PSYCHOSOCIAL THEORIES

Many theories discussed in this

chapter were not based on empirical or research evidence; rather, they evolved
from individual experiences and might more appropriately be called
conceptual models or frameworks.

1- Psychoanalytic Theories
Sigmund Freud: The Father of Psychoanalysis
Sigmund Freud, known as the founder of psychoanalysis, developed his theories in
Vienna during the late 19th and early 20th centuries. While other theorists have
contributed, Freud remains the central figure. His theory posits that all human
behavior is deterministic, largely driven by repressed sexual impulses and desires,
as observed in his early patients.

Personality Components: Id, Ego, and Superego

Freud's model of personality comprises the id, ego, and superego. The id represents
innate desires, while the superego embodies moral and ethical standards. The ego
mediates between these conflicting forces. Freud believed that anxiety arises from
the ego's attempts to balance these instincts and societal norms.
Behavior Motivated by Subconscious Thoughts and Feelings
Freud proposed that human behavior is driven by subconscious thoughts and
feelings, which operate at three levels of awareness: conscious, preconscious, and
unconscious. Conscious awareness involves immediate perceptions, thoughts, and
emotions. Preconscious thoughts and emotions are retrievable with effort, like
childhood memories. The unconscious motivates behavior despite being outside
conscious awareness, housing defense mechanisms and instinctual drives.
Traumatic events deemed too painful are repressed into the unconscious. Freud
believed that much of our actions and speech are influenced by subconscious
thoughts or feelings, manifesting in Freudian slips—unintended expressions
revealing hidden emotions or thoughts in casual conversation.

Freud's Dream Analysis

Freud posited that dreams offer a window into the subconscious mind, often laden
with symbolic meanings. Dream analysis, a cornerstone of psychoanalysis, involves
dissecting dreams to unveil their true significance. For instance, recurring dreams of
being chased by snakes may indicate a fear of intimacy with men, with the snake
symbolizing the phallus. Another technique, free association, prompts clients to
respond spontaneously to words, aiming to reveal hidden thoughts or emotions.
Freud believed that these rapid responses could unveil subconscious or repressed
feelings, aiding in therapeutic exploration.

Ego Defense Mechanisms

Freud proposed that individuals utilize ego defense mechanisms to safeguard
themselves and handle basic drives or emotionally distressing experiences. These
mechanisms, detailed in Table 3.1, aid in managing challenging thoughts, feelings,
or events. For instance, denial is evident when someone refuses to acknowledge a
dire diagnosis like terminal cancer. Similarly, reaction formation may occur when a
person exhibits persistent cheerfulness despite facing a life-threatening illness.
Often operating unconsciously, these defense mechanisms may require external
support for individuals to confront reality.

TABLE 3.1 Ego Defense Mechanisms

Five Stages of Psychosexual Development

Freud's theory of childhood development revolves around the notion of sexual
energy, or libido, as the primary driving force behind human behavior. He proposed
five stages of psychosexual development: oral (birth to 18 months), anal (18-36
months), phallic/oedipal (3-5 years), latency (5-11 years or 13 years), and genital
(11-13 years). These stages, detailed in Table 3.2, are accompanied by specific
developmental tasks. Psychopathology may arise when individuals struggle to
transition between stages or become fixated or regress to earlier stages. Freud's
open discussion of sexual impulses, particularly in children, was deemed
controversial in his time.

TABLE 3.2 Freud's Developmental Stages

Transference and Countertransference

Freud introduced the concepts of transference and countertransference in therapy.
Transference involves projecting feelings from past relationships onto the therapist,
while countertransference occurs when therapists project their own emotions onto
clients. Awareness of these dynamics is crucial in therapeutic settings.
Current Psychoanalytic Practice
Contemporary psychoanalysis aims to uncover and resolve unconscious conflicts
causing anxiety. Techniques such as free association and dream analysis remain
central. However, psychoanalysis is expensive and time-consuming, making it
accessible primarily to affluent individuals.

