It’s another edition of Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. Last week, I posted the second section of Chapter 2: Literature Review which included a general overview of adolescent cognitive development. This week is the next section of Chapter 2: Literature Review, a general discussion of adolescent psychosocial development. This one is pretty lengthy…

Psychosocial

Erik Erikson’s theory of development is based on Freud’s theories of human development. Erikson expanded on Freud’s biological approach, taking into account the impact of society on development. Erikson developed “a set of eight psychosocial stages covering the lifespan, by studying the development of identity, and by developing methods that reach beyond the structural psychoanalytic setting used with adults” (Miller, 1993, p. 156). According to Miller (1993), “in the psychosocial view, physical maturation has personal and social repercussions. Maturation brings a new skill that opens up new possibilities for the child but also increases society’s demands on him” (p. 156).

Erikson’s first stage of development is Basic Trust versus Basic Mistrust, roughly the first year of life. Miller (1993) sums up the main task of this stage: “to acquire a favorable ratio of trust to mistrust” (p. 161). According to Erikson (1968),

a sense of basic trust … is a pervasive attitude toward oneself and the world derived from the experiences of the first year of life” (p. 96). “Babies develop trust in themselves from the feeling that others accept them and from increased familiarity with their bodily urges. (Miller, 1993, p. 161)

The bodily urges and physical experiences of an infant—sucking, biting, grasping— “are prototypes for the psychosocial modality of getting and giving” (Miller, 1993, p. 162). The baby’s primary focus is the mouth as a means of receiving, the oral stage from a psychoanalytic framework; from a more general standpoint it is the incorporative stage (Erikson, 1968, p. 98). The infant is taking nourishment orally, but he is also taking in with his other senses, learning and making sense of his environment visually, tactilely, aurally, odorously and kinesthetically.

It is necessary for some level of mistrust to be present “at all ages in order to detect impending danger or discomfort and to discriminate between honest and dishonest persons” (Miller, 1993, p. 162). An unhealthy ratio between trust and mistrust, with mistrust dominating, will result in a child or adult, who lacks self-confidence and is withdrawn and suspicious of others (Miller, 1993, p. 162), a barrier to forming and maintaining healthy relationships.

It is the relationship between mother (or primary caregiver) and infant which determines the developmental outcome of this stage, the extent to which an infant trusts or mistrusts his environment. “From the mother’s side of the interaction, there must also be trust—trust in herself as a parent and in the meaningfulness of her caretaking role” (Miller, 1993, p. 162).

Mothers create a sense of trust in their children by that kind of administration which in its quality combines sensitive care of the baby’s individual needs and a firm sense of personal trustworthiness within the trusted framework of the community’s life style. This forms the very basis in the child for a component of the sense of identity which will later combine a sense of being “all right,” of being oneself, and of becoming what other people trust one will become. (Erikson, 1968, p. 103)

Thus, the ratio of trust versus mistrust which develops in the infant serves as a structural basis for the formation of identity.

The second stage of development in Erikson’s theory is Autonomy versus Shame and Doubt, from about age two to age three, and corresponds with the psychoanalytic anal stage of development. “The psychosocial modality is holding on versus letting go, the counterpart to retention and elimination. This ambivalence pervades the child’s behavior and attitude” (Miller, 1993, p. 163). According to Erikson (1968),

the over-all significance of this second stage of early childhood lies in the rapid gains in muscular maturation, in verbalization, and in the discrimination and consequent ability—and doubly felt inability—to co-ordinate a number of highly conflicting action patterns characterized by the tendencies of ‘holding on’ and ‘letting go’. (p. 107)

Erikson (1968) characterizes this stage as a “battle for autonomy. For as he gets ready to stand on his feet more firmly, the infant also learns to delineate his world as ‘I’ and ‘you,’ and ‘me’ and ‘mine’” (p. 108).

Every mother knows how lovingly a child at this stage will snuggle close to her and how ruthlessly he will suddenly try to push her away. At the same time the child is apt both to hoard things and to discard them, to cling to treasured objects and to throw them out of the windows of houses and vehicles. (Erikson, 1968, p. 108-109)

The child’s ambivalence is reflected in the very meanings of his actions. “‘To hold’ can become a destructive and cruel retaining or restraining, and it can become a pattern of care: ‘to have and to hold.’ To ‘let go,’ too, can turn into an inimical letting loose of destructive forces, or it can become a relaxed ‘to let pass’ and ‘to let it be’ (Erikson, 1968, p. 109).

