Argumentación del Objeto de Estudio: Métricas de Calidad en el proceso de

BIOGRAPHICAL BACKGROUND

Harry Stack Sullivan was born in 1892 in Norwich, New York. He was the only surviving child of Irish Catholic farmers, who had to struggle to provide the basic necessities for their son. A shy, awkward boy, he had difficulty getting along with the other children in the predominantly Protestant Yankee community in which he lived.

Although Sullivan suggested that ethnic and religious differences were the primary contributors to his feelings of isolation as a child, personality difficulties created by his home life and his own character were probably equally important. Sullivan did not have a close relationship with his father, whom he described as “remarkably taciturn.” His mother, a complaining semi-invalid, was the more important figure in his life. Mrs.

Sullivan resented the fact that through marriage she, a Stack, from a professional middle-class family, had sunk in social, educational, and economic status. Her son bore the brunt of her laments, tales of earlier family prominence, and unrealistic dreams.

When Sullivan was eight and a half, he developed a close friendship with a thirteen-year-old sexually mature adolescent boy. Although Swick-Perry (1982), Sullivan’s biogra-pher, has argued that the relationship was not homosexual, it was viewed as such by the townspeople. Sullivan later wrote (1972) that close relationships between a young child and an early-blossoming adolescent of the same sex invariably lead to homosexuality. As an adult, he admitted with regret that he never achieved a heterosexual genital relation-ship. Most of his patients and Sullivan himself expressed concern regarding their “homosexual” orientations (Wake, 2008).

Sullivan was valedictorian of his high school class and won a state scholarship to Cornell. Encouraged by one of his teachers, he decided to become a physicist in order to rise above his poverty.

At Cornell, however, his grades fell, and in his second year he was suspended for academic failure. During the next six years, Sullivan earned enough money to enter the Chicago College of Medicine and Surgery, an inferior school that he later described as a

“diploma mill,” suggesting that it granted degrees for payment of tuition rather than academic performance. The school closed in 1917, the same year in which Sullivan received his degree.

The shabby education that Sullivan received had detrimental effects in his later life. He never learned to write well, and he did not have a solid formal training in scientific methodology and research. Nor did Sullivan receive any formal training in psychia-try. Thus there were gaps in his medical knowledge. He was also

Sullivan believed that the personality of an individual could never be stud-ied in isolation. He explored the dynamics of interpersonal relationships and their influence on personality development.

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relatively ignorant of many cultural subjects. Nevertheless, Sullivan worked hard at self-instruction, and his lack of formal education may have freed him from some of the set attitudes and prejudices that a standard education can foster.

Sullivan entered psychiatry at the age of thirty when he was appointed to the staff of Saint Elizabeth’s Hospital in Washington, D.C. Here Sullivan developed a working knowledge of psychiatry through his work with disturbed veterans and his attendance at lectures, seminars, and case history presentations. He later suggested that his patients were his primary teachers. In 1923 Sullivan moved to the Sheppard and Enoch Pratt Hospital in Baltimore. His energy and devotion to work and his descriptions of thera-peutic techniques brought him to the forefront of American psychiatry. However, his stress on the treatment environment has been deemphasized with the advent of psychopharmacology (Schulz, 2006).

In 1930 Sullivan moved to New York and established a private practice. While in New York he had some three hundred hours of personal psychoanalysis. In 1933 Sullivan assisted in founding the William Alanson White Psychiatric Foundation, named after a neuropsychiatrist who had greatly influenced Sullivan’s work. He started the journal Psychiatry to publicize his own views.

In his later years Sullivan served as a consultant to the Selective Service Board and to UNESCO. To the end of his life, Sullivan involved himself in the political struggles and social conflicts of the United States. He was one of the first psychoanalysts to pay serious attention to the problems of African Americans in both the South and the North. After Hiroshima, he was quick to recognize the implication: Either world wars or human life must end. He died suddenly in Paris in 1949 while returning from an executive board meeting of the World Federation for Mental Health at which he had been trying to enlist the support of psychiatrists from all over Europe to oppose any further use of nuclear weapons.

