There won’t be a video for this post because of it’s graphic nature, but I hope you find something interesting nonetheless.
In The Closet
As Object Relations moved forward, researchers and theoreticians began to take the original elements of projection and transference, and moved them into the realm of purpose, and what this mental output was hinting at about the human psyche. Because humans have desires, and desires are political, meaning they want cooperation from others, it creates a need for readers to learn about psychologists and their personal psychological makeup to see what is inferred in their writings. Psychoanalyst Harry Stack Sullivan was a perfect example for having this core of personal desire and needing society to change and make accommodations for all the different ways of being and lifestyles that humans live in. In Private Practices, by Naoko Wake, she outlined the difficulty, especially in the 1920s, for psychiatric hospitals to decide whether patients needed treatments or if society itself was in need of reform. In this more conservative environment of early psychoanalysis, “these scientists artfully separated what they argued in public from who they were in private. For instance, Sullivan and his colleagues continued to describe heterosexuality and homosexuality in dualistic terms—’healthy versus sick,’ ‘virile versus effeminate,’ and ‘mature versus immature’—in their published writings. Following the precepts of Sigmund Freud, these psychiatrists did not think of homosexuality itself as an illness unless it caused a person distress, a belief that was in sharp contrast with the mainstream medical notion that sexual ‘perversion’ constituted a clinical entity. Nevertheless, their position most often expressed in public was that, given the prevailing homophobia, homosexual persons tended to be mentally and socially unstable, constituting a risk group that often required medical attention…Sullivan as a gay psychiatrist pursued a fuller depathologization of homosexuality in his treatment of psychiatrically disturbed homosexual men, even as he defined them as ‘immature’ individuals in his published writings.”
Sexuality Pt 3: Homosexuality – Sigmund Freud & Beyond: https://rumble.com/v1gtqk5-sexuality-pt-3-homosexuality-sigmund-freud-and-beyond.html
Case Studies: Dora and Freud: https://rumble.com/v1gu2dt-case-studies-dora-and-freud.html
This need for a double life professionally also mirrored the double life that homosexual scientists lived. With scandals waiting to be discovered, the only way to live on the edge was to harbor a desire for a new world of acceptance and to incrementally move the current world forward one step at a time. For people who were homosexual or bisexual, and were more comfortable in their lifestyles, they could network together, along with researchers, and create a haven of tolerance, much like religious refugees hiding in a church for safety. In a pluralistic society, there was a developing live and let live co-existence, but if people crossed the line from one person’s haven to another with different values, the hostility would begin to rise. This would be a difficulty as soon as a person looks for a job and is forced to encounter people with completely different viewpoints. Of course, the sensible attitude is that when you are doing commerce with others you are not engaging in moral inventories, but so many people, even today, don’t have the boundary skills for that. They require mandatory cooperation and alignment of values from the economic to the social and political spheres, with the usual cancel culture, escalations, petitions, and protests. Because humans can imitate suggestions of savoring and different ways of doing it, it requires a lot of awareness and control of the mimetic capacity to imitate people in the environment, which can easily be seen when people imitate cultures and accents unconsciously while going on in their lives. When different ways and suggestions appear, that are culturally prohibited, a conflict is brewing unconsciously and ready to bubble up to consciousness, and lead people to adapt by making their personal lives into a pathological secret. For example, [Sullivan’s partner James Inscoe believed that Sullivan] “‘had experienced hostility from a great many people’ throughout his life; hence he must be defended against ‘nasty rumor’ that might rise out of releasing any aspects of his personal life.”
Penetrating through sensitive boundaries wasn’t only on the conservative side and psychoanalytic theories began to experiment. When you work with people on the outskirts of society, because they have to exchange everyone else in the economy, you are already being revolutionary, even if your activities are compartmentalized. Sullivan’s controversial relationship with James Inscoe, a minor at age 15, had to be covered up with the usual economic disguises. James was treated as a hired assistant so that he could leave his parents, who were struggling financially, and move into this avant-garde circle. Sullivan also hired hospital employees and aides that would follow his instructions and allow some of his controversial experiments, while shielding his methods from scrutiny in his published papers and interviews. “Sullivan obliquely criticized homophobia at an academic conference, using insights arising from his far more straightforward one-on-one discussions with his patients in clinical settings.” These case studies and discussions illustrated repression, from society, and suppression from the patients themselves. For Sullivan, his goal was to have more and more patients release their inhibitions and to learn to accept their homosexual sides. This included negotiation with patients to allow aides to kiss and touch to increase self-acceptance. There was also a certain sense of snobbery and pride that existed in homophile cultures as well as in parallel academic situations that allowed these kinds of professional risks. “Just as small outposts of psychiatric care would help improve an entire community’s mental health, a homophile climate that ‘sophisticated’ individuals created in their small circle would eventually work against homophobia in the public…Oftentimes this secrecy supported the belief that members of the protected, ‘therapeutic’ community were the most ‘civilized’ and ‘sophisticated’ in sexual matters.” Sullivan was also interested in taking the Freudian case study method and to make it more prominent than pure theorizing. “Sullivan seldom discussed the Freudian idea of repression in his clinical practice, although it would have been a crucial concept for examining sexual conflicts were he an orthodox Freudian. Sullivan’s approach was more oriented to acts and experiences than to theories and interpretations. He tried to get facts, or at least get patients to talk about what they considered to be facts, so that they could have something concrete in front of them to work with. In Sullivan’s view, such immediacy and direct connection to patients’ real-life situations were highly effective. Within a few years this approach was precisely what would bring medical doctors together with social scientists who were interested in an individual’s life history.”
