29 Concepts Of Personality Development PDF

29 Concepts of Personality Development CORE CONCEPT Growth and Development: Personality CHAPTER OUTLINE Objectives Introduction Psychoanalytic Theory Interpersonal Theory Theory of Psychosocial Development Theory of Object Relations A Nursing Model—Hildegard E. Peplau Summary and Key Points Rev...

29 Concepts of Personality Development CORE CONCEPT Growth and Development: Personality CHAPTER OUTLINE Objectives Introduction Psychoanalytic Theory Interpersonal Theory Theory of Psychosocial Development Theory of Object Relations A Nursing Model—Hildegard E. Peplau Summary and Key Points Review Questions Clinical Judgment Questions KEY TERMS counselor ego id libido personality psychodynamic nursing superego surrogate symbiosis technical expert temperament OBJECTIVES After reading this chapter, the student will be able to: 1. Define personality. 2. Identify the relevance of knowledge associated with personality development to nursing in the psychiatric mental health setting. 3. Discuss the major components of the following developmental theories: a. Psychoanalytic theory—Freud b. Interpersonal theory—Sullivan c. Theory of psychosocial development—Erikson d. Theory of object relations development—Mahler e. A nursing model of interpersonal development—Peplau Introduction The American Psychological Association (2021) describes personality as the characteristic patterns of thinking, feeling, and behaving that define individual differences and clarify how the various parts of a person come together as a whole. Nurses must have a basic knowledge of human personality development to understand maladaptive behavioral responses commonly seen in psychiatric patients. Developmental theories identify behaviors associated with various stages through which individuals pass, thereby specifying what is appropriate or inappropriate at each developmental level. Child development specialists believe that infancy and early childhood are the major life periods for the origination and occurrence of developmental change. Specialists in life-cycle development believe that people continue to develop and change throughout life, thereby suggesting the possibility for renewal and growth in adults. Developmental stages are identified by age. Behaviors can then be evaluated for age appropriateness. Ideally, an individual successfully fulfills all the tasks associated with one stage before moving on to the next stage (at the appropriate age). Realistically, however, this type of orderly progression seldom happens. One reason is related to temperament, or the inborn personality characteristics that influence an individual’s manner of reacting to the environment and ultimately his or her developmental progression. Research supports that the Big Five personality traits, defined as openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism (emotional instability), are heritable traits (Power & Pluess, 2015). Estimates of the heritable components of these traits range from 40% to 60%. In addition to a person’s inborn temperament, environment may also influence one’s personality development. Individuals who are reared in a dysfunctional family system often have delayed ego development. Specialists in life-cycle development posit that behaviors from an unsuccessfully completed stage can be modified and corrected in a later stage. Stages overlap, and an individual may be working on tasks associated with several stages at one time. When an individual becomes fixed in a lower level of development, with age-inappropriate behaviors focused on fulfillment of those tasks, psychopathology may become evident. “Only when personality traits are inflexible and maladaptive, and cause significant functional impairment or subjective distress do they constitute personality disorders” (American Psychiatric Association [APA], 2022, p. 735). Maladaptive traits may be described as any personality traits that deviate markedly from the expectations for behavior in one’s culture. These maladaptive traits may be manifested in a person’s way of thinking or feeling, interpersonal relationships, or impulse control.  CORE CONCEPT Personality Characteristic ways of thinking, feeling, and behaving that are influenced by genetics and environment. Psychoanalytic Theory Sigmund Freud (1961), who has been called the father of psychiatry, is credited as the first to identify development by stages. He considered the first 5 years of a child’s life to be the most important, because he believed that an individual’s basic character is formed by the age of 5 years. Freud’s personality theory can be conceptualized according to structure and dynamics of the personality, topography of the mind, and stages of personality development. Structure of the Personality Freud organized the structure of the personality into three major components: the id, ego, and superego. They are distinguished by their unique functions and different characteristics. Id The id is the locus of instinctual drives—the pleasure principle. Present at birth, it endows the infant with instinctual drives that seek to satisfy needs and achieve immediate gratification. Id-driven behaviors are impulsive and may be irrational. Ego The ego, also called the rational self or the reality principle, begins to develop between the ages of 4 and 6 months. The ego experiences the reality of the external world, adapts to it, and responds to it. As the ego develops and gains strength, it seeks to bring the influences of the external world to bear upon the id and to substitute the reality principle for the pleasure principle. A primary function of the ego is one of mediator, that is, to maintain harmony among the external world, the id, and the superego. Superego If the id is identified as the pleasure principle, and the ego the reality principle, the superego might be referred to as the perfection principle. The superego, which develops between the ages of 3 and 6 years, internalizes the values and morals set forth by primary caregivers. Derived from a system of rewards and punishments, the superego is composed of two major components: the ego-ideal and the conscience. When children are consistently rewarded for “good” behavior, self-esteem is enhanced, and behavior becomes part of the ego-ideal—that is, it is internalized as part of their value system. The conscience is formed when children are consistently punished for “bad” behavior. They learn what is considered morally right or wrong from feedback received from parental figures and from society or culture. When moral and ethical principles or even internalized ideals and values are disregarded, the conscience generates a feeling of guilt within the individual. The superego is important in the socialization of the individual because it assists the ego in the control of id impulses. When the superego becomes rigid and punitive, however, problems with low self-confidence and low self-esteem arise. Examples of behaviors associated with these components of the personality are presented in Table 29–1. TABLE 29–1 Structure of the Personality: Behavioral Examples COMPONENTS OF PERSONALITY SITUATIONS ID EGO SUPEREGO Finding money “I found this “I already have “It is never right wallet; I will keep money. This to take something the money.” money doesn’t that doesn’t belong to me. belong to you.” Maybe the person who owns this wallet doesn’t have any money.” Parents are away “Mom and Dad “Mom and Dad “Never disobey are gone. Let’s said no friends your parents.” party!!!!!” over while they are away. Too risky.” Sexual behavior “I’ll have sex “Promiscuity can “Sex outside of with whomever I be very marriage is please, whenever dangerous.” always wrong.” I please.” Topography of the Mind Freud classified all mental contents and operations into three categories: the conscious, the preconscious, and the unconscious. Conscious: Includes all memories that remain within an individual’s awareness. It is the smallest of the three categories. Events and experiences that are easily remembered or retrieved are considered to be within one’s conscious awareness. Examples include telephone numbers, birthdays of self and significant others, dates of special holidays, and what one had for lunch today. The conscious mind is thought to be under the control of the ego, the rational and logical structure of the personality.  