Psychiatry 75(1) Spring 2012 3

Sullivan
Conceptions of Modern Psychiatry

Conceptions of Modern Psychiatry: The First

William Alanson White Memorial Lectures
Harry Stack Sullivan

The role of William Alanson White in the last four decades of American psychiatry
was great indeed. To most of his students, the Professor was American psychiatry and a
kindly benevolent father. In psychiatry he was a leader, a champion of progressive develop-
ments. He was a calm influence at the conference table and a wise counselor to those with
whom he collaborated. In medicine, he was the foremost exponent of the doctrine of the
Organism-as-a-whole.
He was an integrator of constructive emergents in the field of the social sciences. He
correlated divers scientific insights in the service of understanding human behavior. In the
family, the community, and in the counsels of legislator and executive, he was a tireless pro-
ponent of the wise dissemination of psychiatry. His purpose and the purposes of psychiatry
were one. Educator, collaborator, integrator, investigator humanitarian; he was a stimulus to
great achievements, an ideal exemplinarian of the doctrine of service. William Alanson White
was admired and loved by all who came to participate with him in the common interests of
human life.
On 4 December, 1933, several former associates of Dr. White caused themselves to be
incorporated as the William Alanson White Psychiatric Foundation. On 9 February, 1934,
Dr. White became a Trustee of the Foundation and its Honorary President for life. Under
his guidance the purposes of the Foundation took shape as directing research into human
personality and interpersonal relations; evolving methods of benevolent intervention in the
mental disorders of individuals and in disintegrating, deviant, or dangerous social processes;
and providing postdoctoral training designed to produce psychiatrists of an entirely new
level of competence.
To the latter end, on 8 May, 1936, the Board of Trustees of the Foundation caused the
incorporation of The Washington School of Psychiatry. Despite his failing health, Dr. White
participated actively in the development of the nuclear plan of the school and lived to see his
ideals embodied in its first Bulletin.

M.D., Chicago Coll. Med. and Surg. 17; Junior Member Board of Examiners, M.C., U.S. A. 18; Asst. [8th] Dist.
Med. Officer, Rehabil. Div., Federal Board Vocational Educ. 19, Med. Exec. Officer of the Division 20-21; Psychia-
try, Public Health Institute 21-22; U.S. Veterans Bureau Liaison Officer, St. Elizabeths Hospital 22-23; Asst. Phys.
Sheppard and Enoch Pratt Hospital 23-25, Director Clinical Research 25-30. Instr. Psychiatry, Univ. Maryland,
School of Medicine 24, Assoc. Prof. 25-30; Lecturer and Supervising Instructor Psychoanalytic Therapy of Schizo-
phrenia and Allied States 33-; Head Department, W.S.P. 36-. Private Practice Psychiatry 31-. Amer. Psychiatric Assn.
Comm. On Relations to the Social Sciences 27-30, Comm. on Research 37-; Hanover Conferences, Social Science
Research Council 27, 30; Seminar Impact of Culture on Personality, Yale 32-33; Natl. Research Council Comm. on
Personality and Culture 34-37; Educational Comm. Washington-Baltimore Psychoanalytic Society 33-37. Consult.
Phys. Harlem Valley [N.Y.] State Hospital; T. and President, William Alanson White Psychiatric Foundation 33-; D.
and President, Washington School of Psychiatry 36-; Assoc. Editor, Amer. J. Psychiatry 24-39; Co-editor, Psychiatry
38-. F.A.P.A., F.A.O.A., A.A.A.S., M. N.Y. Acad. Sci., Washington-Baltimore Psychoanalytic Society, etc. For bibli-
ography, see Reference List section of this issue. [Note: Bibliography not included in this reprint.]

© 2012 Guilford Publications, Inc.

4 Sullivan

In 1937, following Dr. White’s untimely death, the Trustees established the quarterly
publication Psychiatry: Journal of the Biology and the Pathology of Interpersonal Relations,
Number One of Volume One bearing the date of February, 1938.
In the Autumn of 1938, the Board of Trustees decided to provide a series of William
Alanson White Memorial Lectures to present to psychiatrists, social scientists, and others,
various important developments in the field to which Dr. White devoted his life.
Dr. Harry Stack Sullivan, one of the more distinguished of Dr. White’s former as-
sociates— for many years Director of Clinical Research in the Sheppard and Enoch Pratt
Hospital; thereafter for ten years in private practice—was chosen to give the first memorial
lectures.
Held at the Auditorium, Interior Department, Washington, D.C. on five successive
Friday evenings beginning 27 October, 1939, under the joint auspices of the Superintendent
and the Staff of Saint Elizabeth’s Hospital and the Board of Trustees of the William Alanson
White Psychiatric Foundation the lectures drew a distinguished audience the continued atten-
dance of whom was most gratifying. Responsive to many requests the series is here presented
as the first article in Volume Three.

In the preface to his autobiography,1 the relations of man to man, perhaps even of
Dr. White remarked “when we look about peoples to peoples.
us and see the confusion that the world is in For those of you who are not too fa-
at the present moment, see the antagonisms miliar with the thinking of psychiatrists,
that are loosed by national rivalries and re- I might suggest something of the diversity
alize the possibilities of war, of disaster, of of their views by mentioning three sorts of
death, which they conceivably may entail, psychiatrists: those to whom all mental pro-
then realize that all of these results hang cesses are but epiphenomena; those to whom
upon the way in which mental factors are mental disorders signify biological—or spir-
evaluated and the powers of mind are uti- itual—inferiority; and, happily; those who
lized, we must come to the conclusion that accept the mental as a scientifically valid, if
we cannot overemphasize the importance of largely unexplored, field.
this field of interest.” Quite beyond diversity of views, how-
Rather than attempt some expression ever, our discipline has two chief bodies of
of the honor which this occasion brings to meaning. One reaches back clearly to the
me, let me take these words of one of the Hippocratic school of medicine, among the
pioneers of modern psychiatry as my text writings of which there are excellent psy-
and proceed with what is bound to prove chiatric contributions. This part of psychi-
too great a task for adequate performance. atry—this definition of the psychiatric field
A definitive expression of the conceptions in- if you please—I have elsewhere described as
hering in modern psychiatry would be a task the art of observing and perhaps influencing
indeed. I shall attempt in this series of lec- the course of mental disorders.2 It was over-
tures little more than an outline of the field whelmed in the recession from the Classic Pe-
of though within which there are insights riod and had its renaissance with Pinel—1745
that seem destined to illuminate some age- to 1826—as physician to the Bicêtre in 1793.
old and many future problems of living, of In those days, people who were the victims