Overall, psychoanalytic theories pioneered by Freud continue to influence

psychology and therapy, albeit with limited practical application in modern clinical
settings.

2- Developmental Theories
2.2. Erik Erikson and Psychosocial Stages of Development
Erik Erikson, a German-born psychoanalyst, expanded Freud's work by focusing on
social and psychological development across the lifespan. In his seminal work
"Childhood and Society" (1950), Erikson outlined eight psychosocial stages, each
requiring the completion of a life task crucial for well-being and mental health.
These stages aim to cultivate virtues such as hope, purpose, and wisdom.

TABLE 3.3 Erikson's Stages of Psychosocial Development

Erikson's model of psychosocial development, comprising eight stages, remains

influential across disciplines. According to Erikson, psychosocial growth unfolds
sequentially, with each stage building upon the completion of the previous one and
its associated life task. For instance, in the infant stage (birth to 18 months),
characterized by trust versus mistrust, infants must cultivate basic trust, ensuring
positive outcomes like adequate care and nourishment. Establishing trust is vital;
failure, leading to mistrust, can hinder lifelong development.

2.3. Jean Piaget and Cognitive Stages of Development

Jean Piaget explored cognitive development in children, positing that intelligence
progresses through distinct stages based on age. He emphasized the role of
biological changes and maturation in cognitive development, with each stage
reflecting higher levels of functioning than the previous one.

1. Sensorimotor Stage (Birth to 2 years old):

 During this stage, infants learn about the world through their senses and motor actions.
 Key achievements include object permanence (understanding that objects continue to
exist even when they are out of sight), the development of basic concepts of cause and
effect, and the beginning of symbolic representation.
2. Preoperational Stage (2 to 7 years old):
 In this stage, children become more proficient in using language and symbols to
represent objects and concepts.
 However, they still struggle with understanding concrete logic and may exhibit
egocentrism (difficulty seeing things from perspectives other than their own), animism
(attributing human-like qualities to inanimate objects), and centration (focusing on only
one aspect of a situation).
3. Concrete Operational Stage (7 to 11 years old):
 During this stage, children begin to think more logically about concrete events and
objects.
 They develop the ability to understand conservation (recognizing that the quantity of a
substance remains the same despite changes in its shape or arrangement), reversibility,
and the ability to classify objects into different categories.
4. Formal Operational Stage (11 years old and beyond):
 In the formal operational stage, individuals become capable of abstract and hypothetical
thinking.
 They can engage in deductive reasoning, solve problems systematically, think about
possibilities and hypothetical scenarios, and consider multiple perspectives.

Piaget emphasized the active role of children in constructing knowledge through their interactions
with the environment, rather than being passive recipients of information. He also highlighted the
importance of cognitive development occurring in stages, with each stage building upon the
achievements of the previous one.
Piaget's four stages of cognitive development are as follows:

3- Interpersonal Theories
3.1. Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy
Harry Stack Sullivan, an American psychiatrist, emphasized the significance of
interpersonal relationships in personality development. He believed inadequate
relationships led to anxiety, the root of emotional problems. Sullivan delineated five
life stages, each focusing on different interpersonal dynamics.
Sullivan delineated five life stages of development: infancy, childhood, juvenile,
preadolescence, and adolescence. Each stage emphasizes different interpersonal
relationships. Additionally, Sullivan identified three developmental cognitive
modes: prototaxic, parataxic, and syntaxic. The prototaxic mode, typical of infancy
and childhood, involves brief, unrelated experiences. Persistent prototaxic
experiences are associated with schizophrenia in adults. The parataxic mode
emerges in early childhood, where the child connects experiences without logical
sense, often perceiving them as coincidence. The syntaxic mode, prevalent in
school-aged children and preadolescents, involves perceiving oneself and the world
within the environmental context and analyzing experiences across settings.
Sullivan suggests that maturity is characterized by the predominance of the syntaxic
mode.

