02 - 4.2 Erik H. Erikson

4.2 Erik H. Erikson

Cotti P. Sexuality and psychoanalytic aggrandisement: Freud’s 1908 theory of cultural history. Hist Psychiatry. 2011;22:58. Cotti P. Travelling the path from fantasy to history: The struggle for original history within Freud’s early circle, 1908– 1913. Psychoanalysis Hist. 2010;12:153. Freud S. The Standard Edition of the Complete Psychological Works of Sigmund Freud. 24 vols. London: Hogarth Press; 1953–1974. Gardner H. Sigmund Freud: Alone in the world. In: Creating Minds: An Anatomy of Creativity Seen Through the Lives of Freud, Einstein, Picasso, Stravinsky, Eliot, Graham, and Ghandi. New York: Basic Books; 2011:47. Hoffman L. One hundred years after Sigmund Freud’s lectures in America: Towards an integration of psychoanalytic theories and techniques within psychiatry. Histor Psychiat. 2010;21(4):455. Hollon SD, Wilson GT. Psychoanalysis or cognitive-behavioral therapy for bulimia nervosa: the specificity of psychological treatments. Am J Psychiatry . 2014;171:13–16. Meissner WW. Classical psychoanalysis. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2009:788. Meissner WW. The God in psychoanalysis. Psychoanal Psychol. 2009;26(2):210. Neukrug ES. Psychoanalysis. In: Neukrug ES, ed. Counseling Theory and Practice. Belmont, CA: Brooks/Cole; 2011:31. Perlman FT, Brandell JR. Psychoanalytic theory. In: Brandell JR, ed. Theory & Practice in Clinical Social Work. 2nd ed. Thousand Oaks, CA: Sage; 2011:41. Tauber AI. Freud, the Reluctant Philosopher. Princeton, NJ: Princeton University Press; 2010. Thurschwell P. Sigmund Freud. 2nd ed. New York: Routledge; 2009. 4.2 Erik H. Erikson Erik H. Erikson (Fig 4.2-1) was one of America’s most influential psychoanalysts. Throughout six decades in the United States, he distinguished himself as an illuminator and expositor of Freud’s theories and as a brilliant clinician, teacher, and pioneer in psychohistorical investigation. Erikson created an original and highly influential theory of psychological development and crisis occurring in periods that extended across the entire life cycle. His theory grew out of his work first as a teacher, then as a child psychoanalyst, next as an anthropological field worker, and, finally, as a biographer. Erikson identified dilemmas or polarities in the ego’s relations with the family and larger social institutions at nodal points in childhood, adolescence, and early, middle, and late adulthood. Two of his psychosexual historical studies, Young Man Luther and Gandhi’s Truth (published in 1958 and 1969 respectively), were widely hailed as profound explorations of how crucial circumstances can interact with the crises of certain great persons at certain moments in time. The interrelationships of the psychological development of the person and the historical developments of the times were more fully explored in Life History and the Historical Moment, written by Erikson in 1975.

FIGURE 4.2-1 Erik Erikson (1902-1994). Erik Homburger Erikson was born June 15, 1902 in Frankfurt, Germany, the son of Danish parents. He died in 1994. His father abandoned his mother before he was born, and he was brought up by his mother, a Danish Jew, and her second husband, Theordor Homburger, a German-Jewish pediatrician. Erikson’s parents chose to keep his real parentage a secret from him, and for many years he was known as Erik Homburger. Erikson never knew the identity of his biological father; his mother withheld that information from him all her life. The man who introduced the term “identity crisis” into the language undoubtedly struggled with his own sense of identity. Compounding his parents’ deception about his biological father—their “loving deceit,” as he called it—was the fact that, as a blond, blue-eyed, Scandinavian-looking son of a Jewish father, he was taunted as a “goy” among Jews, at the same time being called a Jew by his classmates. His being a Dane living in Germany added to his identity confusion. Erikson was later to describe himself as a man of the borders. Much of what he was to study was concerned with how group values are implanted in the very young, how young people grasp onto group identity in the limbo period between childhood and adulthood, and how a few persons, like Gandhi, transcend their local, national, and even temporal identities to form a small band of people with wider sympathies who span the ages. The concepts of identity, identity crisis, and identity confusion are central to Erikson’s thought. In his first book Childhood and Society (published in 1950) Erikson observed that “the study of identity…becomes as strategic in our time as the study of sexuality was in Freud’s time.” By identity, Erikson meant a sense of sameness and continuity “in the inner core of the individual” that was maintained amid external change. A sense of identity, emerging at the end of adolescence,

