Commentary on H.S. SullivanSchulz

Commentary on Transcription of Fragments of Lecturesin 1948 by Harry Stack Sullivan

Applying Sullivans Theory of Anxiety versus Fear

Clarence G. Schulz

The publication of Harry S. Sullivans1948 lecture fragments offers us the possibilityof reassessing Sullivans contributions to psy-chiatry from the distant vantage point of 56years after his death. Of all his concepts sub-sumed under his term interpersonal, I shall fo-cus on what I see as the most overlooked semi-nal contribution; namely, his concept ofanxiety. Psychotherapeutic technique derivedfrom this formulation of anxiety will occupythe major portion of my commentary.

The authors account of these lecturesbrought back memories of my having attendedSullivans final three lectures at the WashingtonSchool of Psychiatry in the last quarter of 1948.He died in Paris the following January. The lec-tures were held at the Federal Security Agencybuilding in Washigton, DC, and I happened toride up in the elevator with Sullivan, who wastalking with Dr. Alfred Stanton, one of hisprotgs. Sullivan appeared tired, thin, andfragile as he complained about the time adjust-ment for him in his flights to Paris as part of hisactivities on behalf of the World Health Orga-nization. He was describing what we todaywould call jet lag, only this was before we hadjet engines. The lecture room was packed.Sulllivan was at his peak of charismatic leader-ship of the Washington School. After gettingout his white cigarette holder, he exchanged hisregular eye glasses for yellow tinted glasses

since he was preparing to read from a manu-script typed on white paper. (Some readers ofPsychiatry will recall that the journal was formany years printed on yellow paperwhich,according to Sullivan, made it easier to read insunlight or full moonlight). Changing his mind,and again his glasses, he explained that sincethese lectures were to be published, he wouldnot read but simply speak to the audience. Hiscomments were laced with scathing remarks asasides. In one example, after describing what tohim was a particularly inept intervention on thepart of a therapist, he added, and they chargefifteen dollars for that.

By now, Sullivans contributions havebeen absorbed into the body of concepts in psy-chiatry and psychoanalysis. He was strugglingto articulate, albeit with his own vocabulary,observations that were the concern of his con-temporaries (Erik Erikson, Ronald Fairbairn,Donald Winnicott, Heinz Kohut, and HansLoewald, among others), who were trying tomake sense out of the same clinical phenomena.The patient as located in a social field, includingdevelopmental experience, therapist, family,and treament milieu, were all part of his andtheir concerns. Each had his particular slant onthings. Sullivans concept of the psychiatrist asparticipant observer is now an accepted con-cept in understanding countertransference.While most of his ideas have been integrated

Psychiatry 69(2) Summer 2006 110

Clarence G. Schulz, MD, is Emeritus Supervising and Training Analyst, Washington Psychoana-lytic Institute; Clinical Professor of Psychiatry, University of Maryland School of Medicine; Assistant Pro-fessor of Psychiatry, Johns Hopkins Medicine.

Address correspondence to Clarence G. Schulz, 8 Olmstead Green Court, Baltimore, MD 21201.E-mail: cgschulzmd@comcast.net

into contemporary practice, two topics remainrelatively unexplored: anxiety, toward which Idevote the bulk of my comments, and the mi-lieu, which as an area of study has been eclipsedby the era of psychopharmacology. Sullivanpracticed a system of milieu therapy mediatedthrough his staff in his special unit atSheppardPratt Hospital. Subsequently, AlfredStanton and Morris Schwartz (of Tuesdayswith Morrie fame) conducted an extensivesociopsychological study of a patient unit atChestnut Lodge. This work, done in the late1940s, was published as a book, The MentalHospital (Stanton & Schwartz, 1954). Sincechlorpromazine appeared in the early 1950s, at-tention to the effects of the milieu never receivedthe notice it continues to deserve.

It is to be noted that while at Sheppard,Sullivan was the first person to record psychi-atric interviews. He had a stenographer, Mr.Campbell, sit in the interview to make a short-hand record which was later transcribed forSullivans use. We can speculate that Sullivanwould have been interested in psychoactivemedications since he was prescribing alcoholfor some patients in the 1920s while on thestaff at Sheppard. (Schulz, 1978).

Incidentally, Sullivan may have gottenthe term interpersonal relations from Dr. JacobMoreno, the inventor of psychodrama. In hisglossary for volume 3 of Psychodrama Moreno(1969) states, Interpersonal Relation. Trans-lated from the German ZwischenMenschlichBeziehung used by Moreno (191923). Wil-liam Alanson White, the superintendent of St.Elizabeths Hospital, referred to Morenos useof the term interpersonal in Whites forewordto Morenos (1934) book, Who Shall Survive?(p. xii). Now it is entirely possible that White gotthe term from Sullivan but his use of the hyphenis identical to the way Moreno spelled the word.The dates 191923" are important to us be-cause Sullivan was a Veterans Liaison Oficer atSt. Elizabeths, and a beginning psychiatrist,from 192022, prior to his move to TheSheppard and Enoch Pratt Hospital in Towson,Maryland. Meanwhile, Moreno was in Viennafrom 192123 originating psychodrama.

