CHAPTER 3: CONCEPTS AND THEORIES OF GROWTH AND
DEVELOPMENT

The American Psychiatric Association defines personality as: Enduring patterns of
perceiving, relating to, and thinking about the environment and oneself that
are exhibited in a wide range of social and personal contexts”
SIGNIFICANCE OF KNOWING PERSONALITY DEVELOPMENT
1. Understanding human personality development help understand maladaptive
behavioral responses
2. Identifying behaviors associated with various stages of human development
determines what is appropriate or inappropriate at each developmental level
3. People continue to develop and change throughout life suggesting the possibility for
renewal and growth in adults
4. Infancy and early childhood are the major life periods for the origination and
occurrence of developmental change
5. Developmental stages are identified by age so behaviors can then be evaluated for
age-appropriateness
6. According to specialists in life-cycle development, behaviors from an unsuccessfully
completed stage can be modified and corrected in a later stage
7. Stages overlap, and an individual may be working on tasks associated with several
stages at one time
8. When an individual becomes fixed in a lower level of development, with ageinappropriate behaviors focused on fulfillment of those tasks, psychopathology may
occur
9. Only when personality traits are inflexible and maladaptive and cause either
significant functional impairment or subjective distress do they constitute
personality disorders
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1. FREUD’S PSYCHOANALYTIC THEORY
DEFINITION

Refers to the dynamics of personality development which underlie and guide
psychoanalytic and psychodynamic psychotherapy

In 1961 Sigmund Freud was the first to identify development by stages. He
considered the first 5 years of a child’s life to be the most important (basic character
had been formed by the age of 5)

Freud’s personality theory can be conceptualized according to:
1. Structure of the personality (Stages of personality development)
2. Dynamics of the personality (Topography of the mind)
STRUCTURE OF THE PERSONALITY

Freud organized the structure of the personality into three major components :
1. Id
2. Ego
3. Superego

They are distinguished by their unique functions and different characteristics.
1. Id (the pleasure principle)

Also called the immediate gratification

Id-driven behaviors are impulsive and may be irrational.
2. Ego (the rational self, the reality principle)

Begins to develop between the ages of 4 and 6 months

Substitute the reality principle for the pleasure principle

A mediator between the external world, the id, and the superego
3. Superego (the perfection principle)

Develops between ages 3 and 6 years

Composed of two major components:
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The Ego-Ideal: The good behavior and value system.
The Conscience: When moral and ethical principles ideals and values are disregarded,
the conscience generates a feeling of guilt within the individual to encourage
reconsidering the perfection principle

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 disciplinary,
problems with low self-confidence and low self-esteem arise
TOPOGRAPHY OF THE MIND

Freud classified all mental contents and operations into three categories:
1. The conscious
2. The preconscious
3. The unconscious
1. 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 (telephones, birthdays).

The conscious mind is thought to be under the control of the ego, the rational and
logical structure of the personality
2. The preconscious (also called Subconscious)

Includes all forgotten memories but, with attention, can readily be recalled into
consciousness (Telephone numbers, feelings, significant life events).

The preconscious enhances awareness by helping to suppress unpleasant or
nonessential memories from consciousness.

It is thought to be partially under the control of the superego, which helps to
suppress unacceptable thoughts and behaviors
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3. The unconscious

Includes all memories that one is unable to bring to conscious awareness

It is the largest of the three topographical levels.

Consists of unpleasant or nonessential memories that have been repressed and can
be retrieved only through therapy, hypnosis, and with certain substances that alter
the awareness and have the capacity to restructure repressed memories.

Unconscious material may also emerge in dreams and in seemingly
incomprehensible behavior.
DYNAMICS OF THE PERSONALITY
1. Psychic Energy (The Libido)

Originating in the id, it instinctually fulfills basic physiological needs (hunger, thirst,
sex)

The force required for mental functioning

As the child matures, psychic energy is diverted from the id to form the ego and then
from the ego to form the superego.

