Assignment: Case Study Analysis Project

Commentary on “H.S. Sullivan”Schulz

Commentary on “Transcription of Fragments of Lectures in 1948 by Harry Stack Sullivan”

Applying Sullivan’s Theory of Anxiety versus Fear

Clarence G. Schulz

The publication of Harry S. Sullivan’s 1948 lecture fragments offers us the possibility of reassessing Sullivan’s contributions to psy- chiatry from the distant vantage point of 56 years 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 of anxiety. Psychotherapeutic technique derived from this formulation of anxiety will occupy the major portion of my commentary. Assignment: Case Study Analysis Project

The author’s account of these lectures brought back memories of my having attended Sullivan’s final three lectures at the Washington School of Psychiatry in the last quarter of 1948. He died in Paris the following January. The lec- tures 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 protégés. Sullivan appeared tired, thin, and fragile as he complained about the time adjust- ment for him in his flights to Paris as part of his activities on behalf of the World Health Orga- nization. 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 leader- ship 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 manu- script typed on white paper. (Some readers of Psychiatry will recall that the journal was for many years printed on yellow paper—which, 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, Sullivan’s contributions have been absorbed into the body of concepts in psy- chiatry and psychoanalysis. He was struggling to articulate, albeit with his own vocabulary, observations that were the concern of his con- temporaries (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. Sullivan’s concept of the psychiatrist as “participant 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 remain relatively unexplored: anxiety, toward which I devote the bulk of my comments, and the mi- lieu, 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 Sheppard–Pratt 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, at- tention to the effects of the milieu never received the notice it continues to deserve. Assignment: Case Study Analysis Project

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 for Sullivan’s 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, “Inter–personal Relation. Trans- lated from the German ‘Zwischen–Menschlich Beziehung’ used by Moreno (1919–23).” Wil- liam Alanson White, the superintendent of St. Elizabeth’s Hospital, referred to Moreno’s use of the term inter–personal in White’s foreword to Moreno’s (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 “1919–23″ are important to us be- cause Sullivan was a Veterans Liaison Oficer at St. Elizabeth’s, and a beginning psychiatrist, from 1920–22, prior to his move to The Sheppard and Enoch Pratt Hospital in Towson, Maryland. Meanwhile, Moreno was in Vienna from 1921–23 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 system” was an organization of security operations de- signed to deal with anxiety and re–establish 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 interper- sonal event accompanied by anxiety. The ear- liest 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 iden- tical. Sullivan found that the following charac- teristics reflect marked differences between them: Anxiety is seldom clearly represented, as such, in awareness, whereas fear is often un- equivocal. 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 anx- ious; i.e., what event immediately preceded it. One’s ability to observe, recall, or have fore- sight regarding the immediate situation was in- variably interfered with by anxiety. While fear may impede processes, it resulted in an in- creased alertness to the situation. One’s effec- tiveness of reacting directly to relieve the source of tension of anxiety is interfered with. Fear, by contrast, enhances one’s 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 one’s knees could shake or whatever. Assignment: Case Study Analysis Project

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

Schulz 111

source, the “when” inquiry leads the patient to observe 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 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 notic- ing what he called “marginal thoughts.” Such thoughts occurred alongside of what one was centrally thinking—in one’s peripheral field so to speak. Such marginal thoughts could be more informative than what was being re- ported centrally. The therapist, too, can gain countertransference data by noticing his or her marginal thoughts. This device was especially helpful in circumventing a patient’s avoiding a subject under discussion or an obessional pa- tient’s resistance via “free association.” Assignment: Case Study Analysis Project

Schizophrenic patients were seen as be- ing made worse, that is, having an increase in anxiety, by an unstructured interview situa- tion. With such patients the therapist should control the anxiety situation by comments, questions, and minimal interpretation. I have found it useful to reinforce the patient’s inter- nal structure by using the patient’s own exam- ples of his ability to regulate and moderate anxiety. For Sullivan, priority was given to pointing 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 of defences and slowly analyze them.

