Sullivan’s Interpersonal Theory

Introduction
Harry Stack Sullivan is considered as the father of the Interpersonal Theory. This theory
explained the role of interpersonal relationships and social experiences in regards to the
shaping of personalities, as well as the importance of life events to psychopathology. Stack-
Sullivan's theory states that the purpose of behavior is for the patient to have his or her needs
met through interpersonal interactions, as well as decrease or avoid anxiety.
Although Sullivan had a lonely and isolated childhood, he evolved a theory of personality
that emphasized the importance of interpersonal relations. He insisted that personality is
shaped almost entirely by the relationships we have with other people. Sullivan’s principal
contribution to personality theory was his conception of developmental stage.

Harry Stack Sullivan

Harry Stack Sullivan was born in Norwich, New York, on February 21, 1892. He was schooled at
Smyrna Union School and began his higher education at Cornell University. After two years, he
transferred to the Chicago College of Medicine and Surgery and earned his MD in 1917. Sullivan
focused his attention on interpersonal relationships and in particular, the effect of loneliness on
mental health. He expanded upon Freud’s theories in his work with the mentally disturbed, and
spent much of his time working with individuals suffering with schizophrenia.

Contribution to Psychology
Sullivan was the first to coin the term "Self System," a phrase that described
personality traits that are formed in childhood as a result of employing survival mechanisms.
When an individual reaches maturity, this self-system becomes the foundation for the
behaviors exhibited in relationships, called parataxical integrations by Sullivan. Sullivan
theorized that people engage this behavior pattern to elicit specific responses, or reactions, in
others. When their expectations are unrealistic, it creates what he called a parataxic distortion,
a dynamic similar to transference, by where people view others as a sum of their past reactions
and behaviors. To overcome these challenges, Sullivan described different communication
styles used by people struggling with distinct behavior patterns as either syntactic or prototaxic.
How clients interact with others is the basis of interpersonal psychoanalysis, a discipline
that was based on Sullivan’s work. He preferred to refer to psychological disturbances as
“problems in living,” and this phrase soon became the chosen way of referring to mental illness
by many involved in the antipsychiatry movement led by Thomas Szasz.

From 1925-1929, Sullivan worked at the Sheppard Pratt Hospital and conducted
experimental treatment, without medication, on schizophrenic patients with an amazing
success rate. The patients were all gay and this experience may have been especially personal
for Sullivan as it was reported that he himself was gay.
 Sullivan contributed much to the field of psychology through his teachings, his writings,
and his leadership. He was a co-founder of the William Alanson White Institute and also was
instrumental in launching the first edition of the journal Psychiatry.
 
Harry Stack Sullivan was one of the most important innovators and seminal thinkers in
American psychiatry. He lived during the first half of the twentieth century, an era marked by
intense excitement over psychoanalysis and the emergence of sociology and anthropology as
fields of thought and endeavor. Sullivan was a synthesizer, bringing the contemporary ideas of
psychiatry and social science together to form what has been called "social psychiatry." The
intellectual roots of the community mental health movement are found in Dr. Sullivan's work
and writings.
After an unhappy public school experience, Sullivan enrolled in medical school and
eventually became a physician. Six years after receiving his medical diploma and with no
training in psychiatry, Sullivan gained a position at St. Elizabeth’s Hospital in Washington, DC, as
a psychiatrist. There, his ability to work with schizophrenic patients won for him a reputation as
a therapeutic wizard. However, despite achieving much respect from an influential group of
associates, Sullivan had few close interpersonal relations with any of his peers. In 1949, at age
56, he died while alone in a hotel room in Paris.
Books by Harry Stack Sullivan

 Personal Psychopathology (1933/1973)
 Conceptions of Modern Psychiatry (1947/1966)
 The Interpersonal Theory of Psychiatry (1953)
 The Psychiatric Interview (1954)
 Schizophrenia as a Human Process (1962)