Autonomy develops as a result of a “supportive atmosphere in which the child can develop a sense of self control without a loss of self-esteem” (Miller, 1993, p. 162). The child’s parents and

his environment must … back him up in his wish to ‘stand on his own feet,’ while also protecting him against … that sense of having exposed himself prematurely and foolishly which we call shame or that secondary mistrust …, which we call doubt—doubt in himself and doubt in the firmness and perspicacity of his trainers. (Erikson, 1968, p. 110)

“Shame supposes that one is completely exposed and conscious of being looked at—in a word, self-conscious … Too much shaming does not result in a sense of propriety but in a secret determination to try to get away with things when unseen” (Erikson, 1968, p. 110). When shame prevails over the development of autonomy, it can result in an adolescent behaviorally “expressing the wish to ‘get away with’ things [yet] his precocious conscience does not let him really get away with anything, and he goes through his identity crisis habitually ashamed, apologetic, and afraid to be seen” (Erikson, 1968, p. 111).

“Doubt is the brother of shame. Whereas shame is dependent on the consciousness of being upright and exposed, doubt has much to do with a consciousness of having a front and a back—especially a ‘behind’” (Erikson, 1968, p. 112). Not only can the child not see, and initially not control this area of his body, but others show their dominance over it, threaten the child’s autonomy through their dominance, and then “designate as evil those products of the bowels which were felt to be all right when they were being passed” (Erikson, 1968, p. 112). The vestiges of doubt prevailing over autonomy are expressed by the adolescent “in a transitory total self-doubt, a feeling that all that is now ‘behind’ in time—the childhood family as well as the earlier manifestations of one’s personality—simply do not add up to the prerequisites for a new beginning” as an emerging adult (Erikson, 1968, p. 112).

This stage of development has particular ramifications for the psychosocial development of adolescents. “The first emancipation, namely, from the mother” is played out in the stage of autonomy (Erikson, 1968, p. 114).

There are clinical reasons … to believe that the adolescent turning away from the whole childhood milieu in many ways repeats this first emancipation. For this reason the most rebellious youths can also regress partially (and sometimes wholly) to a demanding and plaintive search for a guidance which their cynical independence seems to disavow. (Erikson, 1968, p. 114)

Erikson’s third stage of development is Initiative versus Guilt, roughly age four to five years. “The theme of this stage is children’s identification with their parents, who are perceived as big, powerful, and intrusive” (Miller, 1993, 164). Erikson moves beyond the Freudian Oedipus complex and concentration on the genitals to “emphasize the social components more than the sexual … Identification brings with it a conscience and a set of interests, attitudes, and sex-typed behaviors” (Miller, 1968, p. 164).

Miller identifies the basic psychosocial modality as “‘making,’ namely, intrusion, taking the initiative, forming and carrying out goals, and competing” (Miller, 1993, p. 164). From the child’s increased control of movement, more refined ability to communicate verbally and understand others, and the combination of movement and language leading to a more expansive imagination, emerges a sense of initiative, the “basis for a realistic sense of ambition and purpose” (Erikson, 1968, p. 115).

At the opposing end of the spectrum from initiative is guilt. “The child settles somewhere along a dimension ranging from successful initiative to overwhelming guilt due to an overly severe conscience that punishes sexual fantasies and immoral thoughts or behavior” (Miller, 1993, p. 164).

“The indispensable contribution of the initiative stage to later identity development, then, obviously is that of freeing the child’s initiative and sense of purpose for adult tasks which promise (but cannot guarantee) a fulfillment of one’s range of capacities” (Erikson, 1968, p. 122). Consistent with the structure of Erikson’s theory, this stage not only builds on the preceding stages and serves as a foundation for subsequent stages, but its themes and tasks will be revisited and reworked as they apply to future stages of development.

Erikson’s fourth stage of development is Industry versus Inferiority, about age six to puberty. During this stage, “the advancing child … ‘sublimates’—that is, applied to concrete pursuits and approved goals—the drives which have made him dream and play. He now learns to win recognition by producing things. He develops perseverance and adjusts himself to the inorganic laws of the tool world” (Erikson, 1968, p. 124). Most significantly, children in this stage enter school, “where they are exposed to the technology of their society” (Miller, 1993, p. 164).