is a psychosocial phenomenon preceded in one form or another by an identity crisis; that crisis may be conscious or unconscious, with the person being aware of the present state and future directions but also unconscious of the basic dynamics and conflicts that underlie those states. The identity crisis can be acute and prolonged in some people. The young Erikson did not distinguish himself in school, although he did show artistic talent. On graduation, he chose to spend a year traveling through the Black Forest, Italy, and the Alps, pondering life, drawing, and making notes. After that year of roaming, he studied art in his home city of Karlruhe and later in Munich and Florence. In 1927 Peter Blos, a high school friend, invited Erikson to join him in Vienna. Blos, not yet a psychoanalyst, had met Dorothy Burlingham, a New Yorker who had come to Vienna to be psychoanalyzed; she had brought her four children with her and hired Blos to tutor them. Blos was looking for a fellow teacher in his new school for the children of English and American parents and students of his new discipline of psychoanalysis. Erikson accepted his offer. Blos and Erikson organized their school in an informal manner—much in the style of the so-called progressive or experimental schools popular in the United States. Children were encouraged to participate in curriculum planning and to express themselves freely. Erikson, still very much the artist, taught drawing and painting, but he also exposed his pupils to history and to foreign ways of life, including the cultures of the American Indian and Eskimo. During that period Erikson became involved with the Freud family, friends of Mrs. Burlingham. He became particularly close to Anna Freud, with whom he began psychoanalysis. Anna Freud, who had been an elementary school teacher, was at that time formulating the new science of child psychiatry, trying to turn attention from the adult’s corrective backward look to a neurosis-preventative study of childhood itself. Under Anna Freud’s tutelage Erikson began more and more to turn his attention to childhood, both his own and that of the children whom he saw in the classroom. Analysis was not then the rigidly structured procedure into which it later developed; Erikson met with Miss Freud daily for his analytic hour and frequently saw her socially as well, as part of the circle of Freud’s followers and associates. Still undecided about his future, Erikson continued to teach school, at the same time studying psychoanalysis at the Vienna Psychoanalytic Institute. He also studied to become accredited as a Montessori teacher. In 1929 he married Joan Mowast Serson, an American of Canadian birth, and he was hastily made a full member, rather than an associate member, of the Vienna Psychoanalytic Society—unorthodoxy that allowed him to leave a Vienna threated by fascism immediately after his graduation in 1933. Earlier, Erikson had met the Viennese Hanns Sachs, cofounder along with Otto Rank of the psychoanalytically oriented journal Imago. Sachs—who had settled in Boston, where he was associated with the Harvard Medical School—was sure that Erikson would be welcome at Harvard and suggested that he make Boston his home. After a brief stay in Denmark, the Eriksons moved to Boston, where he became the city’s only child analyst. He held positions at the Harvard Medical School and at Massachusetts General Hospital, served as a consultant at the Judge Baker Guidance Center, and maintained a private practice. Erikson was much influenced by Cambridge’s circle of young social scientists, including anthropologists Margaret Mead and Ruth Benedict. Exposure to the views of those vigorous thinkers helped to shape his theories of child psychology and his cross-cultural approach to human development. Classical psychoanalysis had traditionally concerned itself with pathology and with treating disturbed people, but Erikson found himself more and more interested in the normal personality and in applying his own observations about how young people function and how childhood play affects character formation. Although he remained in the Boston area only three years, he established a solid reputation as a skilled clinician and researcher before moving to Yale University’s Institute of Human Relations. There he furthered an interest sparked at Harvard in the work of American anthropologists. In 1938 he traveled to South Dakota to study the children of the Sioux Indians of the Pine Ridge Reservation. His observations about how communal and historical forces powerfully influence child rearing became an important contribution to psychology and to the study of humans in society. In 1939 Erikson moved to a post at Berkeley, from which he studied the Yurok

