Abstract
Harry Stack Sullivan’s writing and teaching, based on his work with patients at St. Elizabeths Hospital, Sheppard Pratt, and finally at Chestnut Lodge, mark him as a pioneer in extending, revising, and rejecting various aspects of Freudian psychoanalytic theory. Helen Swick Perry’s 1982 biography of Sullivan, runner-up for a Pulitzer Prize, has been the definitive text on the life and work of this giant of American psychiatry. Now Marco Conci, an Italian psychoanalyst and prolific scholar of all things related to Sullivan, has written a magnificently comprehensive book that includes the history of early developments in the discipline of psychiatry in the United States, a biographical review of Sullivan’s life, and a systematic annotated reading of his major writings. Conci’s project is clearly one of love and devotion to his subject. Perhaps it takes an analyst from afar to bring us fresh news about the ongoing relevance of one of our own.
For various reasons, Sullivan has been a minor figure in many psychoanalytic institutes, while revered and read extensively in others. This may be a product of his work with psychotic patients in a hospital setting, the split between psychoanalysts in New York (ego psychology) and Washington, D.C. (interpersonal psychoanalysis) that evolved in the 1930s, Sullivan’s early dismissal of Freud’s libido theory, or his reconceptualizing of Freud’s zones of excitation (one-person situation) as zones of interaction (two-person situation) occurring in the interpersonal sphere. While Sullivan placed transference (parataxic distortion) and unconscious dynamics at the center of his theory, he was less enthusiastic about a cure that comes through interpretation, and more focused on the healing that comes from a relationship between an “expert and a patient.” A late adolescent breakdown and being gay marked Sullivan with a twin stigma in twentieth-century psychoanalytic culture, a likely contributor to ongoing ambivalence about his writings (Blechner 2005). Such theoretical and biographical facts placed Sullivan on a collision course with what Cooper (2008) has recently referred to as the “rejectionist” stance of so-called mainstream classical or orthodox psychoanalysis in North America.
Conci divides his book into two parts, each consisting of four chapters. In the first part, Conci provides a comprehensive and well-documented account of the historical and scientific context of American psychiatry and Sullivan’s place within that unfolding history. In the second part Conci argues for Sullivan’s ongoing relevance for clinical practice and theorizing in contemporary psychoanalysis, giving a careful chapter-by-chapter summary of Sullivan’s published books.
For those interested in the history of American psychiatry and the origins of psychoanalysis in this country, Conci’s first two chapters provide a robust review of major theorists and schools, including William James and functionalism, James Jackson Putnam in Boston, and Adolf Meyer, the dean of early academic North American psychiatry. Sullivan’s “commonsense psychiatry” developed in the context of his early exposure to pragmatism and the influence of William Alanson White, Adolf Meyer, and Edward Kempf. The relationships between G. Stanley Hall, Ernest Jones, Smith Ely Jelliffe, and others are described in sufficient detail to hold the reader’s interest and curiosity. In the section “Psychoanalysis in North-America: Deformation or Emancipation?” Conci examines how Freudian psychoanalytic theory and technique became modified, mainly through a fusion of psychoanalysis with North American psychiatry and the “creation of the new discipline that became known as ‘dynamic psychiatry,’ of which . . . Sullivan was the unsurpassed ‘maestro’” (p. 89). No doubt what some may have seen as a “deformation” of Freud’s ideas others may want to think of as adaptations.
Working at the Austen Riggs Center, which houses the Erik Erikson Institute for Education and Research, I am naturally curious about the biographical and theoretical similarities between Erikson and Sullivan, and so a footnote in Conci’s book was of great interest: “Erikson never mentions Sullivan’s name, apparently because his work had long been proscribed by the psychoanalytic mainstream, although Erikson was well acquainted with interpersonal theory” (p. 360). One reason may have been the tag of “neo-Freudian” given to Sullivan, Fromm, Horney, Thompson, Silverberg, and Fromm-Reichmann. Conci tells us that “neo-Freudian” was not a label the group gave themselves; according to Fromm, it was given to them in an effort to mark them as dissidents from those hewing to a more orthodox reading of Freud. Chodorow (2004) places Erikson and Loewald in what she has termed the American Independent Tradition of intersubjective ego psychology, a midpoint between the ego psychology of Hartmann and the interpersonal theory of Sullivan. The theories of Sullivan and Erikson emerge from their life histories and have striking similarities. Sullivan’s interest in working with psychotic patients is likely related to his own adolescent breakdown, while Erikson’s well-documented adolescent and young adult wandering shaped his interest in what he came to call the “identity crisis.” Both emphasized the role of context, childhood development, and life history, both offered their own epigenetic stages of development, and both recognized the profound shaping factor of culture on personality.