Many theories that criticized homosexuality essentially allowed it, with the promise that treatment would allow further development. In Sullivan’s environment he was careful not to apply labels to individuals but instead to homosexual acts. This allowed for more bisexual patients the ability to accept themselves but also not to rule out heterosexuality, especially with children who were sexually abused before they could actively assert one kind of orientation or another. Within the pool of patients there was a wide variety of behavior that was not exclusively homosexual. There were many stories of adults, including fathers, abusing children and then children acting out the same behavior with their little brothers, often asleep at night, so for some patients mimetics was at play, but they were also capable of interest in the opposite sex. Others also felt guilty in engaging in mutual masturbation. Though, many patients were very panicked about their homosexual behavior, and sometimes even thoughts alone caused a panic. “For many men it was not easy to admit homosexual experiences. Homophobia apparently had found its way into the minds of many patients, and some were not shy about expressing it straightforwardly. A patient who had confessed his sense of guilt over masturbation and a relationship with a prostitute, but nothing of a homosexual nature, still noted that he did not want Sullivan ‘to have the idea that [when] all doors were closed…I was a cock sucker.'” Fellatio at that time was considered the lowest form of male homosexuality because of the connotation with weakness and subservience. Some patients were in homosexual situations but they didn’t really like it, especially the aspect of being the object of sexual attraction, like a heterosexual woman, as opposed to being the stronger masculine seeker for an object. “Homosexual experiences in youth often involved exploitation by older persons. One patient recalled his older brother ‘going into my rear’ when they were sleeping in the same bed. The patient ‘couldn’t understand it.’ He related, ‘I said I wanted a separate bed,’ and claimed that mutual masturbation with the brother, as well as anal sex with him, was ‘revolting.’ This was, the patient said, because he did not want to ‘think of [himself] as the sexual object of a man…’ [Another patient was afraid of] fellatio, and ‘fairies—people who use their mouths,’ [who] represented to him what was fearful about homosexuality…Given the feminine attributes of fairies, femininity—and the succumbing of masculinity to it—was what ignited in this patient the worst fear of homosexuality.” There were also early examples of transsexual feelings in these case studies. “One patient, for instance, told doctors that he had had ‘many homosexual…experiences’ and that he had a constant ‘craving…[in] my throat [for fellatio].’ Indeed, he believed ‘he was really a woman, and wishe[d] an operation to remove his genital.”
The Irishman – A fairy named Ferrie: https://www.youtube.com/watch?v=yvAahGbIWXk
Queer Connections in the 1920s: https://www.youtube.com/watch?v=yRb4eQUTnUs
Because psychoanalysis was at an early stage, so many categories were lumped together. Like in Freud’s analysis of Daniel Paul Schreber’s book, many schizophrenic patients had concerns about their sexual orientation along with the typical hallucinations. Sullivan’s work was able to divide the greater category into subcategories, but always with an understanding that having a grip on reality along with healthy interpersonal relations was the ultimate sign of health, not necessarily a heterosexual outcome. Typical of new clinicians, they eventually specialize in areas that they are good at and patients with the same problems started to group around Sullivan. “As a scientist, he became an expert in the definition of schizophrenia as a socially and culturally constructed illness…He did not seem either skilled or interested in treating female patients. In his comments during interviews with them he was often tense, frustrated, and disagreeable, more frequently so than when he was with male patients. Sullivan’s gift as a psychiatric interviewer shined when he talked to young men with sexual concerns, not with their female counterparts.” Sullivan was skilled at breaking down stigma surrounding sex acts. “I have received a great number of people who are terribly concerned lest they are homosexual…If one says, ‘To hell with everything, I am going to perform fellatio,’ the chances are all his training which is directed against immoral practices…will come in conflict with his impulses…Sullivan was aware of the uncanny effect of fellatio. During a one-on-one interview with another patient, he argued that fellatio could ‘expose an area of weakness to another person.’ He did not mention the gendered nature of such weakness, while he surely thought that fellatio should not cause weakness in anyone. In the same interview, he said that he had ‘had a theory for a long time that fellatio was avoided by a large number of people…for the effect that it would have on their prestige.’ If there were no fear of disgrace, there would be no stigmatization of fellatio. Thus Sullivan encouraged the patient to see the sexual act as something that just ‘is,’ not something entangled with social preconceptions.”
Case Studies: Daniel Paul Schreber – Freud and Beyond: https://rumble.com/v1gu84v-case-studies-daniel-paul-schreber-freud-and-beyond.html
Sullivan’s inner convictions and private practices continually conflicted with his outer theories. For instance, he felt that “if there were no social prohibition of same-sex intimacy, people would grow healthily into ‘mature’ sexuality. But given the current prevalence of homophobia, homosexual experience was inevitably an episode that preceded and even produced the illness.” Because schizophrenia is largely treated with medications today, the kernel of Sullivan’s practice was to connect stigma, social panic, and self-hatred to illness. When treating patients with both homosexual phobias and delusions, the same treatments would lead to a variety of outcomes depending on the differences in each patient. In terms of homosexuality, the fight was against the patient’s feeling that they were different and that there was something wrong with them. “If a homosexual person did not have enough awareness of the ‘contrary’ nature of his or her sexuality, even a single episode of homosexual contact could cause a schizophrenic breakdown. Some might not act on their homosexual desires, but would still develop a so-called homosexual panic because the mere presence of such desire could shake a person’s sense of security. This is unfortunate, Sullivan argued, particularly because the homosexual mode of adjustment came right before the heterosexual stage, in his theory of human psychosexual development.”
It was predictable that Sullivan would be called out on his personal life, because he certainly wasn’t an example of someone who moved into a “mature” relationship with an adult woman, and the authentic treatment was really in the end a normalization of homosexuality. Practicing with men to get better at sex with women didn’t always lead to sex with women, and for some people it never would. To be living without stigma would mean living a life where a person would not feel stress or a sense of being different or excluded if they lived their life fully in the world and in public with their homosexual partner. This would also expand as far as possible with other sexual acts to diffuse shame before it started.
PATIENT: Do you mean that a person who had no mental tension and no concern about it—that he could masturbate as often as he cared without injuring himself?
SULLIVAN: I think if one had…no notion of the evil of masturbation, he perhaps would do himself a wee bit of good.
“[Sullivan] prefers what he called a ‘primitive state’ of human relations, which was not bound to current social norms and institutions. Thus he would suggest a vision of a therapeutic colony or community where people who did not make heterosexual adjustments were encouraged to construct homosexual relationships without being stigmatized.” This stigma towards homosexuality put homosexuals in a mental health risk area for Sullivan, because the unacceptability of it in the wider culture meant that there would be men not staying in long-term relationships and there would be shocks from time to time when partners would marry a woman to gain more acceptance. “The homosexual love object all too frequently fails to ‘stay put,’ causing homosexual men ‘one disappointment after another.'” Sullivan also found problems in the heterosexual marriage and it’s effect on children and their possibility of experimenting with homosexuality to relieve sexual tensions. If marriages were cold in the marital bed, and there were fights related to infidelity, this could turn children off of the idea of marriage altogether. “One such ‘disastrous’ consequence is the boy’s attempt to avoid all things sexual, because of what he sees as their inevitable consequence: a dysfunctional marriage, just like his parents’. But soon, the child would find it impossible to eliminate his sexual desire, and either masturbation or a homosexual contact would follow. Both of them require, as Sullivan put it ironically, ‘an infinity of rationalizations…in our so called advanced society,’ meaning that it is in fact unconscionable for many. They would ruin the boy’s budding sense of manhood, leading him to a mental breakdown…[Sullivan]…considered…outdated social expectations for both men and women—as the ultimate problem behind illness.”