As noted, anxiety in anything more than the smallest degree, will interfere with observation and memory. Sullivan recom- mended making frequent summaries of what has been observed in the therapy sessions. In order to enhance the patient’s self respect, he specifically included positive gains in the sum- maries. When the patient’s disclosures re- vealed topics experienced as shameful, Sullivan would attempt to detoxify these by dealing with them as though they were com- monplace. Finally in this list, if the patient was about to become involved in an impulsive de- cision 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 therapist’s 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 presenta- tions. 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). Assignment: Case Study Analysis Project

REFERENCES

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

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 White Foundation.

Schulz, C. (1978). Sullivan’s clinical contribu- tion during the Sheppard Pratt Era: 1923–1930. Psychiatry, 41, 117–128.

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

Sullivan, H. (1949). The theory of anxiety and the nature of psychotherapy. Psychiatry, 12, 3–12.

White, M. (1977). Sullivan and treatment. Jour- nal of Contemporary Psychoanalysis, 13, 317–346.

112 Commentary on “H.S. Sullivan”

PSYC 6220/5220/8221: Psychology of Personality

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University

Press via the Copyright Clearance Center.

“The Case of Mrs. C” is excerpted from Systems of Psycotherapy: A Transtheoretical Analysis, 9th Edition,

by James O. Prochaska and John C. Norcross, and does not reflect a clinical assessment of the client and

the family members’ experiences.

THE CASE OF MRS. C Psychotherapy systems are not merely static combinations of change processes, theoretical contents, and research studies. The systems are, first and foremost, concerned with serious disorders afflicting fellow humans. In comparing systems, it is essential to picture how the psychotherapies conceptualize and treat the presenting problems of an actual client. The client selected for comparative purposes is Mrs. C. Mrs. C is a 47-year-old mother of six children: Arlene, 17; Barry, 15; Charles, 13; Debra, 11; Ellen, 9; and Frederick, 7. Without reading further, and astute observer might discern Mrs. C‘s personality configuration. The orderliness of children named alphabetically and of childbirths every 2 years are consistent with obsessive-compulsive disorder (OCD). For the past 10 years, Mrs. C has been plagued by compulsive washing. Her baseline charts, in which she recorded her behavior each day before treatment began, indicated that she washed her hands 25 to 30 times a day, 5 to 10 minutes at a time. Her daily morning shower lasted about 2 hours with rituals involving each part of her body, beginning with her rectum. If she lost track of where she was in her ritual, then she would have to start all over. A couple of times this had resulted in her husband, George, going off to work while his wife was in the shower only to return 8 hours later to find her still involved in the lengthy ritual. To avoid extended showers, George had begun helping his wife keep track of her ritual, so that at times she would yell out, “Which arm, George?” and he would yell back, “Left arm, Martha.” His participation in the shower ritual required George to rise at 5:00 A.M. in order to have his wife out of the shower before he left for work at 7:00 A.M. After 2 years of this schedule, George was ready to explode. George was, understandably, becoming increasingly impatient with many of his wife’s related symptoms. She would not let anyone wear a pair of underwear more than once and often wouldn’t even let the underwear be washed. There were piles of dirty underwear in each bedroom corner. When we asked her husband to gather up the underwear for the laundry, we asked him to count them, but he quit counting after the thousandth pair. He was depressed to realize that he had more than $2,000 invested in once-worn underwear. Other objects were scattered around the house because a fork or a can of food dropped on the floor could not be retrieved in Mrs. C‘s presence. She felt it was contaminated. Mrs. C had been doing no housework—no cooking, cleaning, or washing—for years. One of her children described the house as a “state dump,” and my (JOP) visit to the home confirmed this impression. Mrs. C did work part -time. What would be a likely job for her? Something to do with washing, of course. In fact, she was a dental technician, which involves washing and sterilizing all the dentist’s equipment. Assignment: Case Study Analysis Project

PSYC 6220/5220/8221: Psychology of Personality

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University

Press via the Copyright Clearance Center.

