1.

Sigmund Freud
Freud (1961), who has been called the father of psychia- try, is credited as the first to identify development by stages.
Freud’s personality theory can be conceptualized accord- ing to structure and dynamics of the personality, topogra- phy 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 dif- ferent 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 impul- sive and may be irrational.
Ego
The ego, also called the rational self or the “reality princi- ple,” 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 devel- ops and gains 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 (Marmer, 2003). 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
the superego might be referred to as the “perfection principle.” The superego, which develops between ages 3 and 6 years, internalizes
the values and morals set forth by primary caregivers. Derived out of a system of rewards and punishments, the superego is com-
posed of two major components: the ego-ideal and the con- science.
Topography of the Mind
Freud classified all mental contents and operations into three categories: the conscious, the preconscious, and the unconscious.
 The 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 tele- phone numbers, birthdays of self and significant oth- ers, the dates of special holidays, and what one
had for lunch today.
 The preconscious includes all memories that may have been forgotten or are not in present awareness but with attention can
be readily recalled into conscious- ness. Examples include telephone numbers or address- es once known but little used and
feelings associated with significant life events that may have occurred at some time in the past.
 The unconscious includes all memories that one is unable to bring to conscious awareness. It is the largest of the three
topographical levels.
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 bore heavily on one’s adaptation patterns and
personality traits in adulthood. Fixation in an early stage of development will almost certainly result in psychopathology.

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, with behaviors that include sucking, chewing, and biting. The infant feels a sense of attach- ment and is unable to differentiate
the self from the person who is providing the mothering.
Anal Stage: 18 Months to 3 Years
The major tasks in the anal stage are gaining independ- ence 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.
Phallic Stage: 3 to 6 Years
In the phallic stage, the focus of energy shifts to the gen- ital area. Discovery of differences between genders 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 this as the child’s uncon- scious desire to eliminate the parent of the same sex and to possess the parent of
the opposite sex for him- or her- self. Guilt feelings result with the emergence of the superego during these years. Resolution of this
internal conflict occurs when the child develops a strong identifi- cation with the parent of the same sex and that parent’s attitudes,
beliefs, and value systems are subsumed by the child.
Latency Stage: 6 to 12 Years
During the elementary school years, the focus changes from egocentrism to more interest in group activities, learning, and
socialization with peers. Sexuality is not absent during this period but remains obscure and imper- ceptible to others. The preference is
for same-sex rela- tionships, 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 behav- iors 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 develop- mental level. Understanding the use of
ego defense mechanisms is important in making determinations about maladaptive behaviors, in planning care for clients to assist in
creating change (if desired) or in helping clients accept themselves as unique individuals.
Developmental Theories
2. Erik Erikson and Psychosocial Stages of Development
Erik Erikson (1902–1994), a German-born psychoanalyst who extended Freud’s work on personality development across the life span
while focusing on social and psychological development in the life stages.
In 1950, Erikson published Childhood and Society, in which he described eight psychosocial stages of development. In each stage, the
person must complete a life task that is essential to his or her well-being and mental health. These tasks allow the person to achieve
life’s virtues: hope, pur- pose, fidelity, love, caring, and wisdom. In his view, psychosocial growth occurs in sequential phases, and
each stage is dependent on completion of the previous stage and life task.

1) Trust versus Mistrust: Birth to 18 Months

Major Developmental Task. From birth to 18 months, the major task is to develop a basic trust in the mothering figure and learn 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.

2) Autonomy versus Shame and Doubt: 18 Months to 3 Years

Major Developmental Task. The major task during the ages of 18 months to 3 years is to gain some self-control and independence
within the environment.
●  Achievement of the task results in a sense of self-con- trol and 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.

3) Initiative versus Guilt: 3 to 6 Years

Major Developmental Task. During the ages of 3 to 6 years 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 exer- cise restraint and self-control of inappropriate social behaviors. Assertiveness
and dependability increase, and the child enjoys learning and personal achieve- ment. The conscience develops, thereby controlling
the impulsive behaviors of the id. Initiative is achieved when creativity is encouraged and performance is rec- ognized 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 situ- ations for which one is not responsible. The child may view him- or herself as evil and deserving of
punish- ment. The task remains unresolved when creativity is stifled and parents continually expect a higher level of achievement than
the child produces.
 4) Industry versus Inferiority: 6 to 12 Years
Major Developmental Task. The major task for 6- to 12-year-olds is to achieve a sense of self-confidence by learning, competing,
performing successfully, and receiv- ing recognition from significant others, peers, and acquaintances.

