Introduction.

Nurses use principles. Concepts and process to guide their observations and understand the phenomena
that are the focus of their interventions. This use of theory precedes and serves as a basis of determining
nursing actions to be taken. Theory maintains that nurses need a theoretical basis and a conceptual
framework for psychiatric and psychological nursing practice.

Psychoanalytic theory

Sigmund Freud (1961), who has been called the father of psychiatry, is credited as the first to identify
development of stages. He considered the first five years of child’s life to be the most important, because he
believed that an individual’s basic character had been formed by the age of 5.

Structure of the personality.

Read organise the structures 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 indoors, the infant with
instinctual drives that seek to satisfy needs and achieve immediate gratification. Id-driven behaviours are
impulsive and may be irrational.

Ego.

The ego, also called the rational self or the “ reality principal” beings to develop between the ages of 4 and
six months. The ego experiences the reality of external worlds, adapt to it ,and respond to it. As the ego
develops and gain strength, it seeks to bring the influences of the external world to bear upon the id, 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 as to as the “perfection principle”. The superego, which develops between ages 3 and six years,
internalise the values and morals set forth by primary caregivers. Derived out of a system of rewards and
punishments, the superego is composed of two major components: the ego-ideal and the consciences. When
a child is consistently rewarded for good behaviour, the self-esteem is enhanced and the behaviour becomes
part of ECHO ideal. That is, it is internalised as part of his or her value system. The conscience is found when
the child is punished consistently for bad behaviour. The child learns 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 internalised 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, problems with low self-
confidence and low self-esteem arise.

Contents of the mind.

Freud classified all mental contents and operations of mind into three categories. They are discussed below.

a. The conscious: this includes all memories of individuals awareness. It is the smallest of three
categories. Events and experiences that are easily remembered or retrieved are considered to be at
the conscious level.
 b. The pre conscious: This includes memories that have been forgotten and are not in the present
awareness, but with a bit of attention and concentration they can be readily recalled into the
conscious. This preconscious enhances awareness by helping to suppress unpleasant or nonessential
memories.
c. The unconscious: This includes all memories that one is unable to bring to the conscious awareness.
It is the largest of the three categories and consists of unpleasant and non-essential memories that
have been repressed and can be retrieved only through therapy.

Sigmund Freud stages of psychosexual development personality.

Stage Period Description

Oral 0-18 months  Relief of anxiety is through the oral gratification.
 Relief of anxiety is through the oral gratification.
 The behaviour is directed by the id.
 The goal is immediate gratification.
 Focus of energy is the mouth.
 Behaviours include sucking, chewing, and biting
 Child is unable to differentiate between self and mother.
 Sense of security and trust is derived from the gratification of his need.

Anal 18 months to 3years  Major task is gaining of independence and control.

 Focus is on the excretory function.
 Strict and rigid toilet training leads to retention, resulting in constipation. And
developing an adult retentive personality that includes stubbornness and
stinginess.
 An alternate reaction is for the child to expel faeces in an inappropriate
manner and time, resulting in the personality that includes wicked, cruel
destructive, disorganized, and untidy behaviour patterns.

Phallic 3-6 years  The focus of energy shifts to the genital area.
 Discovers differences between genders.
 Has heightened interest in the sexuality of self and others.
 Has sexual self-exploratory and group-exploratory play.
 Develops oedipus complex (boys) and electra complex (girls). (There is a desire
sexual for the opposite sex parent.)
 To avoid punishment, they adopt the same sex resulting parent's
characteristics and values to the formation of superego.
 Relation among the id, ego, and superego is established.
 The individual's basic personality orientation is established.

Latency 6-12 years  Sexuality is repressed.

 Sexual instincts die down.
 The focus is on relationships with the same-sex peers.
 Child acquires new social values from adults outside the family.

Genital 12-20years  Maturing of the genital organs result in reawakening of the libido.
 Focus is on relationships with the opposite sex.
 Preparation with selecting a mate. Next plane. Sexual maturity evolves from
self-gratification to behaviours deemed as acceptable by society.
 Interpersonal relationships are based on genuine pleasure, derived from
interaction.