Even though were are talking about sexuality in the first half of the 20th century, many of the topics are now current with debates today. With normalization, and in fact a stigma against homophobic attitudes, there is a rush to normalize other orientations like pedophilia, and in Sullivan’s case, people engaging in hebephilia, which are those who are attracted to adolescents as opposed to children. This updates the conflict between stigma, including why it’s there, and Sullivan’s “primitive” societies, which are primitive in the sense that they look at the desire and the satisfaction as it is without moral qualms. In modern papers like Hebephilia as Mental Disorder?, stigma is deconstructed into what is considered a mental disorder vs. a crime. The irony is that what is considered a progressive left-wing topic can conflict with other ones. The argument on one side is that many people can have problematic thought patterns and still be considered normal, for example, seeing details of what is sexually attractive in minors without a compulsion to act on those thoughts, vs. people who act and identify with the activity, which in many modern societies is a crime. The same legal arguments continue in which each person has freedom until it interferes with the freedom of another person. Modern egalitarian arguments against sex with minors, because of undue influence, who cite the economic and power dependencies that a minor is involved in, can be a form of exploitation. This way a person who sees the adult qualities of a minor, that’s already in puberty, can avoid self-hatred for the thoughts, because if there’s no intention to make those thoughts into an active lifestyle, the self-stigma should be reduced, while at the same time, someone like Sullivan would be considered a criminal in today’s sensitivities over his actions, but not mentally disordered. The simple understanding of the modern way, where if a minor has less mental development, experience, and resources in a relationship, it would be similar to the example of a mentally intelligent adult having a sexual relationship with a mentally-handicapped person. When you are using a person as a piece of meat for gratification, this is an obvious form of exploitation. Pedophilia would be considered a mental disorder because there’s absolutely no Darwinian adaptation argument for sex with prepubescents, but for Hebephilia it would be considered a crime, but not a disorder, because human cultures throughout history have had young marriages that produced healthy children, and also passed on a genetic trait for this attraction. Currently in Canada the age of 16 is the floor for marriages. The guardrails for stigma would be based on power differentials and undue influence, with the modern understanding of crime. A person can self-police their actions if there’s enough empathy to see how their short-term desires would be detrimental to others, like using powerless people for sexual gratification. The lack of empathy, meaning acting on those thoughts, would constitute a crime and the mental disorder side of it would be judged based on biological adaptation, being no advantage with pedophilia. The modern ideal of a good intimate relationship is one where people have commensurate intellectual levels or a complementariness that allows for advantageous exchanges involving love and care. Using individuals for sexual gratification while neglecting everything a good relationship needs, is a hallmark of abuse. As these values become clarified, the mental health industry has to provide enough awareness through social work and therapy to guide people in the love and care direction, to avoid needless incarceration, and avoid needless moral panics over disturbing thoughts that may lead to other pathologies, as well as getting help for those that are truly mentally disordered.
Schizophrenia
In the early days of psychology, so many mental disorders were still being defined and teased apart. Sullivan was one of the early researchers that was able to help hospitals understand Schizophrenia much better. Typically these patients were considered hopeless and their “word-salad” was unintelligible for analysis. This resulted in limited treatments and a lot of neglect in psychiatric hospitals. “A great many of the people who get involved in schizophrenic disturbance proceed through it to one of two very unfortunate outcomes. One we call the paranoid maladjustment, in which sundry elements of blame and guilt in the personality are attached to other people round about, with such disastrous effects on the possibility of intimacy and simple relation with anybody in the environment that there is no way back. In the other outcome, people literally disintegrate so much under the force of horror in this schizophrenic business that they become examples of something scarcely noticed in the developmental years—namely, relatively satisfactory preoccupation with the simple pleasures of the zones of interaction provoked by one’s own manipulations, which seems to be about the essence of what we call the hebephrenic [disorganized] change, or the hebephrenic dilapidation of personality. These illnesses are not to be regarded, according to my light, as part of schizophrenia, but as very unfortunate outcomes of schizophrenic episodes. [It] is not always the case; some people make stable paranoid maladjustments which are singularly free from schizophrenic processes, which actually insure them from occasions where they will have schizophrenic processes. And I am sure that some people dilapidate in such a fashion that they are very little troubled by schizophrenic processes. But a great many of the people who have undergone these very unfortunate developments have not solved life to the point where they can be happy though psychotic.”
Simple Schizophrenia: https://www.youtube.com/watch?v=PcMJ98sNZOk
The Disordered Mind: Paranoid Schizophrenia: https://www.youtube.com/watch?v=Rw0PdXYf4Yo
Catatonic Schizophrenia: https://www.youtube.com/watch?v=gYwGmWWxY48
Teenager with Hebephrenic-Catatonic Schizophrenia: https://www.youtube.com/watch?v=LWDAkJDUlXM
Psychiatric teaching interview with Gay Teenager: https://www.youtube.com/watch?v=AvciA2PD3tI
Case Studies: Daniel Paul Schreber – Sigmund Freud: https://rumble.com/v1gu84v-case-studies-daniel-paul-schreber-freud-and-beyond.html
Case Studies: The Wolf Man (1/3) – Freud and Beyond: https://rumble.com/v1gucp1-case-studies-the-wolf-man-13-freud-and-beyond.html
Sullivan was influenced by William Alanson White, who was famous in psychology circles for getting therapists to “determine what the patient is trying to do.” He then focused more interpersonal relations to understand symptoms and his patient’s difficulties in living. “The attainment of satisfactions and security are seen to be the goals, the end-states, of human behavior, interpersonal processes. In popular language, they explain in general terms what one is after in any situation with other persons, real or fantastic, or a blend of both. From a slightly different point of view, they are ‘integrating tendencies.’ They explain why any situation in which two or more people are involved becomes an inter-personal situation. Furthermore, it is because of these needs that one cannot live and be human except in communal existence with others.”