Conci systematically reviews Sullivan’s major publications, including The Interpersonal Theory of Psychiatry (1953). There Sullivan offers his famed one-genus postulate that the difference between “normal” and the most seriously ill schizophrenic patient is a matter of quantity and not of quality. In other words, “we are much more human than otherwise” (pp. 32–33). Sullivan creates a new conceptual lexicon for psychiatry, and like Freud’s ideas, so many of these terms are in the mainstream of contemporary thought that little recognition is given to their author. For instance, from Sullivan’s work, terms and concepts like self-esteem, malevolent transformation, the role of anxiety in problems of living, consensual validation, therapeutic alliance, and dynamic psychiatry have become routine parts of our discourse.
In chapter 5, the subject of psychotherapy for the treatment of schizophrenia is explored. Conci reviews the history of the Zurich school and A. A. Brill’s training at the Burghölzli in 1907. Through encountering the ideas of Freud and interpretive psychiatry, Brill developed an early interest in treating schizophrenia and continued to treat patients with psychosis in his private practice using psychoanalysis (p. 230). For Brill, Oberndorf, and Sullivan, treating psychotic patients was the best way to learn about psychoanalytic theory. Sullivan’s collection of papers published as Schizophrenia as a Human Process (1962) summarizes his work at Sheppard Pratt in the 1920s. These papers have been criticized for being overly optimistic about the treatment of schizophrenia, leading to a tremendous backlash over the years about the role of psychotherapy in the treatment of psychotic patients. Conci gives a precise explanation of Sullivan’s emphasis on the interpersonal disasters occurring in the developmental history of his patients and the genesis of psychopathology, and his de- emphasis of the patient’s innate characteristics. Through Conci’s exposition the reader is able to see how Sullivan’s early thinking anticipates attachment theory, developmental lines, and the biopsychosocial views that have shaped modern psychiatry.
The densest chapter of the book, in my opinion, is chapter 6, where Conci attends to the interdisciplinary roots of Sullivan’s thinking. As a medical student Sullivan was deeply influenced by the Chicago school of sociology, among whom participant-observation was established as a primary method of inquiry. Sullivan, the interdisciplinarian, imported this social science method into the practice of psychiatry. Conci reviews the history, work, and influence of George Herbert Mead and the anthropologists Edward Sapir and Franz Boas, among others. This chapter also includes Sullivan’s growing interest in psychiatric training, his founding of the journal Psychiatry in 1938, and his various editorials and publications.
The final two chapters of Conci’s book continue the careful synopses of The Interpersonal Theory of Psychiatry (1953), The Psychiatric Interview (1954), and Clinical Studies in Psychiatry (1956), all posthumously published. Conci links the evolution of Sullivan’s work with his influence on his Chestnut Lodge colleagues Frieda Fromm-Reichmann, Otto Will, and Harold Searles. Sullivan’s eventual influence on Levenson, Greenberg, and Mitchell in their development of relational psychoanalysis is also reviewed. In his lifetime, Sullivan and his interpersonal colleagues were viewed as apostates from classical psychoanalysis. At this point in our development, his ideas have become widely accepted in psychoanalytic circles, and this Conci’s careful project successfully demonstrates.
The book, published in Italian, German, and now English, is an excellent reference for scholars interested in the history of North American psychoanalysis. It is marred, however, by numerous typographical errors, which unfortunately may be expected in the current era of decline in psychoanalytic publishing. Lengthy quotes from Sullivan’s writings are useful, but in several instances are repeated more than once. This is where more careful editing might have helped the end product. Finally, the book has a name index but lacks a subject index, which would have been extremely helpful to scholars hoping to use the book as the detailed reference work it is. Overall, Conci has given our field a carefully planned and written history of one of North America’s most important psychoanalytic pioneers.