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therapy and various treatment settings. The medical model of treatment is based on the neurobiologic theories discussed in Chapter 2.
FIGURE 3.1. Sigmund Freud: The father of psychoanalysis.
Personality Components: Id, Ego, and Superego. Freud conceptualized personality structure as having three components:
id, ego, and superego (Freud, 1923/1962). The id is the part of one’s nature that reflects basic or innate desires such as pleasure-seeking behavior, aggression, and sexual impulses. The id seeks instant gratification, causes impulsive unthinking behavior, and has no regard for rules or social convention. The superego is the part of a person’s nature that reflects moral and ethical concepts, values, and parental and social expectations; therefore, it is in direct opposition to the id. The third component, the ego, is the balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully in the world. Freud believed that anxiety resulted from the ego’s attempts to balance the impulsive instincts of the id with the stringent rules of the superego. The accompanying drawing demonstrates the relationship of these personality structures.
Behavior Motivated by Subconscious Thoughts and Feelings. Freud believed that the human personality functions at three levels of awareness: conscious, preconscious, and unconscious (Freud, 1923/1962). Conscious refers to the perceptions, thoughts, and emotions that exist in the person’s awareness, such as being aware of happy feelings or thinking about a loved one. Preconscious thoughts and emotions are not currently in the person’s awareness, but he or she can recall them with some effort—for example, an adult remembering what he or she did, thought, or felt as a child. The unconscious is the realm of thoughts and feelings that motivates a person even though he or she is totally unaware of them. This realm includes most defense mechanisms (see discussion to follow) and some instinctual drives or motivations. According to Freud’s theories, the person represses into the unconscious the memory of traumatic events that are too painful to remember.
Freud believed that much of what we do and say is motivated by our subconscious thoughts or feelings (those in the preconscious or unconscious level of awareness). A Freudian slip is a term we commonly use to describe slips of the tongue—for example, saying “You look portly today” to an overweight friend instead of
“You look pretty today.” Freud believed that these slips are not accidents or coincidences, but rather are indications of subconscious feelings or thoughts that accidentally emerge in casual day-to-day conversation.
Freud’s components of personality
Freud’s Dream Analysis. Freud believed that a person’s dreams reflect his or her subconscious and have significant meaning, although sometimes the meaning is hidden or symbolic. Dream analysis, a primary technique used in psychoanalysis, involves discussing a client’s dreams to discover their true meaning and significance. For example, a client might report having recurrent frightening dreams about snakes chasing her. Freud’s interpretation might be that the woman fears intimacy with men; he would view the snake as a phallic symbol, representing the penis.
Another method used to gain access to subconscious thoughts and feelings is free association, in which the therapist tries to uncover the client’s true thoughts and feelings by saying a word and asking the client to respond quickly with the first thing that comes to mind. Freud believed that such quick responses would be likely to uncover subconscious or repressed thoughts or feelings.
Ego Defense Mechanisms. Freud believed that the self, or ego, uses ego defense mechanisms, which are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events.
Defense mechanisms are explained in Table 3.1. For example, a person who has been diagnosed with cancer and told he has 6 months to live but refuses to talk about his illness is using the defense mechanism of denial, or refusal to accept the reality of the situation. If a person dying of cancer exhibits continuously cheerful behavior, he could be using the defense mechanism of reaction formation to protect his emotions. Most defense mechanisms operate at the unconscious level of awareness; so people are not aware of what they are doing and often need help to see the reality.
Five Stages of Psychosexual Development. Freud based his theory of childhood development on the belief that sexual energy, termed libido, was the driving force of human behavior. He proposed that children progress through 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). Table 3.2 describes these stages and the accompanying developmental tasks. Psychopathology results when a person has difficulty making the transition from one stage to the next or when a person remains stalled at a particular stage or regresses to an
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earlier stage. Freud’s open discussion of sexual impulses, particularly in children, was considered shocking for his time (Freud, 1923/1962).
Table 3.1 Ego Defense Mechanisms
Compensation Overachievement in one area to offset real or perceived deficiencies in another area Napoleon complex: diminutive man becoming emperor
Nurse with low self-esteem working double shifts so her supervisor will like her
Conversion Expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature
Teenager forbidden to see X-rated movies is tempted to do so by friends and develops blindness, and the teenager is unconcerned about the loss of sight.
Denial Failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue
Diabetic person eating chocolate candy Spending money freely when broke
Waiting 3 days to seek help for severe abdominal pain
Displacement Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings Person who is mad at the boss yells at his or her spouse.
Child who is harassed by a bully at school mistreats a younger sibling.
Dissociation Dealing with emotional conflict by a temporary alteration in consciousness or identity Amnesia that prevents recall of yesterday’s auto accident
Adult remembers nothing of childhood sexual abuse.