Preconscious: Includes all memories that may have been forgotten or are not in present awareness but, with attention, can readily be recalled into consciousness. Examples include telephone numbers or addresses once known but little used and feelings associated with significant life events that may have occurred at some time in the past. The preconscious enhances awareness by helping to suppress unpleasant or nonessential memories from consciousness. It is thought to be partially under the control of the superego, which helps to suppress unacceptable thoughts and behaviors. Unconscious: Includes all memories that one is unable to bring to conscious awareness. It is the largest of the three topographical levels. Unconscious material consists of unpleasant or nonessential memories that have been repressed and can be retrieved only through therapy, through hypnosis, and with certain substances that alter the awareness and have the capacity to restructure repressed memories. Unconscious material may also emerge in dreams and in seemingly incomprehensible behavior. Dynamics of the Personality Freud believed that psychic energy is the force or impetus required for mental functioning. Originating in the id, it instinctually fulfills basic physiological needs. Freud called this psychic energy (or the drive to fulfill basic physiological needs such as hunger, thirst, and sex) the libido. Although today the term libido has been used to describe specifically the sex drive, in Freud’s theory the term referred to all psychic energy. As the child matures, psychic energy is diverted from the id to form the ego and then from the ego to form the superego. Psychic energy is distributed within these three components, with the ego retaining the largest share to maintain a balance between the impulsive behaviors of the id and the idealistic behaviors of the superego. If an excessive amount of psychic energy is stored in one of these personality components, behavior reflects that part of the personality. For instance, impulsive behavior prevails when excessive psychic energy is stored in the id. Overinvestment in the ego reflects self- absorbed, or narcissistic, behaviors; an excess within the superego results in rigid, self-deprecating behaviors. Freud used the terms cathexis and anticathexis to describe the forces within the id, ego, and superego that are used to invest psychic energy in external sources to satisfy needs. Cathexis is the process by which the id invests energy into an object in an attempt to achieve gratification. An example is the individual who instinctively turns to alcohol to relieve stress. Anticathexis is the use of psychic energy by the ego and the superego to control id impulses. In the example cited, the ego would attempt to control the use of alcohol with rational thinking, such as, “I already have had problems associated with drinking too much. I will call my AA sponsor for support. I will not drink.” The superego would exert control with such thinking as, “I shouldn’t drink. If I drink, my family will be hurt and angry. I should think of how it affects them. I’m such a weak person.” Freud believed that an imbalance between cathexis and anticathexis resulted in internal conflicts, producing tension and anxiety within the individual. Freud’s daughter Anna devised a comprehensive list of defense mechanisms believed to be used by the ego as a protective device against anxiety in mediating between the excessive demands of the id and the excessive restrictions of the superego (see Chapter 1, “Mental Health and Mental Illness”). Freud’s Stages of Personality Development Freud described formation of the personality through five stages of psychosexual development. He placed much emphasis on the first 5 years of life and believed that characteristics developed during these early years weigh heavily on one’s adaptation patterns and personality traits in adulthood. Fixation in an early stage of development almost certainly results in psychopathology. An outline of these five stages of psychosexual development is presented in Table 29–2. Oral Stage: Birth to 18 Months During the oral stage, behavior is directed by the id, and the goal is immediate gratification of needs. The focus of energy is the mouth, and behaviors include sucking, chewing, and biting. The infant feels a sense of attachment and is unable to differentiate the self from the person who is providing the mothering. This includes feelings such as anxiety. Because of this lack of differentiation, a pervasive feeling of anxiety on the part of the mother may be passed on to her infant, leaving the child vulnerable to similar feelings of insecurity. With the beginning of development of the ego at age 4 to 6 months, the infant starts to view the self as separate from the mothering figure. A sense of security and the ability to trust others are derived from the gratification of fulfilling basic needs during this stage. Anal Stage: 18 Months to 3 Years The major task in the anal stage is gaining independence and control with particular focus on the excretory function. Freud believed that the manner in which the parents and other primary caregivers approach the task of toilet training may have far-reaching effects on the child in terms of values and personality characteristics. When toilet training is strict and rigid, the child may choose to retain the feces, becoming constipated. Adult retentive personality traits influenced by this type of training include stubbornness, stinginess, and miserliness. An alternate reaction to strict toilet training is for the child to expel feces in an unacceptable manner or at inappropriate times. Far-reaching effects of this behavior pattern include malevolence, cruelty to others, destructiveness, disorganization, and untidiness. Toilet training that is more permissive and accepting attaches the feeling of importance and desirability to feces production. The child becomes extroverted, productive, and altruistic. Phallic Stage: 3 to 6 Years In this stage, the focus of energy shifts to the genital area. Discovery of differences between sexes results in a heightened interest in the sexuality of self and others. This interest may be manifested in sexual self-exploratory or group-exploratory play. Freud proposed that the development of the Oedipus complex (males) or Electra complex (females) occurred during this stage of development. He described the Oedipus and Electra complexes as the child’s unconscious desire to eliminate the parent of the same sex and to possess the parent of the opposite sex. Guilt feelings result with the emergence of the superego during these years. Resolution of this internal conflict occurs when the child develops a strong