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Chapter13. Theories of Personality and Psychopathology Contents: Sigmund freud and classic psychoanalysis The theory of Erik Erikson Sigmund freud and classic psychoanalysis 1. Topographic model of the mind 2. Instinct or drive theory 3. Ego psychology 4. Classical psychoanalytic theory of neuroses 5. Treatment and technique Introduction——Sigmund Freud 1 Sigmund Freud was born on May 6, 1856, in Freiburg, a small town in Moravia, which is now a part of the Czech Republic. When Freud was 4 years old, his father, a Jewish wool merchant, moved the family to Vienna, where Freud spent most of his life. Introduction——Sigmund Freud 2 Following medical school, he specialized in neurology and studied for a year in Paris with Jean-Martin Charcot. He was also influenced by Ambroise-August Liebault and Hippolyte-Marie Bernheim, both of whom taught him hypnosis while he was in France. After his education in France, he returned to Vienna and began clinical work with hysterical patients. Between 1887 and 1897, his work with these patients led him to develop psychoanalysis. 1.Topographic model of the mind The Conscious The Preconscious The Unconscious Limitations of the Topographic Theory 1.1The Conscious the part of the mind in which perceptions coming from the outside world or from within the body or mind are brought into awareness. Consciousness is a subjective phenomenon whose content can be communicated only by means of language or behavior. Freud assumed that consciousness employed a form of neutralized psychic energy that he referred to as attention cathexis. In other words, people were aware of a particular idea or feeling as a result of investing a discrete amount of psychic energy in the idea or feeling. 1.2The Preconscious The preconscious system is composed of those mental events, processes, and contents capable of being brought into conscious awareness by the act of focusing attention. Conceptually, the preconscious interfaces with both unconscious and conscious regions of the mind. To reach conscious awareness, contents of the unconscious must become linked with words and thus become preconscious. The preconscious also serves to maintain the repressive barrier and to censor unacceptable wishes and desires. 1.3The Unconscious The unconscious system is characterized by primary process thinking, which has as its principal aim the facilitation of wish fulfillment and instinctual discharge. It is governed by the pleasure principle and therefore disregards logical connections, has no concept of time, represents wishes as fulfillments, permits contradictions to exist simultaneously, and denies the existence of negatives. The contents of the unconscious can become conscious only by passing through the preconscious; when censors are overpowered, the elements can enter consciousness. 1.4 Limitations of the Topographic Theory two main deficiencies : First, many patients' defense mechanisms that guard against distressing wishes, feelings, or thoughts were themselves not initially accessible to consciousness. Repression, then, cannot be identical with the preconscious, because by definition this region of the mind is accessible to consciousness. Second, Freud's patients frequently demonstrated an unconscious need for punishment. 2 Instinct or drive theory Instincts Pleasure and Reality Principles Infantile Sexuality Object Relationships in Instinct Theory Concept of Narcissism 2.1 Instincts Libido Ego Instincts Aggression Life and Death Instinct introductions Instinct, for example, refers to a pattern of species- specific behavior that was genetically derived and therefore is more or less independent of learning. In Freud's view, an instinct has four principal characteristics: source, impetus, aim, and object. The source refers to the part of the body from which the instinct arises. The impetus is the amount of force or intensity associated with the instinct. The aim refers to any action directed toward tension discharge or satisfaction, and the object is the target (often a person) for this action. Libido Freud defined libido as "that force by which the sexual instinct is represented in the mind." Freud's intent was to encompass the general notion of pleasure as well as sexuality . Libido就是指精神能量，是一切心理活动的内在动 力。 