Psychic energy is distributed within these three components, with the ego retaining
the largest share to maintain a balance between the impulsive behaviors of the id
and the idealistic behaviors of the superego.

If an excessive amount of psychic energy is stored in one of these personality
components, behavior reflects that part of the personality.

High psych energy within the id= self-absorbed, narcissistic behaviors

High Superego psychic energy= rigid, self-criticizing behaviors.
2. Cathexis

Is the process by which the id invests energy into an object in an attempt to achieve
gratification (alcohol to relieve stress)
3. Anti-cathexis

Is the use of psychic energy by the ego and the superego to control id impulses
(control the use of alcohol with rational thinking Ego: ulcers, superego: should not
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drink)

Imbalance between cathexis and anti-cathexis results in internal conflicts producing
tension and anxiety within the individual

Defense mechanisms believed to be used by the ego as a protective device against
anxiety in mediating between the excessive demands of the id and the excessive
restrictions of the superego
FREUD’S STAGES OF PERSONALITY DEVELOPMENT

Freud described formation of the personality through five stages of psychosexual
development. As mentioned earlier, he placed much emphasis on the first 5 years of
life and believed that characteristics developed during these early years that have
great effect on one’s adaptation patterns and personality traits in adulthood.

Fixation in an early stage of development almost certainly results in
psychopathology.
1. 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, and behaviors include sucking, chewing, and
biting.

The infant feels a sense of attachment and is unable to differentiate the self from the
person who is providing the mothering; this includes feelings such as anxiety.

Because of this lack of differentiation, a pervasive feeling of anxiety on the part of
the mother may be passed on to her infant, leaving the child vulnerable to similar
feelings of insecurity.

With the beginning of development of the ego at age 4 to 6 months, the infant starts
to view the self as separate from the mothering figure.

A sense of security and the ability to trust others are derived out of gratification
from fulfillment of basic needs during this stage.
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2. Anal Stage: 18 Months to 3 Years

The major task is gaining independence and control, with particular focus on the
excretory function.

The task of toilet training may have far-reaching effects on the child in terms of
values and personality characteristics.

When toilet training is strict and rigid, the child may choose to retain the feces,
becoming constipated.

Adult retentive personality traits influenced by this type of training include
stubbornness, stinginess, and greed.

When the training is loose or the child to expel feces in an unacceptable manner or
at inappropriate times, a far-reaching effects of this behavior pattern include
malevolence (evil), cruelty to others, destructiveness, disorganization, and
untidiness.

Toilet training that is more permissive and accepting attaches the feeling of
importance and desirability to feces production. The child becomes extroverted,
productive, and altruistic.
3. Phallic Stage: 3 to 6 Years

In this stage, the focus of energy shifts to the genital 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 unconscious desire to eliminate the parent of the
same gender and to possess the parent of the opposite gender for himself or herself.

Guilt feelings result with the emergence of the superego during these years.

Resolution of this internal conflict occurs when the child develops a strong
identification with the parent of the same gender and internalizes that parent’s
attitudes, beliefs, and value system.
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4. Latency Stage: 6 to 12 Years

During the elementary school years, the focus changes from egocentrism to one of
more interest in group activities, learning, and socialization with peers.

Sexuality is not absent during this period but remains obscure and invisible to
others.

Children of this age show a distinct preference for same-gender relationships, even
rejecting members of the opposite gender.
5. 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 gender and preparations
for selecting a mate.

The development of sexual maturity evolves from self-gratification to behaviors
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 gives nurses the ability to recognize
behaviors associated with the id, the ego, and the superego to assist in the
assessment of developmental 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 and in helping clients accept themselves as unique individuals.
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2. SULLIVAN’S ITERPERSONAL THEORY OF DEVELOPMENT
DEFINITION

Interpersonal theory deals with people's characteristic interaction patterns, which
vary along the dimensions of dominance and friendliness.