Achievement of the task results in a sense of satisfac- tion and pleasure in the interaction and involvement with others. The individual
masters reliable work habits and develops attitudes of trustworthiness. He or she is conscientious, feels pride in achievement, and
enjoys play but desires a balance between fanta- sy and “real world” activities. 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 inadequa- cy. The individual can
neither cooperate and compro- mise with others in group activities nor problem solve or complete tasks successfully. He or she may
become either passive and meek or overly aggressive to cover up for feelings of inadequacy. If this occurs, the indi- vidual may
manipulate or violate the rights of others to satisfy his or her own needs or desires; he or she 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.

5) Identity versus Role Confusion: 12 to 20 Years

Major Developmental Task. At 12 to 20 years, the goal is to integrate the tasks mastered in the previous stages into a secure sense of
self.
●  Achievement of the task results in a sense of confi- dence, emotional stability, and a view of the self as a unique individual.
Commitments are made to a value system, to the choice of a career, and to relationships with members of both genders. Identity is
achieved when adolescents are allowed to experience independ- ence 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-conscious- ness, doubt, and confusion about one’s role in life. Personal values or goals
for one’s life are absent. Commitments to relationships with others are nonex- istent, but instead are superficial and brief. 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

6) Intimacy versus Isolation: 20 to 30 Years

Major Developmental Task. The objective for 20- to 30-year-olds is to form an intense, lasting relationship or a commitment to
another person, a cause, an institution, or a creative effort (Murray & Zentner, 2001).

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 commit-
ment in which personal sacrifices are made for anoth- er, whether it be another person or, if one chooses, 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
capac- ity 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 isola- tion, and aloneness. The individual is unable to form lasting, intimate
relationships, often seeking intimacy through numerous superficial sexual contacts. No career is established; he or she 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 deprived or distorted through the younger years (Murray & Zentner, 2001). One fails to achieve the
ability to give of the self without having been the recipient early on from primary caregivers.

7) Generativity versus Stagnation or Self- Absorption: 30 to 65 Years

Major Developmental Task. The major task here 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 gratifica- tion from personal and professional achievements, and from meaningful
contributions to others. The individ- ual 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. He or she 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.

8) Ego Integrity versus Despair: 65 Years to Death

Major Developmental Task. Between the age of 65 years and death, 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. The indi- vidual derives a sense of dignity from his or her life experiences and does not fear death,
viewing it instead as another phase 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. The individual would like to start
over and have a second chance at life. He or she feels worthless and helpless to change. Anger, depression, and loneliness are evident.
The 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.