Ego Instincts From 1905 on, Freud maintained a dual instinct theory, subsuming sexual instincts and ego instincts connected with self-preservation. Freud viewed narcissistic investment as an essentially libidinal instinct and called the remaining nonsexual components the ego instincts. Aggression When psychoanalysts today discuss the dual instinct theory, they are generally referring to libido and aggression. Freud, however, originally conceptualized aggression as a component of the sexual instincts in the form of sadism. Finally, in 1923, to account for the clinical data he was observing, he was compelled to conceive of aggression as a separate instinct in its own right. The source of this instinct, according to Freud, was largely in skeletal muscles, and the aim of the aggressive instincts was destruction. Life and Death Instincts The life and death instincts were regarded as forces underlying the sexual and aggressive instincts. Freud thought that the dominant force in biological organisms had to be the death instinct. In contrast to the death instinct, Eros (the life instinct) refers to the tendency of particles to reunite or bind to one another, as in sexual reproduction. The prevalent view today is that the dual instincts of sexuality and aggression are sufficient to explain most clinical phenomena without recourse to a death instinct. Pleasure and Reality Principles In 1911, Freud described two basic tenets of mental functioning, the pleasure principle and the reality principle. The pleasure principle is defined as an inborn tendency of the organism to avoid pain and to seek pleasure through the discharge of tension. The reality principle is considered to be a learned function closely related to the maturation of the ego; this principle modifies the pleasure principle and requires the delay or postponement of immediate gratification. Infantile Sexuality （1） Freud set forth the three major tenets of psychoanalytic theory when he published Three Essays on the Theory of Sexuality. First, he broadened the definition of sexuality to include forms of pleasure that transcend genital sexuality. Second, he established a developmental theory of childhood sexuality that delineated the vicissitudes of erotic activity from birth through puberty. Third, he forged a conceptual linkage between neuroses and perversions(反常). Infantile Sexuality（2） Freud noted that infants are capable of erotic activity from birth, but the earliest manifestations of infantile sexuality are basically nonsexual and are associated with such bodily functions as feeding and bowel-bladder control. As libidinal energy shifts from the oral zone to the anal zone to the phallic zone, each stage of development is thought to build on and to subsume the accomplishments of the preceding stage. Infantile Sexuality（3） Freud suggested that phallic erotic activity in boys is a preliminary stage leading to adult genital activity. Freud postulated that females have two principal erotogenic zones, the vagina and the clitoris. He thought that the clitoris was the chief erotogenic focus during the infantile genital period but that erotic primacy shifted to the vagina after puberty. Studies of human sexuality have subsequently questioned the validity of this distinction. Psychosexual Stages Oral Stage birth - 18 months old Anal Stage 18 months - 3 years Phallic Stage 3 years - 6 years Latency Stage 6 years - 12 years Genital Stage 12 years - adult Object Relationships in Instinct Theory Freud suggested that the choice of a love object in adult life, the love relationship itself, and the nature of all other object relationships depend primarily on the nature and quality of children's relationships during the early years of life. In describing the libidinal phases of psychosexual development, Freud repeatedly referred to the significance of a child's relationships with parents and other significant people in the environment. Fixation Fixation(固着)：根据弗洛伊德的理论，如果在性心理发展的某个阶段得到 过分的满足或者受到挫折会导致固着，固着将导致无法正常的进入性心理发 展的下一阶段。 性心理发展的早期经验对人格形成和成人行为模式有着很深层次的影响。 Oral Stage —— Definition The earliest stage of development in which the infant's needs, perceptions, and modes of expression are primarily centered in the mouth, lips, tongue, and other organs related to the oral zone. Oral Stage —— Description Oral drives consist of two separate components: libidinal and aggressive. The oral triad consists of the wish to eat, to sleep, and to reach that relaxation that occurs at the end of sucking just before the onset of sleep. Oral aggression may express itself in biting, chewing, spitting, or crying. Oral aggression is connected with primitive wishes and fantasies of biting, devouring, and destroying. Oral Stage —— Objectives To establish a trusting dependence on nursing and sustaining objects, to establish comfortable expression and gratification of oral libidinal needs without excessive conflict or ambivalence from oral sadistic wishes. Oral Stage —— Pathological traits Such traits can include excessive optimism, narcissism, pessimism, and demandingness（贪得无厌）. Oral characters are often excessively dependent and require others to give to them and to look after them. Oral characters are often extremely dependent on objects for the maintenance of their self-esteem. Envy and jealousy are often associated with oral traits. Oral Stage —— Character traits Successful resolution