Chapter One: Introduction
A person’s first deep connection is with those responsible for their very survival. They are completely dependent on their interpersonal environment. As children develop, to the extent their primary parenting one(s) can validate experiences with people and phenomena outside their immediate orbit, they are also influenced by the wider world. It is this blending that defines our humanness and our unique personalities, which, in their complexities, work with varying degrees of success to navigate a satisfying or not so satisfying life.
Evolving Self examines how repetitive patterns of interactions with significant others and the wider world, particularly but not exclusively in the formative years,are primarily responsible for one’s ever-expanding personality, and how some repetitive patterns can also create debilitating “problems in living.”
Our book is rooted in interpersonal theory, developed by Harry Stack Sullivan (1953), Frieda Fromm-Reichman (1960) and their colleagues and students, and further interpreted and enhanced by the faculty of the Sullivan Institute for Research in Psychoanalysis, founded by Jane Pearce and Saul Newton (1963). It is also grounded in more than 50 years of clinical experience in the practice of psychotherapy in various settings by each of the authors, who were students and analysands of Pearce, Newton and the Institute faculty.
Currently, the dominant orientation of psychiatry and most related mental health professions is that, with some exceptions, most problems in living (depression, psychosis, learning delays, delinquency, etc.) are based in physiological aberrations, whether neurological or glandular, which can be solved through the correct application of the right medication and/or some short-term psychotherapy. That orientation is closely tied to the continued and dominant usage of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2013), which classifies human disorders via a listing of symptomatology. These diagnostic categories are in turn recognized by health insurance companies that cover “mental health” treatment. The insurance companies do not recognize problems in living as such, nor do they connect those problems to real-life situations. For that reason, issues such as an unhappy marriage, an unsatisfying career or despair about one’s capacity for intimacy with people are not covered for treatment unless they can be presented as symptoms of a syndrome found in the DSM.
Fusing his theory of human development with the socio-economic climate of his time, Sullivan wrote about race, war, and poverty in 20th century terms. The fusion is even more urgent now, as the world faces ever-increasing oppression and devastating international conflict. Paralleling these world developments, the mental health field is less and less focused on human needs and more and more reliant on solutions based on corporate financial profit and behavioral conformity.
Our book was written against the current backdrop of psychiatric perspectives devoted to “curing” via medication along with various forms of neurological and/or other physiological manipulation. These include short-term cognitive-behavioral approaches or other quick fixes designed to be consistent with “evidence-based” research. The term “evidence-based” is very common and is usually applied to therapy modalities that are focused on measurable indices that are narrow in scope, such as number of positive or negative interactions. The approach does not connect the interactions with the broader context of a person’s life. While there might be a number of behavioral changes, the theory in this volume elucidates how it is crucial that the person understand symptoms in the context of their own development for the changes to be long-lasting.
While not universal, the mainstream mental health community in the United States tends to be focused on treatment that fits what can be covered by insurance, and not enough on what promotes lasting human growth and development. The standard of successful treatment offered by the American Psychological Association (APA) is to bring a person back to “functioning within normal limits,” which is considered the “actual clinical benefit,” when evaluating psychotherapy (2002). Besides the obvious difficulty of researching outcomes and defining “normal” functioning (APA, 2002), it is our view that such a definition of a favorable treatment outcome is superficial, constrained by an arbitrary definition of “mental health” plaguing psychology and other social sciences. We posit that “mental health” is an open-ended process of continual personality growth rather than the achievement of or a return to “normal” functioning.
Much of the research and literature in the mainstream mental health community has never stopped advocating for “talk therapy,” not only for people seeking help with their problems in living, but often as an ancillary to medication management and/or post-psychiatric hospitalization. Among the most popular of these talk modalities is short-term therapy called “Interpersonal Psychotherapy” (IPT). Although borrowing the term “interpersonal” from Sullivan, the treatment modality has very little to do with Sullivan or with interpersonal psychoanalytic theory as delineated in this volume. IPT is defined as a time-limited psychotherapy that focuses on interpersonal issues, which are understood to be a factor in the genesis and maintenance of psychological distress. The targets of IPT are symptom resolution, improved interpersonal functioning, and increased social support. Typical courses of IPT range from 6-20 sessions with provision for maintenance treatment as necessary. (Interpersonal Psychotherapy Institute, 2016)
Its popularity, however, bespeaks the recognition in the mainstream therapeutic community that “talk therapy” should be part of a treatment plan.
Many schools of thought, some of which are integrated into this volume, have been shown to be helpful to people and are gaining in recognition. Developed over the past 50 years, some of these theories are contemporaneous with, but not related to, the rise of the marriage between Big Pharma and the health insurance companies. These include psycho-biologists, who have studied the development of the nervous system as one-celled organisms evolved into human beings. These studies demonstrate the importance of early relationships, including the infant’s persistent drive to relate, in developing human personality through videotaped mother-infant interactions in the first hours of birth and beyond. Based on these studies, many researchers and practitioners have coined the term “intersubjective” to describe a theory about the development of human personality and the treatment of problems in living. Many other developments in psychiatric research and theory that focus on interactions between people are compiled in the Handbook of Interpersonal Psychoanalysis (Lionells, Fiscalini, & Stern, 2015).