In the modern world, despite the introduction of many popular anti-psychotic drugs, there’s still a talking therapy discipline that is built off of the interpersonal relations theory. Much of what Sullivan developed helped to merge Social Work with Psychology to focus on needs. Mark L. Ruffalo MSW described the change therapists had towards Schizophrenic symptoms. “At the heart of the psychodynamic approach to schizophrenia is the idea that psychotic symptoms are not random or meaningless phenomena, but rather rich, symbolic expressions of the patient’s inner world. Hallucinations and delusions are concrete representations of abstract ideas, wishes, and conflicts…In psychodynamic terms, patients with schizophrenia engage in concretization and perceptualization. The latter term refers to the process of transforming abstract concepts into specific sensory perceptions. For instance, patients who think poorly of themselves may smell a foul odor emanating from their body; the rotten self-perception becomes the rotten body that smells. In the absence of sensory perceptions (eg, in patients who experience delusions without hallucinations), concretization is used. This refers to patients who project onto the outside world their self-condemnation and come to believe that others are targeting them. Perceptualization can be considered the most advanced level of concretization.”
Michael Garrett MD, talks about the importance of meaning in some schizophrenic systems. “Psychotic persons use figurative language in idiosyncratic ways. Driven by intense, unbearable affects, they construct concrete metaphors and fanciful delusional identities that are meaningful expressions of their emotional lives. These constructions are regarded by others as alien and incomprehensible because the associational links in the psychotic person’s figurative language are not readily accessible to the average person. A central aim of psychodynamic work in psychotherapy is to help patients reconstruct the emotional meaning of their psychotic symptoms in the protective holding environment of the therapeutic relationship.”
In the time of Sullivan, there were examples of more or less recovered patients. “A socially recovered schizophrenic is often still psychotic, but is certainly less schizophrenic than is a patient requiring active institutional supervision…The non-schizophrenic individual, in his interaction with other persons, behaves and thinks in complete consonance with their mutual cultural make-up. Then, to the extent that one’s behavior and thought dealing with another diverges from the mutual culture—traditions, conventions, fashions—to that extent he would be schizophrenic…If the ‘contact’ with external reality is wholly unintelligible per se to the presumably fairly sane observer, then the subject-individual manifests a content indistinguishable from a dream, and is either in a state of serious disorder of the integrating systems, or is schizophrenic…How does it happen that most of us are able to sort out our dreams and our waking experience with a very high degree of success, while the schizophrenic fails in this?…In the writer’s opinion, the restoration of balance in favor of the dissociating system is achieved by some adjustment of interpersonal relations…A persisting dream-state represents a failure of interpersonal adjustment, such that the tendency system previously dissociated is now as powerful in integrating interpersonal situations as is the previously successful dissociating system…A degree of consciousness may vary, but conflict and a consciously perceived threat of eruption of the dissociated system is sustained.” When there is difficulty in integrating with others, the typical response for the patient is to self-isolate to reduce distressing experiences.
When the therapist arrives on the scene, the resulting situation they are in is to investigate and find out what those failed interpersonal relationships were before the breakdown via transference from the patient onto the therapist. “There seems to the writer to be nothing other than the purpose of the interpersonal situation which distinguishes the psychoanalytic transference relation from other situations of interpersonal intimacy. In other words, it seems to be a special case of interpersonal adaptation, distinguished chiefly by the role of subordination to an enlightened physician skilled in penetrating the self-deceptions to which man is uniquely susceptible, with a mutually accepted purpose of securing the patient an increased skill in living.”
When there is a breakdown and a need for psychiatric isolation, there is a limited time frame to try and get as much information as possible from the patient to piece together the daily failures that occurred beforehand. “The procedure of treatment begins with removing the patient from the situation in which he is encouraged to renew efforts at adjustment with others. This might well be elsewhere than to an institution dealing with a cross-section of the psychotic population; certainly it should not be a large ward of mental patients of all sorts of ages. The sub-professional must…be aware of the…extreme sensitivity underlying whatever camouflage the patient may use. They must be activated by a well-integrated purpose of helping in the re-development or the development of self-esteem as an individual attractive to others.” The well people, the physicians, are communicated to the patient as being there to give the patient “a chance to get well. From the start, he is treated as a person among persons…Every disappointment is another obstacle to his recovery.”
As the early part of the treatment begins, the sensitivity to the patient’s self-esteem must be vigilant. “Everyone is to regard the outpouring of thought or the doing of acts as at least valid for the patient, and to be considered seriously as something that at least he should understand. The individualism of the patient’s performances is neither to be discouraged nor encouraged, but instead, when they seem clearly morbid, to be noted and perhaps questioned. The questioning must not arise from ethical grounds, but from a desire to center the patient’s attention on the discovery of the factors concerned. If there is violence, it has to be discouraged, unemotionally, and in the clearly expressed interest of the general or special good…A considerable proportion of these patients proceed in this really human environment to the degree of social recovery that permits analysis, without much contact with the supervising physician. Moreover, in the process, they become aware of their need for insight into their previous difficulties, and somewhat cognizant of the nature of the procedures to be used to that end. They become not only ready but prepared for treatment.”
So much of what happens in therapy is an investigation because the reality behind the hallucinations is what needs to be understood and reintegrated with the patient. “Energy is expended chiefly in reconstructing the actual chronology of the psychosis…[The] free associational technique is introduced at intervals to fill in ‘failures of memory.’ The role of significant persons and their doings is emphasized, the patient being constantly under the influence of the formulation above set forth—viz., that however mysteriously the phenomena originated, everything that has befallen him is related to his actual living among a relatively small number of significant people, in a relatively simple course of events. Psychotic phenomena recalled from more disturbed periods are subjected to study as to their relation to these people. Dreams are studied under this guide…Interpretations are never to be forced on him, and preferably none are offered excepting as statistical findings. In other words, if the patient’s actual insight seems to be progressing at a considerable pace, it can occasionally be offered that thus-and-so has, in some patients, been found to be the result of this-and-that, with a request for his associations to this comment.”
Even though psychopharmacology to control dopamine levels has taken over much of the treatment, these psychodynamic methods have some therapeutic value, even if it takes some time to show efficacy. Mark had a patient that was able to explain their internal experience of improvement. “The work didn’t click for me until years in. Every psychotic experience was always preceded by a split-second shift in my emotional state. Over time, I was able to feel this window open up… and my experiences slowly dissipated. I still experience psychotic symptoms but at a much less frequent rate. Every session, a new layer of what has happened to me is unraveled through therapy. Almost every time a link has been discovered, I subsequently experience [fewer] symptoms.”
