Theoretical model

INTRODUCTION
• Nurses must have a basic knowledge of
human personality development to
understand maladaptive behavioral responses
commonly seen in psychiatric clients.
• Developmental theories identify behaviors
associated with various stages through which
individuals pass, thereby specifying what is
appropriate or inappropriate at each
developmental level.
• Developmental stages are identified by age.
Behaviors can then be evaluated for age
appropriateness

PSYCHOANALYTICAL MODEL
 Given by Sigmund Freud.
 It is based on the concept of intrapsychic
conflict within the individual.
• Founder of psychoanalysis
• Proposed the first complete theory of
personality.
• A person’s thoughts and behaviors emerge
from tension generated by unconscious
motives and unresolved childhood conflicts.

BASIC CONCEPT OF PSYCHOANALYTICAL
MODEL
Structure of personality
Topography of mind
Dynamics of personality
Stages of psychosexual development

THE STRUCTURAL THEORY OF MIND :
• The Id
Biological component
• The Ego
controls and regulates the
personality.
• The Superego
The judicial branch of personality.
moral codes , right or wrong.

ID
• Completely unconscious
• No contact with reality
• illogical
• The infant seeks gratification of need without
regard for what is possible or what is proper.
• Pleasure principle

Ego
• The only region of the
mind in contact with
reality.
• Consider unrealistic
demands of id and
superego. Ego maintains
a balance between id
and super ego on one
hand and the reality on
the other.
• Reality principle
• Develop at 4-6 months

SUPEREGO
• Super ego referred to as a perfection
principle
• The moral and ideal aspects of
personality.
• Develop at 3- 6 years .
• Moralistic/ idealistic principles.
• Composed of the conscience and ego-
ideal

THERE ARE TWO PARTS OF THE
SUPEREGO:
• The ego ideal includes the rules and standards
for good behaviors. These behaviors include
those which are approved of by parental and
other authority figures. Obeying these rules
leads to feelings of pride, value and
accomplishment.
•
The conscience includes information about
things that are viewed as bad by parents and
society. These behaviors are often forbidden
and lead to bad consequences, punishments or
feelings of guilt and remorse.

BEHAVIORAL EXAMPLES
ID EGO SUPER EGO
“I found this
wallet; I will keep
the money.”
– “I already have
money. This
money doesn’t
belong to me.
Maybe the person
who owns this
wallet doesn’t
have any money”.
– “It is never
right to take
something that
doesn’t belong to
you”.

LEVELS OF MENTAL LIFE
 Indicates both a location and a process.
1. Consciousness
2. Unconsciousness
3. Preconsciousness

CONSCIOUSNESS
• Freud believed that everything we are
aware of is stored in our conscious.
Our conscious makes up a very small
part of who we are.
• This is the aspect of our mental
processing that we can think and talk
about rationally. A part of this
includes our memory, which is not
always part of consciousness but can be
retrieved easily at any time and
brought into our awareness.

UNCONSCIOUS
• Drives, urges, instincts beyond awareness
but nevertheless motivate most of our
words, feelings, and actions.
• It explains the meaning behind dreams,
slips of tongue, and repression.
• Phylogenetic endowment
• Obtained from previous ancestors
• (collective unconscious)

PRECONSCIOUS
• Contains all those
elements that are not
conscious but can become
conscious either readily or
with difficulty.
• Its sources are conscious
perception and the
unconscious, often
transformed or disguised.

DYNAMICS OF 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 fulfil basic
physiological needs such as hunger,
thirst, and sex) the libido.

• 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.

• Over investment 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.

• 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.

Freud’s Stages of
Personality
Development

ORAL STAGE (0-10 months)
mouth is the first organ to
provide pleasure.
Infant feels sense of attachment
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 out of gratification
from fulfilment of basic needs
during this stage

ANAL STAGE (18month-3 years)
anus as the sexually
pleasurable zone; toilet
training.
• A child who had received a
strict treatment from his
parent during the anal
stage could develop into
an anal expulsive
personality and grow up to
be messy and irresponsible.
Alternatively, the child
could develop into an anal
retentive personality,
growing up to be obstinate,
over-orderly, and righteous.

PHALLIC STAGE (3-6 years)
• genital area as the
sexually pleasurable
zone; male and female
distinction;
• Oedipus Complex (son
love his mother)
• Elektra complex
(daughter love her
father)

LATENCY STAGE (6-12 years)
 During this period the
libido interests are
suppressed. This stage
is defined as a period
of calm. At six years
old the child enters
into school and
becomes more
interested in developing
relationships.
 parents punish their
children to prevent
sexual activity.