1. William Alanson White: The Autobiography of a Purpose; Garden City, N.Y.; Doubleday, Doran and Co., 1938
(xix and 293 pp). The next paragraph in the preface expresses the author’s qualified belief “that the average medical
man is, by and large, about as thoroughly lacking in information as to the significance of mental factors in relation
to disease as is the average layman.”
2. Psychiatry. Enclyclopaedia of the Social Sciences; New York, Macmillan (1934) 12:578-580
Conceptions of Modern Psychiatry 5

of serious mental disorders were treated in breadth of human psychiatry. However, of

rather barbarous fashion, only occasion- this more anon.
ally being as fortunate in this regard as were The medical man of the Hippocratic
those imprisoned for crime. He eliminated era was a skillful observer, and, since Para-
the chains and shackles, the brutal handling, celsus, this tradition has been renewed in the
exsanguination, and drugging. As Director Western world. The course of development
of the Salpetriere, from 1795, he evolved a of modern medicine ran through anatomical
remarkably modern system of psychiatric and then pathological studies, with increasing
institutional care which was fortunately per- concentration on the cellular structure of liv-
petuated by his most distinguished student, ing tissues—and recently on the biochemical
and successor, Equirol—1772 to 1840.3 and biophysical aspects of the tissue and cell
The second body of meaning of psy- function. While there arose a class of medical
chiatry—the alternative definition of the practitioners who tended to exemplify the
psychiatric field—is coeval with the man as finest sort of physicians, the vast increase of
a social being. In the shadows before prehis- medical information led presently to increas-
tory, as man began to take on the social habit ing specialization of interest, and diagnostic
of life, the germs of this discipline must have and therapeutic practice. The physician to
sprouted. As man appears clearly in history, the ailing patient tended to fade out and give
it showed itself in the performances of his way to the medical expert dealing with the
medicine men and magicians, his seers and disease which interested him.
prophets and sages. They observed their fel- Again in retrospect, in the days of
lows with unusual clarity and elaborated Pinel, there lived Pierre Jean George Ca-
wisdom from experience to the end of lead- banis—1774 to 1838—a medical scientist
ership, guidance, and the cure of disorders who came to hold that all mental functions
of living. were functions of the brain.4 Franz Joseph
This broader aspect of psychiatry Gall—1758 to 1828—meanwhile having de-
would include the narrower medical as- voted some years to the study of the brain,
pect and if I mistake not, in time to come came to understand something of cerebral lo-
the medical aspect must expand to the full calizations of motor functions, and reported

3. A history of culture would have as its most significant part a history of ideas and information about man’s con-
stitution, functional activity, and communal existence with his natural, biological and personal environment. This
would be the history of “human nature.” These and the following remarks are no more than a laying of the pen-
point on paper for writing such a history. The appended references are but an iota in the alphabet of psychiatric
history. Given opportunity, one should certainly read Semelaigne, Rene Alienistes et Philanthropes; Paris, Steinheil,
1912 (4 and 548 pp ).
See Pinel, Phillippe, Traite medico-philosophique sur l’alienation mentale ou la manie [2 ed]; Paris, Brosson, 1809
(xxxii and 496 pp.), and Nosographie philosophique [6 ed.]; Paris, Borsson, 1818 (3 volumes). See also Esquirol,
Jules-Etienne Dominique, Mental Maladies. A Treatise on Insanity [tr. from the French, with additions, by E.K.
Hunt, M.D.]; Philadelphia, Lea and Blanchard, 1845 (xviii and 496 pp.)
Esquirol may be called the father of modern psychiatry, for Pinel, while spurning materialistic philosophy, looked
chiefly to physiological formulations and taught that mental disorders were the results of heredity and stresses and
excesses in living. Esquirol’s observations directed his thinking much more toward explanations in psychological
or psychobiological terms.
It is to be noted that Johannes Weyer, a sixteenth century psychiatrist-author of De Proestigiis Doemonum pub-
lished in 1566- is considered by Gregory Zilboorg to be the father of scientific psychiatry. He refers its moral
awakening to Weyer; its humanistic, to Pinel. See his The Medical Man and the Witch During the Renaissance [The
Hideyo Noguchi Lectures]; Baltimore, The Johns Hopkins Press, 1935 (x and 215 pp.) ; also Binz, Carl, Doktor
Johann Weyer; Bonn, Mareus, 1885, to which Zilboorg refers.

4. The remark is attributed to Cabanis that the brain secretes thought as the liver secretes bile. See his Rapports du
physique et du moral de l’homme; Paris, Bureau de la Bibliotheque choisie, 1830 (2 vols. 405 and 430 pp.).
6 Sullivan