As if these were not sufficient concerns, Mrs. C had become unappealing in appearance. She had not purchased new clothes in 7 years, and her existing clothes were becoming ragged. Never in her life had she been to a beautician and now she seldom combed her own hair. Her incessant washing of her body and hair led to a presentation somewhere between a prune and a boiled lobster with the frizzies. Mrs. C‘s washing ritual also entailed walking around the house nude from the waist up as she went from her bedroom bath to the downstairs bath to complete her washing. This was especially upsetting to Mr. C because of the embarrassment it was producing in their teenage sons. The children were also upset by Mrs. C‘s frequent nagging to wash their hands and change their underwear, and she would not allow them to entertain friends in the house. Consistent with OCD features, Mrs. C was a hoarder: she had two closets filled with hundreds of towels and sheets, dozens of unused earrings, and her entire wardrobe from the past 20 years. She did not consider this hoarding a problem because it was a family characteristic, which she believes she inherited from her mother and from her mother’s mother. Mrs. C also suffered from a sexual arousal disorder; in common parlance, she was “frigid.” She said she had never been sexually excited in her life, but at least for the first 13 years of her marriage she engaged in sexual relations to satisfy her husband. However, in the past 2 years they had intercourse just twice, because sex and become increasingly unpleasant for her. To complete the list, Mrs. C was clinically depressed. She had made a suicide gesture by swallowing a bottle of aspirin since she had an inkling that her psychotherapist was giving up on her and her husband was probably going to commit her to a psychiatric hospital. Mrs. C‘s compulsive rituals revolved around and obsession with pinworms. Her oldest daughter had come home with pinworms 10 years earlier during a severe flu epidemic. Mrs. C had to care for a sick family while pregnant, sick with the flu herself, and caring for a demanding 1-year-old child. Her physician told her that, to avoid having the pinworms spread throughout the family, Mrs. C would need to be extremely careful about the children’s underwear, clothes, and sheets and that she should boil all of these articles to kill any pinworm eggs. Mrs. C confirmed that both she and her husband were rather anxious about a pinworm epidemic in the home and were both preoccupied with cleanliness during this time. However, Mrs. C’s preoccupation with cleanliness and pinworms continued even after it was confirmed that her daughter’s pinworms were eliminated. The C couple acknowledged a relatively good marriage before the pinworm episode. They had both wanted a sizable family, and Mr. C‘s income as a business executive had allowed them to afford a large family and comfortable home without financial strain. During the first 13 years of their marriage, Mrs. C had demonstrated some of her obsessive-compulsive traits, but never to such a degree that Mr. C considered them a problem. Mr. C and the older children recalled many happy times with Mrs. C, and they kept alive the warmth and love that they had once shared with this now preoccupied person. Mrs. C hailed from a strict, authoritarian, and sexually repressed Catholic family. She was the middle of three girls, all of whom were dominated by a father who was 6 feet, 4 inches tall and weighed 250 pounds. When Mrs. C was a teenager, her father would wait up for her after dates to question her about what she had done; he once went so far is to follow her on a date. He tolerated absolutely no expression of anger, especially toward himself, and when she would try to explain her point of view politely, he

PSYC 6220/5220/8221: Psychology of Personality

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University

Press via the Copyright Clearance Center.

would have to tell her to shut up. Mrs. C‘s mother was a cold, compulsive woman who repeatedly regaled her daughters about her disgust with sex. She also frequently warned her daughters about diseases and the centrality of cleanliness. In developing a psychotherapy plan for Mrs. C, one of the differential diagnostic questions was whether Mrs. C was plagued with a severe obsessive-compulsive disorder or whether her symptoms were masking a latent schizophrenic process. A full battery of psychological testing was completed, and the test results were consistent with those from previous evaluations that had found no evidence of a thought disorder or other signs of psychotic processes. Mrs. C had previously undergone a total of six years of mental health treatment, and throughout that time the clinicians had uniformly considered her problems to be severe but nonpsychotic in nature. The only time schizophrenia was offered as a diagnosis was after some extensive individual psychotherapy failed to lead to any improvement. The consensus in our clinic was that Mrs. C was demonstrating severe OCD that was going to be extremely difficult to treat. Assignment: Case Study Analysis Project