Sullivan (1953) believed that individual behavior and personality development are
the direct result of interpersonal relationships.
CONCEPTS OF SULLIVAN’S INTERPERSONAL THEORY
1. Anxiety
Is a feeling of emotional discomfort, toward the relief or prevention of which all
behavior is aimed. Sullivan believed that anxiety is the “chief disruptive force in
interpersonal relations and the main factor in the development of serious difficulties in
living.”
It arises out of one’s inability to satisfy needs or achieve interpersonal security.
2. Satisfaction of needs
Is the fulfillment of all requirements associated with an individual’s physiochemical
environment (oxygen, food, water, warmth, tenderness, rest, activity, sexual expression)
and anything that, when absent, produces discomfort in the individual.
3. Interpersonal security
Is the feeling associated with relief from anxiety. When all needs have been met, one
experiences a sense of total well-being
4. Self-system
Is a collection of experiences, or security measures, adopted by the individual to protect
against anxiety. Sullivan identified three components of the self system, which are based
on interpersonal experiences early in life:
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A. The Good Me

Is the part of the personality that develops in response to positive feedback from the
primary caregiver where feelings of pleasure, contentment, and gratification are
experienced

The child learns which behaviors elicit this positive response as it becomes
incorporated into the self system.
B. The Bad Me

Is the part of the personality that develops in response to negative feedback from
the primary caregiver where anxiety is experienced, eliciting feelings of discomfort,
displeasure, and distress

The child learns to avoid these negative feelings by altering certain behaviors.
C. The Not Me

Is the part of the personality that develops in response to situations that produce
intense anxiety in the child where feelings of horror, awe, dread, and loathing are
experienced in response to these situations, leading the child to deny these feelings
in an effort to relieve anxiety.

These feelings, having then been denied, become “not me,” but someone else

This withdrawal from emotions has serious implications for mental disorders in
adult life.
SULLIVAN’S STAGES OF PERSONALITY DEVELOPMENT
Sullivan described six stages of personality development.
1. Infancy: Birth to 18 Months
During this 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
2. Childhood: 18 Months to 6 Years

The child learns that interference with fulfillment of personal wishes and desires
may result in delayed gratification and learns to accept this and feel comfortable
with it, recognizing that delayed gratification often results in parental approval, a
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more lasting type of reward

Tools of this stage include the mouth, the anus, language, experimentation,
manipulation, and identification.
3. Juvenile: 6 to 9 Years

The major task of the juvenile stage is formation of satisfactory relationships within
the peer group

This is accomplished through the use of competition, cooperation, and compromise
4. Preadolescence: 9 to 12 Years

The tasks of this stage focus on developing relationships with persons of the same
gender where one’s ability to collaborate with and show love and affection for
another person begins at this stage
5. Early Adolescence: 12 to 14 Years

During early adolescence, the child is struggling with developing a sense of identity,
separate and independent from the parents

The major task is formation of satisfactory relationships with members of the
opposite gender

Sullivan saw the emergence of lust in response to biological changes as a major force
occurring during this period
6. Late Adolescence: 14 to 21 Years

This stage is characterized by tasks associated with the attempt to achieve
interdependence within the society and the formation of a lasting, intimate
relationship with a selected member of the opposite gender

The genital organs are the major developmental focus of this stage
RELEVANCE OF INTERPERSONAL THEORY TO NURSING PRACTICE

The interpersonal theory has significant relevance to nursing practice Relationship
development is a major concept of this theory, and is also a major psychiatric
nursing intervention
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
Nurses develop therapeutic relationships with clients in an effort to help them
generalize this ability to interact successfully with others

With knowledge about the behaviors associated with all levels of anxiety and
methods for alleviating anxiety, nurses can help clients achieve interpersonal
security and a sense of well-being, a higher degree of independent and interpersonal
functioning.
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3. ERIKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT
DEFINITION
It explains eight stages through which a healthily developing human should pass from
infancy to late adulthood. In each stage the person confronts, and hopefully masters,
new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as
problems in the future.
ERIKSON’S STAGES OF PERSONALITY DEVELOPMENT

Erikson (1963) studied the influence of social processes on the development of the
personality

He described eight stages of the life cycle during which individuals struggle with
developmental “crises.”