Fixation Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage
Never learning to delay gratification Lack of a clear sense of identity as an adult
Identification Modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal
Nursing student becoming a critical care nurse because this is the specialty of an instructor she admires Intellectualization Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not
the emotions
Person shows no emotional expression when discussing serious car accident.
Introjection Accepting another person’s attitudes, beliefs, and values as one’s own Person who dislikes guns becomes an avid hunter, just like a best friend.
Projection Unconscious blaming of unacceptable inclinations or thoughts on an external object
Man who has thought about same-gender sexual relationship, but never had one, beats a man who is gay.
Person with many prejudices loudly identifies others as bigots.
Rationalization Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect Student blames failure on teacher being mean.
Man says he beats his wife because she doesn’t listen to him.
Reaction formation Acting the opposite of what one thinks or feels
Woman who never wanted to have children becomes a supermom.
Person who despises the boss tells everyone what a great boss she is.
Regression Moving back to a previous developmental stage to feel safe or have needs met A 5-year-old asks for a bottle when new baby brother is being fed.
Man pouts like a 4-year-old if he is not the center of his girlfriend’s attention.
Repression Excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness Woman has no memory of the mugging she suffered yesterday.
Woman has no memory before age 7, when she was removed from abusive parents.
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Resistance Overt or covert antagonism toward remembering or processing anxiety-producing information Nurse is too busy with tasks to spend time talking to a dying patient.
Person attends court-ordered treatment for alcoholism but refuses to participate.
Sublimation Substituting a socially acceptable activity for an impulse that is unacceptable Person who has quit smoking sucks on hard candy when the urge to smoke arises.
Person goes for a 15-minute walk when tempted to eat junk food.
Substitution Replacing the desired gratification with one that is more readily available Woman who would like to have her own children opens a day care center.
Suppression Conscious exclusion of unacceptable thoughts and feelings from conscious awareness Student decides not to think about a parent’s illness to study for a test.
Woman tells a friend she cannot think about her son’s death right now.
Undoing Exhibiting acceptable behavior to make up for or negate unacceptable behavior Person who cheats on a spouse brings the spouse a bouquet of roses.
Man who is ruthless in business donates large amounts of money to charity.
Transference and Countertransference. Freud developed the concepts of transference and countertransference.
Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships (Freud, 1923/1962). Transference patterns are automatic and unconscious in the therapeutic relationship. For example, an adolescent female client working with a nurse who is about the same age as the teen’s parents might react to the nurse like she reacts to her parents. She might experience intense feelings of rebellion or make sarcastic remarks; these reactions are actually based on her experiences with her parents, not the nurse.
Table 3.2 Freud’s Developmental Stages
Phase Age Focus
Oral Birth to 18 months Major site of tension and gratification is the mouth, lips, and tongue; includes biting and sucking activities.
Id is present at birth.
Ego develops gradually from rudimentary structure present at birth.
Anal 18–36 months Anus and surrounding area are major source of interest.
Voluntary sphincter control (toilet training) is acquired.
Phallic/oedipal 3–5 years Genital is the focus of interest, stimulation, and excitement.
Penis is organ of interest for both sexes.
Masturbation is common.
Penis envy (wish to possess penis) is seen in girls; oedipal complex (wish to marry opposite-sex parent and be rid of same-sex parent) is seen in boys and girls.
Latency 5–11 or 13 years Resolution of oedipal complex
Sexual drive channeled into socially appropriate activities such as school work and sports.
Formation of the superego.
Final stage of psychosexual development.
Genital 11–13 years Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy.
Adapted from Freud, S. (1962). The ego and the id (The standard edition of the complete psychological works of Sigmund Freud) (J. Strachey, Trans.).
New York, NY: W. W. Norton & Company.
Countertransference occurs when the therapist displaces onto the client attitudes or feelings from his or her past. For example, a female nurse who has teenage children and who is experiencing extreme frustration with an adolescent client may respond by adopting a parental or chastising tone. The nurse is countertransfering her own attitudes and feelings toward her children onto the client. Nurses can deal with countertransference by examining their own feelings and responses, using self-awareness, and talking with colleagues.
Current Psychoanalytic Practice
Psychoanalysis focuses on discovering the causes of the client’s unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety and on helping the client to gain insight into and resolve these conflicts and anxieties. The analytic therapist uses the techniques of free association, dream analysis, and interpretation of behavior.
Psychoanalysis is still practiced today but on a very limited basis. Analysis is lengthy, with weekly or more frequent sessions for several years. It is costly and not covered by conventional health insurance programs;
thus, it has become known as “therapy for the wealthy.”