Schizophrenia from the Psychodynamic perspective – Mark L. Ruffalo, MSW, DPsa: https://www.psychiatrictimes.com/view/schizophrenia-from-the-psychodynamic-perspective
For those who managed to improve with treatment the goal was always to provide vocational rehabilitation and social skills training. By the 1950s anti-psychotic drugs made an entrance. There currently is no cure, but with lifelong treatment, a normal life can be carved out for many patients, with an emphasis on early diagnoses and treatment. For Sullivan, “the psychiatrist has to compromise with the ideal of cure and proceed along the line of amelioration…One achieves mental health to the extent that one becomes aware of one’s interpersonal relations; this is the general statement that is always expressed to the patient…Progressively…there goes an expanding of the self to such final effect that the patient as known to himself is much the same person as the patient behaving with others. This is psychiatric cure. There may remain a need for a great deal of experience and education before the psychiatric cure is a social cure, implying a more abundant life in the community. It may be impractical to achieve this more abundant life, the collaborative participation with others, in that particular community. A change of social setting may be mandatory but impractical, in which case adequate mediate relationships and clearly understood reformulations of some of one’s interpersonal goals must fill the gaps. The possibility of achieving a social cure arises solely from the fact of psychiatric cure. The probability of its achievement is a matter of circumstances, limited chiefly by factors inhering in the culture-complex and selectively reflected in all the people available for interpersonal relations. Be social cure achieved or not, however, the person who knows himself has mental health. He is content with his utilization of the opportunities that come to him. He values himself as his conduct merits. He knows and mostly obtains the satisfactions that he needs, and he is greatly secure.”
Interpersonal Theory
Harry Stack Sullivan, like many other psychoanalysts after Freud, understood that there were more avenues of research beyond the usual theorizing and uncovering of internal conflicts or the expressing of repressed emotions, as important as those techniques are. Depending on the kinds of patients, psychoanalysis was forced to experiment and try new things. With things like transference, projection and countertransference, there is an underlying relationship going on with other people. Even in the initial consultation, the words chosen, the tone, and body language is communicating how one is feeling to the patient and all these things can help or hinder the treatment. Each patient has more or less knowledge about the therapeutic process but one mustn’t assume. “Do not assume you know what the patient is talking about. You don’t know until you find out by engaging in an active dialogue in which you test each hypothesis and check each fact.” Because this process is about collecting patient experiences and organizing them, it was best not to overlay a theory too soon. This gave flexibility to the process so the case could take hairpin turns if needed and the resonances for the patient ended up being more authentic.
In The Interpersonal Theory of Psychiatry, Sullivan made an early breakdown of different types of patients, and at this point you can see a pattern with psychoanalysts that like to describe psychology types they have encountered, which were usually limited to a certain specialty, but also there was often a cross-section of other patients who benefited from one type of talking therapy or another. In Sullivan’s case, he grouped many different types into paranoia and self-esteem. “…Failure to achieve late adolescence is the last blow to a great many warped, inadequately developed personalities with low self-esteem. And the usual solution in chronological maturity is to cover over one’s chronic defect in self-esteem by disparaging others—a solution which is used by all of us in varying degrees.” Different people had different reactions to the social environment which led to different coping mechanisms. “With the beginning of the emphasis on cooperation, the child undergoes the experience of fear when he does not live up to the required behavior, and the complex anxiety derivatives of shame and guilt are inculcated. Thus the child is presumed to deserve or require punishment at times, and this punishment takes the form of the infliction of pain, which may be accompanied by anxiety. As a result, the child often has to make complex discriminations of authority situations, so that the ability to conceal things from the authoritative figures and to deceive them becomes a necessity which is implemented by the authority-carrying figures themselves. As a part of this comes the development of precautionary techniques and propitiatory activities such as verbal ‘excusing,’ often with the evolution of techniques for the maintenance of ‘social distance.’ A great many children learn that anger will aggravate the situation and they develop instead resentment…”
For Sullivan, self-esteem has to be based on normal needs that a person has and skillful ways of meeting them with other people. The typical pathological response is to make endless comparisons with other people. There were also philosophical questions about how much choice we could make use of at different times in the past. A typical stuck area is for people to ignore their dependent situation as a child, or adolescent, and to assume that adult choices should have been made across the board. Even in adulthood there is a difficulty in shedding old influences, but it is easier than in childhood. As a child you needed parents to take care of you and you had to accommodate them to avoid rejection and that always leads children to adopted habits along the way in the form of narrowed choices. As children develop there’s a fear of ostracism as those who are better looking, more adaptable, more intelligent with relationships, or intelligent with power, tend to dominate a hierarchy and make life hard for the rest. Shame, guilt, and the need to tear down others can eat away at a personality if one is not careful. The same therapeutic methods are required for all these personality problems where lessons can be learned to improve future responses in interpersonal relationships. The failure to learn and adapt keeps the patient stuck in the same situations. “Even though there may be many actual opportunities, various security operations interfere with observation and analysis, and thus prevent the profit one might gain from experience.”
Coping mechanisms described in the book include: pretending to be someone better than one is, pretending the world is different from the actual facts, moving attention away to the most interesting or exciting distractions all the time, getting eaten up with envy and jealousy, and being addicted to fantasies where there is wish-fulfillment but no actual manifestation in real life. “Many of the people who have…low self-esteem minimize their anxiety by the use of sundry concealments, one extreme of which is actual social isolation.” In response to low self-esteem, one can exploit others by dominating them and enslaving them. One could also become a hangers-on and use the pity of others to gain sympathy or other rewards in return. Some turn to obsessive rituals, including hypochondria, where various medicines are applied unscientifically to behaviors, locations, and situations that tend to inflame the self-esteem. There are also preoccupations with body shape and size. All these concerns are brought into the clinic or hospital and require a teasing apart with emphasis on the relationships. In The treatment techniques of Harry Stack Sullivan by Arthur Harry Chapman, these problems can be found out, and more importantly when employing Sullivan’s angle, the environment of the patient is also illuminated.