identification with the parent of the same sex and internalizes that parent’s attitudes, beliefs, and value system. TABLE 29–2 Freud’s Stages of Psychosexual Development AGE STAGE MAJOR DEVELOPMENTAL TASKS Birth–18 Oral Relief from anxiety through oral gratification of months needs 18 months–3 Anal Learning independence and control with focus on years the excretory function 3–6 years Phallic Identification with parent of same sex; development of sexual identity; focus on genital organs 6–12 years Latency Sexuality repressed; focus on relationships with same-sex peers 13–20 years Genital Libido reawakened as genital organs mature; focus on relationships with members of the opposite sex Latency Stage: 6 to 12 Years During the elementary school years, the focus changes from egocentrism to one of more interest in group activities, learning, and socialization with peers. Sexuality is not absent during this period but remains obscure and imperceptible to others. The preference is for same-sex relationships, even rejecting members of the opposite sex. Genital Stage: 13 to 20 Years In the genital stage, the maturing of the genital organs results in a reawakening of the libidinal drive. The focus is on relationships with members of the opposite sex and preparations for selecting a mate. The development of sexual maturity evolves from self-gratification to behaviors deemed acceptable by societal norms. Interpersonal relationships are based on genuine pleasure derived from the interaction rather than from the more self-serving implications of childhood associations. Relevance of Psychoanalytic Theory to Nursing Practice Knowledge of the structure of the personality can assist nurses who work in the mental health setting. The ability to recognize behaviors associated with the id, the ego, and the superego assists in the assessment of developmental level. Understanding the use of ego defense mechanisms is important in making determinations about maladaptive behaviors, in planning care for patients to assist in creating change (if desired), or in helping patients accept themselves as unique individuals. CLINICAL PEARL: Assessing Patient Behaviors Id Behaviors: Those behaviors that follow the principle of “if it feels good, do it.” Social acceptability and cultural acceptability are not considered. Id behaviors reflect a need for immediate gratification. Individuals with a strong id show little, if any, remorse for their unacceptable behavior. Ego Behaviors: Behaviors that reflect the rational part of the personality. An effort is made to delay gratification and to satisfy societal expectations. The ego uses defense mechanisms to cope with and regain control over id impulses. Superego Behaviors: Behaviors that are somewhat uncompromising and rigid. Based on morality and society’s values, behaviors of the superego strive for perfection. Violation of the superego’s standards generates guilt and anxiety in an individual who has a strong superego. Interpersonal Theory Harry Stack Sullivan (1953) believed that individual behavior and personality development are the direct result of interpersonal relationships. Before the development of his own theoretical framework, Sullivan embraced the concepts of Freud. Later, he changed the focus of his work from the intrapersonal view of Freud to one with a more interpersonal approach, in which human behavior could be observed in social interactions with others. His ideas, which were not universally accepted at the time, have been integrated into the practice of psychiatry through publication only since his death in 1949. Sullivan’s major concepts include the following:  Anxiety is a feeling of emotional discomfort. All behavior is aimed toward the relief or prevention of this discomfort. Sullivan believed that anxiety is the primary cause of difficulties in interpersonal relations, which contributes to serious problems in living. Anxiety arises out of one’s inability to satisfy needs or achieve interpersonal security. Satisfaction of needs is the fulfillment of all requirements associated with an individual’s physiochemical 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 that individuals have an innate need for interpersonal security. Self-system is a collection of experiences, or security measures, adopted by the individual to protect against anxiety. Sullivan identified three components of the self-system, which are based on interpersonal experiences early in life: The “good me” is the part of the personality that develops in response 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 response to situations that produce intense anxiety in the child. Feelings of horror, awe, dread, and loathing are experienced in response 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. Sullivan’s Stages of Personality Development Sullivan described six stages of personality development (1953). An outline of the stages of personality development according to Sullivan’s interpersonal theory is presented in Table 29–3. Infancy: Birth to 18 Months During this 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. Childhood: 18 Months to 6 Years At ages 18 months to 6 years, children learn that interference with fulfillment of personal wishes and desires may result in delayed gratification. They learn to accept and feel comfortable with this, recognizing that delayed gratification often results 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 major task of the juvenile stage is formation of satisfactory relationships within the peer group. This is accomplished through the use of competition, cooperation, and compromise. Preadolescence: 9 to 12 Years The tasks of the preadolescence stage focus on developing relationships with persons of the same sex. One’s ability to collaborate with and show love and affection for another person begins at this stage. Early Adolescence: 12 to 14 Years During early adolescence, the child is struggling to develop a sense of identity separate and independent from the parents. The major task is formation of satisfactory relationships with members of the opposite sex (although recent schools of thought would add that this could include developing satisfactory relationships with anyone to whom an individual experiences sexual attraction). Sullivan saw the emergence of need for sexual expression in response to biological changes as a major force occurring during this period. TABLE 29–3 Stages of Development in Sullivan’s Interpersonal Theory MAJOR DEVELOPMENTAL AGE STAGE TASKS Birth–18 months Infancy Relief from anxiety through oral gratification of needs 18 months–6 Childhood Learning to experience a delay in years personal gratification without undue anxiety 6–9 years Juvenile Learning to form satisfactory peer relationships 9–12 years Preadolescence Learning to form satisfactory relationships with persons of same sex; initiating feelings of affection for another person 12–14 years Early adolescence Learning to form satisfactory relationships with persons of the opposite sex; developing a sense of identity 14–21 years Late adolescence Establishing self-identity; experiencing satisfying relationships; working to develop a lasting, intimate opposite-sex relationship Late Adolescence: 14 to 21 Years The late adolescence period is characterized by tasks associated with the attempt to achieve interdependence within the society and the formation of a lasting, intimate relationship with a selected member of the opposite sex. The genital organs are the major developmental focus of this stage. Relevance of