BASIC CONCEPTS

Sullivan (1953) defined personality as the characteristic ways in which an individual deals with other people. He believed that it was meaningless to think of an individual as an object of psychological study, because an individual develops and exists only in the context of relations with other people. Interpersonal relations constitute the basis of personality.

Indeed, the very term personality was only a hypothesis for Sullivan (1964). It was merely an imaginary construct that is used to explain and predict certain behaviors. It would be a mistake, Sullivan suggested, to consider personality as a separate entity apart from the interpersonal situations in which it emerges. Thus Sullivan’s definition of personality stresses the empirical components that we can directly observe rather than intrapsychic structures. We can see, hear, and feel that an individual is relating to other people in certain ways, such as in a passive or dominant fashion.

Anxiety and Unawareness

Anxiety is a central concept in Sullivan’s theory, as it was for Freud. Sullivan conceived of anxiety as any painful feeling or emotion that may arise from organic needs or social insecurity. However, he emphasized the anxiety that arises from social insecurity and thought of anxiety as interpersonal in origin, beginning with the child’s empathetic per-ception of the mother’s concerns.

Sullivan also emphasized the empirical character of anxiety, pointing out that it can be described and observed through a subjective description of how one feels or an objec-tive notation of physical appearance and reactions and through physiological changes that are indicative of anxiety.

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In our relationships with others, we are to some extent aware of what we are doing and why we are doing it, and to some extent unaware of these things. Sullivan appreciated that an individual may be unconscious or unaware of some of his or her motives and beha-viors. The ease with which a person can become aware of his or her interpersonal relation-ships varies from individual to individual and can be objectively demonstrated by talking with someone and observing that person’s actions. Thus the concepts of awareness and unawareness are also empirically based. However, if we are unaware of our interpersonal relationships, we do not experience them and cannot learn from them. An individual who believes that he or she is inept may be aware only of the way in which he or she bungles things but unaware of successful experiences. When we are aware of the pattern of our interpersonal relationships, we can modify and change them.

Security Operations

In order to reduce anxiety and enhance security, we employ security operations of which we are usually unaware (Sullivan, 1953). A security operation is an interpersonal device that a person uses to minimize anxiety. These security operations are healthy if they increase our security without jeopardizing our competence in interpersonal relations;

they are unhealthy if they provide security at the expense of developing more effective interpersonal skills. Unhealthy security operations merely blunt our anxiety and may lead to other painful emotions and psychiatric illness.

Sullivan’s notion of security operations parallels Freud’s concept of defense mechan-isms. Both are processes of which we are unaware and means by which we reduce anxi-ety. The primary difference lies in Sullivan’s stress on what is observable and interpersonal. Sullivan’s emphasis is not on an intrapsychic activity, such as repression, but on the way in which a person may become disassociated from certain aspects of his or her experience of the world. Sullivan pointed out that security operations are pro-cesses that we can observe as they arise in the matrix of interpersonal relationships.

Some of the security operations that Sullivan described are sublimation, selective inat-tention, and “as if” behavior. Sullivan reconceived Freud’s mechanism of sublimation to include an emphasis on how we learn to behave in interpersonal situations. Sublimation to Sullivan is the expression and discharge of uncomfortable feelings in ways that are interpersonally acceptable, such as releasing anger verbally rather than by hitting or kick-ing the object of anger. Sullivan also described selective inattention, the failure to observe some factor in an interpersonal relationship that might cause anxiety, such as not notic-ing a spouse’s flirtations because those activities threaten one’s own self-esteem. Sullivan considered selective inattention a very powerful and potentially dangerous security oper-ation that may blind us to what is going on in our world and make it difficult for us to cope effectively with events. Finally, “as if” behavior means that we act out a false but practical role. A person may act “as if” he or she were stupid to fulfill the expectations of others, when in actuality the person is not stupid. For the mentally disturbed person

“as if” may mean acting as normally as possible. As in Adler’s theory, the mechanism of

“as if” may also have positive consequences. We may convince ourselves that we are competent by behaving consistently in an effective fashion.