on this work to the Institute of France. The aversion to mental disorder which is the lin-
great comparative anatomist, Georges Cuvi- ear descendant of belief in demoniacal pos-
er—1769 to 1832—and Pinel were members session and witchcraft, still makes it more
of the Institute’s committee. The phrenologi- certainly respectable to be treated by a neu-
cal buncombe which was mixed with Gall’s rologist for a “nervous breakdown” than to
scientific work led to an unfavorable recep- consult a psychiatrist about one’s difficulties
tion. in living. The euphemism covers supersti-
Pierre Flourens—1794 to 1867—about tion and protects conceit: both are powerful
the same time was experimenting on local- checks on the progress not along of psychia-
ized damages to the brain with observations try, but of civilization as a whole.
of the animal’s subsequent loss of functions. Processes in the central nervous sys-
This pioneer neurophysiologist is entitled to tem, in the other nervous systems, and in the
high honor, for he perceived clearly the total- autocoid dynamism, have importance in ex-
function aspect of the central nervous system plaining some of the conditions of behavior,
in contradistinction to those more localized human or infrahuman. We have to look to
phenomena which were soon—prefaced by the broader aspects of psychiatry for light on
Marshall Hall, 1790 to 1857, who evolved some other indispensable conditions of hu-
in 1833 the conception of reflex action— man behavior.7 And we have a great deal to
to influence the psychological formulations learn in both fields.
throughout the era of the mechanistic phi- In the enlightenment, the broader field
losophies, and to underwrite the misalliance of psychiatric interest evolved in direction
of medical psychiatry with neurology which which took many of its students far from
persists in many quarters to this day. A great medial preoccupations. It became the con-
figure in this was Hughlings Jackson—1834 viction of many that the study of man in the
to 1911—who progressed from the study group would be productive of information
of epileptic phenomena to the formulation valuable in government and in promoting
of rather simple cerebro-mechanical expla- the common weal. The social sciences thus
nations of many of our most complex per- developed techniques for studying, and alleg-
formances in relations with others. Henry edly studying, group behavior, factors mak-
Head—b. 1861—may be said to have re- ing for mass performances, and specialized
opened the field, 5 although the neurophysi- aspects of man’s social life. Only recently
ologists had already destroyed the neat struc- have there appeared social scientists who are
ture of reflexology.6 We may rest secure in interested in the data of medical psychiatry,
the knowledge that much is yet to be learned and still more recently psychiatrists who are
concerning the central nervous system. interested in such fields as cultural anthro-
The mesalliance of neurology and pology and sociology. While I had something
psychiatry has by no means been dissolved. to do with starting the latter rapprochement,
The emergency of the World War brought us the appearance of this trend towards a com-
neuropsychiatrists, and a cultural factor, the plete psychiatry depended primarily on three
5. Head, Henry, Aphasia and Kindred Disorders of Speech; Cambridge, The University Press, 1926 (Vol. 1: xiv
and 549 pp.).
6. See in particular, among many relevant contributions: Bard, Philip, On Emotional Expression after Decortica-
tion with Some Remarks on Certain Theoretical Views. Psychol. Rev. (1934) 41: 309-329 and 424-449. Rioch,
David McK. And Brenner, Charles, Experiments on the Corpus Striatum and Rhinencephalon. J. Comp. Neurol.
(1938) 1:339-345. Rioch, David McK., A Review of the Physiology of the Corpus Striatum and Globus Pallidus,
PSYCHIATRY. See, also Bard, Philip, Central Nervous Mechanisms for Emotional Behavior Patterns in Animals.
Research Publications of the Association for Research in Nervous and Mental Diseases, 19: 190-218.
7. My own interest in those types of explanations which Adolf Meyer has so aptly termed “neurologizing tautol-
ogy,” I owe to a conversation with Gilbert Horrax, the neurosurgeon, shortly after the World War. His comments
on the sequelae and the lack of sequelae, of serious cerebral wounds was most illuminating.
Conceptions of Modern Psychiatry 7

great figures who appeared in the later years the way for the scientific study of people,
of the Nineteenth Century—Sigmund Freud, in contra-distinction to mind, or society, or
Adolf Meyer, and William Alanson White.8 brain or glands.9
Freud—1856 to 1939—and Josef “It is manifestly impossible to formu-
Breuer—1842 to 1925—published in 1895, late all the difficulties of human adaptation
Studien über Hysterie in which they indi- in biological terms, in psychological terms,
cated that hysterical symptoms arose from or in sociological terms; or, for that matter, in
extra-conscious mental processes, the en- a meaningful blend of any or all of these. The
ergy of which was diverted or converted psychobiology of Adolf Meyer—b. 1866—is
into a personally meaningless disorder of the most distinguished recent effort to find a
function. Freud presently invented the free- new locus for problems, a new level of reality
associational technique for reintegrating re- and knowledge, and new conceptual tools.
pressed material, evolved the psychoanalytic Meyer recognizes the hierarchies of organi-
instinct-theory, and drew attention to what zation and proceeds from a consideration of
he called transference. His Traumdeuting organismic integrating factors . . . to bridge
was published in 1900, and by 1905, he had the gap between biology and psychiatry by
formulated the libido theory and the doc- the concept of mentation, a peculiarly effec-
trine of the Oedipus complex, as the most tive integrating activity by the use of sym-
important conflict in the growth of the child, bols and meanings.” Meyer finally emanci-
and the problem, failure to solve which leads pated psychology from its medieval heritage.
to “neurosis.” There followed the evolution Himself a most competent neurologist and
of psychoanalysis and depth-psychology neuropathologist, he denied the usefulness
with dynamic, economic, and topographi- of preoccupation with neural analogies. He
cal points of view; and the postulation of a indicated that it is by a superordination of
Todestrieb, or death-instinct. physiology by means of the integrating func-
It is with the first fruits of Freud’s ge- tions and particularly by means of the use of
nius that we shall concern ourselves. The symbols as tools that man was able to devel-
phenomena appearing in prolonged free-as- op, on the one hand, his grasp on reality, and
sociational interviews, with the study of the the other, his remarkable problems in dealing
transference-distortions that accompany—or with his personal reality and the reality of
precede—the verbal material, together pro- others around him.10
vide a bridge across those discontinuities The genius of William Alanson
which had hitherto prevented the formula- White—1870 to 1937—was of amazing
tion of a comprehensive psychology of men- scope. The particular contribution which I
tal content. Freud revealed the experiential would stress here is his perception that his
origin of specific limitations of personal psychiatry, now principally centered on men-
awareness. By this achievement, he cleared tation and the utilization of symbols, very

8. Listings of recent significant persons must express personal convictions as to the probable appraisal of their work
by scholars yet to come.”….of the six major contributors to psychiatry in the last twenty-five years (Kraepelin,
Freud, Sherrington, Pavlov, Wagner von Jauregg, and Cannon), three are physiologists:; a footnote to his “Problems
in Cerebral Anatomy and Physiology: in The Problem of Mental Disorder; N.Y. and London, McGraw-Hill, 1934
( x and 388 pp. ). Dr. Cobb is of the opinion that “no sound psychologist doubts that the brain is the organ of the
mind.”
9. See Intuition, Reason, and Faith: An editorial. PSYCHIATRY (1939) 2:129-132 from which the quotation that
follows is taken.
10. The bibliography of Meyer is published in a special number of Archives of Neurology and Psychiatry (1937)
37: 725-751. For an exposition closely related to his views and often in his own language, see Muncie, Wendell,
Psychobiology and Psychiatry; St. Louis, Mosby, 1939 (739 pp.).
8 Sullivan