The therapist has to maintain professional distance while at the same time not be too aloof and uninterested. The questions under Sullivan’s method are a little different than regular interviews. If there is a behavior in a person, the recognition just doesn’t stay as “I’m too passive. I’m too masochistic.” Questions elucidate which relationships are involved. If you are too passive, which interpersonal relationships is this relevant? If people in the interpersonal relations are described with an adjective, like they are “hostile,” more questions to put together the scenarios and some of the dialogue may paint a different picture. Since the therapist can easily speculate, and the patient is also speculating, because they wouldn’t see a therapist if they truly knew their situation clearly, more detail has to be brought out. The questioning of course is not like a tense interrogation but done with a countenance of someone who wants to understand the situation better. If there are obvious delusional elements and contents in the answer, the therapist can use the word that, like “what do you mean by that?” This allows the therapist to be skeptical while still being open to hear more detail.
At some point, if a patient is needing to see a therapist, there is usually a wounding of some kind that has caused a bout of low self-esteem. Therapists can start with the current emotions. “Now tell me, what did you ever do that causes you to have such a low opinion of yourself?” If there’s any distorted, purity seeking, perfectionistic, rigid thoughts, then any corrections to have the patient follow something more human and flexible, could open up a possibility for healing. This can involve normalization, to point out how common their experiences are with the general population. If parents have worldviews, those views could be challenged, especially if they are pathological, perfectionistic and inhuman. Another method to increase insight is to investigate with the patient the things that are going right in their relationships so that the problem is not catastrophized. This is especially important if people want to repair a relationship and not just give up after every disappointment. When a person is triggered with anxiety or shame, they are not usually taking in as much information and have left behind the common place reality happening in the present moment. “Anxiety hinders the perception and understanding of experience.” The memory is filled with time distortions, hiatuses, gaps and incongruities. The trick is to avoid adding to a patient’s worthlessness with the practiced line of questioning. Questions are also detailed and they should look for specific answers in events instead of generalities with adjectives for nouns, like “I am bad.” It’s better for a question to elicit an answer like, “when I did this thing, I felt bad.” The therapist can also communicate that they need more information and detail to understand better, to project a countenance of someone who listens well, as opposed to someone criticizing the patient’s communication skills. It’s less about judgment and more about clarity. “You do not tell a patient what is wrong with him, but with him jointly explore what his trouble is.” By seeing what has happened in more realistic detail the “assimilated experience [can be drawn upon] in later interpersonal relationships.”
Because interpersonal theory is about human insecurity and relieving the stress of self-criticism, it’s always better to look at behaviors and choices as opposed to a global label that doesn’t allow variety, learning, and the chance for people to change their points of view. As therapists gather information, they are likely to jump to conclusions of how a patient got stuck in a pathological thought vortex with toxic labels, so it’s good to ask confirmation questions so that with a yes or a no, the client can correct the therapists intuitions to keep the therapist from forcing a theory on them. “Was your mother afraid of arousing irritability in other people? Was she timid in approaching people whom she did not know well?” These kinds of questions help to flesh out the interpersonal relationship so that the therapist learns more about them as well. As one gets closer to embarrassing topics, the indirect questions ask about what events happened one step at a time so that the patient gets closer to a voluntary confession. Asking direction questions like “did you and Bob have any homosexual activities?” may end the therapy sessions altogether. It’s best if the patient offers up that information. When there’s a confession of one kind or another, the therapist can then explore thoughts and beliefs that make one feel bad to understand the impacts better. If the feelings are authentic and reasonable, the expression of the emotion connected with the event can be cathartic. If there are distorted views that make the patient feel uniquely bad, they have to be explored and dismantled until something more human and flexible can arise. Therapists also have to avoid loaded questions that judge events, like asking “why did you do that hostile thing?” You want to find out how the patient felt and not interject how you personally judge the patient’s behavior.
Because therapy is about taking what is vast in the unconscious and processing it in an awake sober manner in a reasonably short time span, only so much information can be processed at one time and insights should be processed one at a time. The summaries and paraphrases of what was learned, need to illuminate each individual important interpersonal relationship so that the patient is now beginning to learn how their environment has been affecting them, as well as their introjected beliefs, because this “remedies a good deal of the often illusory, usually morbid, feeling of being different, which is such a striking part of rationalizations of insecurity in later life.” The reason why this method can be so potent is that “things going on between people in interpersonal relationships can be directly observed.” Sticking with the reality and trying to understand it better from different angles can improve learning for the patient. Learning then facilitates new strategies and behaviors so interpersonal relationships can change, evolve, or part ways. Ideally, if enough good changes are made, the patient is making more sense of their life and purpose. The more observable, well-founded those facts, the easier it is to see what changes need to be made. Theories can also be developed much more independently this way so older theories can be developed upon.
Sullivan’s investigation of a patient’s self-system builds up an insightful inventory of symptoms and behaviors. Those reactions include addictive responses, a pattern of ending relationships too soon, a dissociation that prevents learning from experience, and these are opportunities for people to develop healthier responses in the future. Healthier responses allow the patient to regulate their emotions without needing maladaptive coping methods. Because each person is very different, and exists in very different environments, it’s important to see how people behave in those specific situations. Eventually, the therapist can really get to know the patient. This is where psychotherapy trumps a lot of life coaching, because if the coaching can’t get at these environmental details that are hindering self-development, any future life coaching goals will fall under self-sabotage.
As important as it is to see how the Freudian Super-ego and Ego are relating internally, Sullivan’s method can help to clear up the Super-ego’s distortions while coming up with realistic prescriptions the Ego can act on in this very particular individual self-system. One doesn’t even have to define these Freudian terms to the patient and still get the same result. The Ego feels better because it knows what to do and has realistic goals, and the Super-ego adjusts expectations to be more realistic to return to a more flow-like state of well-being that may have existed before the the onset of a recent breakdown. The more realistic options there are for this very particular patient, the more successful the therapy sessions will be. Patients will ideally leave with less anxiety about themselves, feel less odd, weird, alone, and worthless, while at the same time have some concrete goals to manage life better. Managing life better means responding to interpersonal relationships more skillfully, which calms insecurity, while ensuring regular satisfactions. People have biological functions that yearn to be satisfied, including the necessities of life, positive emotions, and sexual gratification or sublimations. Because of projection, how people view themselves can spill over into self-confidence and see their interpersonal relationships in a different light with positive possibilities. “If there is a valid and real attitude toward the self, that attitude will manifest as valid and real toward others. It is not that as ye judge so shall ye be judged, but as you judge yourself so shall you judge others; strange but [this is] true so far as I know, and with no exception.”