Anxiety, for Sullivan, was the experi-ence of a threatened loss of the sense of secu-

rity of the self. Security operations were ef-forts to counteract anxiety. The self systemwas an organization of security operations de-signed to deal with anxiety and reestablish asense of security. Anxiety was an acquired,learned interpersonal integration reflectingthe disapproval of actual or fantasized others.A dream could be an example of an interper-sonal event accompanied by anxiety. The ear-liest experience of anxiety was in relation tothe mothering one.

These days fear and anxiety are oftenused interchangeably, but for Sullivan therewas clearly a difference between the two. As afelt body experience the two affects were iden-tical. Sullivan found that the following charac-teristics reflect marked differences betweenthem: Anxiety is seldom clearly represented, assuch, in awareness, whereas fear is often un-equivocal. The situation arousing anxiety isobscure and infinitely varied. Fear causation isroughly the same for all people. What makes aperson fearful is usually obvious. Sullivan saidone could not get an answer as to why someonewas anxious, but that it might be possible tohave someone notice when one became anx-ious; i.e., what event immediately preceded it.Ones ability to observe, recall, or have fore-sight regarding the immediate situation was in-variably interfered with by anxiety. While fearmay impede processes, it resulted in an in-creased alertness to the situation. Ones effec-tiveness of reacting directly to relieve the sourceof tension of anxiety is interfered with. Fear, bycontrast, enhances ones ability to remove, de-stroy, or escape from the source. Finally, anxi-ety is dealt with immediately by defences,called security operations by Sullivan. If not,anxiety could escalate to panic. In fear the reac-tion can be postponed until after the event,when ones knees could shake or whatever.

These characteristics of anxiety havepractical application to psychotherapeutic tech-nique. Instead of attempting to obliterate anxi-ety by medications, or other means, the patientand therapist could make use of it as an indica-tor to gain information about the patients con-flicts. The following recommendations regard-ing technique come from Sullivans ideas aboutanxiety. Since anxiety obscures awareness of its

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source, the when inquiry leads the patient toobserve sequences of context. I have used the ex-ample of a strip of movie film in which one ob-serves a sudden shift of scene. The patient will beunable to identify this shift in the initial times heor she is asked about it but, after several ormany efforts, becomes educated to making thisvaluable observation.

Sullivan instructed the patient in notic-ing what he called marginal thoughts. Suchthoughts occurred alongside of what one wascentrally thinkingin ones peripheral field soto speak. Such marginal thoughts could bemore informative than what was being re-ported centrally. The therapist, too, can gaincountertransference data by noticing his or hermarginal thoughts. This device was especiallyhelpful in circumventing a patients avoiding asubject under discussion or an obessional pa-tients resistance via free association.

Schizophrenic patients were seen as be-ing made worse, that is, having an increase inanxiety, by an unstructured interview situa-tion. With such patients the therapist shouldcontrol the anxiety situation by comments,questions, and minimal interpretation. I havefound it useful to reinforce the patients inter-nal structure by using the patients own exam-ples of his ability to regulate and moderateanxiety. For Sullivan, priority was given topointing out the security operations protect-ing against anxiety in relation to the therapist.Since resulting overwhelming anxiety can re-sult if defences are too rapidly made ineffec-

tive, the therapist should be respectful ofdefences and slowly analyze them.

As noted, anxiety in anything morethan the smallest degree, will interfere withobservation and memory. Sullivan recom-mended making frequent summaries of whathas been observed in the therapy sessions. Inorder to enhance the patients self respect, hespecifically included positive gains in the sum-maries. When the patients disclosures re-vealed topics experienced as shameful,Sullivan would attempt to detoxify these bydealing with them as though they were com-monplace. Finally in this list, if the patient wasabout to become involved in an impulsive de-cision pointing toward acting out, he wouldnot advise against the action. Instead hewould raise questions, cast doubt, and addwhat he called a touch of dramatics by takingtime out, which might include getting upfrom his chair and moving about.

For Sullivan, success in psychotherapywas largely dependent on the therapists abilityto monitor and regulate the amount of anxietyexperienced by the patient and oneself. I wouldhope that those readers who are encounteringSullivan for the first time in these Fragmentswill not be put off by these sample presenta-tions. The publications listed in the referenceswould provide a much clearer translation ofSullivan, and I would especially recommendthe works by Patrick Mullahy (1955), MaryWhite (1977), and Sullivan (1949).

REFERENCES

Moreno, J. (1934). Who shall survive? Washing-ton, DC: Nervous and Mental Disease PublishingCo.

Moreno, J. (1969). Psychodrama (Vol. 3). Bea-con, NY: Beacon House.

Mullahy, P. (1947). A theory of interpersonal re-lations and the evolution of personality. In H.Sullivan (Ed.), Conceptions of modern psychia-try. Washington, D.C.: William Alanson WhiteFoundation.

Schulz, C. (1978). Sullivans clinical contribu-tion during the Sheppard Pratt Era: 19231930.Psychiatry, 41, 117128.

Stanton, A., & Schwartz, M. (1954). The mentalhospital. New York: Basic Books.

Sullivan, H. (1949). The theory of anxiety and thenature of psychotherapy. Psychiatry, 12, 312.

White, M. (1977). Sullivan and treatment. Jour-nal of Contemporary Psychoanalysis, 13,317346.

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