Indians, a group of salmon fishers. He left Berkeley in 1950 after refusing to sign what he called a vague, fearful addition to the loyalty oath. He resettled at the Austen Riggs Center in Stockbridge, Massachusetts, working with young people. In 1960 he was appointed to a professorship at Harvard. After his retirement from Harvard, Erikson in 1972 joined Mount Zion Hospital in San Francisco as senior consultant in psychiatry. Until his death in 1994 he continued to focus on many of his earlier interests, examining the individual in this historical context and elaborating on concepts of the human life cycle, especially those of old age. EPIGENETIC PRINCIPLE 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 that failure in the form of physical, cognitive, social, or emotional maladjustment. Relation to Freudian Theory Erikson accepted Freud’s concepts of instinctual development and infantile sexuality. For each of Freud’s psychosexual stages (e.g., oral, anal, and 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. Eight Stages of the Life Cycle Erikson’s conception of the eight stages of ego development across the life cycle is the centerpiece of his life’s work, and he elaborated the conception throughout his subsequent writings (Table 4.2-1). The eight stages represent points along a continuum of development in which physical, cognitive, instinctual, and sexual changes combine to trigger an internal crisis the resolution of which results in either psychosocial regression or growth and the development of specific virtues. In Insight and Responsibility Erikson defined virtue as “inherent strength,” as in the active quality of a medicine or liquor. He wrote in Identity: Youth and Crisis that “crisis” refers not to a “threat of catastrophe, but to a turning point, a crucial period of increased vulnerability and heightened potential, and therefore, the ontogenetic source of generational strength and maladjustment.” Table 4.2-1 Erikson’s Psychosocial Stages

Stage 1: Trust versus Mistrust (Birth to about 18 Months). In Identity: Youth and Crisis, Erikson noted that the infant “lives through and loves with” its mouth. Indeed, the mouth forms the basis of its first mode or pattern of behavior, that of incorporation. The infant is taking the world in through the mouth, eyes, ears, and sense of touch. The baby is learning a cultural modality that Erikson termed to get, that is, to receive what is offered and elicit what is desired. As the infant’s teeth develop and it discovers the pleasure of biting, it enters the second oral stage, the active-incorporative mode. The infant is no longer passively receptive to stimuli; it reaches out for sensation and grasps at its surroundings. The social modality shifts to that of taking and holding on to things. The infant’s development of basic trust in the world stems from its earliest experiences with its mother or primary caretaker. In Childhood and Society, Erikson asserts that trust depends not on “absolute quantities of food or demonstrations of love, but rather on the quality of maternal relationship.” A baby whose mother can anticipate and respond to its needs in a consistent and timely manner despite its oral aggression will learn to tolerate the inevitable moments of frustration and deprivation. The defense mechanisms of introjection and projection provide the infant with the means to internalize pleasure and externalize pain such that “consistency, continuity, and sameness of experience provide a rudimentary sense of ego identity.” Trust will predominate over mistrust, and hope will crystallize. For Erikson, the element of society corresponding to this stage of ego identity is religion, as both are founded on “trust born of care.”