Interpersonal Theory to Nursing Practice The interpersonal theory has significant relevance to nursing practice. Relationship development, which is a major concept of this theory, is foundational to many psychiatric nursing interventions. Nurses develop therapeutic relationships with patients in an effort to help them generalize their ability to interact successfully with others. Knowledge about the behaviors associated with all levels of anxiety and methods for alleviating anxiety help nurses to assist patients in achieving interpersonal security and a sense of well-being. Nurses use the concepts of Sullivan’s theory to help patients achieve a higher degree of independent and interpersonal functioning. Theory of Psychosocial Development Erik Erikson (1963) studied the influence of social processes on the development of the personality. He described eight stages of the life cycle during which individuals struggle with developmental “crises.” Specific tasks associated with each stage must be completed for resolution of the crisis and for emotional growth to occur. Failure to meet the tasks of any stage, according to Erikson, would culminate in physical, cognitive, social, or emotional maladaptation later. An outline of Erikson’s stages of psychosocial development is presented in Table 29–4. Erikson’s Stages of Personality Development Trust Versus Mistrust: Birth to 18 Months In this stage, the major task is to develop a basic trust in the mothering figure and be able to generalize it to others. Achievement of the task results in self-confidence, optimism, faith in the gratification of needs and desires, and hope for the future. The infant learns to trust when basic needs are met consistently. Nonachievement results in emotional dissatisfaction with the self and others, suspiciousness, and difficulty with interpersonal relationships. The task remains unresolved when primary caregivers fail to respond to the infant’s distress signal promptly and consistently. TABLE 29–4 Stages of Development in Erikson’s Psychosocial Theory MAJOR DEVELOPMENTAL AGE STAGE TASKS Infancy (birth–18 Trust vs. mistrust To develop a basic trust in the months) mothering figure and learn to generalize it to others Early childhood Autonomy vs. To gain some self-control and (18 months–3 shame and doubt independence within the years) environment Late childhood Initiative vs. guilt To develop a sense of purpose and (3–6 years) the ability to initiate and direct own activities School age (6–12 Industry vs. To achieve a sense of self-confidence years) inferiority by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances Adolescence (12– Identity vs. role To integrate the tasks mastered in the 20 years) confusion previous stages into a secure sense of self Young adulthood Intimacy vs. To form an intense, lasting (20–30 years) isolation relationship or a commitment to another person, cause, institution, or creative effort Adulthood (30–65 Generativity vs. To achieve the life goals established years) stagnation for oneself while also considering the welfare of future generations Old age (65–79 Ego integrity vs. To review one’s life and derive years) despair meaning from both positive and negative events while achieving a positive sense of self-worth 80 years and older Transcendence To develop a broader sense of one’s meaning and spirituality that transcends themselves Autonomy Versus Shame and Doubt: 18 Months to 3 Years The major developmental task in this stage is to gain some self-control and independence within the environment. Achievement of the task results in a sense of self-control, the ability to delay gratification, and a feeling of self-confidence in one’s ability to perform. Autonomy is achieved when parents encourage and provide opportunities for independent activities. Nonachievement results in a lack of self-confidence, a lack of pride in the ability to perform, a sense of being controlled by others, and a rage against the self. The task remains unresolved when primary caregivers restrict independent behaviors, both physically and verbally, or set the child up for failure with unrealistic expectations. Initiative Versus Guilt: 3 to 6 Years During this stage the goal is to develop a sense of purpose and the ability to initiate and direct one’s own activities. Achievement of the task results in the ability to exercise restraint and self-control of inappropriate social behaviors. Assertiveness and dependability increase, and the child enjoys learning and personal achievement. The conscience develops, thereby controlling the impulsive behaviors of the id. Initiative is achieved when creativity is encouraged and performance is recognized and positively reinforced. Nonachievement results in feelings of inadequacy and a sense of defeat. Guilt is experienced to an excessive degree, even to the point of accepting liability in situations for which one is not responsible. Children may view themselves as evil and deserving of punishment. The task remains unresolved when creativity is stifled and parents continually expect a higher level of achievement than the child produces. Industry Versus Inferiority: 6 to 12 Years The major developmental task of this stage is to achieve a sense of self- confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances.  Achievement of the task results in a sense of satisfaction and pleasure in the interaction and involvement with others. Individuals master reliable work habits and develop attitudes of trustworthiness. They are conscientious, feel pride in achievement, and enjoy play but desire a balance between fantasy and “real-world” activities. Industry is achieved when individuals are encouraged to participate in activities and to assume responsibilities in the school and community, as well as in the home, and they receive recognition for accomplishments. Nonachievement results in difficulty in interpersonal relationships because of feelings of personal inadequacy. Individuals can neither cooperate nor compromise with others in group activities nor problem solve or complete tasks successfully. They may become either passive and meek or overly aggressive to cover up for feelings of inadequacy. If this occurs, individuals may manipulate or violate the rights of others to satisfy their own needs or desires; they may become a workaholic with unrealistic expectations for personal achievement. This task remains unresolved when parents set unrealistic expectations for the child, when discipline is harsh and tends to impair self-esteem, and when accomplishments are consistently met with negative feedback. Identity Versus Role Confusion: 12 to 20 Years At this stage, the goal is to integrate the developmental tasks mastered in the previous stages into a secure sense of self. Achievement of the task results in a sense of confidence, emotional stability, and a view of the self as a unique individual. Commitments are made to a value system, a career, and relationships with members of both genders. Identity is achieved when adolescents are allowed to experience independence by making decisions that influence their lives. Parents should be available to offer support when needed but should gradually relinquish control to the maturing individual in an effort to encourage the development of an independent sense of self. Nonachievement results in a sense of self-consciousness, doubt, and confusion about one’s role in life. Personal values or goals for one’s life are absent. Long-term commitments to relationships with others are nonexistent. A lack of self-confidence