convenient and effective devices for dealing sounds and so on impinge on our sense or-
with very complex entities and relations in gans. They send certain specific impulses to
the world—that this science, which had be- a more central organ in which this group of
gun to grasp the realities of the troubles of impulses is connected with more or less re-
living, was a science not only qualified to deal lated impulses which we experienced in our
with the mentally ill but a science having vast historic past. And out of this blend, this in-
relevance in human affairs, touching I know stantaneous comparison in the central ner-
not how many fields of human endeavor and vous system and related tissue, there arises in
human problems; in fact, a fundamental dis- our mind a conviction that we are observing,
cipline for all those fields that deal with the say, an orange, or something of that kind; on
performance of man, whether in health or in the one hand, the object, eternally separated
illness or in those vast congeries of twilight from us by the act of perceiving it, and, on
states which the individual regards as health the other, the percept in our mind.
but society might well regard as illness. Now, when it comes to the matter of
There was effected in Dr. White’s vi- perceiving another person, not only is there
sion the first synthesis of the two great the object, this other person, and the percep-
trends of psychiatric meaning—the medical tion of the emanations from that person—
discipline concerned with human ills, and appearances transmitted by light rays, indices
the other great body of observational tech- transmitted by sound waves, meanings trans-
niques, formulations, hypotheses and experi- mitted by statements, implications transmit-
ments which are included in all those efforts ted in the whole act of communicating—but
to understand social situations and to deal also the distorting and confusing and compli-
with social problems as they have appeared cating factor of our past experience with oth-
in the history of man. er people who looked like this, who sounded
This synthesis is not yet complete. The like this who made those statements, who
next, I trust, great step in its emergence came had certain implications that happen to be
with the realization that the field of psychia- irrelevant here, and so on. In other words,
try is neither the mentally sick individual, the central synthesis of acquaintance, the
nor the successful and unsuccessful processes percept in our mind, concerning another per-
that may be observed in groups and that son is fabulously more complicated than is
can be studied in detached objectivity. Psy- the case with non-personal reality.
chiatry, instead, is the study of processes that So complex is this synthesis that it
involve or go on between people. The field is practically impossible to elaborate tech-
of psychiatry is the field of interpersonal re- niques by which we can make our objective
lations, under any and all circumstances in contact with another individual reasonably
which these relations exist. It was seen that good. His performances in a situation, what
a personality can never be isolated from the he says and does; and, with increased uncer-
complex of interpersonal relations in which tainty, what he says as to what is going on in
the person lives and has his being.11 him: these we can observe scientifically. We
Let me suggest to you a few of the can improve our techniques for participant
problems that we encounter by mentioning observation in an interpersonal situation in
that our ordinary relation between and ob- which we are integrated with our subject-
ject and a percept has a generally overlooked person. This is evidently the procedure of
but none the less necessary link the act of psychiatry. I urge it as implying the root-
perceiving. There is the object: emanations premise of psychiatric methodology.
from it in the form of light waves, odors,

11. Sullivan, Harry Stack, Socio-Psychiatric Research: Its Implications for the Schizophrenia Problem and for Men-
tal Hygiene. Amer. J. Psychiatry (1931) 10[o.s. 87]: 977-991
Conceptions of Modern Psychiatry 9

The unique individuality of the other desire for sleep leads to such performances.
fellow need never concern us as scientists. It The state of being which is marked by the
is a great thing in our wives and our children. presence of lust is in this group; and finally,
They have, however, aesthetic and other val- as the most idling example, the state of being
ues that are outside of science: when it comes which we call loneliness. All these states lead
to science, let us confine ourselves to some- to activity which is the pursuit of satisfac-
thing at which we have some chance of suc- tion.
cess. We can study the phenomena that go On the other hand, the pursuit of se-
on between the observer and the observed in curity pertains rather more closely to man’s
the situation created by the observer partici- cultural equipment than to his bodily or-
pating with the observed. I hold that this is ganization. By “cultural” I mean what the
the subject matter of psychiatry; some rather anthropologist means—all that which is
remarkable results have already come from man-made, which survives as monument to
its definition. preexistent man, that is the cultural. And as
It must be understood that the perfor- I say, all those movements, actions, speech,
mances of a person in interpersonal relations thoughts, reveries and so on which pertain
include not only acts, including speech but more to the culture which has been impeded
also the subject matter of certain remarks. in a particular individual than to the orga-
If I say to you, “This is a beautiful room,” nization of his tissues and glands, is apt to
while it may not possess quite the validity of belong in this classification of the pursuit of
your opinion that it is a beautiful room, still security.
it may be accepted as highly probably my The thing which many people if they
opinion of the room. It is the type of indirect were quite honest with themselves would say
communication of a subjective phenomenon that they were after when they are showing
which gives the, if you please, lunatic fringe a process of this type is prestige, and one of
to psychiatry even in its much more refined my long-acquainted colleagues, Harold D.
state. Lasswell, a political scientist, worked out a
Human performances, the subject of statement for this field in three terms: secu-
our study, including revery processes and rity, income, and deference. All these pertain
thought, are susceptible of a two-part classi- to the culture to the social institutions, tra-
fication which is based on the end states, the ditions, customs, and the like, under which
end conditions toward which these processes we live to our social order rather than to the
are obviously moving, or which our previ- peculiar properties of our bodily or somatic
sion has reached. In other words, now and organizations.
then you set out to start for somewhere. You This second class, the pursuit of secu-
preview the steps which will be necessary to rity, may be regarded as consisting of ubiqui-
get there and we can foresee the whole pro- tous artifacts—again in the anthropological
cess on the basis of your reaching that place. sense, man-made—evolved by the cultural
The most general basis on which in- conditioning or training; that is, education
terpersonal phenomena, interpersonal acts, of the impulses or drives which underlie the
may be classified, is one which separates the first class. In other words, given our biologi-
sought end states into the group which we cal equipment we are bound to need food and
call satisfactions and those which we call se- water and so on—certain conditioning influ-
curity or the maintenance of security. Satis- ences can be brought to bear on the needs
factions in this specialized sense are all those for satisfaction. And the cultural condition-
end states which are rather closely connected ing gives rise to the second group, the second
with the bodily organization of man. Thus great class of interpersonal phenomena, the
the desire for food and drink leads to certain pursuit of security.
performances which are in this category. The
10 Sullivan