In keeping with his emphasis on the epigenetic character of psychosocial change, Erikson conceived of many forms of psychopathology as examples of what he termed aggravated development crisis, development, which having gone awry at one point, affects subsequent psychosocial change. A person who, as a result of severe disturbances in the earliest dyadic relationships, fails to develop a basic sense of trust or the virtue of hope may be predisposed as an adult to the profound withdrawal and regression characteristic of schizophrenia. Erikson hypothesized that the depressed patient’s experience of being empty and of being no good is an outgrowth of a developmental derailment that causes oral pessimism to predominate. Addictions may also be traced to the mode of oral incorporation. Stage 2: Autonomy versus Shame and Doubt (about 18 Months to about 3 Years). In the development of speech and sphincter and muscular control, the toddler practices the social modalities of holding on and letting go, and experiences the first stirrings of the virtue that Erikson termed will. Much depends on the amount and type of control exercised by adults over the child. Control that is exerted too rigidly or too early defeats the toddler’s attempts to develop its own internal controls, and regression or false progression results. Parental control that fails to protect the toddler from the consequences of his or her own lack of self-control or judgment can be equally disastrous to the child’s development of a healthy sense of autonomy. In Identity: Youth and Crisis, Erikson asserted: “This stage, therefore, becomes decisive for the ratio between loving good will and hateful self-insistence, between cooperation and willfulness, and between self-expression and compulsive self-restraint or meek compliance.” Where that ratio is favorable, the child develops an appropriate sense of autonomy and the capacity to “have and to hold”; where it is unfavorable, doubt and shame will undermine free will. According to Erikson, the principle of law and order has at its roots this early preoccupation with the protection and regulation of will. In Childhood and Society, he concluded, “The sense of autonomy fostered in the child and modified as life progresses, serves (and is served by) the preservation in economic and political life of a sense of justice.” A person who becomes fixated at the transition between the development of hope and autonomous will, with its residue of mistrust and doubt, may develop paranoiac fears of persecution. When psychosocial development is derailed in the second stage, other forms of pathology may emerge. The perfectionism, inflexibility, and stinginess of the person with an obsessive-compulsive personality disorder may stem from conflicting tendencies to hold on and to let go. The ruminative and ritualistic behavior of the person with an obsessive-compulsive disorder may be an outcome of the triumph of doubt over autonomy and the subsequent development of a primitively harsh conscience. Stage 3: Initiative versus Guilt (about 3 Years to about 5 Years). The child’s increasing mastery of locomotor and language skills expands its participation in the outside world and stimulates omnipotent fantasies of wider exploration and

conquest. Here the youngster’s mode of participation is active and intrusive; its social modality is that of being on the make. The intrusiveness is manifested in the child’s fervent curiosity and genital preoccupations, competitiveness, and physical aggression. The Oedipus complex is in ascendance as the child competes with the same-sex parent for the fantasized possession of the other parent. In Identity: Youth and Crisis, Erikson wrote that “jealousy and rivalry now come to a climax in a final contest for a favored position with one of the parents: the inevitable and necessary failure leads to guilt and anxiety.” Guilt over the drive for conquest and anxiety over the anticipated punishment are both assuaged in the child through repression of the forbidden wishes and development of a superego to regulate its initiative. This conscience, the faculty of self-observation, self-regulation, and self-punishment, is an internalized version of parental and societal authority. Initially, the conscience is harsh and uncompromising; however, it constitutes the foundation for the subsequent development of morality. Having renounced oedipal ambitions, the child begins to look outside the family for arenas in which it can compete with less conflict and guilt. This is the stage that highlights the child’s expanding initiative and forms the basis for the subsequent development of realistic ambition and the virtue of purpose. As Erikson noted in Childhood and Society, “The ‘oedipal’ stage sets the direction toward the possible and the tangible which permits the dreams of early childhood to be attached to the goals of an active adult life.” Toward this end, social institutions provide the child with an economic ethos in the form of adult heroes who begin to take the place of their storybook counterparts. When there has been an inadequate resolution of the conflict between initiative and guilt, a person may ultimately develop a conversion disorder, inhibition, or phobia. Those who overcompensate for the conflict by driving themselves too hard may experience sufficient stress to produce psychosomatic symptoms. Stage 4: Industry versus Inferiority (about 5 Years to about 13 Years). With the onset of latency, the child discovers the pleasures of production. He or she develops industry by learning new skills and takes pride in the things made. Erikson wrote in Childhood and Society that the child’s “ego boundaries include his tools and skills: the work principle teaches him the pleasure of work completion by steady attention and persevering diligence.” Across cultures, this is a time when the child receives systematic instruction and learns the fundamentals of technology as they pertain to the use of basic utensils and tools. As children work, they identify with their teachers and imagine themselves in various occupational roles. A child who is unprepared for this stage of psychosocial development, either through insufficient resolution of previous stages or by current interference, may develop a sense of inferiority and inadequacy. In the form of teachers and other role models, society becomes crucially important in the child’s ability to overcome that sense of inferiority and to achieve the virtue known as competence. In Identity: Youth and Crisis, Erikson noted: “This is socially a most decisive stage. Since industry involves doing things beside and with others, a first sense of division of labor and of differential opportunity, that is,