TABLE 3.4 Sullivan's Life Stages

Therapeutic Community or Milieu

Sullivan advocated for therapeutic communities where client interactions are
therapeutic. He coined the term "participant observer" for therapists who both
engage and observe clients' progress. Milieu therapy, pioneered by Sullivan,
underscores the therapeutic potential of client-to-client interactions. While milieu
therapy was once prevalent, its practice has diminished due to shorter hospital stays.
Nonetheless, nurses play a crucial role in managing the environment and fostering
social interaction in healthcare settings.
3.2. Hildegard Peplau: Therapeutic Nurse-Patient Relationships
Hildegard Peplau (1909-1999; Fig. 3.2) was a nursing theorist and clinician
who built on Sullivan's interpersonal theories and also saw the role of the nurse as a
participant observer. Peplau developed the concept of the therapeutic nurse-patient
relationship, which includes four phases: orientation, identification, exploitation,
and resolution (Table 3.5).
TABLE 3.5 Peplau's Stages and Tasks of Relationships

Roles of the Nurses in the Therapeutic Relationship

Peplau also wrote about the roles of the nurses in the therapeutic relationship and
how these roles help meet the client's needs. The primary roles she identified are as
follows:
• Stranger-offering the client the same acceptance and courtesy that the nurse would
to any stranger
• Resource person-providing specific answers to questions within a larger context
• Teacher-helping the client learn either formally or informally
• Leader-offering direction to the client or group
• Surrogate-serving as a substitute for another, such as a parent or sibling
• Counselor-promoting experiences leading to health for the client, such as
expression of feelings

Peplau also believed that the nurse could take on many other roles,
including consultant, tutor, safety agent, mediator, administrator, observer,
and researcher. These were not defined in detail but were "left to the
intelligence and imagination of the readers" (Peplau, 1952, p. 70).

Four Levels of Anxiety

Peplau defined anxiety as the initial response to a
psychic threat. She described four levels of anxiety: mild, moderate, severe,
and panic (Table 3.6). These serve as the foundation for working with clients
with anxiety in a variety of contexts (see Chapter 13).

1. Mild anxiety is a positive state of heightened awareness and sharpened

senses, allowing the person to learn new behaviors and solve problems.
The person can take in all available stimuli (perceptual field).
2. Moderate anxiety involves a decreased perceptual field (focus on
immediate task only); the person can learn new behavior or solve problems
only with assistance. Another person can redirect the person to the task.
3. Severe anxiety involves feelings of dread or terror. The person cannot be
redirected to a task; he or she focuses only on scattered details and has
physiologic symptoms of tachycardia, diaphoresis, and chest pain. A
person with severe anxiety may go to an emergency department, believing
he or she is having a heart attack.
4. Panic anxiety can involve loss of rational thought, delusions,
hallucinations, and complete physical immobility and muteness. The
person may bolt and run aimlessly, often exposing him or herself to injury.

TABLE 3.6 Anxiety Levels

4-Humanistic Theories
Humanism signifies a paradigm shift away from the psychoanalytic perspective,
which viewed individuals as neurotic and impulse-driven, towards a focus on
positive qualities and the capacity for change. It emphasizes the promotion of self-
esteem and directs attention towards the present and future rather than dwelling on
past experiences.

4.1. Abraham Maslow: Hierarchy of Needs

Abraham Maslow, an American psychologist (1921-1970), emphasized a holistic
approach to understanding individuals and prioritized health over illness. His
Hierarchy of Needs, depicted as a pyramid, illustrates the fundamental drives
motivating people. Beginning with physiological needs like food and shelter, the
hierarchy progresses through safety, love/belonging, esteem, and culminates in self-
actualization. Maslow proposed that lower-level needs dominate behavior until
fulfilled, allowing higher-level needs to emerge. Self-actualization represents
achieving one's fullest potential, although it's rare. Maslow's theory elucidates how
individual motivations fluctuate, particularly during life crises, guiding nurses in
understanding client behaviors and motivations.