of the oral phase provides a basis in character structure for capacities to give to and receive from others without excessive dependence or envy and a capacity to rely on others with a sense of trust, as well as with a sense of self- reliance and self-trust. Anal Stage —— Definition The stage of psychosexual development that is prompted by maturation of neuromuscular control over sphincters, particularly the anal sphincters, thus permitting more voluntary control over retention or expulsion of feces. Anal Stage —— Description This period is marked by a recognizable intensification of aggressive drives mixed with libidinal components and in sadistic impulses. Acquisition of voluntary sphincter control is associated with an increasing shift from passivity to activity. Anal Stage —— Objectives The anal period is essentially a period of striving for independence and separation from the dependence on and control by the parent. The objectives of sphincter control without overcontrol (fecal retention) or loss of control (messing) are matched by the child's attempts to achieve autonomy and independence without excessive shame or self-doubt from loss of control. Anal Stage —— Pathological traits Orderliness, obstinancy, stubbornness, willfulness, frugality, and parsimony are features of the anal character derived from a fixation on anal functions. Anal characteristics and defenses are most typically seen in obsessive-compulsive neuroses. Anal Stage —— Character traits personal autonomy independence personal initiative a capacity for self-determining behavior without a sense of shame or self-doubt, Phallic Stage —— Definition The phallic stage of sexual development begins sometime during the third year of life and continues until approximately the end of the fifth year. Phallic Stage —— Description The phallic phase is characterized by a primary focus of sexual interests, stimulation, and excitement in the genital area. The penis becomes the organ of principal interest to children of both sexes. The phallic phase is associated with an increase in genital masturbation accompanied by predominantly unconscious fantasies of sexual involvement with the opposite-sex parent. Phallic Stage —— Objectives The objective of this phase is to focus erotic interest in the genital area and genital functions. Phallic Stage —— Pathological traits 幼儿开始将性能量里比多指向外界对象，男孩的性欲指向 母亲，女孩的欲望指向父亲，叫做俄狄帕斯情结，又名子 恋母（仇父）情结。 男孩的欲望指向母亲时，总要无意识地与父亲争夺爱，敌 视父亲。这种冲突导致另一情结--阉割情结，小男孩害怕 父亲，害怕他惩罚自己的恋母感情，阉割自己的生殖器， 小男孩随后放弃了恋母情结，转而与父亲同化。女孩的性 心理发展也大致经过了一个从恋父到放弃恋父，与母亲同 化的过程。 Phallic Stage —— Character traits The phallic stage provides the foundations for an emerging sense of sexual identity, a sense of curiosity without embarrassment, initiative without guilt. The Oedipus Story Once upon a time… King Laius and Queen Jocasta of Thebes have a new baby boy. They are warned by a prophet, “Your child will grow up to murder his father and marry his mother.” Why is this story meaningful? Because Oedipus acts out a wish that everyone has had in early childhood (Freud)! This is the incest fantasy, falling in love with the mother, jealousy of the father – the Oedipus Complex. Latency Stage ages 6 years to 12 years sexual drives and impulses become inactive maturation of the ego consolidation of the superego energy channeled into friendships and mastering the environment Genital Stage ages 13 years through life adolescents struggle for balance between dependency and independence healthy adults have capacity to work and play creatively and efficiently toward meaningful goals Freud的性心理发展阶段 阶段 性敏感区 潜在冲突来源 固着导致的性格特点 口欲期 口、嘴唇、 断奶 嘴部行为，如抽烟、过度饮 舌 食；被动性和易上当 肛欲期 肛门 上厕所的训练 杂乱无章、吝啬、固执，或 者相反 生殖器 生殖器 俄狄浦斯情结 虚荣，莽撞，或者相反 期 潜伏期 无特定区 防御机制的发 无（一般此阶段不会发生固 域 展 着） 生殖期 生殖器 成熟的性亲密 成功完成早期阶段的成年人 行为 会对他人产生真诚的兴趣并 具有成熟的性特征 Structural Model of Personality A. Id B. Ego C. Superego Id Only mental system present at birth encompasses all inherited personality wants pleasure/immediate gratification all of our energy comes through the id too much = psychopathology Ego interacts directly with real, external world mediates between id and external environment is the policeman of our mind balances us and keeps id and superego in check Superego contains moral standards and value systems “shoulds” develops out of ego by parental teaching acts as a conscience (or “ego ideal”) too much = neurosis, anxiety, depression Structural Theory of the Mind Id ego superego ID Freud used this term to refer to a reservoir of unorganized instinctual drives. Operating under the domination of the primary process, the id lacks the capacity to delay or modify the instinctual drives with which an infant is born. The id should not, however, be viewed as synonymous with the unconscious because both the ego and the superego have unconscious components. ego The ego spans all three topographic dimensions of