3. Jean piaget

Jean Piaget (1896–1980), a swiss psychologist, explored how intelligence and cognitive functioning develop in children. He believed
that human intelligence progresses through a series of stages based on age, with the child at each successive stage demonstrating a
higher level of functioning than at previ- ous stages. In his schema, Piaget strongly believed that biologic changes and maturation were
responsible for cog- nitive development.
Piaget’s four stages of cognitive development are as follows:
a) Sensorimotor—birth to 2 years: The child develops a sense of self as separate from the environment and the concept of object
permanence; that is, tangible objects do not cease to exist just because they are out of sight. He or she begins to form mental
images.
b) Preoperational—2 to 6 years: The child develops the ability to express self with language, understands the meaning of symbolic
gestures, and begins to classify objects.
c) Concrete operations—6 to 12 years: The child begins to apply logic to thinking, understands spatiality and re- versibility, and is
increasingly social and able to apply rules; however, thinking is still concrete.
d) Formal operations—12 to 15 years and beyond: The child learns to think and reason in abstract terms, fur- ther develops logical
thinking and reasoning, and achieves cognitive maturity.
**Optional: Piaget’s the- ory is useful when working with children. The nurse may better understand what the child means if the nurse
is aware of his or her level of cognitive development. Also, teaching for children is often structured with their cogni- tive development
in mind.
4. Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy
Harry Stack Sullivan (1892–1949) was an American psy- chiatrist who extended the theory of personality development to include the
significance of interpersonal relationships. Sullivan believed that one’s personality involves more than individual characteristics,
particularly how one interacts with others. He thought that inadequate or nonsatisfying relationships produce anxiety, which he saw as
the basis for all emotional problems
Sullivan established five life stages of development—infancy, childhood, juvenile, preadoles- cence, and adolescence, each focusing
on various interper- sonal relationships.
Infancy: Birth to 18 Months
During the beginning stage, the major developmental task for the child is the gratification of needs. This is accomplished through
activity associated with the mouth, such as crying, nursing, and thumb sucking.
Childhood: 18 Months to 6 Years
At ages 18 months to 6 years, the child learns that inter- ference with fulfillment of personal wishes and desires may result in delayed
gratification. He or she learns to accept this and feel comfortable with it, recognizing that delayed gratification often results in parental
approval, a more lasting type of reward. Tools of this stage include the mouth, the anus, language, experimentation, manip- ulation,
and identification.
Juvenile: 6 to 9 Years
The major task of the juvenile stage is formation of satis- factory relationships within peer groups. This is accom- plished through the
use of competition, cooperation, and compromise.
Preadolescence: 9 to 12 Years
The tasks at the preadolescence stage focus on develop- ing relationships with persons of the same sex. One’s abil- ity 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 with developing a sense of identity that is separate and inde- pendent from the
parents. The major task is formation of satisfactory relationships with members of the opposite sex. Sullivan saw the emergence of lust
in response to biologi- cal changes as a major force occurring during this period.
Late Adolescence: 14 to 21 Years
The late adolescent period is characterized by tasks associ- ated with the attempt to achieve interdependence within the society and the
formation of a lasting, intimate relation- ship with a selected member of the opposite sex. The gen- ital organs are the major
developmental focus of this stage.
**He also described three developmental cognitive modes of experience and believed that mental disorders are related to the
persistence of one of the early modes.
 The prototaxic mode, characteristic of infancy and childhood, involves brief, unconnected experi- ences that have no
relationship to one another.
 The parataxic mode begins in early childhood as the child begins to connect experiences in sequence. The child may not
make logical sense of the experiences and may see them as coincidence or chance events. The child seeks to relieve anxiety
by repeating familiar experiences, although he or she may not understand what he or she is doing.
 In the syntaxic mode, which begins to appear in school-aged children and be- comes more predominant in preadolescence,
the person begins to perceive himself or herself and the world within the context of the environment and can analyze experi-
ences in a variety of settings.
Sullivan envisioned the goal of treatment as the establishment of satisfying inter- personal relationships. The therapist provides a
corrective interpersonal relationship for the client. Sullivan coined the term participant observer for the therapist’s role, meaning that
the therapist both participates in and ob- serves the progress of the relationship.
Sullivan is also credited with developing the first therapeutic community or milieu with young men with schizophrenia in 1929
In the concept of therapeutic community or milieu, the interaction among clients is seen as beneficial, and treatment emphasizes the
role of this client-to-client interaction. Until this time, it was believed that the interaction between the client and the psychiatrist was
the one essential component to the client’s treatment.
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 nurs- ing intervention. Nurses develop therapeutic relation- ships with clients in an effort to help them
generalize this ability to interact successfully with others.
Knowledge about the behaviors associated with all levels of anxiety and methods for alleviating anxiety helps nurses to assist clients
achieve interpersonal security and a sense of well-being. Nurses use the concepts of Sullivan’s theory to help clients achieve a higher
degree of independent and interpersonal functioning.
5. Lawrence Kohlberg: Theory of Moral Development
Kohlberg’s (1968) 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 each.
Level I. Preconventional Level: (Prominent from Ages 4 to 10 Years)
Stage 1: Punishment and Obedience Orientation. At the punishment and obedience orientation stage, the individ- ual is responsive
to cultural guidelines of good or bad and right or wrong, but primarily in terms of the known relat- ed consequences. Fear of
punishment is likely to be the incentive for conformity (e.g., “I’ll do it, because if I don’t I can’t watch TV for a week.”)
Stage 2: Instrumental Relativist Orientation. Behaviors at the instrumental relativist orientation stage are guid- ed by egocentrism