is often expressed by delinquent and rebellious behavior. Entering adulthood, with its accompanying  responsibilities, may be an underlying fear. This task can remain unresolved for many reasons. Examples include the following: When independence is discouraged by the parents and the adolescent is nurtured in the dependent position When discipline within the home has been overly harsh, inconsistent, or absent When there has been parental rejection or frequent shifting of parental figures Intimacy Versus Isolation: 20 to 30 Years The objective during this stage is to form an intense, lasting relationship or a commitment to another person, a cause, an institution, or a creative effort. Achievement of the task results in the capacity for mutual love and respect between two people and the ability of an individual to pledge a total commitment to another. The intimacy goes far beyond the sexual contact between two people. It describes a commitment in which personal sacrifices are made for another, whether it be another person, a career, or other type of cause or endeavor to which an individual elects to devote his or her life. Intimacy is achieved when an individual has developed the capacity for giving of oneself to another. This is learned when one has been the recipient of this type of giving within the family unit. Nonachievement results in withdrawal, social isolation, and aloneness. The individual is unable to form lasting, intimate relationships, often seeking intimacy through numerous superficial sexual contacts. No career is established; the individual may have a history of occupational changes (or may fear change and thus remain in an undesirable job situation). The task remains unresolved when love in the home has been absent or distorted through the individual’s younger years. The individual fails to achieve the ability to give of the self without having been the recipient early on from primary caregivers. Generativity Versus Stagnation or Self- Absorption: 30 to 65 Years The major developmental task of this stage is to achieve the life goals established for oneself while also considering the welfare of future generations. Achievement of the task results in a sense of gratification from personal and professional achievements and from meaningful contributions to others. The individual is active in the service of and to society. Generativity is achieved when the individual expresses satisfaction with this stage in life and demonstrates responsibility for leaving the world a better place in which to live. Nonachievement results in lack of concern for the welfare of others and total preoccupation with the self. The individual becomes withdrawn, isolated, and highly self-indulgent with no capacity for giving of the self to others. The task remains unresolved when earlier developmental tasks are not fulfilled and the individual does not achieve the degree of maturity required to derive gratification out of a personal concern for the welfare of others. Ego Integrity Versus Despair: 65 to 79 Years During this stage, the goal is to review one’s life and derive meaning from both positive and negative events while achieving a positive sense of self. Achievement of the task results in a sense of self-worth and self- acceptance as one reviews life goals, accepting that some were achieved and some were not. Individuals derive a sense of dignity from their life experiences and do not fear death, rather viewing it as another stage of development. Ego integrity is achieved when individuals have successfully completed the developmental tasks of the other stages and have little desire to make major changes in how their lives have progressed. Nonachievement results in a sense of self-contempt and disgust with how life has progressed. These individuals would like to start over and have a second chance at life. They feel worthless and helpless to change. Anger, depression, and loneliness are evident. Their focus may be on past failures or perceived failures. Impending death is feared or denied, or ideas of suicide may prevail. The task remains unresolved when earlier tasks are not fulfilled: self-confidence, a concern for others, and a strong sense of self-identity were never achieved. Transcendence: 80 Years and Older This additional stage/developmental task, articulated by Joan Erikson from ideas that were being developed by her late husband, has been identified to reflect the needs of the older, older adult because Erikson’s original model did not consider the expanded life span of today’s older population. Transcendence refers to a period in which one develops a broader sense of one’s meaning and spirituality that transcends the individual. Achievement entails confronting the previous eight stages in a convergence of understanding about one’s whole being and what extends beyond the self. It results in a cosmic, transcendent perspective culminating in a greater sense of inner peace and contentment. Nonachievement results in a greater sense of despair than that of the eighth stage, including greater feelings of hopelessness, anger, bitterness, contempt for others, and lack of acceptance of death. Relevance of Psychosocial Development Theory to Nursing Practice Erikson’s theory is particularly relevant to nursing practice in that it incorporates sociocultural concepts into the development of personality. Erikson provides a systematic, stepwise approach and outlines specific tasks that should be completed during each stage. This information can be used quite readily in psychiatric mental health nursing. Many individuals with mental health problems are still struggling to achieve tasks from a number of developmental stages. Nurses can plan care to assist these individuals to complete these tasks and move on to a higher developmental level. CLINICAL PEARL During assessment, nurses can determine whether a patient is experiencing difficulties associated with specific life tasks as described by Erikson. Knowledge about a patient’s developmental level, along with other assessment data, can help to identify accurate nursing interventions. Theory of Object Relations Margaret Mahler (Mahler et al., 1975) formulated a theory that describes the separation-individuation process of the infant from the maternal figure (primary caregiver). She described this process as progressing through three major phases, and she further delineated phase III, the separation- individuation phase, into four subphases. Mahler’s developmental theory is outlined in Table 29–5. Mahler’s Phases of Infant Development Phase I: The Autistic Phase (Birth to 1 Month) In the autistic phase, also called normal autism, the infant exists in a half- sleeping, half-waking state and does not perceive the existence of other people or an external environment. The fulfillment of basic needs for survival and comfort is the focus and is merely accepted as it occurs. Phase II: The Symbiotic Phase (1 to 5 Months) Symbiosis is a type of “psychic fusion” of mother and child. The child views the self as an extension of the mother but with a developing awareness that it is she who fulfills the child’s every need. Mahler suggested that absence of, or rejection by, the maternal figure at this phase can lead to symbiotic psychosis. Phase III: Separation-Individuation (5 to 36 Months) This third phase represents what Mahler called the “psychological birth” of the child. Separation is defined as the physical and psychological attainment of a sense of personal distinction from the mothering figure. Individuation occurs