conscious, preconscious, and unconscious. Logical and abstract thinking and verbal expression are associated with conscious and preconscious functions of the ego. Defense mechanisms reside in the unconscious domain of the ego. The ego is the executive organ of the psyche and controls motility, perception, contact with reality, and, through the mechanisms of defense available to it, the delay and modulation of drive expression. Freud believed that the modification of the id occurs as a result of the impact of the external world on the drives. The pressures of external reality enable the ego to appropriate the energies of the id to do its work. As the ego brings influences from the external world to bear on the id, it simultaneously substitutes the reality principle for the pleasure principle. Freud emphasized the role of conflict within the structural model and observed that conflict occurs initially between the id and the outside world, only to be transformed later to conflict between the id and the ego. superego The superego establishes and maintains an individual's moral conscience based on a complex system of ideals and values internalized from parents. Freud viewed the superego as the heir to the Oedipus complex: Children internalize parental values and standards around the age of 5 or 6 years. The superego then serves as an agency that provides ongoing scrutiny of a person's behavior, thoughts, and feelings; makes comparisons with expected standards of behavior; and offers approval or disapproval. These activities occur largely unconsciously. The ego ideal is often regarded as a component of the superego: It is an agency that prescribes what a person should do according to internalized standards and values. The superego, by contrast, is an agency of moral conscience that proscribes-that is, dictates what a person should not do. Throughout the latency period and thereafter, people continue to build on early identifications through their contact with admired figures who contribute to the formation of moral standards, aspirations, and ideals. Ego psychology Structural Theory of the Mind Id Ego superego Functions of the Ego Defense Mechanisms Theory of Anxiety Ego psychology: Structural Theory of the Mind Id: Freud used this term to refer to a reservoir of unorganized instinctual drives. Operating under the domination of the primary process, the id lacks the capacity to delay or modify the instinctual drives with which an infant is born. The id should not, however, be viewed as synonymous with the unconscious because both the ego and the superego have unconscious components. Ego The ego spans all three topographic dimensions of conscious, preconscious, and unconscious. Logical and abstract thinking and verbal expression are associated with conscious and preconscious functions of the ego. Defense mechanisms reside in the unconscious domain of the ego. The ego is the executive organ of the psyche and controls motility, perception, contact with reality, and, through the mechanisms of defense available to it, the delay and modulation of drive expression. Superego The superego establishes and maintains an individual's moral conscience based on a complex system of ideals and values internalized from parents. Freud viewed the superego as the heir to the Oedipus complex: Children internalize parental values and standards around the age of 5 or 6 years. The superego then serves as an agency that provides ongoing scrutiny of a person's behavior, thoughts, and feelings; makes comparisons with expected standards of behavior; and offers approval or disapproval. These activities occur largely unconsciously. EGO PSYCHOLOGY ego psychology as it is known today really began with the publication in 1923 of The Ego and the Id. This landmark publication also represented a transition in Freud's thinking from the topographic model of the mind to the tripartite structural model of ego, id, and superego. He had observed repeatedly that not all unconscious processes can be relegated to a person's instinctual life. Elements of the conscience, as well as functions of the ego, are clearly unconscious as well. The theory of Erik Erikson Contents: Introduction 简介 Epigenetic principle渐次生成原则 Psychopathology精神病理学 Treatment治疗 一 Introduction 1: Erik Homburger Erikson was born in 1902 in Frankfurt, Germany. His father, a Danish Protestant新教徒, and his mother, a Danish Jew犹太教徒, separated before he was born, and he grew up in the home of his mother and German-Jewish stepfather, a pediatrician儿科医生. Erikson trained as a lay psychoanalyst in Europe and was schooled in the Montessori Method of education. Erikson immigrated to the United States in 1933. Introduction 2: He became interested in the influence of culture on child development, and as a result of his studies in the 1930s and the 1940s, including anthropological work with the Sioux in South Dakota and the Yurok in northern California, his book Childhood and Society was published in 1950. In this publication, he presented a psychosocial theory of development that describes crucial steps in people's relationships with the social world, based on the interplay between biology and society. 