This is crucial because many can be brainwashed with low self-esteem with all the habitual efforts of unconscious people in society to disparage others for their own self-esteem project. An emotional parasitical paradigm. You want to be self-generating, by acknowledging human needs, and integrate them with societal exchanges. To get to this point is to get to the point where one can have new experiences, but if the world of paranoid projection is allowed to influence the patient further, there will be no development. “Our awareness of our performances, and our awareness of the performances of others are permanently restricted to a part of all that goes on and the structure and character of that part is determined by our early training; its limitation is maintained year after year by our experiencing anxiety whenever we tend to overstep the margin.” This is why a good upbringing with flexible views, optimistic attitudes, focuses the individual on what to do next and what the next best action is.
Those who had a negative upbringing, who introjected a negative worldview, they will seek to see the negative in the main and become resigned and passive. “When there is anxiety, it tends to exclude the situation that provoked it from awareness, and so the person made anxious by the mathematical problem tends to overlook certain commonplace, obvious aspects of the problem that are well within his grasp. The tendency is to move away from, rather than simply to grasp, the factors making up the situation presented to him…As a generality, that healthy development of personality is inversely proportionate to the amount, to the number, of tendencies which have come to exist in dissociation. Put in another way, if there is nothing dissociated, then whether one be a genius or an imbecile, it is quite certain that he will be mentally healthy…” This constitutes self-development for Sullivan: To make conscious unsatisfied needs and then to satisfy those desires in harmony with others.
The minefield of course is matching values where people can share positive experiences with joint activities or work together in complimentary ways. “But when somebody else begins to matter as much as I do, then what this other person values must receive some careful consideration from me.” Like an event planner, people are negotiating preferences and discharges of satisfaction in complex ways. “‘One achieves mental health to the extent that one becomes aware of one’s interpersonal relations….’ He learns to understand what he is doing. ‘Most patients have for years been acting out conflicts, substitutions, and compromises; the benefits of treatment come in large part from their learning to notice what they are doing, and this is greatly expedited by carefully validated verbal statements as to what seems to be going on.’ There is ‘an expanding of the self to such final effect that the patient as known to himself is much the same person as the patient behaving with others.’ But it takes a good deal of education and experience effectively to grasp the meaning and significance of uncomplicated interpersonal relations, to realize the full benefits of a more abundant life. Increasing knowledge and insight make possible a less complicated, richer experience. New experience in turn makes possible still greater insight. This process does not stop with the end of treatment. Theoretically, at any rate, it continues throughout life.” To summarize, the complexity of the analysis leads to a clear understanding of needs and skill deficits so that patients find clear goals and simple social exchanges that can be negotiated without endless analysis paralysis. If a person needs an intimate partner, they can learn through trial and error and persist in dating environments because they clearly know what they want and if candidates can communicate what they want, social exchanges are easier to make.
The way of boundaries based on knowing what you want is similar to the Law of Attraction, but it’s more closely understood by how people imitate in ways that can conflict or harmonize based on their self-esteem vibration. People who are incompatible will part ways unless one member of the interpersonal relation adjusts to match the other person’s vibration, which would be detrimental if it’s a low vibration. “A loving person, however free of self-distortion, cannot love a hateful person, because the latter is incapable of responding in a loving way. A situation having the qualities categorized as love cannot be integrated because opposites do not unite. There can only be conflict or withdrawal. In the latter case, the situation is disintegrated. If an interpersonal integration occurs and persists, it can only be on the basis of hostility, because a hateful person cannot love, but a loving person, under appropriate circumstances, can be hostile, if only for his own defence…”
Before this synergy can manifest, the patient has to undergo a personal investigation to find what is still dissociated. Dissociation can be defined as “selective inattention, in which one simply doesn’t happen to notice an infinite series of more-or-less meaningful details of one’s living…Selective inattention is, more than any other of the inappropriate and inadequate performances of life, the classic means by which we do not profit from experience which falls within the areas of our particular handicap. We don’t have the experience from which we might profit—that is, although it occurs, we never notice what it might mean; in fact we never notice that a good deal of it has occurred at all…” Sullivan’s dissociation is similar to Freud’s displacement, where an “all-paralyzing anxiety” is connected to situations or behaviors that are awful, dreadful, that one is loathe to experience, or is a horror. There can be a failure to learn and adapt, partially because one views these situations as a “not-me,” or I would say a “I want it to be not-me” versus more conscious attitudes of a “good-me” that is more easily shown to the world. The mind can go into dissociation and unconsciously operate within the not-me, to reduce anxiety at the same time it is “concealing, or excusing…unsatisfactory and undesirable attributes…Whenever dissociated systems of motives are involved, we find a relative suspension of awareness as to any effects that these motives have.” These “automatisms” betray a lack of meaning and the denial that certain behaviors have happened, whereas a person who reacts with some emotion to the behavior, with an understanding, they at least have a chance to integrate that knowledge. This is assuming that there is enough memory, skill, and enough energy to develop new responses. When people integrate what is unpleasant they develop skills and routines that deal with the not-me problematic behaviors and cease to project it onto others as a defense, and cease to ignore the lessons that are readily available. Skills of course are a way of automating newer behaviors and managing energy so as to habituate behaviors into effortlessness. The mind goes into a learning mentality and avoids being stuck in dissociation and repetition. Usually if there’s regression it’s because energy and motivation is lacking, or there’s too much unpleasantness while the new habit is not engrained enough to compensate for that stress. People freeze, avoid, try to numb the pain with other activities, or just neglect unpleasant details and move on to another activity.
The most difficult dissociations to remedy are those that are “founded in early life,” and “occur in the preadolescent and adolescent phases of development.” Sullivan’s descriptions of integration are a little sketchy, but the two ways he mentions involve experimentation, and a figuring out a solution while being inattentive vs., a dramatic roleplaying where a person takes on a new role and “people [it] fight out, with tremendous expenditures of energy…A few people have had experiences in their developmental years of meeting situations actually characterized by these extremely disquieting extraordinary repelling uncanny emotions, in which for a while, they acted as if they were one of the demigods or the demidevils or what not, and got through it, and so from then on knew more about life on the far side of it.” Regardless, a person has to repeatedly do a new behavior long enough so as to create a new habit or skill, and a certain amount of resistance and energy is going to be expended in doing what one normally avoids until it begins to feel familiar. This is a process that affects everyone more or less, including the therapist, so there isn’t a long enough lifespan for most people to truly master all areas of life, and part of the reason for social life is to trade specialties with others in the libido-economy to balance out what is missing in one’s life.