However, in today’s mental health environment, crucial clinical decisions are often made based on short-term symptom reduction and diagnostic categories. Because of pressure from insurance companies, including ones provided by the government, many psychiatric hospitalizations consist of quickly formulating a diagnosis and then regulating people via medications in order to stabilize and discharge them in the shortest time possible, without the full opportunity to work through very strenuous issues in a protected, closed environment. They are often discharged to outpatient clinics where psychotropic treatment (medicated maintenance) is usually continued. Perhaps people receive “long-term” talk therapy, maybe six months to a year, which may or may not provoke insight into the developmental history of life-restricting patterns of living and may or may not validate attempts to change those patterns. In addition, many therapists and the people they work with assume that mental health problems constitute symptoms of “chronic diseases” that must be regulated, not unlike diabetes or a thyroid condition.
The time is ripe for our book because it belongs among theories available to practitioners who grope for treatment modalities that will satisfy the requirements of insurance companies but will also better serve the needs of the people they work with. However, our book makes a case for longer-term psychotherapy not driven by the insurance/pharmaceutical industries and not bound by “outcome” studies, which, given the subjective nature of the field, are extremely difficult to evaluate (APA, 2002). More traditional talk therapy modalities are indeed back on the table, and, in many instances, have never really left the table. In cogent, easy-to-read detail, our approach makes sense and hopefully will help change the way mental health practitioners think about their work in spite of pressures from corporations, which drive most graduate schools, medical schools and institutes to train to the short-term.
With notable exceptions, such as Harry Stack Sullivan: Interpersonal Theory and Psychotherapy by F. Barton Evans III (1996), Sullivan Revisited by Marco Conci (2013),and Handbook of Interpersonal Psychoanalysis by Lionells, Fiscalini, & Stern (2015), much of the invaluable theories of earlier interpersonalists such as Sullivan, Fromm-Reichmann, Pearce, and Newton have been given perfunctory recognition or omitted altogether in new and popular psychotherapeutic volumes. Our book is not intended to replace the foundational works, but to make readable much of their somewhat dated and convoluted prose and to elaborate and expand their formulations into a modern, comprehensive theory. References to original conceptualizations are cited within the text and readers are urged to supplement their knowledge with specific fundamental readings, such as The Interpersonal Theory of Psychiatry (Sullivan, 1953), The Psychiatric Interview (Sullivan, 1954), Principles of Intensive Psychotherapy (Fromm-Reichmann, 1960) and The Conditions of Human Growth (Pearce & Newton, 1963).
Using concrete examples within the contemporary social/economic/political milieu,Evolving Self delineates the internal conflicts and the real-life opportunities and obstacles that accompany each human developmental era. Rather than just looking at the individual, it is crucial to examine the interaction between people in a developmental sequence—in the context of the nuclear family or primary caretaker(s), the extended family, the community, and the larger world, especially in the era of social media. Our book also addresses practical applications; the insurance/pharmaceutical industries’ role in placing profit over need; and the larger issue of how the interpersonal approach to the social development of individual people relates to theories of the development of societies.
To the best of our ability, the prose eschews technical and complex terminology. However, it is impossible to discuss conceptualizations without using some “shortcut” words and phrases we posit and define in the initial chapters. Our purpose is for readers to have an unencumbered experience.
Logic of Organization
The chapters are organized so that readers can move smoothly from very fundamental concepts to the more complex intricacies of interpersonal theory. After defining terminology, including the “self-system” and anxiety, the first section covers the human developmental eras, delineating how growth takes place in an orderly sequence involving interactive experiences with people. The second section covers aspects of personality structure, including cognitive development and the process of learning. Although practical applications are discussed throughout, along with short case illustrations, the third section specifically addresses psychotherapy itself, including dream analysis from an interpersonal perspective. Finally, the fourth section brings the theory into the larger sociopolitical sphere.
After “Basic Concepts,” the book need not be read in sequence. Nonetheless, reading the book in the presented order is likely to offer the best understanding of interpersonal theory and practice. Because each subsequent chapter can stand on its own, there is some repetition. Since some of the issues can arouse discomfort, even for seasoned practitioners, repetition using different words and phrases can allow readers to “hear” better.
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders V. Washington, DC: American Psychiatric Association.
American Psychological Association. (2012). Recognition of psychotherapy effectiveness. Retrieved November 6, 2016, from http://www.apa.org/about/policy/resolution-psychotherapy.aspx
Blechner, M. J. (2009). Sex changes; Transformations in society and psychoanalysis. New York: Routledge.
Conci, M. (2013). Sullivan Revisited. Life and work. Harry Stack Sullivan’s relevance for contemporary psychiatry, psychotherapy and psychoanalysis. (L. Cohen, D. Lee, & M. Bacciagalucci, Trans.) Trento, Italy: Tangram Edizioni Scientifiche Trento.
Damasio, A. (2018). The strange order of things: Life, feeling, and the making of cultures. New York: Pantheon Books, Penguin Random House LLC.