Dynamisms

Sullivan maintained that we can observe certain processes in an individual’s interper-sonal relationships and that these processes can be used to describe the development of the individual’s personality. One such process is a dynamism, a pattern of energy trans-formation that characterizes an individual’s interpersonal relations (1953). Dynamisms result from experiences with other people. Sullivan’s work differs from Freud’s in that it

replaces a Newtonian mechanical concept of material objects and forces in the universe with a contemporary view of the flow and transformation of energy in the universe. In Freud’s theory, forces come out of the id, ego, and superego. When they collide, they create emotional conflict. Sullivan focused on the transformation of energy as it flows between people in relationships. The interpersonal contact between mother and infant, particularly with reference to nursing, begins a flow of energy. The mother nurses the child, and her activities lead the infant to respond in certain ways, such as feeling satis-fied and behaving contentedly. This creates a dynamism or pattern of energy character-istic of the interpersonal relationship. In cases where a child experiences neglect, abuse, or indifference and develops a derogatory self-dynamism towards others and the self, malevolence may appear as a major pattern of interpersonal relation. This malevolent transformation of personality, as Sullivan (1953) called it, was a creative effort to understand himself, his patients, and also to explain how a person may be capable of acting in an evil manner while remaining fundamentally good (Cornett, 2008).

In later childhood and adolescence the dynamisms become more complex. The child who is afraid of strangers illustrates the dynamism of fear. The young male who during adolescence seeks sexual relations with young women is expressing the dynamism of lust.

One of the more significant dynamisms is that of the self or system. The self-system is made up of all of the security operations by which an individual defends the self against anxiety and ensures self-esteem. It is a self-image constructed on the basis of interpersonal experiences. Sullivan suggests that the concept of self is no more than a response to the interpersonal relationships in which one has been involved. The dyna-mism arises out of the child’s recognition of potentially anxious situations—that is, parental disapproval and rejection, and the child’s attempts to avoid them.

Out of the child’s experiences with rewards and anxiety, three phases of what will eventually be “me” emerge. The term good-me self refers to the content of awareness when one is thoroughly satisfied with oneself. It is based on experiences that were rewarding and is characterized by a lack of anxiety. The bad-me self is the self-awareness that is organized around experiences to be avoided because they are anxiety producing. The not-me self entails aspects of the self that are regarded as dreadful and

A child who is afraid of doctors is expressing a dynamism of fear.

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that cannot be permitted conscious awareness and acknowledgment. These dynamisms are processes rather than structures, behavior patterns that have come to characterize one’s interpersonal relationships. But they can result in a dissociation of the self in which certain experiences literally become cut off from identification with the self.

Personifications

A personification is a group of feelings, attitudes, and thoughts that have arisen out of one’s interpersonal experiences (Sullivan, 1953). Personifications can relate to the self or to other persons. Personifications of the good-mother and the bad-mother develop out of satisfying or anxiety-producing experiences with the child’s mother. In fairy tales, these personifications find expression as the good fairy and wicked stepmother or witch.

Personifications are seldom accurate; nevertheless, they persist and are influential in shaping our attitudes and actions toward others. Moreover, on a group level, they are the basis of stereotypes, or prejudgments, which frequently hinder our ability to relate to people of diverse cultures and backgrounds.

Stages of Development

Sullivan (1953) outlined six stages in personality development prior to adulthood: infancy, childhood, the juvenile era, preadolescence, early adolescence, and late adolescence. His stages remind us of Freud’s in that they frequently emphasize bodily zones. However, Sullivan thought that the stages themselves were determined socially rather than biologically, and he saw the period of adolescence as crucial, warranting three stages (see Table 4.1).

Cognitive Processes

Sullivan described three cognitive processes by which we experience the world and relate to others in the course of personality development. The process that occurs at the lowest

Sullivan believed that a “chum” relationship is the beginning of genuine human relationships. In healthy preadolescence the relationship may but need not entail overt homosexual genital activity.