To follow this line of thought profit- can always be depended on. If there is a valid
ably however, one must look closely at this and real attitude toward the self, that atti-
conception of conditioning, and one must tude will manifest as valid and real toward
consider especially the states characterized others. It is not that as ye judge so shall ye
by the feeling of ability or power. This or- be judged, but as you judge yourself so shall
dinarily much more important in the human you judge others; strange but true so far as I
being than are the impulses resulting from know, and with no exception.
a feeling of hunger, or thirst, and the fully The infant has as perhaps his mighti-
developed feeling of lust comes so very late est tool the cry. The cry is a performance of
in biological maturation that it is scarcely a the oral apparatus, the lips, mouth, throat,
good source for conditioning. cheeks, vocal cords, intercostal muscles, and
We seem to be born, however, with diaphragm. From this cry is evolved a great
something of this power motive in us. An collection of most powerful tools which man
oft-told story beautifully illustrates the early uses in the development of his security with
appearance of what I am discussing as the his fellow man. I refer to language behavior,
motive toward the manifestation of power or operations including words.
ability. The infant seeing for the fist time the Originally the infant’s magical tool
full moon, reaches for it. Nothing transpires. for all sorts of purposes, all too many of
He utters a few goos and nothing transpires; us still use vocal behavior as our principal
then he starts to cry in rage, and the whole adaptive device; and while none of you, of
household is upset. But he does not get the course, would do this, you must all know,
moon, and the moon becomes ‘marked’ un- some people who can do in words practically
attainable. anything and who have a curious faith that
This is an instance of the frustration of having said the right thing, all else is forgiven
the manifestation of power; one has failed at them. In other words, they are a little more
something which you might say one expects like the infant than we are; they figure that a
oneself to be able to achieve—not that the series of articulate noises turns any trick. We
infant does much thinking, but the course of have of course learned that many other acts,
events indicates the application of increas- performances, and foresights are necessary
ingly complex techniques in the effort to for success in living. None the less, denied
achieve the object. our language behavior and the implied rev-
The full development of personality ery processes that reach their final formula-
along the lines of security is chiefly founded tions in words, we would be terribly reduced
along the infant’s discovery of his powerless- in our competence and materially diminished
ness to achieve certain desired end states with in our security in dealing with other people.
the tools, the instrumentalities, which are at At this point, point, I wish to say that if
his disposal. From the disappointments in the this series of lectures, is to be reasonably suc-
very early stages of life outside the womb— cessful, it will finally have demonstrated that
in which all things were given—comes the there is nothing unique in the phenomenon
beginning of this vast development of ac- of the gravest functional illness. The most
tions, thoughts, foresights, and so on, which peculiar behavior of the acutely schizophren-
are calculated to protect one from a feeling ic patient, I hope to demonstrate, is made up
of insecurity and helplessness in the situation of interpersonal processes with which each
which confronts one. This accultural evolu- one of us is our historically has been famil-
tion begins thus, and when it succeeds, when iar. Far the greater part of the performances,
one evolves successfully along this line, then the interpersonal processes, of the psychotic
one respects oneself, and as one respects one- patient are exactly of a piece with processes
self so one can respect others. That is one which we manifest some time every twenty-
of the peculiarities of human personality that four hours. Some of the psychotic perfor-
Conceptions of Modern Psychiatry 11

mances seem very peculiar indeed, and, as I it endures throughout life, at least in some
surmised in 1924,12 for the explanation and people. There are few unmistakable instanc-
familiarization of these performances, we es of its function in most of us, however, in
have to look to the interpersonal relations of our later years; I find it convenient to assume
the infant, to the first eighteen months or so that the time of its great importance is later
of life after birth. infancy and early childhood—perhaps age
To return to the epoch of infancy, first six to twenty-seven months. So much for
let me state that this is the period of matura- empathy.
tion, of experimentation, of empathic ‘obser- The other strange term in our state-
vation,’ and of autistic invention in the realm ment about the epoch of infancy is autistic,
of power. Two of these terms may need some an adjective by which we indicate a primary,
explanation. unsocialized, an acculturated state of symbol
From birth it is demonstrable that the activity, and later states pertaining more to
infant shows a curious relationship or con- this primary condition than to the conspicu-
nection with the significant adult, ordinarily ously effective consensually validated symbol
the mother. If the mother, for example, hated activities of more mature personality. The
the pregnancy and deplores the child, it is a meaning of the autistic will become clearer in
pediatric commonplace that there are feed- my discussion of language.
ing difficulties, unending feeding difficulties, We see our infant, then, expanding as
with the child. If a mother, otherwise deeply a personality through the exercise of ability
attached to the infant, is seriously disturbed of power. We see him using the magic tool of
by some intercurrent event around nursing the cry. We now see him acquiring another
time,is frightened by something or worried tool, which in turn also becomes magical. I
about something around the time of nursing, refer here to his expression of satisfaction. It
then on that occasion there will be feeling dif- is biological for the infant when nourished
ficulty or the infant has indigestion. All in all to show certain expressive movements which
we know that there is an emotional linkage we call the satisfaction-response, and it is
between the infant and the significant adult. probably biological for the parent concerned
Empathy is the term that we use to to be delighted to see these things. Due to
refer to the peculiar emotional linkage that the empathic linkage, this, the reaction of
subtends the relationship of the infant with the parent to the satisfaction-response of the
other significant people—the mother or the infant, communicates good feeling to the in-
nurse. Long before there are signs of any un- fant and this he learns that this response has
derstanding of emotional expression there is power. Actually, this may be taken to be the
evidence of this emotional contagion or com- primitive root of human generosity, the sat-
munion. This feature of the infant-mother isfaction in giving satisfaction and pleasure:
configuration is of great importance for an another thing learned by some people in in-
understanding of the acculturation or cultur- fancy.
al conditioning to which I have referred. I shall pass infancy now to return pres-
We do not know much about the fate ently to one aspect of it. As soon as the infant
of empathy in the developmental history of has picked up a vocal trick, saying perhaps
people in general. There are indications that “ma” and getting a tremendous response
12. See discussion of “Primitive Mentality and the Racial Unconscious,” Amer. J. Psychiatry (1925) 4: 671. The
matter in point is illustrated, for example, by Ribble, Margarethe A., Clinical Studies of Instinctive Reactions in
New Born Babies. Amer. J. Psychiatry (1938) 95: 149-158. Note the stupor reaction following defeat of the infant’s
efforts at sucking-pp. 154-157. See, then, Sullivan, Harry Stack. The Oral Complex. Psychoanalytic Rev. (1925)
12:31-38 and, the same, Erogenous Maturation. Psychoanalytic Rev. (1926) 13: 1-15. Note also Hadley, Ernest
E., The Psychoanalytic Clarification of Personality Types. Amer. J. Psychiatry (1938) 94: 1417-1430; in particular,
pp. 1424-1425. Some observations in this connection were reported at the 1938 meeting of the Association for
Research in Nervous and Mental Diseases; McGraw, Myrtle B., Research Publications 19:224-246.
12 Sullivan