艾里克森（Erik Homburger Erikson, 1902-1994）生于德国的法兰克 福，只受过大学预科教育。 1933年他参加了维也纳精神分析学会，并追随安娜学习儿童精神分析。 同年，他在美国波士顿开业; 1936-1939年在耶鲁大学医学研究院精神病学系工作; 1939-1944年参加加利福尼亚大学伯克利分校儿童福利研究所的纵向 “儿童指导研究”。40年代他曾到印第安人的苏族和尤洛克部落从事 儿童的跨文化现场调查; 1951-1960年在匹兹堡大学医学院任精神病学教授; 1960年起任哈佛大学人类发展学教授，直到1970年退休; 艾里克森是继哈特曼之后自我心理学的杰出代表，他进一步发展了哈 特曼所重视的社会环境对自我适应作用的思想，从生物、心理和社会 环境三个方面考察了自我的发展，提出了以自我为核心的人格发展渐 成说。 Introduction 3: Erikson drew on much of freudian psychology, but he added to Sigmund Freud's theory of infantile sexuality幼 稚性欲 by concentrating on children's development beyond puberty青春期. Erikson concluded that human personality is determined not only by childhood experiences, but also by those of adulthood. 2 Epigenetic principle（1） Erikson's formulations were based on the concept of epigenesis, a term borrowed from embryology. His epigenetic principle holds that development occurs in sequential, clearly defined stages, and that each stage must be satisfactorily resolved for development to proceed smoothly. According to the epigenetic model, if successful resolution of a particular stage does not occur, all subsequent stages reflect the failure in the form of physical, cognitive, social, or emotional maladjustment. 2.1Relation to Freudian Theory Erikson accepted Freud's concepts of instinctual development and infantile sexuality. For each of Freud's psychosexual stages (for example, oral, anal, phallic), Erikson described a corresponding zone with a specific pattern or mode of behavior. Thus, the oral zone is associated with sucking or taking-in behavior; the anal zone is associated with holding on and letting go. Erikson emphasized that the development of the ego is more than the result of intrapsychic wants or inner psychic energies. It is also a matter of mutual regulation between growing children and a society's culture and traditions. 2.2 Stages of the Life Cycle Erikson described eight stages of the life cycle (Table 6.3). Each stage is marked by one or more internal crises, defined as turning points-periods when people are in a state of increased vulnerability. Ideally, when a crisis is mastered successfully, people gain strength and move on to the next stage. Stage1. Basic Trust versus Basic Mistrust (Birth to about 1 year) Corresponds to the oral psychosexual stage Trust shown by ease of feeding, depth of sleep, bowel relaxation Depends on consistency and sameness of experiences provided by caretaker or outer provider Second 6 months: teething and biting move infant from getting to taking Weaning leads to nostalgia for lost paradise If basic trust is strong, child maintains hopeful attitude, develops self-confidence Oral zone associated with mode of being satisfied Stage2. Autonomy versus Shame and Doubt (About 1 to 3 years) Corresponds to the muscular-anal stage Biologically includes learning to walk, feed self, talk Need for outer control, firmness of caretaker before development of autonomy Shame occurs when child is overly self-conscious through negative exposure and punishment Self-doubt can evolve if parents overly shame child, eg, about elimination Anal zone associated with mode of holding on and letting go Stage3. Initiative versus Guilt (3 to 5 years) Corresponds to the phallic psychosexual stage Initiative arises in relation to tasks for the sake of activity, both motor and intellectual Guilt may arise over goals contemplated (especially aggressive goals) Desire to mimic adult world; involvement in oedipal struggle leads to resolution through social role identification Sibling rivalry frequent Phallic zone associated with mode of competition and aggression Stage4. Industry versus Inferiority (6 to 11 years) Corresponds to the latency psychosexual stage Child is busy building, creating, accomplishing Receives systematic instruction and fundamentals of technology Danger of sense of inadequacy and inferiority if child despairs of tools, skills, and status among peers Socially decisive age No dominant zone or mode Stage5. Identity versus Role Diffusion (11 years through end of adolescence) Struggle to develop ego identity (sense of inner sameness and continuity) Preoccupation with appearance, hero worship, ideology Group identity (with peers) develops Danger of role confusion, doubts about sexual and vocational identity Psychosexual moratorium, stage between morality learned by the child and the ethics developed by the adult No dominant zone or mode Stage6. Intimacy versus Isolation (21 to 40 years) Tasks are to love and to work Intimacy is characterized by