Interpersonal theory.
Harry Stack Sullivan received his training in psychiatry in the United States in the 1920s and 1930s. During early years of Freud’s
profound influence on American psychiatry. He believed that individual behavior and personality development are the direct result
of interpersonal relationships. Sullivan he is best known for his creative psychotherapy work with severely disturbed patients. He
believed that even the most psychotic patient could be reached through the human relationship of psychotherapy.
Major concepts.
The major concepts that Sullivan focused are as follows.
 Anxiety: According to him, anxiety is a feeling of emotional discomfort towards the relief or prevention of
which all behaviour is aimed at. He believed that anxiety is the chief disruptive force 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 personal security.
 Satisfaction of needs: Satisfaction of needs is the fulfilment of all requirements associated with an
individual’s psychochemical environment. According to him, this environment includes the need for
oxygen, food, water, warmth, tenderness, rest, activity, sexual expression, etc. This environment includes
virtually anything that, when absent, produces discomfort in the individual.
 Interpersonal security: Interpersonal security is a feeling associated with relief from anxiety. When all
needs have been made, one experiences a sense of total well-being. This feeling of total well-being is
terminated interpersonal security. According to Sullivan, every individual has an inbuilt need for
interpersonal security.
 Self-system: This is a collection of experiences, all security measures, adopted by individual for protection
against anxiety. Sullivan identified 3 components of self-system which are based on interpersonal
experiences in early life. These three components are as follows.
 The good me: This is the part of personality that develops in response to positive feedback from
the primary caregiver. Feeding up blazer containment and gratification has been experienced.
The child learns to identify the behaviour that elicited this positive response and the behaviour
that gets incorporated into the self-system.
 The bad me: This is a part of the personality that developed in response to negative feedback
from the primary care giver. Anxiety is experienced “The bad me” elicits feelings of discomfort,
displeasure and distress. The child learns to avoid these negative feelings by altering certain
behaviours.
 Not me: This is a part of the personality that developed in response to situations that produce
intense anxiety in the child. Feeling of horror, awe, dread and loathing, which is experienced in
response to these situations, leads the child to deny these feelings in an effort to retrieve anxiety.
These feelings have 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 interpersonal theory.

Interdependence and lasting intimate relationships.

Relationship with opposite gender.

Relationship with same gender.

Satisfying relationships.

Delayed gratification.

Gratification of needs.
Stages of development. In Sullivan’s interpersonal theory.

Age Stage Major developmental task.

Birth-18months Infancy. Relief from anxiety through oral
gratification of needs.

18 months to six years. Childhood Learning experience, a delay in

personal gratification without undue
anxiety.

6 to 9 years. Juvenile Learning found satisfactory peer

relationships.

9 to 12 years. Preadolescence Learning from satisfactory

relationships with persons of same
gender, initiating feelings of
affection for another person.

12 to 14 years. Early adolescence Learning from satisfactory

relationship with persons of opposite
gender, developing a sense of
identity.

14 to 21 years. Late adolescence Establishing self-identity,

experiencing satisfying relationships,
working to develop a lasting,
intimate opposite gender
relationships.

