteristic forms of interaction. The analyst, like a sensitive instrument, uses her awareness of these subtle interpersonal pulls and pushes to develop hypotheses about the patient’s security operations. But Sullivan did not regard it as helpful for the analyst to get deeply personally involved with the patient. The analyst was an expert at interpersonal relations, and her expert status would keep her from getting drawn into pathological integrations. She needs to be aware enough of minor eruptions of anxiety within herself to avoid engaging in security operations of her own. The competent analyst would not need anything interpersonally from the patient and therefore would have no strong or turbulent feelings for the patient.
Contemporary interpersonal analysts tend to position the analyst differently. The patient’s interpersonal gambits are regarded as powerful inducements to join the patient in his relational patterns. The analyst is regarded as having interpersonal needs, anxieties, and security operations that are inevitably evoked in interactions with the patient. Because the present is given relatively more weight than the past, the analyst is seen less as a semidetached observer of the patient’s operations and more as a full participant in interpersonal patterns they create and maintain together.
Edgar Levenson (1972), the most influential of contemporary interpersonal theorists, has used the term isomorphic transformations to describe the way the same fundamental interactional patterns that constitute the patient’s personality are repeated in all important areas of his life: in the past, in current relationships outside the analytic situation, and in the analytic relationship itself.
Let us reconsider Emily’s treatment from a more contemporary interpersonal perspective. We had noted that she had learned, in her relationship with her parents, that other people were not likely to contribute anything positive to her experience, but required careful handling and deflecting. The analyst was able to describe to Emily her characteristic mode of operating with others and the way it functioned at cross-purposes with her seeking help from the analyst. But how did the analyst arrive at this understanding?
The important relationships in Emily’s life all reflected the same pattern. She kept her parents, her close friends, her boyfriends at a measured distance from the center of her life: her own intense, isolated productivity. She would check in with others, ascertain what they seemed to need from her, and provide it effectively. She tended to regard the men she became involved with as excessively dependent and clingy, and, according to her descriptions, they indeed seemed to be. She experienced everyone she was involved with as somehow wanting a great deal from her and was proud of her facility for being helpful to them. She was always genuinely surprised when lovers or friends broke off relationships with her because they somehow felt a lack of commitment on her part.
The analyst experienced himself as being treated by Emily with officious respect. Her job involved periodic, unplanned trips out of town, necessitating occasional phone calls to cancel and reschedule sessions. Returning Emily’s phone calls entailed dealing with her secretary, who handled the analyst the way she handled Emily’s clients, properly guarding the time of her important employer, with a slight air of condescension toward those who would intrude upon it.
As noted above, the analyst felt Emily could drive the sessions along largely on her own. Nevertheless, he generally found some way to engage her that seemed productive. What he began to notice, however, was an odd discontinuity between his experience at the end of each session and the beginning of the next. He would generally end sessions with a sense of accomplishment and connection with Emily. On her return for the next session she always seemed somehow remote and a bit perplexed about what she was doing there. She often had no memory of the previous session and would sometimes begin by saying something like, “Well, what shall we talk about today?” as if arriving at a meeting whose agenda was organized by someone else. When it was established that the analyst did not having anything to propose, it became apparent that Emily invariably did have something to work on, and worked productively. This way of beginning sessions increasingly struck the analyst as having an odd, almost ritualized quality, the effect of which was to create the impression that she was meeting the analyst for the first time.
The analyst became increasingly aware of several features of his experience of Emily. Despite his efforts to maintain his professional dignity, he felt put off by the way Emily and her secretary treated him, by the continual reminders that her time, indeed, her very existence, was more important than his. He also became aware of a subtle but increasingly discernible pressure to make himself useful to Emily, to break into her self-contained labors, to be important to her. He began to realize that the ritualized beginnings of sessions and the discontinuity in emotional connectedness between one session and the next were designed to negate him and his impact. It was as if the value of his previous efforts had evaporated, and he had to begin all over again.
These self-observations and reflections led the analyst to an understanding of Emily’s patterns of interacting with others. She was handling the analyst in the same manner she handled others: she expected nothing terribly useful, discerned what he needed, took care of that, and went on her way. The analyst was able to use his reactions to Emily (the countertransference) as a source of hypotheses about the ways she was structuring her relationship with him along characteristic lines.
The analyst began to describe his sense that Emily kept him at a distance, let him contribute only reluctantly, and had dispersed his input by the time she returned for the next session. He of course did not lay this on her all at one time, but rather, little by little, with what he felt was a sympathetic regard for her underlying anxiety and the historical need for these security operations. Emily responded in two ways: Sometimes she was hurt and genuinely puzzled about how the analyst could possibly feel diminished by her when she had been so conscientious in her efforts as a patient. Sometimes she reacted in an “understanding” and concerned fashion, as if to reassure the analyst that he really had something to offer. It gradually became apparent that there were many ways that Emily experienced the analyst as similar to her friends and lovers—as someone who needed to feel wanted, was excessively demanding, and needed reassurance.
How should we understand Emily’s beliefs about the analyst’s vulnerabilities and the necessity for her careful handling of them? Were they transference? In the classical Freudian model they would be considered temporal displacements, pieces of the patient’s history infused with sexual and aggressive aims that were superimposed on the present experience with the analyst. Sullivan would understand them similarly as displaced fragments of earlier interpersonal integrations, sensed by the analyst through his own participation in the present.