Interpersonal theory
Sullivan (1953) believed that individual behavior and personality development are the
direct result of interpersonal relationship. Before the development of his own theoretical frame
work, Sullivan embraced the concepts of Freud. Later, he changed the focus of his work from
the interpersonal view of Freud to one with more interpersonal flavor in which human behavior
could be observed in social interaction with others. His ideas have been integrated into the
practice of psychiatry through publication only after his death in 1949.
Major assumptions
Sullivan’s major assumptions include the following:
Anxiety is a feeling of emotional discomfort, towards the relief or prevention of which all
behavior is aimed. Sullivan believed that anxiety is the “chief disruptive force in interpersonal
relations and the main factor in the development of serious difficulties in living”. It arises out of
one’s inability to satisfy needs or to achieve interpersonal security.
 Satisfaction of the needs is the fulfillment of all requirements associated with an
individual’s physicochemical environment. Sullivan identified examples of these requirements
as oxygen, food, water, warmth, tenderness, rest, activity, sexual expression- virtually anything
that, when absent, produces discomfort in the individual.
Interpersonal security is the feeling associated with relief from anxiety. When all needs
have been met, one experiences a sense of total well-being, which Sullivan termed
interpersonal security. He believed individuals have an innate need for interpersonal security.
Self-systems are a collection of experiences, or security measures, adopted by the
individuals to protect against anxiety. Sullivan identified three components of the self-systems,
which are based on interpersonal experiences early in life;
 The “good me” is the part of the personality that develops in respond to positive
feedback from the primary caregiver. Feelings of pleasure, contentment, and
gratification are experienced. The child learns which behaviors elicit this positive
response as it becomes incorporated into the self-system.
 The “bad me” is the part of the personality that develops in response to negative
feedback from the primary caregiver. Anxiety is experienced, eliciting feelings of
discomfort, displeasure, and distress. The child learns to avoid these negative feelings by
altering certain behaviors.
 The “not me” is the part of the personality that develops in responds to situations that
produce intense anxiety in the child. Feeling of horror, awe, dread, and loathing are
experienced in the responds to these situations, leading the child to deny these feelings
in an effort to relieve anxiety. These feelings, having then been denied, become “not
me,” but someone else. This withdrawal from emotions has serious implications for
mental disorders in adult life.
Tensions & Harry Stack Sullivan
Sullivan conceptualized personality as an energy system, with energy existing either as tension
(potentiality for action) or as energy transformations (the actions themselves). He further
divided tensions into needs and anxiety.
 Needs
o Needs can relate either to the general well-being of a person or to specific zones,
such as the mouth or genitals. General needs can be either physiological, such as
food or oxygen, or they can be interpersonal, such as tenderness and intimacy.
 Anxiety
o Unlike needs—which are conjunctive and call for specific actions to reduce them
—anxiety is disjunctive and calls for no consistent actions for its relief. All infants
learn to be anxious through the empathic relationship that they have with their
mothering one. Sullivan called anxiety the chief disruptive force in interpersonal
relations. A complete absence of anxiety and other tensions is called euphoria.
Dynamisms of Harry Sullivan
Sullivan used the term dynamism to refer to a typical pattern of behavior. Dynamisms may
relate either to specific zones of the body or to tensions.
 Malevolence
o The disjunctive dynamism of evil and hatred is called malevolence, defined by
Sullivan as a feeling of living among one’s enemies. Those children who become
malevolent have much difficulty giving and receiving tenderness or being
intimate with other people.
 Intimacy
o The conjunctive dynamism marked by a close personal relationship between two
people of equal status is called intimacy. Intimacy facilitates interpersonal
development while decreasing both anxiety and loneliness.
 Lust
o In contrast to both malevolence and intimacy, lust is an isolating dynamism. That
is, lust is a self-centered need that can be satisfied in the absence of an intimate
interpersonal relationship. In other words, although intimacy presupposes
tenderness or love, lust is based solely on sexual gratification and requires no
other person for its satisfaction.
 Self-System
o The most inclusive of all dynamisms is the self-system, or that pattern of
behaviors that protects us against anxiety and maintains our interpersonal
security. The self system is a conjunctive dynamism, but because its primary job
is to protect the self from anxiety, it tends to stifle personality change.
Experiences that are inconsistent with our self-system threaten our security and
necessitate our use of security operations, which consist of behaviors designed
to reduce interpersonal tensions. One such security operation is dissociation,
which includes all those experiences that we block from awareness. Another is
selective inattention, which involves blocking only certain experiences from
awareness.
Personifications in Interpersonal Theory
Sullivan believed that people acquire certain images of self and others throughout the
developmental stages, and he referred to these subjective perceptions as personifications.
 Bad-Mother, Good-Mother
o The bad-mother personification grows out of infants‘experiences with a nipple
that does not satisfy their hunger needs. All infants experience the bad-mother
personification, even though their real mothers may be loving and nurturing.
Later, infants acquire a good-mother personification as they become mature
enough to recognize the tender and cooperative behavior of their mothering
one. Still later, these two personifications combine to form a complex and
contrasting image of the real mother.