from the significant adult, without any idea ised on a certain birthday a pony. As you
of precisely what has happened but catching listen to the child talk about the pony you
on the second time it happens, as soon as the realize perhaps sadly that twenty-five years
rudiments of language habits have appeared, from now when he talks about ponies, pony
we say that infancy as a state of personality will not have a thousandth of the richness
development has ceased and that the young of personal meaning that pony has for him
one has become a child. now. The word of the child is autistic, it has
Childhood includes a rapid accultura- a highly individual meaning, and the pro-
tion, but not along in the basic acquisition cess of learning language habits consists to a
of language, which is itself an enormous cul- great extent, once one has got a vocabulary,
tural entity. By this I mean that in childhood in getting a meaning to each particular term
the peculiar mindlessness of the infant which which is useful in communication. None of
seems to be assumed by most parents passes us succeeds completely in this; some of us do
off and they begin to regard the little one as not succeed noticeably.
in need of training, as being justifiably an Along with learning of language, the
object of education; and what they train the child is experiencing many restraints on the
child in consists of select excerpts from the freedom which it had enjoyed up till now.
cultural heritage, from that surviving of past Restraints have to used in the teaching of
people, incorporated in the personality of the some of the personal habits that the culture
parent. This includes such things as habits of requires everyone should show, and from
cleanliness—which are of extremely good these restraints there comes the evolution of
repute in the Western culture—and a great the self system—an extremely important part
many other things. And along with all this of the personality—with a brand-new tool,
acculturation, toilet habits, eating habits, a tool so important that I must give you its
and so on and so forth, there proceeds the technical name, which unhappily coincides
learning of the language as a tool for com- with a word of common speech which may
munication. mean to you anything. I refer to anxiety.
The ability to pick phonemal stations With the appearance of the self system
in vocal sound—that is, the peculiar ones of on the self dynamism, the child picks up a
a continuum of sounds which are used in the new piece of equipment which we technically
forming of words, which varies, incidentally, call anxiety. Of the very unpleasant experi-
from language to language—the ability, as ences which the infant can have we may say
I say, to learn phonemes,13 to connect them that there are generically two, pain and fear.
into syllables and words, is inborn. That is Now comes the third.
given in the human organism. The original It is necessary in the modification of
usage of these phonemal stations, syllables, activity in the interest of power in interper-
words, however, is magical, as witness the sonal relations, including revery and elemen-
“ma” and as witness, for example, any of tary constructive revery—that is, though—
you who have a child who has been prom- that one focus, as it were, one’s interest into

13. The phoneme is a particular zone or station in the continuum of audible vibrations around which the use of a
particular language has established meaning for the identification of verbal intention. A phoneme is more than a
particular number of cycles per second of vibration; it is a family of such particular c.p.s. plus overtones, etc. The K
sounds in can, cool, keep, come are of one phoneme. The phoneme is the linguistic unit of the person’s speech; the
diaphone is the corresponding term for the approximate phonemal coincidences that make up intelligible speech.
See Sapir, Edward, Language, An Introduction to the Study of Speech; New York, Harcourt, Brace, 1921, reprinted
1929 (vii and 258 pp.); Sound Patterns in Language. Language (1925) 1:37-51; Dialect, Encyclopaedia of the
Social Sciences; New York MacMillan (1931) 5: 123-126; Language. The same (1933) 9:155-169; La Realite
Psychologiques des Phonemes. Journal de Psychologie (1933) 30: 247-265. A selected bibliography of this great
linguist and cultural anthropologist appears in PSYCHIATRY (1938) 1: 154-157.
Conceptions of Modern Psychiatry 13

certain fields that work. It is in learning this scope, it interferes with noticing the rest of
process that the self is evolved and the instru- the world. When you are staring through
mentality of anxiety comes into being. your microscope, you don’t see much ex-
As one proceeds into childhood, dis- cept what comes through that channel. So
approval, dissatisfaction with one’s perfor- with the self dynamism. It has a tendency
mances become more and more the tool of to focus attention on performances with the
the significant adult in educating the infant significant other person which get approba-
in the folk ways the tradition, the culture in tion or disfavor. And that peculiarity, closely
which he is expected to live. This disapproval connected with anxiety, persists thenceforth
is felt by the child through the same empath- through life. It comes about that the self, that
ic linkage which has been so conspicuous in to which we refer when we say “I,” is the
infancy. Gradually he comes to perceive dis- only thing which has alertness, which notices
approving expressions of the mother, let us what goes on in its own field. The rest of the
say; gradually he comes to understand disap- personality gets along outside of the aware-
proving statements; but before this percep- ness. Its impulses, its performances, are not
tion and understanding he has felt the disap- noted.
proval which he was not able to comprehend Not only does the self become the
through the ordinary sensory channels. custodian of awareness, but when anything
This process, coupled with the prohi- spectacular happens that is not welcome to
bitions and the privations that he must suffer the self, not sympathetic to the self dyna-
in his education, sets off the experiences that mism, anxiety appears, almost as if anxiety
he has in this education and gives them a pe- finally became the instrument by which the
culiar coloring of discomfort neither pain nor self maintained its isolation within the per-
fear but discomfort of another kind Along sonality.
with these experiences there go in all well Needless to say, the self is extremely
regulated homes and schools a group of re- important in psychiatry and in everyday life.
wards and approbations of successes. These, Not only does anxiety function to discipline
needless to say, are not accompanied by this attention, but it gradually restricts personal
particular type of discomfort, and when that awareness. The facilitations and deprivations
discomfort is present and something is done by the parents and significant others are the
which leads to approbation, then this pecu- source of the material which is built into the
liar discomfort is assuaged and disappears. self dynamism. Out of all that happens to the
The peculiar discomfort is the basis of what infant and child, only this ‘marked’ experi-
we ultimately refer to as anxiety. ence is incorporated into the self, because
The self dynamism is built up out of through the control of personal awareness
this experience of approbation and disap- the self itself from the beginning facilitates
proval, of reward and punishment. The pe- and restricts its further growth. In other
culiarity of the self dynamism is that as it words, it is self-perpetuating, if you please,
grows it functions, in accordance with its tends very strongly to maintain the direction
state of development, right from the start. As and characteristics which it was given in in-
it develops, it becomes more and more re- fancy and childhood.
lated to a microscope in its function. Since For the expression of all things in the
the approbation of the important person personality other than those which were ap-
is very valuable, since disapprobation de- proved and disapproved by the parent and
nies satisfaction and gives anxiety the self other significant persons, the self refuses
becomes extremely important. It permits a awareness, so to speak. It does not accord
minute focus on those performances of the awareness, it does not notice; and these im-
child which are the cause of approbation and pulses, desires, and needs come to exist dis-
disapprobation, but, very much like a micro- sociated from the self, or dissociated. When
14 Sullivan