4.2. Carl Rogers: Client-Centered Therapy

Carl Rogers (1902-1987), an American humanistic psychologist, developed client-
centered therapy, focusing on the therapeutic relationship. He preferred the term
"client" over "patient" and believed that individuals are experts in their own
experiences. In this therapy, clients drive their healing process within a supportive
environment.
The therapist assumes a person-centered, supportive role, promoting the client's
self-esteem 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 asserted that humans naturally gravitate towards self-actualization.
Supportive relationships nurture self-worth and personal growth, while conflicts or
unsupportive relationships diminish self-esteem, hindering self-actualization.

5- Behavioral Theories
Behaviorism arose in response to introspection models, which delved into the
mind's contents and operations. This psychological school focuses on observable
behaviors and external actions to induce behavior changes, eschewing explanations
of mental processes. Behaviorists believe behavior modification occurs through a
system of rewards and punishments. For instance, a regular paycheck serves as a
positive reinforcer, motivating individuals to maintain positive workplace behavior.
Conversely, receiving a speeding ticket acts as a negative reinforcer, likely reducing
speeding behavior. However, if negative reinforcement is removed, behaviors may
revert, as seen when a motorist resumes speeding after avoiding detection for four
weeks.

5.1. Ivan Pavlov: Classical Conditioning

Ivan Pavlov's classical conditioning theory stems from laboratory experiments with
dogs. He observed that dogs naturally salivated in response to food stimuli. Pavlov
aimed to modify this behavior through conditioning. By pairing the presentation of
food with the ringing of a bell, Pavlov established a new stimulus-response
association. Over time, the dogs learned to salivate at the sound of the bell alone,
demonstrating classical conditioning. This process illustrates how behavior can be
changed through environmental stimuli, leading to a conditioned response.

5.2. B.F. Skinner: Operant Conditioning

6- Existential theories
Existential theories posit that behavioral deviations stem from a lack of connection
with oneself or the environment, resulting in feelings of loneliness, sadness, and
helplessness. Individuals who are self-alienated struggle to engage in fulfilling
relationships due to a lack of self-awareness and harsh self-criticism, limiting their
choices and yielding to external pressures. Existential therapies aim to facilitate the
discovery of an authentic self, promoting personal responsibility for emotions,
behaviors, and choices while advocating for living fully in the present and
anticipating the future. Carl Rogers is occasionally associated with existential
therapists, and Table 3.7 provides a summary of existential therapies.

TABLE 3. 7 Existential Therapies

Cognitive Therapy
Many existential therapists employ cognitive therapy to address immediate thought
processing, focusing on how individuals perceive and interpret experiences, which
influences emotions and behaviors. For instance, Aaron Beck pioneered cognitive
therapy for depression by emphasizing the role of thought patterns in emotional
states.

Rational Emotive Therapy

Albert Ellis introduced rational emotive therapy, targeting 11 "irrational beliefs"
contributing to unhappiness. Ellis emphasized the identification of automatic
thoughts using the ABC technique, which involves recognizing activating events,
identifying automatic thoughts, and understanding excessive responses.

Viktor Frankl and Logotherapy

Viktor Frankl developed logotherapy based on observations from Nazi
concentration camps, highlighting the importance of finding meaning (logos) in life.
Frankl's concepts, particularly the search for meaning, are integral to spirituality and
grief counseling.

Gestalt Therapy
Founded by Frederick "Fritz" Perls, Gestalt therapy emphasizes present awareness
to foster self-acceptance and responsibility for one's feelings and thoughts.
Therapeutic activities such as journaling and role-playing aim to increase self-
awareness and focus on the present.

Reality Therapy
William Glasser's reality therapy focuses on personal behavior hindering life goals,
challenging clients to take responsibility for their actions. Glasser believed in
addressing clients' tendencies to blame external factors for their problems,
encouraging responsible behavior to achieve life goals.

* Crisis Intervention
A crisis represents a significant turning point causing overwhelming emotional
responses, often surpassing an individual's coping abilities. Caplan identified stages
of crisis, including exposure to stressors, ineffective coping, attempts at new coping
methods, and subsequent distress. Crises can be maturational, situational, or
adventitious, encompassing a range of life events and circumstances.