 Me Personifications
 o During infancy children acquire three “me” personifications: (1) the bad-me,
which grows from experiences of punishment and disapproval, (2) the good-me,
which results from experiences with reward and approval, and (3) the not-me,
which allows a person to dissociate or selectively not attend to the experiences
related to anxiety.
 Eidetic Personifications
o One of Sullivan’s most interesting observations was that people often create
imaginary traits that they project onto others. Included in these eidetic
personifications are the imaginary playmates that preschool-aged children often
have. These imaginary friends enable children to have a safe, secure relationship
with another person, even though that person is imaginary.
Levels of Cognition in Interpersonal Theory
Sullivan recognized three levels of cognition, or ways of perceiving things—prototaxic,
parataxic, and syntaxic.
 Prototaxic Level
o Experiences that are impossible to put into words or to communicate to others
are called prototaxic. Newborn infants experience images mostly on a prototaxic
level, but adults, too, frequently have preverbal experiences that are momentary
and incapable of being communicated.
 Parataxic Level
o Experiences that are prelogical and nearly impossible to accurately communicate
to others are called parataxic. Included in these are erroneous assumptions
about cause and effect, which Sullivan termed parataxic distortions.
 Syntaxic Level
o Experiences that can be accurately communicated to others are called syntaxic.
Children become capable of syntaxic language at about 12 to 18 months of age
when words begin to have the same meaning for them that they do for others.

The total configuration of personality traits is known as the self-system which develops in
various stages and is the outgrowth of inter-personal experiences, rather than unfolding of
intrapsychic forces. During infancy, anxiety occurs for the first time when infants primary needs
are not satisfied. During childhood, from 2 to 5 years, a child’s main tasks are to learn to
requirements of the culture and how to deal with power full adults. As a juvenile, 5 to 8 years, a
child has a need for peers and must learn how to deal with them. In preadolescence, from 8 to
12 years, the capacity for love and for collaboration with another person of the same sex
develops. This so-called chum period, is the prototype for a sense of intimacy. In the history of
patients with schizophrenia, this experience of chums is often missing. During adolescence,
major tasks include the separation from the family, the development of standards and values,
and the transition of heterosexually.
The therapy process requires the active participation of the therapists, who is known as a
participant observer. Modes of experience, particularly the parataxic, need to be clarified, and
new patterns of behavior need to be implemented. Ultimately, person need to be see
themselves as they really are, instead of as they are or as they want others to think they are.
Sullivan’s stages of personality development
Infancy; birth to 18 months
During the beginning stage, the major developmental task for the child is the gratification
of needs. This is accomplished through activity associated with the mouth, such as crying,
nursing, and thumb sucking.
The period from birth until the emergence of syntaxic language is called infancy, a time
when the child receives tenderness from the mothering one while also learning anxiety through
an empathic linkage with the mother. Anxiety may increase to the point of terror, but such
terror is controlled by the built-in protections of apathy and somnolent detachment that allow
the baby to go to sleep. During infancy children use autistic language, which takes place on a
Prototaxic or parataxic level