Specific tasks associated with each stage must be completed for resolution of the
crisis and for emotional growth to occur.
1. Trust versus Mistrust: Birth to 18 Months
Major Developmental Task

The major task is to develop a basic trust in the mothering figure and be able to
generalize it to others

Achievement of the task results in self-confidence, optimism, faith in the
gratification of needs and desires, and hope for the future. The infant learns to trust
when basic needs are met consistently

Non-achievement 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 is to gain some self-control and independence within the
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environment

Achievement of the task results in a sense of self control 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

Non-achievement 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 this stage 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 exercise restraint and self-control of
inappropriate social behaviors

Assertiveness and dependability increase, and the child enjoys learning personal
achievement

The conscience develops controlling the impulsive behaviors of the id. Initiative is
achieved when creativity is encouraged and performance is recognized and
positively reinforced.

Non-achievement 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
situations for which one is not responsible.

The child may view him- or herself as evil and deserving of punishment. The task
remains unresolved when creativity is silenced 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 of this stage is to achieve a sense of self confidence by learning,
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competing, performing successfully, and receiving recognition from significant
others, peers, and acquaintances.

Achievement of the task results in a sense of satisfaction 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 fantasy and “real-world” activities

Industry is achieved when encouragement is given to performance of activities and
responsibilities in the school and community, as well as those within the home, and
recognition is given for accomplishments

Non-achievement results in difficulty in interpersonal relationships because of
feelings of personal inadequacy

The individual can neither cooperate nor compromise with others in group activities
nor problems 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 individual may manipulate or violate the rights of others to satisfy
his or her own needs or desires and 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 this stage, 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 confidence, emotional stability, and a
view of the self as a unique individual

Commitments are made to a value system, to the choice for a career, and to
relationships with members of both genders
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
Identity is achieved when adolescents are allowed to experience independence by
making decisions that influence their lives

Parents should be available to offer support when needed but should gradually
relinquish control to the maturing individual in an effort to encourage the
development of an independent sense of self

Non-achievement results in a sense of self-consciousness, doubt, and confusion
about one’s role in life

Personal values or goals for one’s life are absent.

Commitments to relationships with others are nonexistent or 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:
-
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 parental rejection or frequent shifting of parental figures has occurred
6. Intimacy versus Isolation: 20 to 30 Years
Major Developmental Task

The objective during this stage is to form an intense, lasting relationship or a
commitment to another person, a cause, an institution, or a creative effort

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

Personal sacrifices are made for another person, a career, or a cause by which
intimacy is achieved

This is learned when one has been the recipient of this type of giving within the
family unit

Non-achievement results in withdrawal, social isolation, and aloneness. The
individual is unable to form lasting, intimate relationships, often seeking intimacy
through numerous superficial sexual contacts
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
No career is established

A history of occupational changes

The task remains unresolved when love in the home has been denied or distorted
during the younger years

One fails to achieve the ability to give of the self without having been the recipient of
such giving early on from primary caregivers
7. Generativity versus Stagnation or Self-Absorption: 30 to 65 Years
Major Developmental Task

To achieve the life goals established for one while also considering the welfare of
future generations

Achievement of the task results in a sense of gratification from personal and
professional achievements and from meaningful contributions to theirs

The individual 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

Non-achievement 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

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 individual derives a sense of dignity from his or her life experiences and does
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not fear death, rather viewing it as another stage 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 the ways their lives have progressed

Non-achievement results in 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 if earlier tasks are not fulfilled: self-confidence, a
concern for others, and a strong sense of self-identity were never achieved.
RELEVANCE OF PSYCHOSOCIAL DEVELOPMENT THEORY TO NURSING PRACTICE