Erikson (1968) defines industry:

While all children at times need to be left alone in solitary play or, later, in the company of books and radio, motion pictures and television, and while all children need their hours and days of make-believe in games, they all, sooner or later, become dissatisfied and disgruntled without a sense of being able to make things and make them well and even perfectly: it is this that I have called the sense of industry. (p. 123)

Children move beyond the realm of family into a new social realm that includes teachers, friends and friends’ parents. In looking to these other people and interacting with them, children learn to be members of society because school is its own sub-culture. “School skill seems to many to be a world all by itself, with its own goals and limitations, its achievements and disappointments” (Erikson, 1968, p. 123).

At risk during this stage is the development of a sense of inferiority.

This may be caused by an insufficient solution to the preceding conflict: the child may still want his mommy more than knowledge; he may still prefer to be the baby at home rather than the big child at school; he still compares himself with his father, and the comparison arouses a sense of guilt as well as a sense of inferiority. (Erikson, 1968, p. 124)

Furthermore, “school life may fail to sustain the promises of earlier stages in that nothing that he has learned to do well so far seems to count with his fellows or his teacher” (Erikson, 1968, p. 124).

Significant to the subsequent stage of development, puberty, there is

the danger threatening individual and society where the schoolchild begins to feel that the color of his skin, the background of his parents, or the fashion of the clothes rather than his wish and his will to learn will decide his worth as an apprentice, and thus his sense of identity —to which we must now turn. (Erikson, 1963, p. 260)

Erik Erikson defines the developmental period of adolescence as a crisis of identity versus identity confusion. Referring to the term, crisis, he states, “It is now being accepted as designating a necessary turning point, a crucial moment, when development must move one way or another, marshaling resources of growth, recovery, and further differentiation” (Erikson, 1968, p. 16). Specifically speaking to the idea of identity formation, Erikson (1968), states:

In psychological terms, identity formation employs a process of simultaneous reflection and observation, a process taking place on all levels of mental functioning, by which the individual judges himself in the light of what he perceives to be the way in which others judge him in comparison to themselves and to a typology significant to them; while he judges their way of judging him in the light of how he perceives himself in comparison to them and to types that have become relevant to him. (p. 22)

The basic task of Erikson’s developmental stage of adolescence “is to integrate the various identifications they bring from childhood into a more complex identity” (Miller, 1993, p. 165). The respective resolutions of the prior developmental stages combine with the rapid physiological changes of puberty and new social pressures and expectations to form a new identity “appropriate for the new needs, skills, and goals of adolescence” (Miller, 1993, p. 165).

An inadequately formed identity results in identity confusion “if adolescents cannot integrate their identifications, roles, or selves … The personality is fragmented, lacking a core” (Miller, 1993, p. 165). This can manifest itself in sexual identity confusion, delinquency, and psychosis, however it more commonly shows itself as an inability to achieve an occupational identity (Erikson, 1963, p. 262). “To keep themselves together they temporarily overidenitify, to the point of apparent complete loss of identity, with the heroes of cliques and crowds” (Erikson, 1963, p. 262).

Adolescents look to peers and society in their effort to understand who they are. “Adolescents not only help one another temporarily … by forming cliques and stereotyping themselves, their ideals, and their enemies; they also insistently test each other’s capacity for sustaining loyalties in the midst of inevitable conflicts of values” (Erikson, 1968, p. 133). In trying to differentiate who they see themselves as and who they do not want to be,

young people can become remarkably clannish, intolerant, and cruel in their exclusion of others who are ‘different,’ in skin color or cultural background, in tastes and gifts, and often in entirely petty [aspects] of dress and gesture arbitrarily selected as the signs of an in-grouper or out-grouper. It is important to understand … that such intolerance may be, for a while, a necessary defense against a sense of identity loss. (Erikson, 1968, p. 132)

Adolescents turn against their parents and other authoritative figures in an attempt to separate and define their identities, since childhood is a time of seeking to identity with caregivers.

In their search for a new sense of continuity and sameness, adolescents have to refight many of the battles of earlier years, even though to do so they must artificially appoint perfectly well-meaning people to play the roles of adversaries. (Erikson, 1963, p. 261)

In order to understand how adolescents with diabetes respond to the demands of their condition, it is necessary to have a knowledge base about the fundamental aspects of normal adolescent development. Physical maturation, the stage of puberty, cognitive development, Piaget’s formal operational stage, and psychosocial development, Erikson’s stage of identity versus identity confusion, all coincide to create the turmoil that characterizes adolescence.

Thanks for reading!
Check back next week for Diabetes: Introduction, Etiology, Pathophysiology, and Epidemiology & Statistics.