with a strengthening of the ego and an acceptance of a sense of “self” with independent ego boundaries. Four subphases through which the child evolves in his or her progression from a symbiotic extension of the mothering figure to a distinct and separate being are described. TABLE 29–5 Stages of Development in Mahler’s Theory of Object Relations MAJOR DEVELOPMENTAL AGE PHASE/SUBPHASE TASKS Birth–1 month I. Normal autism Fulfillment of basic needs for survival and comfort 1–5 months II. Symbiosis Development of awareness of external source of need fulfillment III. Separation- individuation 5–10 months a. Differentiation Commencement of a primary recognition of separateness from the mothering figure 10–16 months b. Practicing Increased independence through locomotor functioning; increased sense of separateness of self 16–24 months c. Rapprochement Acute awareness of separateness of self; learning to seek “emotional refueling” from mothering figure to maintain feeling of security 24–36 months d. Consolidation Sense of separateness established; on the way to object constancy (i.e., able to internalize a sustained image of loved object/person when it is out of sight); resolution of separation anxiety Subphase 1—Differentiation (5 to 10 Months) The differentiation phase begins with the child’s initial physical movements away from the mothering figure. A primary recognition of separateness commences. Subphase 2—Practicing (10 to 16 Months) With advanced locomotor functioning, children experience feelings of exhilaration from increased independence. They are now able to move away from, and return to, the mothering figure. A sense of omnipotence is manifested. Subphase 3—Rapprochement (16 to 24 Months) This third subphase, rapprochement, is extremely critical to the child’s healthy ego development. During this time, children become increasingly aware of their separateness from the mothering figure, while the sense of fearlessness and omnipotence diminishes. The child, now recognizing the mother as a separate individual, wishes to reestablish closeness with her but shuns the total re-engulfment of the symbiotic stage. The child needs the mothering figure to be available to provide “emotional refueling” on demand. Critical to this subphase is the mothering figure’s response to the child. If the mothering figure is available to fulfill emotional needs as they are required, the child will develop a sense of security in the knowledge that they are loved and will not be abandoned. However, if emotional needs are inconsistently met or if the mother rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment develop and often persist into adulthood. Subphase 4—Consolidation (24 to 36 Months) With achievement of the consolidation subphase, a definite individuality and sense of separateness of self are established. Objects are represented as whole with the child having the ability to integrate both “good” and “bad.” A degree of object constancy is established as the child is able to internalize a sustained image of the mothering figure as enduring and loving while maintaining the perception of her as a separate person in the outside world. Relevance of Object Relations Theory to Nursing Practice Understanding of the concepts of Mahler’s theory of object relations helps the nurse assess the patient’s level of individuation from primary caregivers. The emotional problems of many individuals can be traced to lack of fulfillment of the tasks of separation-individuation. Examples include problems related to dependency and excessive anxiety. The individual with borderline personality disorder is thought to be fixed in the rapprochement phase of development, harboring fears of abandonment and underlying rage. Recognizing that disrupted interpersonal relationships in adulthood (common in individuals with borderline personality disorder) may be deeply rooted in long-standing fears of abandonment may assist the nurse to understand the motivation behind patient behaviors, approach patients with greater empathy, and design interventions that focus on building healthier interpersonal relationship skills. A Nursing Model—Hildegard E. Peplau Hildegard Peplau (1991) applied interpersonal theory to nursing practice and, most specifically, to nurse-patient relationship development. She established a framework for psychodynamic nursing, the interpersonal involvement of the nurse with a patient in a given nursing situation. Peplau stated, “Nursing is helpful when both the patient and the nurse grow as a result of the learning that occurs in the nursing situation” (p. ix). Peplau correlated the stages of personality development in childhood to stages through which patients advance during the progression of an illness. She also viewed these interpersonal experiences as learning situations for nurses to facilitate forward movement in the development of personality. She believed that when there is fulfillment of psychological tasks associated with the nurse-patient relationship, the personalities of both can be strengthened. Key concepts include the following: Nursing is a human relationship between an individual who is sick, or in need of health services, and a nurse especially educated to recognize and respond to the need for help. Psychodynamic nursing is being able to understand one’s own behavior, to help others identify difficulties being felt, and to apply principles of human relations to the problems that arise at all levels of experience. Roles are sets of values and behaviors that are specific to functional positions within social structures. Peplau identified the following nursing roles: A stranger. A nurse is at first a stranger to the patient. The patient is also a stranger to the nurse. Peplau (1991) stated,  Respect and positive interest accorded a stranger is at first nonpersonal and includes the same ordinary courtesies that are accorded to a new guest who has been brought into any situation. This principle implies: (1) accepting the patient as he is; (2) treating the patient as an emotionally able stranger and relating to him on this basis until evidence shows him to be otherwise. (p. 44) A resource person is one who provides specific, needed information that helps the patient understand his or her problem and the new situation. A counselor is one who listens as the patient reviews feelings related to difficulties he or she is experiencing in any aspect of life. “Interpersonal techniques” have been identified to facilitate the nurse’s interaction in the process of helping the patient solve problems and make decisions concerning these difficulties. A teacher is one who identifies learning needs and provides information to the patient or family that may aid in improvement of the life situation. A leader is one who directs the nurse-patient interaction and ensures that appropriate actions are undertaken to facilitate achievement of the designated goals. A technical expert is one who understands various professional devices and possesses the clinical skills necessary to perform the interventions that are in the best interest of the patient. A surrogate is one who serves as a substitute figure for another. Phases of the Nurse-Patient Relationship Phases of the nurse-patient relationship are stages of overlapping roles or functions in relation to health problems during which the nurse and client learn to work cooperatively to resolve difficulties. Peplau identified four phases: 1. Orientation is the phase during which the patient, nurse, and family work together to recognize, clarify, and define the existing problem. 