a sense of the technological ethos of a culture, develops at this time.” The pathological outcome of a poorly navigated stage of industry versus inferiority is less well defined than in previous stages, but it may concern the emergence of a conformist immersion into the world of production in which creativity is stifled and identity is subsumed under the worker’s role. Stage 5: Identity versus Role Confusion (about 13 Years to about 21 Years). With the onset of puberty and its myriad social and physiological changes, the adolescent becomes preoccupied with the question of identity. Erikson noted in Childhood and Society that youth are now “primarily concerned with what they appear to be in the eyes of others as compared to what they feel they are, and with the question of how to connect the roles and skills cultivated earlier with the occupational prototypes of the day.” Childhood roles and fantasies are no longer appropriate, yet the adolescent is far from equipped to become an adult. In Childhood and Society, Erikson writes that the integration that occurs in the formation of ego identity encompasses far more than the summation of childhood identifications. “It is the accrued experience of the ego’s ability to integrate these identifications with the vicissitudes of the libido, with the aptitudes developed out of endowment, and with the opportunities offered in social roles.” The formation of cliques and an identity crisis occur at the end of adolescence. Erikson calls the crisis normative because it is a normal event. Failure to negotiate this stage leaves adolescents without a solid identity; they suffer from identity diffusion or role confusion, characterized by not having a sense of self and by confusion about their place in the world. Role confusion can manifest in such behavioral abnormalities as running away, criminality, and overt psychosis. Problems in gender identity and sexual role may manifest at this time. Adolescents may defend against role diffusion by joining cliques or cults or by identifying with folk heroes. Intolerance of individual differences is a way in which the young person attempts to ward off a sense of identity loss. Falling in love, a process by which the adolescent may clarify a sense of identity by projecting a diffused self-image onto the partner and seeing it gradually assume a more distinctive shape, and an overidentification with idealized figures are means by which the adolescent seeks self-definition. With the attainment of a more sharply focused identity, the youth develops the virtue of fidelity—faithfulness not only to the nascent selfdefinition but also to an ideology that provides a version of self-in-world. As Erik Erikson, Joan Erikson, and Helen Kivnick wrote in Vital Involvement in Old Age, “Fidelity is the ability to sustain loyalties freely pledged in spite of the inevitable contradictions of value systems. It is the cornerstone of identity and receives inspiration from confirming ideologies and affirming companionships.” Role confusion ensues when the youth is unable to formulate a sense of identity and belonging. Erikson held that delinquency, gender-related identity disorders, and borderline psychotic episodes can result from such confusion. Stage 6: Intimacy versus Isolation (about 21 Years to about 40 Years). Freud’s famous response to the question of what a normal person should be able to do