they are expressed, their expression is not from the self; in other words, if it shows in
noticed by the person. the witting performances towards others, it is
Our awareness of our performances, within the limits of personal awareness and
and our awareness of the performances of not outside, resisted, so to say, by anxiety.
others are permanently restricted to a part of The relative silence about the low self-
all that goes on and the structure and char- appraisal is achieved in part by the clamor of
acter of that part is determined by our early derogating others, in part by preoccupation
training: its limitation is maintained year af- with implicit revery processes that dramatize
ter year by our experiencing anxiety when- the opposite of one’s defects, or protest one’s
ever we tend to overstep the margin. rights, or otherwise manifest indirectly one’s
Needless to say, limitations and pecu- feeling of unworthiness and inferiority.
liarities of the self may interfere with the pur- Let us rest this matter here for the
suit of biologically necessary satisfactions. time being, and review what has been said.
When this happens the person is to that ex- We have seen something of the origin and
tent mentally ill. Similarly, they may interfere organization of the self and of its marked
with security, and to that extent also the per- tendency to stabilize the course of its devel-
son is mentally ill. opment. We have seen that if, for example,
The self may be said to be made up of it is a self which arose through derogatory
reflected appraisals. If these were chiefly de- experience, hostility toward the child, disap-
rogatory, as in the case of an unwanted child proval, dissatisfaction with the child, then
who was never loved, of a child who has fall- this self more or less like a microscope tends
en into the hands of foster parents who have to preclude one’s learning anything better, to
no real interest in him as a child; as I say, cause one’s continuing to feel a sort of limi-
if the self dynamism is made up of experi- tation in oneself, and while this can not be
ence which is chiefly derogatory, then the self expressed clearly while the child or the adult
dynamism will itself be chiefly derogatory. It that came from the child does not express
will facilitate hostile, disparaging appraisals openly self-depreciatory trends, he does have
of other people and it will entertain dispar- a depreciatory attitude toward everyone else
aging and hostile appraisals of itself. and this really represents a depreciatory at-
As I have said, the peculiarity exists titude toward the self.
that one can find in others only that which The stabilizing influence of past expe-
is in the self. And so the unhappy child who rience is due to the fact that when it is in-
grows up without love will have a self dyna- corporated in the organization of the self,
mism which shows great capacity for find- the structure of the self dynamism, it pre-
ing fault with others and by the same token, cludes the experience of anything corrective,
with himself. That low opinions of oneself anything that would be strikingly different.
are seldom expressed with simple frankness The direction of growth in the self is main-
can also be explained. tained by the control exercised over personal
So difficult is the maintenance of a awareness and by the circumscribing of ex-
feeling of security among his fellows for any- perience by anxiety, when anything quite dif-
one who has come to have a hostile-deroga- ferent from one’s prevailing attitude tends to
tory self, that the low self-appreciation must be noticed.
be excluded from direct communication. A We have seen how the self can be a de-
person who shrewdly attacks the prestige of rogatory and a hateful system, in which case
sundry other people can scarcely add to each the self will inhibit any experience of friend-
such performance, a statement to the effect liness, of positive attitude toward other per-
that he knows, because he has the same fault sons, and thus continue to go on derogatory,
or defect. At the same time, we know that hostile, negative, in its attitude toward oth-
that which is in the self is not dissociated ers.
Conceptions of Modern Psychiatry 15

This selective exclusion of experience oneself. It is merely a question, then, of when

which leads to one’s being occupied with or a derogatory and hostile attitude, ordinarily
noticing only the hostile unfriendly aspect of directed toward the outer world, is directed
living not only is manifested in one’s attitude with full force toward the self.
toward others, but also is represented in the I do not need to tell you in the connec-
attitude toward the self. No matter how well tion how hatefully conceived and executed
the outward manifestations of self-contempt many suicides really are, if you have taken
may be disguised, we may be assured that the trouble to study any instance of this
they are there. We see here the explanation event. This, of course, does not get into the
of one of the greatest mysteries of human newspaper accounts, but if you know a fam-
life, how some unfortunate people carry on ily situation in which such an event has oc-
in the face of apparently overwhelming dif- curred you will be impressed with the fact
ficulties whereas other people are crushed by that the self-destruction had an evil effect,
comparatively insignificant events, contem- and may well have been calculated to have
plate suicide, perhaps actually attempt it. a prolonged evil effect on some other people.
This is to be understood on the basis This is literally a miracle of the dissociation
not of the particular ‘objective’ events which which education gives us, by which our im-
brings about the circumstance of success un- pulse to live—our grasp on the always nu-
der great hardship or self-destruction; it is merous and largely unpredictable future pos-
to be understood on the basis of the experi- sibilities—by which the optimism that makes
ence which is the foundation of the self sys- us look toward the unpredictable with hope
tem, the organization of experience reflected shall, in these people, be vanquished entirely
to one from the significant people around by a hateful combination of impulses which
one—which determines the personal charac- leads to destroying oneself in order to strike
teristics of those events. In no other fashion at some other person.
can we explain the enormous discrepancy The act of suicide at the moment is
between people’s reactions to comparable again becoming fashionable. When I say that
life situations. it is becoming fashionable, I do not refer
Every one of you knows of circum- to some index, some statistical sign, which
stances in which people encounter things means that out of 100,000 such and such
which you would regard as too much to be number have this year destroyed themselves.
borne, yet they go on with a certain measure I refer to the fact which has been seen repeat-
of cheerfulness and optimism; whereas other edly during so brief a compass as my own
people who, so far as you can see, have ev- lifetime, that, regardless of economic factors
ery advantage, have much to look forward and other indices of the gross movements in
to, meet some, to you, rather trifling rebuff, the population and in the affairs of the peo-
become depressed, and may actually destroy ple, the frequency of suicide periodically—or
themselves. aperiodically—mounts rapidly and then de-
The practice of suicide is a strange in- clines. It is common human experience that
gredient of culture. So far as we know, there suicide is much more often contemplated
is nothing remotely approaching it in the in- than it is attempted. It appears that to think
frahuman primates or any of the lower ani- of destroying oneself, to follow a train of
mals. It is distinctly a human performance, revery in which one’s death is a feature, is
and to some a very mystifying one. It is to not at all unusual; certainly in many people
be understood in many cases, if not in all, by it is not at all unusual, although, parentheti-
realizing the force of the dictum which I have cally, in some people it would be very strange
offered to the effect that the attitude mani- indeed.
fested toward others reflects faithfully the The revery in which self-destruction
attitude which must be manifested toward is, for our purpose, the theme, does not stop
16 Sullivan