2. Identification is the phase after which the patient’s initial impression has been clarified and during which he or she begins to respond selectively to  persons who seem to offer the help that is needed. Patients may respond in one of three ways: (1) on the basis of participation or interdependent relations with the nurse, (2) on the basis of independence or isolation from the nurse, or (3) on the basis of helplessness or dependence on the nurse (Peplau, 1991). 3. Exploitation (more currently referred to as the working phase) is the phase during which the patient proceeds to take full advantage of the services offered to him or her. Having learned which services are available, feeling comfortable within the setting, and serving as an active participant in his or her own health care, the patient exploits the services available and explores all possibilities of the changing situation. 4. Resolution (more currently referred to as the termination phase) occurs when the patient is freed from identification with helping persons and gathers strength to assume independence. Resolution is the direct result of successful completion of the other three phases. Peplau’s Stages of Personality Development Psychological tasks are developmental lessons that must be learned on the way to achieving maturity of the personality. Peplau (1991) identified four psychological tasks that she associated with the stages of infancy and childhood described by Freud and Sullivan. She stated, When psychological tasks are successfully learned at each era of development, biological capacities are used productively and relations with people lead to productive living. When they are not successfully learned they carry over into adulthood and attempts at learning continue in devious ways, more or less impeded by conventional adaptations that provide a superstructure over the baseline of actual learning. (p. 166) In the context of nursing, Peplau (1991) related these four psychological tasks to the demands made on nurses in their relations with patients. She maintained that Nursing can function as a maturing force in society. Since illness is an event that is experienced along with feelings that derive from older experiences but are reenacted in the relationship of nurse to patient, the nurse-patient relationship is seen as an opportunity for nurses to help patients to complete the unfinished psychological tasks of childhood in some degree. (p. 159) TABLE 29–6 Stages of Development in Peplau’s Interpersonal Theory MAJOR DEVELOPMENTAL AGE STAGE TASKS Infancy Learning to count Learning to communicate in various on others ways with the primary caregiver to have comfort needs fulfilled Toddlerhood Learning to delay Learning the satisfaction of pleasing satisfaction others by delaying self-gratification in small ways Early childhood Identifying Learning appropriate roles and oneself behaviors by acquiring the ability to perceive the expectations of others Late childhood Developing skills Learning the skills of compromise, in participation competition, and cooperation with others; establishing a more realistic view of the world and a feeling of one’s place in it Peplau’s psychological tasks of personality development include the following four stages. An outline of the stages of personality development according to Peplau’s theory is presented in Table 29–6. Learning to Count on Others Nurses and patients first come together as strangers. Both bring to the relationship certain “raw materials,” such as inherited biological components, personality characteristics (temperament), individual intellectual capacity, and specific cultural or environmental influences. Peplau related these to the same “raw materials” with which an infant comes into the world. Newborns are capable of experiencing comfort and discomfort. They soon learn to communicate feelings in a way that results in the fulfillment of comfort needs by the mothering figure who provides love and care unconditionally. However, fulfillment of these dependency needs is inhibited when goals of the mothering figure become the focus, and love and care are contingent upon meeting the needs of the caregiver rather than the infant.  Patients with unmet dependency needs regress during illness and demonstrate behaviors that relate to this stage of development. Other patients regress to this level because of physical disabilities associated with their illness. Peplau believed that when nurses provide unconditional care, they help these patients progress toward more mature levels of functioning. This may involve the role of “surrogate mother” in which the nurse fulfills needs for the patient with the intent of helping him or her grow, mature, and become more independent. Learning to Delay Satisfaction Peplau related this stage to that of toddlerhood, or the first step in the development of interdependent social relations. Psychosexually, it is compared to the anal stage of development, when children learn that, because of cultural mores, they cannot empty the bowels for relief of discomfort at will but must delay for use of the toilet, which is considered more culturally acceptable. When toilet training occurs too early or is very rigid, or when appropriate behavior is set forth as a condition for love and caring, tasks associated with this stage remain unfulfilled. These children feel powerless and fail to learn the satisfaction of pleasing others by delaying self-gratification in small ways. They may also exhibit rebellious behavior by failing to comply with demands of the mothering figure in an effort to counter the feelings of powerlessness. These children may accomplish this by withholding the fecal product or failing to deposit it in the culturally acceptable manner. Peplau cites Fromm (1949) in describing the following potential behaviors of individuals who have failed to complete the tasks of the second stage of development: Exploitation and manipulation of others to satisfy their own desires because they are unable to do so independently Suspiciousness and envy of others, directing hostility toward others in an effort to enhance their own self-image Hoarding and withholding possessions from others; miserliness Inordinate neatness and punctuality Inability to relate to others through sharing of feelings, ideas, or experiences  Ability to vary the personality characteristics to those required to satisfy personal desires at any given time When nurses observe these types of behaviors in patients, it is important to encourage full expression and to convey unconditional acceptance. When patients learn to feel safe and unconditionally accepted, they are more likely to let go of the oppositional behavior and advance in the developmental progression. Peplau (1991) stated, Nurses who aid patients to feel safe and secure, so that wants can be expressed and satisfaction eventually achieved, also help them to strengthen personal power that is needed for productive social activities. (p. 207) Identifying Oneself “A concept of self develops as a product of interaction with adults” (Peplau, 1991, p. 211). Children learn to structure self-concept by observing how others interact with them. Roles and behaviors are established out of the child’s perception of the expectations of others. When children perceive that adults expect them to maintain more-or-less permanent roles as infants, they perceive themselves as helpless and dependent. When the perceived expectation is that children must behave in a manner beyond