well, “Lieben und arbeiten” (to love and to work), is one that Erikson often cited in his discussion of this psychosocial stage, and it emphasizes the importance he placed on the virtue of love within a balanced identity. Erikson asserted in Identity: Youth and Crisis that Freud’s use of the term love referred to “the generosity of intimacy as well as genital love; when he said love and work, he meant a general work productiveness which would not preoccupy the individual to the extent that he might lose his right or capacity to be a sexual and a loving being.” Intimacy in the young adult is closely tied to fidelity; it is the ability to make and honor commitments to concrete affiliations and partnerships even when that requires sacrifice and compromise. The person who cannot tolerate the fear of ego loss arising out of experiences of self-abandonment (e.g., sexual orgasm, moments of intensity in friendships, aggression, inspiration, and intuition) is apt to become deeply isolated and self-absorbed. Distantiation, an awkward term coined by Erikson to mean “the readiness to repudiate, isolate, and, if necessary, destroy those forces and persons whose essence seems dangerous to one’s own,” is the pathological outcome of conflicts surrounding intimacy and, in the absence of an ethical sense where intimate, competitive, and combative relationships are differentiated, forms the basis for various forms of prejudice, persecution, and psychopathology. Erikson’s separation of the psychosocial task of achieving identity from that of achieving intimacy, and his assertion that substantial progress on the former task must precede development on the latter have engendered much criticism and debate. Critics have argued that Erikson’s emphasis on separation and occupationally based identity formation fails to take into account the importance for women of continued attachment and the formation of an identity based on relationships. Stage 7: Generativity versus Stagnation (about 40 Years to about 60 Years). Erikson asserted in Identity: Youth and Crisis that “generativity is primarily the concern for establishing and guiding the next generation.” The term generativity applies not so much to rearing and teaching one’s offspring as it does to a protective concern for all the generations and for social institutions. It encompasses productivity and creativity as well. Having previously achieved the capacity to form intimate relationships, the person now broadens the investment of ego and libidinal energy to include groups, organizations, and society. Care is the virtue that coalesces at this stage. In Childhood and Society Erikson emphasized the importance to the mature person of feeling needed. “Maturity needs guidance as well as encouragement from what has been produced and must be taken care of.” Through generative behavior, the individual can pass on knowledge and skills while obtaining a measure of satisfaction in having achieved a role with senior authority and responsibility in the tribe. When persons cannot develop true generativity, they may settle for pseudoengagement in occupation. Often, such persons restrict their focus to the technical aspects of their roles, at which they may now have become highly skilled, eschewing greater responsibility for the organization or profession. This failure of generativity can lead to profound personal stagnation, masked by a variety of

escapisms, such as alcohol and drug abuse, and sexual and other infidelities. Mid-life crisis or premature invalidism (physical and psychological) can occur. In this case, pathology appears not only in middle-aged persons but also in the organizations that depend on them for leadership. Thus, the failure to develop at midlife can lead to sick, withered, or destructive organizations that spread the effects of failed generativity throughout society; examples of such failures have become so common that they constitute a defining feature of modernity. Stage 8: Integrity versus Despair (about 60 Years to Death). In Identity: Youth and Crisis, Erikson defined integrity as “the acceptance of one’s one and only life cycle and of the persons who have become significant to it as something that had to be and that, by necessity, permitted of no substitutions.” From the vantage point of this stage of psychosocial development, the individual relinquishes the wish that important persons in his life had been different and is able to love in a more meaningful way—one that reflects accepting responsibility for one’s own life. The individual in possession of the virtue of wisdom and a sense of integrity has room to tolerate the proximity of death and to achieve what Erikson termed in Identity: Youth and Crisis a “detached yet active concern with life.” Erikson underlined the social context for this final stage of growth. In Childhood and Society, he wrote, “The style of integrity developed by his culture or civilization thus becomes the ‘patrimony’ of his soul…. In such final consolidation, death loses its sting.” When the attempt to attain integrity has failed, the individual may become deeply disgusted with the external world and contemptuous of persons as well as institutions. Erikson wrote in Childhood and Society that such disgust masks a fear of death and a sense of despair that “time is now short, too short for the attempt to start another life and to try out alternate roads to integrity.” Looking back on the eight ages of man, he noted the relation between adult integrity and infantile trust, “Healthy children will not fear life if their elders have integrity enough not to fear death.” PSYCHOPATHOLOGY Each stage of the life cycle has its own psychopathological outcome if it is not mastered successfully. Basic Trust 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. Persons who develop and rely on the defense of projection—in which, according to Erikson, “we endow significant persons with the evil which actually is in us”—experienced a sense of social mistrust in the first years of life and are likely to develop paranoid or delusional disorders. Basic mistrust is

