Psychiatry 69(2) Summer 2006

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Commentary on H.S. Sullivan

Schulz

Commentary on Transcription of Fragments of Lectures

in 1948 by Harry Stack Sullivan

Applying Sullivans Theory of Anxiety versus Fear

Clarence G. Schulz
The publication of Harry S. Sullivans
1948 lecture fragments offers us the possibility
of reassessing Sullivans contributions to psychiatry from the distant vantage point of 56
years after his death. Of all his concepts subsumed under his term interpersonal, I shall focus on what I see as the most overlooked seminal contribution; namely, his concept of
anxiety. Psychotherapeutic technique derived
from this formulation of anxiety will occupy
the major portion of my commentary.
The authors account of these lectures
brought back memories of my having attended
Sullivans final three lectures at the Washington
School of Psychiatry in the last quarter of 1948.
He died in Paris the following January. The lectures were held at the Federal Security Agency
building in Washigton, DC, and I happened to
ride up in the elevator with Sullivan, who was
talking with Dr. Alfred Stanton, one of his
protgs. Sullivan appeared tired, thin, and
fragile as he complained about the time adjustment for him in his flights to Paris as part of his
activities on behalf of the World Health Organization. He was describing what we today
would call jet lag, only this was before we had
jet engines. The lecture room was packed.
Sulllivan was at his peak of charismatic leadership of the Washington School. After getting
out his white cigarette holder, he exchanged his
regular eye glasses for yellow tinted glasses

since he was preparing to read from a manuscript typed on white paper. (Some readers of
Psychiatry will recall that the journal was for
many years printed on yellow paperwhich,
according to Sullivan, made it easier to read in
sunlight or full moonlight). Changing his mind,
and again his glasses, he explained that since
these lectures were to be published, he would
not read but simply speak to the audience. His
comments were laced with scathing remarks as
asides. In one example, after describing what to
him was a particularly inept intervention on the
part of a therapist, he added, and they charge
fifteen dollars for that.
By now, Sullivans contributions have
been absorbed into the body of concepts in psychiatry and psychoanalysis. He was struggling
to articulate, albeit with his own vocabulary,
observations that were the concern of his contemporaries (Erik Erikson, Ronald Fairbairn,
Donald Winnicott, Heinz Kohut, and Hans
Loewald, among others), who were trying to
make sense out of the same clinical phenomena.
The patient as located in a social field, including
developmental experience, therapist, family,
and treament milieu, were all part of his and
their concerns. Each had his particular slant on
things. Sullivans concept of the psychiatrist as
participant observer is now an accepted concept in understanding countertransference.
While most of his ideas have been integrated

Clarence G. Schulz, MD, is Emeritus Supervising and Training Analyst, Washington Psychoanalytic Institute; Clinical Professor of Psychiatry, University of Maryland School of Medicine; Assistant Professor of Psychiatry, Johns Hopkins Medicine.
Address correspondence to Clarence G. Schulz, 8 Olmstead Green Court, Baltimore, MD 21201.
E-mail: cgschulzmd@comcast.net

Schulz

into contemporary practice, two topics remain

relatively unexplored: anxiety, toward which I
devote the bulk of my comments, and the milieu, which as an area of study has been eclipsed
by the era of psychopharmacology. Sullivan
practiced a system of milieu therapy mediated
through his staff in his special unit at
SheppardPratt Hospital. Subsequently, Alfred
Stanton and Morris Schwartz (of Tuesdays
with Morrie fame) conducted an extensive
sociopsychological study of a patient unit at
Chestnut Lodge. This work, done in the late
1940s, was published as a book, The Mental
Hospital (Stanton & Schwartz, 1954). Since
chlorpromazine appeared in the early 1950s, attention to the effects of the milieu never received
the notice it continues to deserve.
It is to be noted that while at Sheppard,
Sullivan was the first person to record psychiatric interviews. He had a stenographer, Mr.
Campbell, sit in the interview to make a shorthand record which was later transcribed for
Sullivans use. We can speculate that Sullivan
would have been interested in psychoactive
medications since he was prescribing alcohol
for some patients in the 1920s while on the
staff at Sheppard. (Schulz, 1978).
Incidentally, Sullivan may have gotten
the term interpersonal relations from Dr. Jacob
Moreno, the inventor of psychodrama. In his
glossary for volume 3 of Psychodrama Moreno
(1969) states, Interpersonal Relation. Translated from the German ZwischenMenschlich
Beziehung used by Moreno (191923). William Alanson White, the superintendent of St.
Elizabeths Hospital, referred to Morenos use
of the term interpersonal in Whites foreword
to Morenos (1934) book, Who Shall Survive?
(p. xii). Now it is entirely possible that White got
the term from Sullivan but his use of the hyphen
is identical to the way Moreno spelled the word.
The dates 191923" are important to us because Sullivan was a Veterans Liaison Oficer at
St. Elizabeths, and a beginning psychiatrist,
from 192022, prior to his move to The
Sheppard and Enoch Pratt Hospital in Towson,
Maryland. Meanwhile, Moreno was in Vienna
from 192123 originating psychodrama.
Anxiety, for Sullivan, was the experience of a threatened loss of the sense of secu-