What comes up again and again in psychoanalysis are particular self-identities that become rigid and resist learning, and these identities involve pleasure and stress, and a combination of them related to consequences. Sullivan brought up homosexual experiences, because in his time, it was one of the most horrible identities one could ascribe to that would create a pathological panic, and possibly a schizophrenic episode of projection, avoidance, and self-hatred. The example he provided could be applied to many identities. The term grooming that is used today, can also be expanded beyond a sexual seduction, and include behaviors like a smoker offering a cigarette to a non-smoker, etc. Anything that involves a sadistic desire to be violent in one manner or another, to enjoy base desires in an addictive and unhelpful way, like a drug addiction, all can be integrated in a learning mentality, but if there’s a striving to be a solid identity with an all or nothing attitude about purity and impurity, an incongruous moment of pleasure seeking behavior that wasn’t previously aligned with a past identity, can cause intense stress with an internal warfare that prevents normal goal orientation and a purposeful action. This is especially so if a new craving arises that one isn’t prepared for. There are also ghettoized experiences where people receive the same kind of attention from an environment over and over again so they feel that new experiences or competitive pleasures can’t arise, then those pleasures habituate into a world-as-it-is. Yet if you pay attention, there are people who put enormous energy into changing their environments, including radical changes like becoming a vegetarian, or learning a new language. What was unfamiliar becomes commonplace and this is easier if there’s an increased pleasure or more peace found in the newly integrated activities. Cravings compete with each other and advance to newer ones or regress to older ones depending on how stuck a person is with an identity. In some environments, people will find that they can’t escape and the current pleasure template is all that can be found, whether in leisure activities, processes, certain relationship ruts, addictions to substances, or sexual experiences.
Sullivan provides an example of “abhorrent cravings…The entrance into personal awareness of increasingly-intense-because-unsatisfied, longings to engage in something which is abhorrent—that is, the picturing of engaging in it is attended by uncanny emotion such as horror, dread, loathing, or the like. The classic instance of this eruption of cravings is the eruption of ‘homosexual’ desires—desires to participate in what the patient feels, classically and outstandingly, to be homosexual performances. I think I can illustrate this, perhaps without misleading you too badly, by mentioning one of my patients, an only boy with five sisters, who had led as sheltered a life as that situation would permit. Shortly after getting into uniform in World War II he was prowling around Washington, and was gathered up by a very well-dressed and charming dentist, who took him to his office and performed what is called fellatio on this boy. The boy felt, I presume, a mild adjustment to the uncanny, and went his way, perhaps in some fashion rewarded. But the next day he quite absentmindedly walked back to the immediate proximity of the dentist’s office—whereupon, finding himself so very near what had happened the day before, he was no longer able to exclude from awareness the fact that he would like to continue to undergo these experiences. This is a classical instance of an abhorrent craving in that it was entirely intolerable to him. The day before it had been a kind of new experience, but when it burst upon him in this way, it was attended by all sorts of revulsions and a feeling that it would be infrahuman, and what not, to have such interests. And he arrived at the hospital shortly afterward in what is called schizophrenic disturbance.”
Now there are a variety of responses to these experiences. Many people won’t go into schizophrenic responses and just go into self-hatred, with thoughts of “I’m not pure” and then hate “groomers” who introduced gay sex, or alcohol, drugs, or whatever the subject matter is, and then rail at the world. A healthier response would be to view one’s pleasure template and challenge it with new experiences to really etch out the boundaries, the rejections, the need for more skill, the bodily imperfections that can’t change, the exercises that can change the body or mind, and new neighborhoods to explore, philosophies, meditations and religions that one could experience. The way that young man wanted a repetition of fellatio after an initial introduction, could also be a craving to repeat a different experience after it was just introduced. Most therapy of any value is getting people to look at their impure lives and use adult reasoning to move into new experiences that are more optimal. In some cases, a homosexual relationship is optimal for that person. Even a person who is tired of dating the same kind of people, they often will experiment in looking for different personality types while at the same time learn what they like in a partner and try to develop into that so as to make a better match, especially if the changes to ones life, to become more attractive for example, are healthy and involve newly integrating better skills. There are also some who have made a lot of changes and found that they only attract the personality disordered and realize that sublimating by engaging in good friendships while developing hobbies, is a much saner way of living, especially when energy is depleted with repeated disappointments. Eventually a mode of life is happened upon that one is at ease with as a minimum or one is excited and wants to expand further. One doesn’t get fixated on temporary identities and carves out a more authentic way of life where one can see oneself repeatedly engaging in optimal pleasure with a clearer conscience.
Sullivan’s influences were international and spread wide as a form of 20th century liberalism that sought to look at the psychological impacts coming directly from society and the responding psychological prescriptions that included social programs for society to take on. As always, there were scandals in these influences related to politics and just bad therapy. One of them was an obsession with self-esteem that influenced a general narcissism in the culture. Even though Sullivan didn’t want an outsized fake self-esteem to develop in people, many therapists and bureaucrats took his advice in that simplistic way and dumbed down the practice leading to some the negative results we see now. Self-esteem is very important and it has been studied in many newer modalities and can’t be separated from human well-being, but it’s not an entitlement to self-esteem decoupled from behavior. On exaggerations in more extreme socialist movements, like in the worse cases of communism, which was like a mental hospital concentration camp, along with a deprogramming curriculum, most western countries adopted a more balanced middle road so that a maximum amount of freedoms were balanced with needed psychiatric interventions. Regardless of one’s politics, most conservatives today would want these institutions to remain, even if they have to be reformed from time to time according to new discoveries, and when situations of homelessness and addiction, sometimes supported by psychopharmacology, rear their ugly head, as well as scandals with pharmaceutical companies that make money sometimes with medications that are ineffective or dangerous.
Private Practices: Harry Stack Sullivan, the Science of Homosexuality, and American Liberalism by Prof. Naoko Wake: https://www.isbns.net/isbn/9780813549583/
Conceptions in Modern Psychiatry – Harry Stack Sullivan: https://www.isbns.net/isbn/9781258850692/
Schizophrenia as a Human Process – Harry Stack Sullivan: https://www.isbns.net/isbn/9780393007213/
The Interpersonal Theory of Psychiatry – Harry Stack Sullivan: https://www.isbns.net/isbn/9780415510943/
The treatment techniques of Harry Stack Sullivan by Chapman, Arthur Harry: https://www.isbns.net/isbn/9781568216737/
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