their maturational level, children are deprived of the fulfillment of emotional and growth needs at the lower levels of development. Children who are given freedom to respond to situations and experiences unconditionally (i.e., with behaviors that are appropriate to their feelings) learn to improve and reconstruct behavioral responses at their own pace. Peplau (1991) stated, The ways in which adults appraise the child and the way he functions in relation to his experiences and perceptions are taken in or introjected and become the child’s view of himself. (p. 213) In nursing, it is important for the nurse to recognize cues that communicate how patients feel about themselves and about their presenting medical problem. In the initial interaction, it is difficult for the nurse to perceive the “wholeness” of patients, because the focus is on the condition that has caused them to seek help. Likewise, it is difficult for the patient to perceive the nurse as a “mother (or father)” or “somebody’s wife (or husband)” or as having a life aside from being there to offer assistance with the immediate presenting problem. As the relationship develops, nurses must be able to recognize patient behaviors that indicate unfulfilled needs and provide experiences that promote growth. For example, the patient who very proudly announces that she has completed activities of daily living independently and wants the nurse to come and inspect her room may still be craving the positive reinforcement that is so necessary at lower levels of development. Nurses must also be aware of the predisposing factors that they bring to the relationship. Attitudes and beliefs about certain issues can have a deleterious effect on the patient and interfere not only with the therapeutic relationship but also with the patient’s ability for growth and development. For example, a nurse who has strong beliefs against abortion may treat a patient who has just undergone an abortion with disapproval and disrespect. Nurses may respond in this manner without even realizing that they are doing so. Attitudes and values are introjected during early development and can be integrated so completely as to become a part of the self-system. Nurses must have knowledge and appreciation of their own concept of self to develop the flexibility required to accept all patients as they are, unconditionally. Effective resolution of problems that arise in the interdependent relationship can be the means for both patient and nurse to reinforce positive personality traits and modify those more negative views of self. Developing Skills in Participation Peplau cited Sullivan’s (1953) description of the juvenile stage of personality development (ages 6 through 9 years). During this stage, the child develops the capacity to “compromise, compete, and cooperate” with others. These skills are considered basic to one’s ability to participate collaboratively with others. If children try to use the skills of an earlier level of development (e.g., crying, whining, or demanding), they may be rejected by peers of this juvenile stage. As this stage progresses, children begin to view themselves through the eyes of their peers. Sullivan called this “consensual validation.” Preadolescents take on a more realistic view of the world and a feeling of their place in it. The capacity to love others (besides the mother figure) develops at this time and is expressed in relation to one’s self-acceptance. Failure to develop appropriate skills at any point along the developmental progression results in an individual’s difficulty with participation in confronting the recurring problems of life. It is not the responsibility of the nurse to teach solutions to problems but rather to help patients improve their problem-solving skills so that they may achieve their own resolution. This is accomplished through development of the skills of competition, compromise, cooperation, consensual validation, and love of self and others. Nurses can assist patients to develop or refine these skills by helping them to identify the problem, define a goal, and take responsibility for performing the actions necessary to reach that goal. Peplau (1991) stated, Participation is required by a democratic society. When it has not been learned in earlier experiences, nurses have an opportunity to facilitate learning in the present and thus to aid in the promotion of a democratic society. (p. 259) Relevance of Peplau’s Model to Nursing Practice Peplau’s model provides nurses with a framework to interact with patients, many of whom are fixed in—or, because of illness, have regressed to—an earlier level of development. She suggested roles that nurses may assume to assist patients to progress, thereby achieving or resuming their appropriate developmental level. Appropriate developmental progression arms the individual with the ability to confront the recurring problems of life. Nurses serve to facilitate learning of that which has not been learned in earlier experiences. Summary and Key Points Growth and development are unique to each individual and continue throughout the life span. Personality is defined as the combination of character, behavioral, temperamental, emotional, and mental traits that are unique to each specific individual. Sigmund Freud, who has been called the father of psychiatry, believed the basic character has been formed by the age of 5 years. Freud’s personality theory can be conceptualized according to the structure and dynamics of the personality, topography of the mind, and stages of personality development. Freud’s structure of the personality includes the id, ego, and superego. Freud classified all mental contents and operations into three categories: the conscious, the preconscious, and the unconscious.  Harry Stack Sullivan, author of The Interpersonal Theory of Psychiatry, believed that individual behavior and personality development are the direct result of interpersonal relationships. Major concepts include anxiety, satisfaction of needs, interpersonal security, and self-system. Erik Erikson studied the influence of social processes on the development of the personality. Erikson described eight stages of the life cycle from birth to death. He believed that individuals struggle with developmental “crises” and that each must be resolved for emotional growth to occur. Erik Erickson’s wife, Joan Erikson, articulated a ninth stage, transcendence, based on her late husband’s notes. This stage addresses the expanded longevity of today’s adults over 80 years of age and suggests that, in this stage of life, individuals must develop a greater sense of self and what transcends beyond themselves in order to achieve contentment and acceptance of death. Margaret Mahler formulated a theory that describes the separation- individuation process of the infant from the maternal figure (primary caregiver). Stages of development describe the progression of the child from birth to object constancy at age 36 months. Hildegard Peplau provided a framework for “psychodynamic nursing,” the interpersonal involvement of the nurse with a patient in a given nursing situation. Peplau identified the nursing roles of stranger, resource person, counselor, teacher, leader, technical expert, and surrogate. Peplau described four psychological tasks that she associated with the stages of infancy and childhood as identified by Freud and Sullivan. Peplau believed that nursing is helpful when both the patient and the nurse grow as a result of the learning that occurs in the nursing situation.