and concern for self. There is an intense desire to satisfy one’s own needs, but occasion- ally the needs of others are considered. For
the most part, decisions are based on personal benefits derived (e.g., “I’ll do it if I get something in return,” or occa- sionally, “. . .
because you asked me to”).
Level II. Conventional Level: (Prominent from Ages 10 to 13 Years and into Adulthood)*
Stage 3: Interpersonal Concordance Orientation. Behavior at the interpersonal concordance orientation stage is guided by the
expectations of others. Approval and acceptance within one’s societal group provide the incentive to con- form (e.g., “I’ll do it
because you asked me to,” “. . . because it will help you,” or “. . . because it will please you”).
Stage 4: Law and Order Orientation. In the law and order orientation stage, there is a personal respect for authority. Rules and laws
are required and override personal princi- ples and group mores. The belief is that all individuals and groups are subject to the same
code of order, and no one shall be exempt (e.g., “I’ll do it because it is the law”).
Level III. Postconventional Level:
(Can Occur from Adolescence Onward)
Stage 5: Social Contract Legalistic Orientation. Individuals who reach stage 5 have developed a system of values and principles
that determine for them what is right or wrong; behaviors are acceptably guided by this value sys- tem, provided they do not violate
the human rights of others. They believe that all individuals are entitled to certain inherent human rights, and they live according to
universal laws and principles. However, they hold the idea that the laws are subject to scrutiny and change as needs within society
evolve and change (e.g., “I’ll do it because it is the moral and legal thing to do, even though it is not my personal choice”).
Stage 6: Universal Ethical Principle Orientation.
Behavior at stage 6 is directed by internalized principles of honor, justice, and respect for human dignity. Laws are abstract and
unwritten, such as the “Golden Rule,” “equality of human rights,” and “justice for all.” They are not the concrete rules established by
society. The con- science is the guide, and when one fails to meet the self- expected behaviors, the personal consequence is intense
guilt. The allegiance to these ethical principles is so strong that the individual will stand by them even know- ing that negative
consequences will result (e.g., “I’ll do it because I believe it is the right thing to do, even though it is illegal and I will be imprisoned
for doing it”).
Relevance of Moral Development Theory to Nursing Practice
Moral development has relevance to psychiatric nursing in that it affects critical thinking about how individuals ought to behave and
treat others. Moral behavior reflects the way a person interprets basic respect for other per- sons, such as the respect for human life,
freedom, justice, or confidentiality. Psychiatric nurses must be able to assess the level of moral development of their clients in order to
be able to help them in their effort to advance in their progression toward a higher level of developmental maturity.
6. Carl Rogers: Client-Centered Therapy
(HUMANISTIC THEORY)
Carl Rogers (1902–1987) was a humanistic American psychologist who focused on the therapeutic relationship and developed a new
method of client-centered therapy. Rogers was one of the first to use the term client rather than patient. Client-centered therapy
focuses on the role of the client, rather than the therapist, as the key to the healing process. Rogers believed that each person experi-
ences the world differently and knows his or her own experience best (Rogers, 1961). According to Rogers, cli- ents do “the work of
healing,” and within a supportive and nurturing client–therapist relationship, clients can cure themselves. Clients are in the best
position to know their own experiences and make sense of them, to regain their self-esteem, and to progress toward self-actualization.
The therapist takes a person-centered approach, a sup- portive role, rather than a directive or expert role, because Rogers viewed the
client as the expert on his or her life.
The therapist must promote the client’s self-esteem as much as possible through three central concepts:
 Unconditional positive regard—a nonjudgmental caring for the client that is not dependent on the client’s behavior
 Genuineness—realness or congruence between what the therapist feels and what he or she says to the client
 Empathetic understanding—in which the therapist senses the feelings and personal meaning from the client and
communicates this understanding to the client.
Rogers also believed that the basic nature of humans is to become self-actualized, or to move toward self- improvement and
constructive change. We are all born with a positive self-regard and a natural inclination to become self-actualized. If relationships
with others are supportive and nurturing, the person retains feelings of self-worth and progresses toward self-actualization, which is
healthy. If the person encounters repeated conflicts with others or is in nonsupportive relationships, he or she loses self-esteem,
becomes defensive, and is no longer inclined toward self-actualization; this is not healthy.
7. Margaret Mahler: Theory of Object Relations
Mahler (Mahler, Pine, & Bergman, 1975) 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. She further delineates
phase III, the separation–individuation phase, into four sub- phases.
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 envi- ronment. 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 his or her 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 “psy- chological birth” of the child. Separation is defined as the physical and
psychological attainment of a sense of per- sonal 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 moth- ering figure to a distinct and separate being are described.
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 experi- ences feelings of exhilaration from increased independ- ence. 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, the child becomes
increasingly aware of his or her sepa- rateness 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 need is for the mothering figure to be available to provide “emotional refueling” on demand.
Subphase 4: Consolidation (24 to 36 Months)
With achievement of the consolidation subphase, a defi- nite 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 moth- ering 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 assists the nurse to assess the client’s level of individuation from
primary caregivers. The emotional problems of many individuals can be traced to lack of ful- fillment of the tasks of
separation/individuation. Examples include problems related to dependency and excessive anxiety. The individual with borderline
person- ality disorders is thought to be fixed in the rapproche- ment phase of development, harboring fears of abandon- ment and
underlying rage. This knowledge is important in the provision of nursing care to these individuals.