It incorporates socio-cultural concepts into the development of personality

The systematic, stepwise approach and outlined specific tasks that should be
completed during each stage can be used in psychiatric/mental health nursing as
many patients are still struggling to accomplish tasks from a number of
developmental stages

Nurses can plan care to assist these individuals in fulfilling the tasks and in moving
on to a higher developmental level
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4. HILDERD PEPLAU'S NURSIN MODEL OF INTERPERSONAL RELATIONS AND THE
THERAPEUTIC NURSE-CLIENT RELATIONSHIP
HILDEGARD E PEPLAU

Peplau (1991) applied interpersonal theory to nurse–client relationship
development in nursing practice
-
A framework for psychodynamic nursing: the interpersonal involvement of the
nurse with a client in a given nursing situation
“Nursing is helpful when both the patient and the nurse grow as a result of the
learning that occurs in the nursing situation.”

Peplau correlated the stages of personality development in childhood to stages
through which clients advance during the progression of an illness

She also viewed these interpersonal experiences as learning situations for nurses to
facilitate forward movement in the development of personality

When there is fulfillment of psychological tasks associated with the nurse–client
relationship, the personalities of both can be strengthened
KEY CONCEPTS INCLUDE THE FOLLOWING:
1. Nursing
Is a human relationship between an individual who is sick, or in need of health services,
and a nurse especially educated to recognize and to respond to the need for help.
2. Psychodynamic nursing
Is being able to understand one’s own behavior, to help others identify felt difficulties,
and to apply principles of human relations to the problems that arise at all levels of
experience
3. Roles
Roles are sets of values and behaviors that are specific to functional positions within
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social structures
Nurses Roles
Peplau identified the following nursing roles:
1. Resource person
Is one who provides specific, needed information that helps the client understand
his or her problem and the new situation.
2. Counselor
Is one who listens as the client reviews feelings related to difficulties he or she is
experiencing in any aspect of life. “Interpersonal techniques” have been identified to
facilitate the nurse’s interaction in the process of helping the client solve problems
and make decisions concerning these difficulties
3. Teacher
Is one who identifies learning needs and provides information to the client or family
that may aid in improvement of the life situation.
4. Leader
Is one who directs the nurse–client interaction and ensures that appropriate actions
are undertaken to facilitate achievement of the designated goals.
5. Technical expert
Is one who understands various professional devices and possesses the clinical skills
necessary to perform the interventions that are in the best interest of the client.
6. Surrogate
Is one who serves as a substitute figure for another
PHASES OF THE NURSE–CLIENT RELATIONSHIP
Are stages of overlapping roles or functions in relation to health problems, during which
the nurse and client learn to work cooperatively to resolve difficulties. Peplau identified
four phases:
Orientation is the phase during which the client, nurse, and family work together to
recognize, clarify, and define the existing problem
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Identification is the phase after which the client’s initial impression has been clarified
and during which he or she begins to respond selectively to persons who seem to offer
the help that is needed
Clients may respond in one of three ways:
(1) On the basis of participation or inter-dependent relations with the nurse
(2) On the basis of independence or isolation from the nurse
(3) On the basis of helplessness or dependence on the nurse
Exploitation is the phase during which the client proceeds to take full advantage of the
services offered to him or her. Having learned which services are available, feeling
comfortable within the setting, and serving as an active participant in his or her own
health care, the client exploits the services available and explores all possibilities of the
changing situation.
Resolution occurs when the client is freed from identification with helping persons and
gathers strength to assume independence. Resolution is the direct result of successful
completion of the other three phases.
PEPLAU’S STAGES OF PERSONALITY DEVELOPMENT
1. Psychological tasks

Are developmental lessons that must be learned on the way to achieving maturity of
the personality.