a major contributor to the development of schizoid personality disorder and, in most severe cases, to the development of schizophrenia. Substance-related disorders can also be traced to social mistrust; substance-dependent personalities have strong oraldependency needs and use chemical substances to satisfy themselves because of their belief that human beings are unreliable and, at worst, dangerous. If not nurtured properly, infants may feel empty, starved not just for food but also for sensual and visual stimulation. As adults, they may become seekers after stimulating thrills that do not involve intimacy and that help ward off feelings of depression. Autonomy The stage in which children attempt to develop into autonomous beings is often called the terrible twos, referring to toddlers’ willfulness at this period of development. If shame and doubt dominate over autonomy, compulsive doubting can 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 persons are parsimonious, punctual, and perfectionistic (the three P’s). 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. Initiative 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. Excessive guilt can 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. Punishment or severe prohibitions during the stage of initiative versus guilt can produce sexual inhibitions. Conversion disorder or specific phobia can result when the oedipal 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 develop psychosomatic

disease. 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 persons, 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. Identity 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 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 persons. Keeping themselves together, they temporarily overidentify, to the point of apparent complete loss of identity, with the heroes of cliques and crowds. 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. 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. Persons 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. 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. Persons who are middle aged show a higher incidence of depression than younger adults, which may be related to middle-aged persons’ 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.

Integrity. Anxiety disorders often develop in older persons. In Erikson’s formulation, this development may be related to persons’ 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 in persons over the age of 65. Persons 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, persons feel despair and hopelessness that can result in severe depressive disorders. TREATMENT Although no independent eriksonian psychoanalytic school exists in the same way that freudian and jungian schools do, Erikson made many important contributions to the therapeutic process. Among his most important contributions is his belief that establishing a state of trust between doctor and patient is the basic requirement for successful therapy. When psychopathology stems from basic mistrust (e.g., depression), a patient must reestablish trust with the therapist, whose task, as 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. Techniques For Erikson, a psychoanalyst is not a blank slate in the therapeutic process, as the psychoanalyst commonly is in freudian psychoanalysis. To the contrary, effective therapy requires that therapists actively convey to patients the belief that they are understood. This is done through both empathetic listening and by verbal assurances, which enable a positive transference built on mutual trust to develop. Beginning as an analyst for children, Erikson tried to provide this mutuality and trust while he observed children recreating their own worlds by structuring dolls, blocks, vehicles, and miniature furniture into the dramatic situations that were bothering them. Then, Erikson correlated his observations with statements by the children and their family members. He began treatment of a child only after eating an evening meal with the entire family, and his therapy was usually conducted with much cooperation from the family. After each regressive episode in the treatment of a schizophrenic child, for instance, Erikson discussed with every member of the family what had been going on with them before the episode. Only when he was thoroughly satisfied that he had identified the problem did treatment begin. Erikson sometimes provided corrective information to the child—for instance, telling a boy who could not release his feces and had made himself ill from constipation that food is not an unborn infant. Erikson often turned to play, which, along with specific recommendations to parents, proved fruitful as a treatment modality. Play, for Erikson, is diagnostically revealing and thus helpful for a therapist who seeks to promote a cure, but it is also curative in its