Childhood: 18 months to 6 years

The stage that lasts from the beginning of syntaxic language until the need for playmates
of equal status is called childhood. The child’s primary interpersonal relationship continues to
be with the mother, who is now differentiated from other persons who nurture the child.
At age 18 months to 6 years, the child learns that interference with fulfillment of personal
wishes and desires may result in delayed gratification. He or she learns to accept this and feel
comfortable with it, recognizing that delayed gratification often result in parental approval, a
more lasting type of reward. Tools of this stage include the mouth, the anus, language,
experimentation, manipulation, and identification.
Juvenile: 6 to 9 years
The juvenile stage begins with the need for peers of equal status and continues until the
child develops a need for an intimate relationship with a chum. At this time children should
learn how to compete, to compromise, and to cooperate. These three abilities, as well as an
orientation toward living, help a child develop intimacy, the chief dynamism of the next
Developmental stage.
The major task of the juvenile stage is information of satisfactory relationships within peer
groups. This is accomplished through the use of competition, cooperation and compromise.
Preadolescence: 9 to 12 years
Perhaps the most crucial stage is preadolescence, because mistakes made earlier can be
corrected during preadolescence, but errors made during preadolescence are nearly impossible
to overcome in later life. Preadolescence spans the time from the need for a single best friend
until puberty. Children who do not learn intimacy during preadolescence have added difficulties
relating to potential sexual partners during later stages.
The task at the preadolescence stage focus on developing relationships with the persons of
the same sex. One’s availability to collaborate with and show love and affection for another
person begins at this stage.
Early adolescence: 12 to 14 years
With puberty come the lust dynamism and the beginning of early adolescence.
Development during this stage is ordinarily marked by a coexistence of intimacy with a single
friend of the same gender and sexual interest in many persons of the opposite gender.
However, if children have no preexisting capacity for intimacy, they may confuse lust with love
and develop sexual relationships that are devoid of true intimacy.
During early adolescence, the child is struggling with developing a sense of identity that
is separate and independent from the parents. The major task is formation of satisfactory
relationship with members of opposite sex. Sullivan saw the emergence of lust in response to
biological changes as a major force occurring during this period.
Late adolescence: 14 to 21 years
Chronologically, late adolescence may start at any time after about age 16, but
psychologically, it begins when a person is able to feel both intimacy and lust toward the same
person. Late adolescence is characterized by a stable pattern of sexual activity and the growth
of the syntaxic mode, as young people learn how to live in the adult world.
The late adolescence period is characterized by task associated by with the attempt to
achieve interdependence within the society and the formation of a lasting, intimate relationship
with a selected member of a opposite sex. The genital organs are the major developmental
focus of this stage.
Adulthood
Late adolescence flows into adulthood, a time when a person establishes a stable
relationship with a significant other person and develops a consistent pattern of viewing the
world
Application of interpersonal theory in psychiatry
Age Stage Major developmental Psychopathology
task
birth to 18 Infancy Relief from anxiety Anxiety disorders
months through gratification Paranoia
of needs Dependent
personality
Substance abuse
18 months to 6 Childhood Learning to Anxiety disorders
years experience delay in Borderline
gratification of needs personality
with undue anxiety Obsessive
compulsive
disorder
Addictive
disorders

6-9 years Juvenile Learning to form Withdrawn

satisfactory behaviour
 relationships Antisocial
personality
Depression

9-12 years Preadolescence Relationships with Schizophrenia

same sex; feelings for Paranoid
opposite sex delusions
Depression
Withdrawal
12-14 years Early adolescence Relationships with Paranoid
opposite sex; sense of schizophrenia
identity Delusional
disorder
Role confusion
14-21 years Late adolescence Self identity; intimate Paranoid
opposite sex delusions
relationships Delusions of
infidelity
Mood disorders

Therapeutic Community or Milieu.