GENITAL STAGE (13-20 years)
reawakening of the sexual aim; sexual energy
is focused on others; reproductive
capability

ROLE OF THE PATIENT AND
THE PSYCHOANALYST
 The client is an active participant, freely revealing all thoughts and
feelings exactly as they occurred and describing the dreams.
 The psychoanalyst is a shadow person; he will not reveal any
personal issues in order to allow the transference process.
 The analyst usually conducts the therapeutic session outside the
direct line of the vision of the client, so that non-verbal responses do
not influence the client’s verbalizations. Verbal responses are brief,
so that it will not interfere with associative flow. By termination of
therapy the patient will be able to view the analyst realistically as
another adult having worked through his conflicts and dependency
needs.

• 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 flavour in which human
behaviour could be observed in social
interactions with others.

● ANXIETY
• Anxiety is a feeling of emotional
discomfort, toward the relief or
prevention of which all behaviour 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 achieve interpersonal
security.

SATISFACTION OF NEEDS
• Satisfaction of needs is the
fulfilment 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
• 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-SYSTEM
• 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

•It 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.

• It 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.

• It 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.

STAGES OF DEVELOPMENT
 Personality continues to
evolve from infancy through
adulthood
 Each stage involves specific
interpersonal challenges or
tasks, and specific types of
interpersonal relationships
 Personality change is most
likely during the transitions
between stages
7
Developmental
Stages
Infancy
Childhood
Juvenile Era
Preadolescence
Early Adolescence
Late Adolescence
Adulthood

A. Infancy: Birth to 18 Months
• During this beginning stage,
the major developmental task
for the child is the gratifi
cation of needs.
• This is accomplished through
activity associated with the
mouth, such as crying,
nursing, and thumb sucking.

B. Childhood: 18 Months to 6
Years
• Imaginary playmate (i.e., eidetic
personification)
• Practice social relations/ rehearsal
• Safe, secure relationships to
practice with no threat of
negative consequences

C. 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.

D. Preadolescence: 9 to 12
Years
• The tasks of the
preadolescence stage focus on
developing relationships with
persons of the same gender.
• One’s ability to collaborate
with and show love and
affection for another person
begins at this stage.

E. Early Adolescence: 12 to 14 Years
• During early adolescence, the child is
struggling with developing a sense of
identity, separate and independent from
the parents.
• The major task is formation of satisfactory
relationships with members of the opposite
gender.
• Sullivan saw the emergence of lust in
response to biological changes as a major
force occurring during this period.

F. Late Adolescence
Feel both intimacy and lust
toward the same person
G. Adulthood
Person establishes a stable
relationship with a significant
other person.
• Learn how to live in the adult
world
• Discovery of self

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 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.
• Nurses use the concepts of Sullivan’s theory
to help clients achieve a higher degree of
independent and interpersonal functioning

Erik Erikson’s psycho-
social
Theory of
Development

Objectives:
• Describe the eight (8) stages of Erikson’s
Theory of Development,
• differentiate the psychosocial crisis in
different life stages and;
• value the importance of the virtue and
maladaptation/malignancy in every stages
of Psycho-social development.

Stage 1. Infancy
(birth to 18 months)

• Trust Versus Mistrust: Birth to
18 Months
Major Developmental Task
- 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.

Stage 2.
Early Childhood (toddle
18 months to 3 years

• Autonomy Versus Shame and
Doubt: 18 Months to 3 Years
- The major task in this stage
is to gain some self-control
and independence within the
environment.

• 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.

Stage 3.
Preschool
3 to 6 years

• 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.

• Initiative is achieved when
creativity is encouraged and
performance is recognized
and positively reinforced.
• Guilt is experienced to an
excessive degree, even to the
point of accepting liability in
situations for which one is not
responsible

Stage 4.
School Age
(6 to 11 years)

• Industry Versus Inferiority: 6 to
12 Years
• The major 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.

• Industry is achieved when
encouragement is given to activities and
responsibilities in the school and
community, as well as those within the
home, and recognition is given for
accomplishments.
• Nonachievement results in difficulty in
interpersonal relationships because of
feelings of personal inadequacy. The
individual can neither cooperate and
compromise with others in group
activities nor problem solve or complete
tasks successfully.

Stage 5.
Adolescence
(12 to 18 years)

• Identity Versus Role
Confusion:12 to 20 Years
- At this stage, the goal is to
integrate the tasks mastered
in the previous stages into a
secure sense of self.

• 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.
• 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.

Stage 6.
Young Adulthood
(19 to 40 years)

• 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

• 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.

Stage 7.
Middle Adulthood
(40 to 65 years)

• Generativity Versus
Stagnationor Self-Absorption:
30 to 65 Years
major Developmental Task
- The major task of this stage
is to achieve the life goals
established for oneself while
also considering the welfare
of future generations.

• 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. He
or she becomes withdrawn, isolated,
and highly self-indulgent, with no
capacity for giving of the self to
others.

Stage 8.
Maturity
(65 to death)

• Ego Integrity Versus Despair:
65 Years to Death
- 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.