Psychological theory.
Several of Freud’s followers took what they thought was useful from his theory, and stretches and rearranged it in ways
that improved their vision. One such important Neo-Freudian was Erik Erikson (1950).
Stages of psychological development.
Stage.
Basic trust versus mistrust
(virtue: hope)
Autonomy versus same
and doubt. (virtue:will)
Initiative versus guilt.
(virtue:purpose)
Industry versus inferiority
(virtue: competence)
Period Description
0 to 1 year.  Develops basics trust in the mothering figure.
 Meets warm responsive care to develop a sense of trust and a
positive attitude towards self and others.
 Achievement of the task results in self-confidence.
 Mouth is the source of satisfaction.
 Has to generalize trust to others.
 Nonachievement results in emotional dissatisfaction with self
and others.
1-3 years  Gaines some self-control and independence within the
environment.
 Learns the extent to which the environment can be
manipulated.
 Is able to delay gratification.
 This task is achieved when parents encourage and provide
opportunities for independent activities.
 Non-achievement result in lack of self-confidence—a lack of
pride in ability to perform.
 Leads to a sense of being controlled and a rage against self.
 This occurs when parents restrict independence and have
unrealistic expectations from the child.
3-6 years  Develops a sense of purpose.
 Develops the ability to initiate and direct own activity
purposively.
 Learns the extent to which the initiative, assertiveness,
motor language, and cognitive skills will influence others.
 Explores the environment with senses, motor thought, and
imaginative skills.
 Engages in real social contact with a cooperative play.
 Nonachievement results in feeling of inadequacy and a sense
of defeat.
 Guilt is experienced to an excessive degree, to the extent
that the child may feel guilty even for those things that he
has not done.
 They may view themselves as evil and deserving punishment.
 This occurs when parents expect a higher level of
achievement than the child produces.
6-12 years  Learns to be creative and develop physical, motor, social and
cognitive skills.
 The task is to achieve a sense of self confidence.
 Achievement results in a feeling of satisfaction and pleasure
in the interaction and involvement with others.
 They master reliable work habits and develop an attitude to
trustworthiness and are conscientious.
 Non achievements result in difficulty in IPR because of
personal inadequacy.
 They are not able to problem solve, cooperate and
compromise with others.
 May become passive, or meek, or overly aggressive.
 May violate the rights of others to satisfy their own need.
 May become a workaholic with unrealistic expectations.
 This occurs due to unrealistic expectations set by parents,
harsh discipline and negative feedback.
Theory of object relations.
Margaret Mahler formulated a theory that describes the separation individuation process of the infant from the maternal figure
(Primary caregiver). She describes this process as progressing through three major phases, and she further delineates Phase III,
the separation-individuation phase into four subphases.
 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 doesn’t
perceive the existence of other people or an external environment. The fulfilment 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 fulfils 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 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.
Individuation occurs with a strengthening of the ego and 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.
 Subphase 1: Differentiation (5 to 10 months)
The differentiation phase begins with the Childs 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 feeling of exhilaration from
increased independence. He or she is 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, this child becomes increasingly aware of his or her
separateness from the mothering figure while the sense of fearlessness and
omnipotence diminish. The child, now recognising the mother as a separate individual,
wishes to re-establish closeness with her, but shuns the total re-engulfment of the
symbiotic stage. The need is for the mothering figure is to be available to provide
‘emotional refuelling’ on demand.
Critical to the subphase is the mothering figure’s response to the child. If the mothering
figure is available to fulfil emotional needs as they arrived, child develops a sense of
security in the knowledge that he or she is loved and will not be abandoned. However. If
emotional needs are inconsistently met or if the mother rewards clinging, dependent
behaviours and withholds nuturing when the child demonstrates independence, feeling
of rage and a 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 internalise 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.
Cognitive Development Theory.
Jean Piaget has been called the father of child psychology. His work concerning cognitive development in children is based on
the premise that human intelligence is an extension of biological adoption, or once ability to adapt psychologically to the
environment. He believed that human intelligence progress through a series of stages that are related to age, demonstrating at
each successive stage a higher level of logical organization than at the previous stages.

From his extensive studies of cognitive development in children, Piaget discovered four major stages, each of which he believed
to be a necessary prerequisite for the one that follows.

Piaget’s stages of Cognitive Development.

Age Stage MAJOR DEVEPLOPMENTAL TASKS

Birth- 2years Sensorimotor With increased mobility and awareness,
development of a sense of self as separate
from the external environment, the concept
of object permanence emerges as the ability
to form mental images evolves.

2-6 years Preoperational Learning to express self with language;

development of understanding of symbolic
gestures; achievement of object
permanence.

6-12 years Concrete operations Learning to apply logic to thinking;

development of understanding of
reversibility and spatiality, learning to
differentiate and classify increased
socialization and application of rules.

12-15+ years Formal operations Learning to think and reason in abstract

terms; making and testing hypothesis;
capability of logical thinking and reasoning
expand and are refined; cognitive maturity
achieved.
Theory of Moral Development.

Lawrence Kohlberg’s (1976) stages of moral development are not closely tied to specific age groups.

Research was conducted with males ranging in age from 10 to 28 years. Kohlberg believed that each stage is necessary and basic to the next
stage and that all individuals must progress through each stage sequentially. He defined three major levels of moral development, each of
which is further subdivided into two stages.

Kohlberg’s stages of Moral Development.

Level/Age Stage Developmental Focus

I. Pre conventional (common 1.Punishment and obedience orientation. Behaviour motivated by fear of punishment.
from age 4 to 10 years.)
2. Instrumental relativist orientation. Behaviour motivated by egocentrism and
concern for self.

II. Conventional (common from 3. Interpersonal concordances orientation. Behaviour motivated by expectations of
age 10 to 13 years and into others; strong desire for approval and
adulthood.) acceptance.

4. Law and order orientation. Behaviour motivated by respect for

authority.

III. Post conventional (can occur
from adolescence on.)
5. Social contract legalistic orientation.
6. Universal ethical principle orientation.
Behaviour motivated by respect for
universal laws and moral principles; guided
by internal set of values.
Behaviour motivated by internalised
principles of honour, justice, and respect for
human dignity; guided by conscience.