A contemporary interpersonal analyst would begin with the assumption that Emily’s beliefs about the analyst were likely to be grounded in her actual interactions with him in the present. Although shaped according to the patterns derived from the past, the patient’s transference is seen as a living reaction to the analyst’s actual presence and behavior, and the analyst’s countertransference is seen as a living reaction to the patient’s actual presence and behavior.
Within this frame of reference, Emily’s lofty self-sufficiency and productive superiority have had an inevitable impact on the analyst’s experience with her, undermining his sense of what he had to offer. He tried to deal with his own anxiety by pressing to find an opening into her solitary labors, to make himself useful. She experienced this pressure in him the way she experienced pressure for contact in the people around her—as a needful demand for her to make the other person feel reassured so that she could get on with her important activities.
From the point of view of the Freudian and classical interpersonal traditions, the analyst’s emotional involvement in these interactions with Emily reflected a departure from what the analyst should be doing: observing and then either interpreting or asking questions from an emotionally neutral position. From a contemporary interpersonal point of view, there is no emotionally neutral position. The analyst will get caught up in the patient’s dynamics no matter how hard he tries not to. The very idea that he might be free of the interactional mix itself is a problem, because it blinds the analyst to his own involvement and requires the patient to collude in that denial. Thus if Emily’s analyst was not aware of the extent to which she had gotten under his skin, he would be likely to make interpretations or ask questions that had a punitive, retaliatory, or beseeching quality. Emily in turn would be likely to experience the interpretations or questions in precisely that way. Because Emily was convinced that the analyst, like everyone else she was close to, was exceedingly vulnerable and needy, this would be the last thing in the world she would want to talk about. She believed it to be true, and therefore had to believe that the analyst would not want to be confronted with it. If the treatment continued, it would be built on a collusion between analyst and analysand, an implicit agreement to pretend that what they were understanding in the patient’s relationships with all the important figures in her life was not happening between them.
In the contemporary interpersonal framework, the analyst assumes that, despite his best intentions, he and the patient will end up playing out the characteristic dynamic patterns of the patient’s inner life. As these patterns are identified in other relationships, the analyst looks for the ways they are also emerging in his experience and in the interaction of the analytic relationship.
What does the analyst do with this more interactive perspective? There are several possibilities. Levenson speaks of the analyst gradually “resisting transformation.” Understanding the ways the analyst has been induced into the repetitive scenario in itself opens up the possibility of a different sort of presence with the patient. As the analyst reflects on and becomes clearer about his own participation, that exploration itself creates a different form of participation. Some of that exploration may go on solely in the mind of the analyst. Some of it may involve confronting the patient with her side of the interaction. Some of it may entail a judicious disclosure to the patient of the analyst’s own experience.
In working on these issues with Emily, her analyst had a fantasy that he ended up sharing with her, which became a point of reference for the two of them. He told her he imagined himself as a door-to-door salesman of vacuum cleaners who would show up every few days and try to interest her in his product. She was always surprised to see him, and treated him as if they had never met before. Despite her skepticism, he demonstrated his cleaner and she was interested. He should come back again, she suggested, but when he did, she acted as though he was arriving for the first time, and they would begin all over again. Meanwhile, she was getting her house cleaned.
What was at stake in acknowledging the possibility that the analyst might actually help her? Did it involve a concession that her house was dirty? A humiliating and dangerous admission that she cannot do everything herself? If she exposed herself to the unfamiliar dependence on another’s help, did she fear being enslaved forever, either by her own needs or by having to reciprocate and take care of the other in a total and terrifying fashion? Could she sustain the uncertainty at the point of anxiety long enough to allow for something else to happen? These are the kinds of questions that characterized subsequent analytic inquiry.
A rich set of controversies concerning technical implications and clinical options has been generated by the interpersonal view of the analytic process in which the analyst’s participation is taken more fully into account. We will consider these issues further in chapter 9. It should be noted here that there has been a broad movement across all the major psychoanalytic traditions in the direction of a more interactive approach to the analytic situation. The interpersonalists have served, in effect, as pioneers who opened up a radical (and still controversial, undeveloped, and problematic) conceptual territory that other settlers have moved into at a more cautious pace.
Sullivan’s work has been prescient with respect to other recent trends in psychoanalytic thought and contemporary intellectual culture. Psychoanalysis has played a major role in the development of a complex, decentered, contextualized understanding of what it means to be a person.4 We noted in chapter 1 that Freud’s exploration of unconscious processes challenged the belief, held for centuries, that the mind is transparent to itself, and that conscious experience is the center of initiative and meaning. Although written in a very different technical language, Sullivan’s work represents a radical extension of that theme. The person one takes oneself to be, the self-system, is a construction, Sullivan suggested, whose purpose is to invent illusions to dispel anxiety.5 Although we experience ourselves as having a self as a quasi-object inside us, we partially construct ourselves variably through memories and anticipations in the moment, depending on the interpersonal context we find ourselves in. Although we experience ourselves as singular, we actually operate through multiple self-organizations that are keyed in to experiences of the other(s) with whom we find ourselves interacting.
In contrast to Freud’s notion of the self as organized vertically, with conflictual areas buried by repression, Sullivan introduced a vision of the self as organized and partitioned horizontally, with incompatible areas separated through dissociative processes. (See Bromberg, 1991, 1993, for a recent development of this approach to the self.) This understanding of self as decentered, multiple, and contextualized is central to the ways subjectivity and experience have been explored in many areas of contemporary philosophy, literature, and social criticism.