self-abandonment, mutuality of sexual orgasm, intense friendship, attachments that are life-long Isolation is marked by separation from others and view that others are dangerous General sense of productivity in this stage No dominant zone or mode Stage7. Generativity versus Stagnation (40 to 65 years) Generativity includes raising children, guiding new generation, creativity, altruism Stagnation not prevented by having a child; parent must provide nurturance and love Self-concern, isolation, and absence of intimacy are characteristic of stagnation No dominant zone or mode Stage 8. Integrity versus Despair (over 65 years) Integrity is a sense of satisfaction that life has been productive and worthwhile Despair is a loss of hope that produces misanthropy and disgust Persons in the state of despair are fearful of death An acceptance of one's place in the life cycle is characteristic of integrity 3 Comment： Erikson's stages are not fixed in time. Development is continuous; a particular stage may dominate at a certain time, but a person may have residual problems carried from one stage to the next or may be under severe stress and regress wholly or in part to an earlier stage. The time boundaries of each stage represent approximations agreed on by most workers in the field. 4 Psychopathology Each stage of the life cycle has its own psychopathological outcome if it is not mastered successfully. Basic Trust Autonomy Initiative Industry Identity Intimacy Generativity Integrity 4.1 Basic Trust 1 An impairment of basic trust leads to basic mistrust. In infants, social trust is characterized by ease of feeding, depth of sleep, smiling, and general physiological homeostasis. Prolonged separation during infancy can lead to hospitalism or anaclitic depression. In later life, this lack of trust may be manifested by dysthymic disorder, a depressive disorder, or a sense of hopelessness. Basic Trust 2 People who experienced a sense of social mistrust in the first years are likely to develop paranoid or delusional disorders, schizoid personality disorder and, in most severe cases, schizophrenia, Substance-related disorders , substance-dependent personalities . If not nurtured properly, infants may feel empty, starved not just for food but also for sensual and visual stimulation. They may become, as adults, seekers after stimulating thrills that do not involve intimacy and that help ward off feelings of depression. 4.2 Autonomy 1 The stage in which children attempt to develop into autonomous beings is often called the terrible 2s, referring to toddlers' willfulness at this period of development. If shame and doubt dominate over autonomy, compulsive doubting may occur. The inflexibility of the obsessive personality also results from an overabundance of doubt. Too rigorous toilet training, commonplace in today's society, which requires a clean, punctual, and deodorized body, can produce an overly compulsive personality that is stingy, meticulous, and selfish. Known as anal personalities, such people are parsimonious, punctual, and perfectionistic (the three Ps). 4.2 Autonomy 2 Too much shaming causes children to feel evil or dirty and may pave the way for delinquent behavior. In effect, children say, "If that's what they think of me, that's the way I'll behave." Paranoid personalities feel that others are trying to control them, a feeling that may have its origin during the stage of autonomy versus shame and doubt. When coupled with mistrust, the seeds are planted for persecutory delusions. Impulsive disorder may be explained as a person's refusing to be inhibited or controlled. 4.3 Initiative 1 Erikson stated: "In pathology, the conflict over initiative is expressed either in hysterical denial, which causes the repression of the wish or the abrogation of its executive organ by paralysis or impotence; or in overcompensatory showing off, in which the scared individual, so eager to `duck,' instead `sticks his neck out.' " In the past, hysteria was the usual form of pathological regression in this area, but a plunge into psychosomatic disease is now common. Initiative 2 Excessive guilt may lead to a variety of conditions, such as generalized anxiety disorder and phobias. Patients feel guilty because of normal impulses, and they repress these impulses, with resulting symptom formation. Punishments or severe prohibitions occurring during the stage of initiative versus guilt can produce sexual inhibitions. Initiative 3 Conversion disorder or specific phobia may result when the oedipal恋母情结的 conflict is not resolved. As sexual fantasies are accepted as unrealizable, children may punish themselves for these fantasies by fearing harm to their genitals. Under the brutal assault of the developing superego, they may repress their wishes and begin to deny them. If this pattern is carried forward, paralysis, inhibition, or