FIG. 2.1 The mind as an iceberg.
Preconscious
Just below the surface of awareness is the preconscious, which contains material that can be retrieved rather easily through conscious effort.
Unconscious
The unconscious includes all repressed memories, passions, and unacceptable urges lying deep below the surface. Memories and emotions associated with trauma may be stored in the
unconscious because the individual finds it too painful to deal with them. The unconscious exerts a powerful yet unseen effect on the conscious thoughts and feelings of the individual. The individual is usually unable to retrieve unconscious material without the assistance of a trained therapist.
Personality Structure
Id
At birth we are all id. The id is totally unconscious and impulsive. It is the source of all drives, instincts, reflexes, and needs. The id cannot tolerate frustration and seeks to discharge tension and return to a more comfortable level of energy. The id lacks the ability to problem solve and is illogical. A hungry, screaming infant is the perfect example of id.
Ego
Within the first few years of life as the child begins to interact with others, the ego develops. The ego resides in the conscious, preconscious, and unconscious levels of awareness. The problem solver and reality tester, the ego attempts to navigate the outside world. It is able to differentiate subjective experiences, memory images, and objective reality.
The ego follows the reality principle, which says to the id, “You have to delay gratification for right now,” then sets a course of action. For example, a hungry man feels tension arising from the id that wants to be fed. His ego allows him not only to think about his hunger but also to plan where he can eat and to seek that destination. This process is known as reality testing because the individual is factoring in reality to implement a plan to decrease tension.
Superego
The superego, which develops between the ages of 3 and 5, represents the moral component of personality. The superego resides in the conscious, preconscious, and unconscious levels of
awareness. The superego consists of the conscience (all the “should nots” internalized from parents and society) and the ego ideal (all the “shoulds” internalized from parents and society). When behavior falls short of ideal, the superego may induce guilt. Likewise, when behavior is ideal, the superego may allow a sense of pride.
In a mature and well-adjusted individual, the three systems of the personality—the id, the ego, and the superego—work together as a team under the administrative leadership of the ego. If the id is too powerful, the person will lack control over impulses. If the superego is too powerful, the person may be self-critical and suffer from feelings of inferiority.
Defense Mechanisms and Anxiety
Freud (1969) believed that anxiety is an inevitable part of living. The environment in which we live presents dangers and insecurities, threats and satisfactions. It can produce pain and increase tension or produce pleasure and decrease tension. The ego develops defenses, or defense mechanisms, to ward off anxiety by preventing conscious awareness of threatening feelings.
Defense mechanisms share two common features: (1) they all (except suppression) operate on an unconscious level and (2) they deny, falsify, or distort reality to make it less threatening. Although we cannot survive without defense mechanisms, it is possible for our defense mechanisms to distort reality to such a degree that we experience difficulty with healthy adjustment and personal growth.
Chapter 15 provides a full list and description of defense mechanisms.
Psychosexual Stages of Development
Freud believed that human development proceeds through five stages from infancy to adulthood.
He believed that experiences during the first 5 years determined an individual’s lifetime adjustment pattern and personality traits. By the time a child enters school, subsequent growth consists of elaborating on this basic structure. Freud’s psychosexual stages of development are in Table 2.1.
Psychoanalytic Therapy
Classical psychoanalysis, as developed by Sigmund Freud, is seldom used today. Freud’s premise that early intrapsychic conflict as the cause for all mental illness is no longer widely thought to be valid. Such therapy requires an unrealistically lengthy period of treatment (i.e., three to five times a week for many years), making it prohibitively expensive and uncovered by insurance.
The purpose of these sessions is to uncover unconscious conflicts. Free association, dream and fantasy analysis, defense mechanism recognition, and interpretation are tools used by the analyst.
Two concepts from classic psychoanalysis that are impor-tant for nurses to know are transference and countertransference (Freud, 1969). Transference refers to unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant other. The
patient may say something like, “You remind me exactly of my sister.” The transference may be positive (affectionate) or negative (hostile). Psychoanalysis actually encourages transference as a way to understand original relationships. Such exploration helps the patient to better understand certain feelings and behaviors.
Countertransference refers to unconscious feelings that the healthcare worker has toward the patient. For instance, if the patient reminds you of someone you do not like, you may unconsciously react as if the patient were that individual. Strong negative or positive feelings toward the patient could be a red flag for countertransference. Such responses underscore the importance of
maintaining self-awareness and seeking supervisory guidance as therapeutic relationships progress. Chapter 8 talks more about countertransference and the nurse-patient relationship.