Evans III, F. B. (1996). Harry Stack Sullivan: Interpersonal theory and psychotherapy (Makers of modern psychotherapy). East Sussex: Routledge.
Fromm-Reichmann, F. (1960). Principles of intensive psychotherapy. Chicago: University of Chicago Press.
Interpersonal Psychotherapy Institute. (2016). About IPT. Retrieved November 6, 2016, from Interpersonal Psychotherapy Institute: https://iptinstitute.com/about-ipt/
Lionells, M., Fiscalini, J., & Stern, D. (2015). Handbook of interpersonal psychoanalysis, 2nd ed. New York: Routledge.
Malloch, S., & Trevarthen, C. (2018, October 4). The human nature of music. Frontiers in Psychology, 9, 1680. doi:10.3389/fpsyg.2018.01680
Merriam-Webster Dictionary. (n.d.). Retrieved from https://www.merriam-webster.com/dictionary/interpersonal
Mullahy, P. (Ed.). (1952). The contributions of Harry Stack Sullivan: a symposium on interpersonal theory in psychiatry and social science. New York: Hermitage House.
Mullahy, P. (1957). A study of interpersonal relations; New contributions to psychiatry. (P. Mullahy, Ed.) New York: Grove Press.
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Pearce, J., & Newton, S. (1963). The conditions of human growth. Secaucus, NY: Citadel Press.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. NY: W.W. Norton & Company.
Sullivan, H. S. (1954). The psychiatric interview. New York: Norton.
Trevarthen, C. (2017, March). The affectionate intersubjective intelligence of the infant, and its innate motives for relational mental health. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 11-53.
Trevarthen, C. (2019a). Sander’s life work, on mother-infant vitality and the emerging person. Psychoanalytic Inquiry, 39(1), 22–35.
[ps2id id=’ftn1′ target=”/] Approximately the first 10 years. [return]
 The phrase “problems in living” was first coined by Harry Stack Sullivan. See, for example, The Interpersonal Theory of Psychiatry (1953). [return]
 “Interpersonal” as a medical term is defined as “being, relating to, or involving relations between persons” (Merriam-Webster Dictionary). [return]
 Pearce’s and Newton’s theoretical contributions are comprehensively summarized in the Handbook of Interpersonal Psychoanalysis (Lionells, Fiscalini, & Stern, 2015). They are also contextualized in Sullivan Revisited, along with excerpts from Pearce’s unpublished lecture on psychotherapy at the William Alanson White Institute in 1957 (Conci M. , 2013). [return]
 This is not to suggest that medications that alleviate anxiety, depression and psychotic symptoms should never be prescribed. However, if the work can be accomplished without long-term dependency on psychotropic medications, the person has a better chance of gaining insight into the etiology of the debilitating issues, has a better chance of growing and changing, and is more likely not to relapse. Because medications can feel like a “cure,” a person might terminate insight-oriented therapy. Fearful that the symptoms will return, they then must deal with the side effects of medications over the long-term. [return]
 It is also crucial to recognize that just because physicians have ruled out physiological causes of a person’s behavioral concerns, it does not necessarily mean that it is “all in the patient’s head.” The person needs to make sure that an underlying medical condition has not been missed. [return]
 This discussion refers to governmental and private insurance programs within the United States. [return]
 “Actual clinical benefit” is the lessening of symptoms that are troublesome either because they are unpleasant or because they are socially “odd,” for example, hallucinations, delusions or powerful moods of despair or rage. The person is said to be cured if those symptoms disappear, regardless of what else is going on in their life. Stopping symptoms via medication and stating the cause to be some form of chemical imbalance is a simple, plausible explanation, but it leaves a lot to be explained. [return]
 For example, (Trevarthen C. , 2017), (Malloch & Trevarthen, 2018) and (Damasio, 2018), among many others. [return]
 “In the 1960s, partly because of the availability of television for micro-analysis of life in spontaneous communication with infants, there was a revolution in the scientific understanding of how the human mind grows. The inquisitive and responsive way a healthy baby moves shows that humans are born for intimate sharing of interests and feelings that are essential for acquiring cultural habits and understanding, including language” (Trevarthen C. , 2019a). [return]
 At Sheppard and Enoch Pratt Hospital in Baltimore in the 1920s, Sullivan organized a closed, long-term, non-judgmental and caring therapeutic community for inpatient schizophrenics that made use of his interpersonal approach. It is known for having an 80 percent “cure” rate (Blechner, 2009, p. 110). [return]
 Earlier works did recognize their important contributions. These include Psychoanalysis and Interpersonal Psychiatry; The Contributions of Harry Stack Sullivan by Patrick Mullahy (1952) and A Study of Interpersonal Relations; New Contributions to Psychiatry, edited with an introduction by Patrick Mullahy (1957). Mullahy also reviewed The Conditions of Human Growth (Pearce & Newton, 1963) in Psychiatry: “This book is a major contribution to interpersonal theory….[It] is the most ambitious work on the interpersonal theory of psychiatry since Sullivan lived and lectured” (1963). [return]
 Coined by Sullivan (The Interpersonal Theory of Psychiatry, 1953). [return]