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rity of the self. Security operations were efforts to counteract anxiety. The self system
was an organization of security operations designed to deal with anxiety and reestablish a
sense of security. Anxiety was an acquired,
learned interpersonal integration reflecting
the disapproval of actual or fantasized others.
A dream could be an example of an interpersonal event accompanied by anxiety. The earliest experience of anxiety was in relation to
the mothering one.
These days fear and anxiety are often
used interchangeably, but for Sullivan there
was clearly a difference between the two. As a
felt body experience the two affects were identical. Sullivan found that the following characteristics reflect marked differences between
them: Anxiety is seldom clearly represented, as
such, in awareness, whereas fear is often unequivocal. The situation arousing anxiety is
obscure and infinitely varied. Fear causation is
roughly the same for all people. What makes a
person fearful is usually obvious. Sullivan said
one could not get an answer as to why someone
was anxious, but that it might be possible to
have someone notice when one became anxious; i.e., what event immediately preceded it.
Ones ability to observe, recall, or have foresight regarding the immediate situation was invariably interfered with by anxiety. While fear
may impede processes, it resulted in an increased alertness to the situation. Ones effectiveness of reacting directly to relieve the source
of tension of anxiety is interfered with. Fear, by
contrast, enhances ones ability to remove, destroy, or escape from the source. Finally, anxiety is dealt with immediately by defences,
called security operations by Sullivan. If not,
anxiety could escalate to panic. In fear the reaction can be postponed until after the event,
when ones knees could shake or whatever.
These characteristics of anxiety have
practical application to psychotherapeutic technique. Instead of attempting to obliterate anxiety by medications, or other means, the patient
and therapist could make use of it as an indicator to gain information about the patients conflicts. The following recommendations regarding technique come from Sullivans ideas about
anxiety. Since anxiety obscures awareness of its

Commentary on H.S. Sullivan

112

source, the when inquiry leads the patient to

observe sequences of context. I have used the example of a strip of movie film in which one observes a sudden shift of scene. The patient will be
unable to identify this shift in the initial times he
or she is asked about it but, after several or
many efforts, becomes educated to making this
valuable observation.
Sullivan instructed the patient in noticing what he called marginal thoughts. Such
thoughts occurred alongside of what one was
centrally thinkingin ones peripheral field so
to speak. Such marginal thoughts could be
more informative than what was being reported centrally. The therapist, too, can gain
countertransference data by noticing his or her
marginal thoughts. This device was especially
helpful in circumventing a patients avoiding a
subject under discussion or an obessional patients resistance via free association.
Schizophrenic patients were seen as being made worse, that is, having an increase in
anxiety, by an unstructured interview situation. With such patients the therapist should
control the anxiety situation by comments,
questions, and minimal interpretation. I have
found it useful to reinforce the patients internal structure by using the patients own examples of his ability to regulate and moderate
anxiety. For Sullivan, priority was given to
pointing out the security operations protecting against anxiety in relation to the therapist.
Since resulting overwhelming anxiety can result if defences are too rapidly made ineffec-

tive, the therapist should be respectful of

defences and slowly analyze them.
As noted, anxiety in anything more
than the smallest degree, will interfere with
observation and memory. Sullivan recommended making frequent summaries of what
has been observed in the therapy sessions. In
order to enhance the patients self respect, he
specifically included positive gains in the summaries. When the patients disclosures revealed topics experienced as shameful,
Sullivan would attempt to detoxify these by
dealing with them as though they were commonplace. Finally in this list, if the patient was
about to become involved in an impulsive decision pointing toward acting out, he would
not advise against the action. Instead he
would raise questions, cast doubt, and add
what he called a touch of dramatics by taking
time out, which might include getting up
from his chair and moving about.
For Sullivan, success in psychotherapy
was largely dependent on the therapists ability
to monitor and regulate the amount of anxiety
experienced by the patient and oneself. I would
hope that those readers who are encountering
Sullivan for the first time in these Fragments
will not be put off by these sample presentations. The publications listed in the references
would provide a much clearer translation of
Sullivan, and I would especially recommend
the works by Patrick Mullahy (1955), Mary
White (1977), and Sullivan (1949).

REFERENCES
Moreno, J. (1934). Who shall survive? Washing- Schulz, C. (1978). Sullivans clinical contributon, DC: Nervous and Mental Disease Publishing tion during the Sheppard Pratt Era: 19231930.
Psychiatry, 41, 117128.
Co.
Moreno, J. (1969). Psychodrama (Vol. 3). Bea- Stanton, A., & Schwartz, M. (1954). The mental
hospital. New York: Basic Books.
con, NY: Beacon House.
Mullahy, P. (1947). A theory of interpersonal relations and the evolution of personality. In H.
Sullivan (Ed.), Conceptions of modern psychiatry. Washington, D.C.: William Alanson White
Foundation.

Sullivan, H. (1949). The theory of anxiety and the

nature of psychotherapy. Psychiatry, 12, 312.
White, M. (1977). Sullivan and treatment. Journal of Contemporary Psychoanalysis, 13,
317346.