impotence can result. Sometimes, in fear of not being able to live up to what others expect, children may turn to psychosomatic disease 4.4 Industry Erikson described industry as a "sense of being able to make things and make them well and even perfectly." When children's efforts are thwarted, they are made to feel that personal goals cannot be accomplished or are not worthwhile, and a sense of inferiority develops. In adults, this sense of inferiority can result in severe work inhibitions and a character structure marked by feelings of inadequacy. For some people, the feelings may result in a compensatory drive for money, power, and prestige. Work can become the main focus of life, at the expense of intimacy. 4.5 Identity 1 Many disorders of adolescence can be traced to identity confusion. The danger is role diffusion. Erikson stated: Where this is based on a strong previous doubt as to one's sexual identity, delinquent and outright psychotic incidents are not uncommon. If diagnosed and treated correctly, those incidents do not have the same fatal significance that they have at other ages. It is primarily the inability to settle on an occupational identity that disturbs young people. Keeping themselves together, they temporarily overidentify, to the point of apparent complete loss of identity, with the heroes of cliques and crowds. Identity 2 Other disorders during the stage of identity versus role diffusion include conduct disorder, disruptive behavior disorder, gender identity disorder, schizophreniform disorder, and other psychotic disorders. The ability to leave home and live independently is an important task during this period. An inability to separate from the parent and prolonged dependence may occur. 4.6 Intimacy The successful formation of a stable marriage and family depends on the capacity to become intimate. The years of early adulthood are crucial for deciding whether to get married and to whom. Gender identity determines object choice, either heterosexual or homosexual, but making an intimate connection with another person is a major task. People with schizoid personality disorder remain isolated from others because of fear, suspicion, the inability to take risks, or the lack of a capacity to love. 4.7 Generativity From about 40 to 65 years, the period of middle adulthood, specific disorders are less clearly defined than in the other stages described by Erikson. People who are middle aged show a higher incidence of depression than do younger adults, a finding that may be related to middle-aged people's disappointments and failed expectations as they review the past, consider their lives, and contemplate the future. The increased use of alcohol and other psychoactive substances also occurs during this time. 4.8 Integrity Anxiety disorders often develop in older people. In Erikson's formulation, this development may be related to people's looking back on their lives with a sense of panic. Time has run out, and chances are used up. The decline in physical functions can contribute to psychosomatic illness, hypochondriasis, and depression. The suicide rate is highest over the age of 65. People facing dying and death may find it intolerable not to have been generative or able to make significant attachments in life. Integrity, for Erikson, is characterized by an acceptance of life. Without acceptance, people feel despair and hopelessness that can result in severe depressive disorders. 5 Treatment For Erikson, establishing a state of trust between doctor and patient is the basic requirement for successful therapy. When psychopathology stems from basic mistrust (for example, depression), a patient must re- establish trust with the therapist, whose task, like that of the good mother, is to be sensitive to the patient's needs. The therapist must have a sense of personal trustworthiness that can be transmitted to the patient. 5.1Techniques Effective therapy requires that therapists actively convey to patients the belief that they are understood. This is done not only through empathetic listening but also by verbal assurances, which enable a positive transference, built on mutual trust to develop. Mutuality, which is important in Erikson's system of health, is also vital to a cure. Erikson urged that the relationship of the healer to the sick person be one of equals "in which the observer who has learned to observe himself teaches the observed to become self- observant." 5.2 Goals Erikson discussed four dimensions of the psychoanalyst‘s job. The patient's desire to be cured and the analyst's desire to cure is the first dimension. The second dimension Erikson called objectivity- participation. The third dimension runs along the axis of knowledge-participation. The fourth dimension is tolerance-indignation.
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