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level is prototaxic experience, which is characteristic of the infant. There is no distinction between the self and the external world. The child directly perceives certain sensations, thoughts, and feelings but does not think about them or draw any conclusions. From masses of undifferentiated sensations, the child gradually distinguishes material objects, people, and him- or herself. This distinction moves the child into the next level.

The parataxic experience perceives causal relations between events that happen together. It involves making generalizations about experience on the basis of proximity.

The infant whose cry has brought the mother to nurse assumes that his or her crying has produced the milk. Superstitions are examples of parataxic thinking.

Random movements or patterns that are reinforced at an inopportune time may be repeated or avoided because they are thought to be the cause of the sat-isfying or anxiety-producing situation. Parataxic thinking is characteristic of the young child, whose mind is too immature to understand the causal laws of nature. Pervasive fear and the inability to react realistically following a terrorist attack reflect parataxic thinking. Sullivan suggests that much of our thinking does not advance beyond the parataxic level.

The highest level of cognitive activity is that of syntaxic experience, which uses symbols and relies on consensual validation, or agreement among persons.

Syntaxic experience relies upon symbols whose meaning is shared by other people in one’s culture, such as the use of language. When a word has been consensually validated, it loses its personal meaning and power, but the validation enables individuals to com-municate with one another and provides a common ground for understanding experi-ences. Syntaxic thought begins to develop in childhood. Ideally as adults our experience is almost completely symbolic and dependent on syntaxic modes of cognition.

PSYCHOTHERAPY, ASSESSMENT,ANDRESEARCH

Sullivan viewed psychotherapy as an interpersonal process in which one person assists another in resolving problems of living (1954). He used the concept of participant obser-vation to define the nature of psychiatric inquiry and treatment (1954). In participant observation, an observer is also a participant in the event being observed. While observ-ing what is goobserv-ing on, the psychiatrist invariably affects the relationship and alters the other person’s behavior. Sullivan suggested that it is absurd to imagine that a psychiatrist Thinking Critically

Can you demonstrate Sullivan’s modes? See the Thinking Critically box

“Prototaxic, Parataxic, and Syntaxic Experience”

on page 104.

TABLE4.1 SULLIVAN’S STAGES OF DEVELOPMENT

In Sullivan’s stages, human personality is shaped by interpersonal relations rather than biology.

STAGE FOCUS

Infancy Interpersonal relationships that crystallize around the feeling situation Childhood The development of healthy relationships with one’s parents

Juvenile era The need to relate to playmates and same-sex peers

Preadolescence A chum relationship, the beginning of intimate reciprocal human relationships. Could entail overt homosexual genital activity

Early adolescence The development of a lust dynamism and a stable heterosexual pattern of sexual satisfaction

Late adolescence Integration and stabilization of culturally appropriate adult social, vocational, and economic behavior

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could obtain from his or her patient data and/or behaviors that are uninfluenced by the therapist’s own behavior in the relationship.

Sullivan, who spent his youth doing manual labor on his father’s farm, suggested that psychotherapy is the hardest possible work, requiring continual alertness, honesty, and flexibility. The therapist is emotionally involved in the therapeutic process. He or she may be interested, bored, frustrated, or angry but must continually be aware of his or her reactions, understand them, and keep them at a minimum in order to continue to be an alert observer. Not only is psychotherapy hard work, but it must not be expected to provide the usual satisfactions of ordinary interpersonal relationships. The therapist does not look for friendship, gratitude, or admiration from the patient but aims simply to have the patient understand him- or herself better. The therapist’s rewards come from doing a job well and being reasonably paid for it.

A major portion of therapy is spent in examining the two-person relationship that exists between the therapist and the patient. This is one sample of the patient’s interper-sonal life that is made available for direct study. During therapy, the patient frequently begins to treat the physician as if he or she were someone else. Freud labeled this

A major portion of therapy is spent in examining the two-person relationship that exists between the therapist and the patient. This is one sample of the patient’s interper-sonal life that is made available for direct study. During therapy, the patient frequently begins to treat the physician as if he or she were someone else. Freud labeled this