with the contemplation of self-destruction. It More illuminating in the same connec-

goes on. Self-destruction therefore is not the tion is the unsuccessful attempt at suicide. To
goal of this revery process, of this daydream, call your attention to a group of processes
this private symbolic operation, if you please. that are concerned in many of these attempts,
Something else is the goal. A quite frank re- I shall tell a story from my own experience
port of some of these reveries shows that which has, so far as I know, nothing to do
while one may start out meditating on how with suicide.
worthless life is, how gladly one would be rid Once upon a time I was able to enjoy
of it and all, one drifts from there to contem- my pleasure in horseback riding, and on a
plations of what the situation in regard to certain occasion under certain unamusing
other people would be after the act. circumstances which I must suppress because
This is the sort of revery which is not their recital would reduce the solemnity of
uncommon. It very often discharges the sui- this occasion, I fell from a horse. Of course,
cidal impulse. One thinks about it to oneself, as I could tell it, the horse threw me; but in
which we call having a revery and then one any case I ceased to be on the back of the
drops it. One drops it because the revery pro- horse and contacted the earth with consider-
cess, after the fashion of revery processes, is able violence, such that I fractured a jaw.
a constructive movement, calculated to dis- Prior to this accident I had been some-
cover the probable effects of an even or the what given to jumping horses. Subsequent
probably successful ways of achieving an to the accident, for over a year and a half,
end. From that standpoint the rumination on I made no successful jumps. I invariably
self-destruction thought through, is seen not pulled the horse off as we approached the
to be a means of obtaining any desire. hurdle, to my great embarrassment and very
The revery studies danger, personal considerable loss of prestige. It none the less
probabilities, with, as an unwitting goal, a happened inevitably, and it was only after
goal that is not noticed by the person who is about a year and a half that I succeeded in so
entertaining the suicidal fantasy, the preven- ‘controlling’ my motor apparatus that I and
tion of this very act of self-destruction. The the horse could get over a hurdle again.
prevention of the hostile-destructive act is The story is told to illustrate the van-
the unwitting goal, the unnoticed goal, of the quishing of my desire for prestige and my
revery process. Suicidal reveries are not as a satisfaction in such things well done by some-
rule fantasies with, as an end the destruction thing which was quite exterior to my control.
of oneself; they are reveries in which one ac- In all it was me, but when I say it was me I
tually considers consequences and reaches he mean that it most emphatically was not my
decision, if you please, that self-destruction self. My self was all set to resume jumping
would not achieve the object concerned. It horses with the pleasure that comes from it
would follow that that object is the exteri- and that special expansive satisfaction that
orizaton of an hostile, derogatory attitude attends doing something about which many
which one has acquired in infancy and child- people are somewhat hesitant and which not
hood particularly childhood, which one has too many people do quite well. Not any need
continued to entertain because of the focus- of security on my part in the sense that I have
ing effect of the self system, and to manifest expressed here, nor any lack of need for the
toward other people. satisfaction that comes from this particular
Almost incidentally the having of this type of sport; neither of these groups of im-
suicidal revery resolves the situation which pulses had anything to do with my pulling
provokes the impulse to self-destruction. the horse away from the jump. Something
Then one drifts into reverie processes that else had to do with that, something of which
lead to constructive, or at least much less de- I had no vivid awareness and over which I
structive, ends. certainly had nothing of what is ordinarily
Conceptions of Modern Psychiatry 17

meant by control. My will, to drop into the ality, the part of the personality that has been
archaic language, was too weak to control growing up under great handicap in contra-
some base impulse in me that thwarted the distinction to the experience to which the self
horse and me. is receptive. In the particular instance which
We have here an instance of a part I have stressed so much, where the individu-
of personality working in dissociation, but al experience as incorporated in the self has
working very powerfully, more powerful- been almost entirely derogatory and hateful
ly than all the motives that are channeled you will realize that the dissociated part con-
through the self. sists of the experience of human warmth and
Many of the attempted suicides which friendliness. It is this part of personality, this
prove such dramatic failures that we are in- group of processes which intervenes to pre-
clined to suspect the honesty and reality of vent a fatal issue of the impulse.
the attempt are of much the same order as It is almost cavalier to rest with such
my failure to jump the horse. The act has fleeting reference to the extra-self—at that,
been contemplated carefully and the motiva- almost as an addendum to consideration of
tion is there. So far as the person is aware suicide. If, however, you have finally seen the
there is not room for doubt but that he will dichotomous character of these hypothetical
now destroy himself. But something ‘stupid’ personalities of ours—how that which is ex-
is done so that the act fails and he does not cluded from awareness by virtue of the di-
die. recting influence of the self dynamism, must
This is not by any means as often a be quite different in some essential aspects
fraudulent dramatic attempt to do something from that which is incorporated in and mani-
which one doesn’t intend to do for the pur- fests as the self—you can see why we seem so
pose of coercing someone else as it is the in- individuated, and yet can be, to quote myself,
tervention of the dissociated part of person- much more simply human than otherwise.
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