Peplau (1991) identified four psychological tasks that she associated with the stages
of infancy and childhood described by Freud and Sullivan. She stated,
“When psychological tasks are successfully learned at each era of development,
biological capacities are used productively and relations with people lead to
productive living. When they are not successfully learned they carry over into
adulthood and attempts at learning continue in devious ways, more or less impeded
by conventional adaptations that provide a super-structure over the baseline of
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actual learning”

In the context of nursing, Peplau related these four psychological tasks to the
demands made on nurses in their relations with clients. She maintained that:
“…nursing can function as a maturing force in society. Since illness is an event that
is experienced along with feelings that derive from older experiences but are
reenacted in the relationship of nurse to patient, the nurse-patient relationship is
seen as an opportunity for nurses to help patients to complete the unfinished
psychological tasks of childhood in some degree”

Peplau’s psychological tasks of personality development include the following four
stages:
Learning to Count on Others

Nurses and clients first come together as strangers. Both bring to the relationship
certain “raw materials,” such as inherited biological components, personality
characteristics (temperament), individual intellectual capacity, and specific cultural
or environmental influences.

Peplau related these to the same “raw materials” with which an infant comes into
this world. The newborn is capable of experiencing both comfort and discomfort.

He or she soon learns to communicate feelings in a way that results in the fulfillment
of comfort needs by the mothering figure that provides love and care
unconditionally. However, fulfillment of these dependency needs is inhibited when
goals of the mothering figure become the focus, and love and care are contingent
upon meeting the needs of the caregiver rather than the infant.

Clients with unmet dependency needs regress during illness and demonstrate
behaviors that relate to this stage of development. Other clients regress to this level
because of physical disabilities associated with their illness.

Peplau believed that, when nurses provide unconditional care, they help these
clients progress toward more mature levels of functioning. This may involve the role
of “surrogate mother,” in which the nurse fulfills needs for the client with the intent
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of helping him or her grow, mature, and become more independent.
Learning to Delay Satisfaction

Peplau related this stage to that of toddlerhood, or the first step in the development
of interdependent social relations. Psychosexually, it is compared to the anal stage of
development, when a child learns that, because of cultural mores, he or she cannot
empty the bowels for relief of discomfort at will, but must delay to use the toilet,
which is considered more culturally acceptable.

When toilet training occurs too early or is very rigid, or when appropriate behavior
is set forth as a condition for receiving love and caring, tasks associated with this
stage remain unfulfilled. The child feels powerless and fails to learn the satisfaction
of pleasing others by delaying self-gratification in small ways. He or she may also
exhibit rebellious behavior by failing to comply with demands of the mothering
figure in an effort to counter the feelings of powerlessness. The child may
accomplish this by withholding the fecal product or failing to deposit it in the
culturally acceptable manner.
Peplau cites From (1949) in describing the following potential behaviors of
individuals who have failed to complete the tasks of the second stage of
development:
(1) Exploitation and manipulation of others to satisfy their own desires because they
are unable to do so independently
(2) Suspiciousness and envy of others, directing hostility toward others in an effort to
enhance their own self-image
(3) Hoarding and withholding possessions from others; greed
(4) Excessive neatness and punctuality
(5) Inability to relate to others through sharing of feelings, ideas, or experiences
(6) Ability to vary the personality characteristics to those required to satisfy personal
desires at any given time.

When nurses observe these types of behaviors in clients, it is important to
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encourage full expression and to convey unconditional acceptance. When the client
learns to feel safe and unconditionally accepted, he or she is more likely to let go of
the oppositional behavior and advance in the developmental progression. Peplau
(1991) stated:
Nurses who aid patients to feel safe and secure, so that wants can be expressed
and satisfaction eventually achieved, also help them to strengthen personal
power that is needed for productive social activities
Identifying Oneself
“The concept of self develops as a product of interaction with adults”

A child learns to structure self-concept by observing how others interact with him or
her

Roles and behaviors are established out of the child’s perception of the expectations
of others

When children have the impression that adults expect them to maintain more or less
permanent roles as infants, they perceive themselves as helpless and dependent