• 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 the ways
their lives have progressed.
• Nonachievement results in a sense of
self-contempt and disgust with how
life has progressed. The individual
would like to start over and have a
second chance at life.

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 suggests 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 calls 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.

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, the child experiences
feelings of exhilaration from
increased independence.
• He or she is now able to move
away from, and return to, the
mothering fi gure. A sense of
omnipotence is manifested.

Subphase 3—Rapprochement
(16 to 24 Months)
• Rapprochement, is extremely
critical to the child’s healthy ego
development.
• During this time, the child becomes
increasingly aware of his or her
separateness from the mothering
figure, while the sense of
fearlessness and omnipotence
diminishes.

Subphase 4—consolidation
(24to36 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.”

Relevance of Object Relations
Theory to Nursing Practice
• Understanding of the concepts of Mahler’s theory
of object relations helps the nurse assess the
client’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 fi xed in the
rapprochement phase of development, harboring
fears of abandonment and underlying rage.
• This knowledge is important in the provision of
nursing care to these individuals.

A NURSING
MODEL -
HILDEGARD
E. PEPLAU

• 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 to respond to the
need for help.
• Psychodynamic nursing is being
able to understand one’s own
behaviour, to help others identify
felt difficulties, and to apply
principles of human relations to
the problems that arise at all
levels of experience.

NURSING ROLE
• A resource person is one who provides
specific, needed information that helps
the client understand his or her
problem and the new situation.
• A counsellor is one who listens as the
client reviews feelings related to
difficulties he or she is experiencing in
any aspect of life.
• A teacher is one who identifies
learning needs and provides
information to the client or family
that may aid in improvement of the
life situation.

• A leader is one who directs the nurse-
client 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 client.
• A surrogate is one who serves as a
substitute figure for another.

Phases of Nurse-Patient
Relationship
A.Orientation Phase
● Orientation is the phase during which
the client, nurse, and family work
together to recognize, clarify, and define
the existing problem.
B. Identification Phase
The client begins to identify problems
to be worked on within relationship
The goal of the nurse: help the patient
to recognize his/her own
interdependent/participation role and
promote responsibility for self

C.Exploitation Phase
Client’s trust of nurse reached full
potential
Client making full use of nursing
services
Solving immediate problems
Identifying and orienting self to
[discharge] goals
D.Resolution Phase
•Client met needs
•Mutual termination of relationship
•Sense of security is formed
•Patient is less reliant on nurse
•Increased self-reliance to deal with
own problems

Peplau’s Stages of Personality
Development
Learning to Count on Others
• Nurses and clients 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
this world. The newborn is capable of
experiencing comfort and discomfort.

• He or she soon learns to communicate
feelings in a way that results in the
fulfilment of comfort needs by the
mothering figure who provides love and care
unconditionally.
• However, fulfilment 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.

• Peplau believed that, when nurses
provide unconditional care, they help
these clients progress toward more
mature levels of functioning.
• This may involve the role of
“surrogate mother,” in which the
nurse fulfils needs for the client with
the intent of helping him or her
grow, mature, and become more
independent.

Learning to Delay Satisfaction
• Pepleu 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 a child learns
that, because of cultural mores, he or she
cannot empty the bowels for relief of
discomfort at will, but must delay to use
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.
• The child feels powerless and fails to
learn the satisfaction of pleasing
others by delaying self gratification in
small ways.

IDENTIFYING ONESELF
• “A concept of self develops as a product of
interaction with adults”. A child learns to
structure self concept by observing how
others interact with him or her.
• 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.

• In nursing, it is important for the nurse to
recognize cues that communicate how the client
feels about himself or herself and about the
presenting medical problem.
• In the initial interaction, it is difficult for the nurse
to perceive the “wholeness” of the client, for the
focus is on the condition that has caused him or
her to seek help.
• As the relationship develops, nurses must be able to
recognize client behaviors that indicate unfulfilled
needs and provide experiences that promote
growth.
• Nurses must also be aware of the predisposing
factors that they bring to the relationship

Developing Skills in Participation
• 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 a child tries to use the skills of an earlier
level of development (e.g., crying, whining,
or demanding), he or she may be rejected
by peers of this juvenile stage.

• As this stage progresses, children begin to
view themselves through the eyes of their
peers
• Preadolescents take on a more realistic view
of the world and a feeling of their place in
it. The capacity to love others 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 clients 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 clients to develop or
refine these skills by helping them to
identify the problem, define a goal, and
take the responsibility for performing the
actions necessary to reach that goal.

 Relevance of Peplau’s Model to Nursing Practice
• Peplau’s model provides nurses with a framework
to interact with clients, many of whom are fixed
in or, because of illness, have regressed to an
earlier level of development.
• She suggests roles that nurses may assume to
assist clients 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.

Theoretical model

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