Sullivan envisioned the goal of treatment as the establishment of satisfying

interpersonal relationships. The therapist provides a corrective interpersonal relationship for
the client. Sullivan coined the term participant observer for the therapist’s role, meaning that
the therapist both participates in and observes the progress of the relationship. Credit also is
given to Sullivan for developing the first therapeutic community or milieu with young men with
schizophrenia in 1929. In the concept of therapeutic community or milieu, the interaction
among clients is seen as beneficial, and treatment emphasizes the role of this client-to-client
interaction. Until this time, it was believed that the interaction between the client and the
psychiatrist was the one essential component to the client’s treatment.
Sullivan observed that interactions among clients in a safe, therapeutic setting provided
great benefits to clients. The concept of milieu therapy, originally developed by Sullivan
involved clients’ interactions with one another; i.e., practicing interpersonal relationship skills,
giving one another feedback about behavior, and working cooperatively as a group to solve
day-to-day problems. Milieu therapy was one of the primary modes of treatment in the acute
hospital setting. In today’s health care environment, however, inpatient hospital stays are often
too short for clients to develop meaningful relationships with one another. Therefore the
concept of milieu therapy receives little attention. Management of the milieu or environment is
still a primary role for the nurse in terms of providing safety and protection for all clients and
promoting social interaction.
PEPLAU’S INTERPERSONAL RELATIONS MODEL:
 Hildegard E. Peplau is universally regarded as the mother of psychiatric nursing. Her
theoretical and clinical work led to the development of the distinct specialty field of psychiatric
nursing.
Peplau’s interpersonal model is based on behavioral science and this enables the nurse
to begin to move away from disease orientation to one where by the psychological meaning of
events, feeling and behaviors could be explored and incorporated into nursing intervention. It
gives nurse an opportunity to teach patients how to express and experience their feelings.

COMPONENTS:
There are four central components in Peplau’s model. They are:
 Interpersonal process
 Nurse
 Patient
 Anxiety
The interpersonal process is the central components of the Peplau’s model. It describes
the method by which the nurse facilitates useful transformation of the patient’s Anxiety. The
interpersonal process represents the points at which the nurse and patient interfere in the
interest of patient health.
There are four distinct phases in this interpersonal process.
1. Orientation
2. Identification
3. Exploitation
4. Resolution

During these phases the nurse assumes various roles such as teacher, resource,
counselor, leader, technical experts and surrogate.

1. Orientation phase: Orientation is the initiation of relationship when the patient

recognizes a felt need or difficulty and seeks professional assistance. The nurse works
collaboratively with the patient and family in analyzing the situation, so that they
together can recognize, clarify and define the existing problems.

2. Identification phase: Here the patient identifies with those who can help him. The nurse
permits exploration of feelings of the patient.

3. EXPLOITATION PHASE: this is the major working phase of relationship. It refers to the
discussion and understanding of patients’ problems.

4. THE RESOLUTION PHASE: during this phase, nurse collaborates to resolve the problem.
In this study patients’ self esteem has improved and using the coping system effectively.
Here the role of the nurse is to create a therapeutic relationship, evaluate the situations
and prepare for discharge plan, health education or psychoeducation and follow up.
II. Nurse is a component of the peplau.
Here nurse act as a leader, teacher, supporter and resource person. She mediates
transformation of energy necessary for the patient movements towards health. There is
an indirect, but vital relationship between nurse and patient health.
Teacher:
 Utilization of already present coping skills in effective way.
 Teaching new coping skills.
 Teach about relaxation technique, medications.
Leaders:
 Take initiative and participate in group work.
 Supervise the clients’ activity.
 Provide positive feedback and encouragement
 Participate in group therapy.
 Involve him in any day activities.
Supporter:
 Provide adequate psychological supports.
 Family support
 Recognize the clients’ abilities and disabilities.
III. Patient:
Patient is depicted as a recipient of the effects of interpersonal process. Here nurses
should maintain a neutral and emotional position and resist being influenced by patient.

Relevance of interpersonal theory to nursing practice

The interpersonal theory has significant relevance to nursing practice. Relationship