When the perceived expectation is that the child must behave in a manner beyond
his or her maturational level, the child is deprived of the fulfillment of emotional and
growth needs at the lower levels of development

Children who are given freedom to respond to situations and experiences
unconditionally learn to improve on and reconstruct behavioral responses at their
own pace. Peplau (1991) stated,
The ways in which adults appraise the child and the way he functions in relation to
his experiences and perceptions are taken in or introjected and become the child’s
view of himself

In nursing, it is important for the nurse to recognize cues that communicate how the
client feels about him or herself, and about the presenting medical problem

In the initial interaction, it is difficult for the nurse to perceive the “wholeness” of the
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client, for the focus is on the condition that has caused him or her to seek help

Likewise, it is difficult for the client to perceive the nurse as a “mother (or father)” or
“somebody’s wife (or husband)” or as having a life aside from being there to offer
assistance with the immediate presenting problem

As the relationship develops, nurses must be able to recognize client behaviors that
indicate unfulfilled needs and provide experiences that promote growth

For example, the client who very proudly announces that he or she has completed
activities of daily living independently and wants the nurse to come and inspect her
room may still be craving the positive reinforcement that is so necessary at lower
levels of development.

Nurses must also be aware of the predisposing factors that they bring to the
relationship. Attitudes and beliefs about certain issues can have a harmful effect on
the client and interfere not only with the therapeutic relationship but also with the
client’s ability for growth and development

For example, a nurse who has strong beliefs against abortion may treat a client who
has just undergone an abortion with disapproval and disrespect

The nurse may respond in this manner without even realizing he or she is doing so

Attitudes and values are introjected during early development and can be integrated
so completely as to become a part of the self-system

Nurses must have knowledge and appreciation of their own concept of self to
develop the flexibility required to accept all clients as they are, unconditionally.

Effective resolution of problems that arise in the interdependent relationship can be
the means for both client and nurse to reinforce positive personality traits and
modify those more negative views of self
Developing Skills in Participation

Peplau cites Sullivan’s (1953) description of the “juvenile” stage of personality
development (ages 6 through 9). During this stage, the child develops the capacity to
“compromise, compete, and cooperate” with others.

These skills are considered basic to one’s ability to participate collaboratively with
others. If a child tries to use the skills of an earlier level of development (e.g., crying,
whining, or demanding), he or she may be rejected by peers of this juvenile stage. As
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this stage progresses, children begin to view themselves through the eyes of their
peers. Sullivan (1953) called this “consensual validation.” Preadolescents take on a
more realistic view of the world and a feeling of their place in it

The capacity to love others (besides the mother figure) develops at this time and is
expressed in relation to one’s self-acceptance

Failure to develop appropriate skills at any point along the developmental
progression results in an individual’s difficulty with participation in confronting the
recurring problems of life. It is not the responsibility of the nurse to teach solutions
to problems, but rather to help clients improve their problem-solving skills so that
they may achieve their own resolution.

This is accomplished through development of the skills of competition, compromise,
cooperation, consensual validation, and love of self and others. Nurses can assist
clients to develop or refine these skills by helping them to identify the problem,
define a goal, and take the responsibility for performing the actions necessary to
reach that goal. Peplau (1991) stated:
“Participation is required by a democratic society. When it has not been
learned in earlier experiences, nurses have an opportunity to facilitate
learning in the present and thus to aid in the promotion of a democratic
society”
RELEVANCE OF PEPLAU’S MODEL TO NURSING PRACTICE

Peplau’s model provides nurses with a framework to interact with clients, many of
whom are fixed in or, because of illness, have regressed to, an earlier level of
development. She suggests roles that nurses may assume to assist clients to
progress, thereby achieving or resuming their appropriate developmental level.

Appropriate developmental progression arms the individual with the ability to
confront the recurring problems of life.

Nurses serve to facilitate learning of that which has not been learned in earlier
experiences.
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