development, which is a major concept of the theory, is a major psychiatric nursing
intervention. Nurses develop therapeutic relationships with clients in an effort to help them
generalize this ability to interact successfully with others.
The theory presents psychiatric phenomena as having roots in interpersonal experiences
and relationships throughout life which in turn impose difficulties in forging new relationships
and shape one’s sense of self that informs social behavior. One’s ability to interact with others
is most fundamentally shaped by relationships with primary caregivers. One’s anxiety system,
which affects one’s ability to participate in and process information from various domains of
life, is formed in those early relationships in response to the discomforts and resistances the
primary caregiver brings to child-caring interactions. Many of those discomforts of caregivers
are in direct response to cultural patterns, expectations, and belief—such as a cultural beliefs in
the willfulness of infants or taboos surrounding certain body parts and functions—which lead
adults to be very concerned lest their child develop into a socially unacceptable person. Both
anxiety and unfortunate disciplining may result.
One protects this early shaped anxiety system through security operations that defuse
anxiety-provoking situations at the expense of limiting one’s ability to participate in them.
Development, nonetheless, can continue through the social and economic opportunities of
one’s cultural time and space. Later interactions, moreover, open the door to reformulation of
the self, as one finds ways to experience (often in collaboration with a trusted partner who
does not share the same pattern of anxieties) those things that were initially anxiety laden.
Language provides a major tool in expanding social interaction as well as one’s reflexive
understanding of the self.
Biographical events—both cultural and biological-- provide the opportunity for new
relationships to form, life horizons to expand, and characterizations of self, others and
situations to change. These events also pose challenges to be addressed, for which one may or
may not have adequate personal resources. These events include transition through levels of
school (themselves culturally shaped institutions with culturally patterned interactions and
expectations), the onset of puberty and the pursuit of sexual urges (in part biological, but
pursued through culturally shaped activities saturated with cultural expectations, proprieties,
and taboos), finding a satisfying and economically viable way of living (shaped by economic and
social factors, including one’s history within school and community). All such events may lead to
greater satisfaction and psychological ease or increasing dissatisfaction, misery, and psychic
distress.
Knowledge about the behaviors associated with all level of anxiety and methods for
alleviating anxiety helps nurse to assist clients achieve interpersonal security and a sense of
well-being. Nurses use the concepts of Sullivan’s theory to help clients achieve a higher degree
of independent and interpersonal functioning.
Strengths and limitations
Sullivan pioneered the notion of the therapist as a participant observer, who establishes an
interpersonal relationship with the patient. He was primarily concerned with understanding
patients and helping them develop foresight, improve interpersonal relations, and restore their
ability to operate mostly on a syntaxic level. Despite Sullivan’s insights into the importance of
interpersonal relations, his theory of personality and his approach to psychotherapy have lost
popularity in recent years.
This theory rates very low in falsifiability, low in its ability to generate research, and
average in its capacity to organize knowledge and to guide action. In addition, it is only average
in self-consistency and low in parsimony. Because Sullivan saw human personality as largely
being formed from interpersonal relations, his theory rates very high on social influences and
very low on biological ones. In addition, it rates high on unconscious determinants; average on
free choice, optimism, and causality; and low on uniqueness.
Conclusion
For Sullivan, mental health can be measured by the balance between the pursuit of
satisfactions and security.  Life is lived between the needs for satisfaction and security. 
Satisfaction leads to constructive integrations with others and the joyful exercise of functions. 
Our ability to attain satisfactions according to socially approved patterns causes a feeling of
well-being, self-approval, and security.  If satisfactions are not fulfilled, then we feel anxious,
insecure, and uneasy.  Insecurity leads to non-constructive integrations and self-absorbed
fantasy and illusion.
Reference
 Mohr WK. Psychiatric Mental Health Nursing. 6th ed. LWW publications; 2006.
 Vyas JN, Ahuja N. Text Book of Post Graduate Psychiatry. 2 nd ed. Jaypee publishers;
2008.
 Stuart GW, Laraira MT. Principles and Practice of Psychiatric Nursing. 8 th ed. Elsevier;
2005.
 Stuart GW. Principles and Practice of Nursing. 9th ed. Mosby-Elsevier; 2009.
 Townsend MC. Essentials of Psychiatric Mental Health Nursing. 4 th ed. Philadelphia;USA:
F.A.Davis publishers; 2008

Websites
 http://www.theglaringfacts.com/psychology/sullivan-interpersonal-theory

 http://quizlet.com/4554326/stages of development-in sullivan- interpersonal-theory

e-journal

 http://www.encognitive.com/files/internet addiction/interpersonal-theory

Liu CY, Kuo FY. A study of internet addiction through the lens of the Interpersonal
theory; Cyber Psychology and Behaviour:2007;vol 10-6:Taiwan.p 799-804