own right. Play is a function of the ego and gives children a chance to synchronize social and bodily processes with the self. Children playing with blocks or adults playing out an imagined dramatic situation can manipulate the environment and develop the sense of control that the ego needs. Play therapy is not the same for children and adults, however. Children create models in an effort to gain control of reality; they look ahead to new areas of mastery. Adults use play to correct the past and to redeem their failures. Mutuality, which is important in Erikson’s system of health, is also vital to a cure. Erikson applauded Freud for the moral choice of abandoning hypnosis, because hypnosis heightens both the demarcation between the healer and the sick and the inequality that Erikson compares with the inequality of child and adult. 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.” Dreams and Free Association As with Freud, Erikson worked with the patient’s associations to the dream as the “best leads” to understanding the dream’s meaning. He valued the first association to the dream, which he believed to be powerful and important. Ultimately, Erikson listened for “a central theme which, once found, gives added meaning to all the associated material.” Erikson believed that interpretation was the primary therapeutic agent, sought as much by the patient as by the therapist. He emphasized free-floating attention as the method that enabled discovery to occur. Erikson once described this attentional stance by commenting that in clinical work, “You need a history and you need a theory, and then you must forget them both and let each hour stand for itself.” This frees both parties from counterproductive pressures to advance in the therapy and allows them both to notice the gaps in the patient’s narrative that signal the unconscious. 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. Mutuality exists in that patient and therapist are motivated by cure, and labor is divided. The goal is always to help the patient’s ego get stronger and cure itself. The second dimension Erikson called objectivity-participation. Therapists must keep their minds open. “Neuroses change,” wrote Erikson. New generalizations must be made and arranged in new configurations. The third dimension runs along the axis of knowledge-participation. The therapist “applies selected insights to more strictly experimental approaches.” The fourth dimension is tolerance-indignation. Erikson stated: “Identities based on Talmudic argument, on messianic zeal, on punitive orthodoxy, on faddist sensationalism, on professional and social ambition” are harmful and tend to control patients. Control widens the gap of inequality between the doctor and the patient and makes realization of the recurrent idea in Erikson’s thought—mutuality—difficult. According to Erikson, therapists have the opportunity to work through past

unresolved conflicts in the therapeutic relationship. Erikson encouraged therapists not to shy away from guiding patients; he believes that therapists must offer patients both prohibitions and permissions. Nor should therapists be so engrossed in patients’ past life experiences that current conflicts are overlooked. The goal of therapy is to recognize how patients have passed through the various stages of the life cycle and how the various crises in each stage have or have not been mastered. Equally important, future stages and crises must be anticipated, so that they can be negotiated and mastered appropriately. Unlike Freud, Erikson does not believe that the personality is so inflexible that change cannot occur in middle and late adulthood. For Erikson, psychological growth and development occur throughout the entire span of the life cycle. The Austen Riggs Center in Stockbridge, Massachusetts, is a repository of Erikson’s work and many of his theories are put into practice there. Erik’s wife, Joan, developed an activities program at the Austen Riggs Center as an “interpretation-free zone,” where patients could take up work roles or function as students with artists and craftspersons, without the burden of the patient role. This workspace encouraged the play and creativity required for the patients’ work development to parallel the process of their therapy. REFERENCES Brown C, Lowis MJ. Psychosocial development in the elderly: An investigation into Erikson’s ninth stage. J Aging Stud. 2003;17:415–426. Capps D. The decades of life: Relocating Erikson’s stages. Pastoral Psychol. 2004;53:3–32. Chodorow NJ. The American independent tradition: Loewald, Erikson, and the (possible) rise of intersubjective ego psychology. Psychoanal Dialogues. 2004;14:207–232. Crawford TN, Cohen P, Johnson JG, Sneed JR, Brook JS. The course and psychosocial correlates of personality disorder symptoms in adolescence: Erikson’s developmental theory revisited. J Youth Adolesc. 2004;33(5):373–387. Friedman LJ. Erik Erikson on identity, generativity, and pseudospeciation: A biographer’s perspective. Psychoanalytic History. 2001;3:179. Hoare CH. Erikson’s general and adult developmental revisions of Freudian thought: “Outward, forward, upward”. J Adult Dev. 2005;12:19–31. Kivnick HQ, Wells CK. Untapped richness in Erik H. Erikson’s rootstock. Gerontologist . 2014;54:40–50. Newton DS. Erik H. Erikson. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2005:746. Pietikainen P, Ihanus J. On the origins of psychoanalytic psychohistory. Historical Psychol. 2003;6:171. Shapiro ER, Fromm MG. Eriksonian clinical theory and psychiatric treatment. In: Sadock BJ, Sadock VA, eds. Comprehensive Textbook of Psychiatry. 7th ed. New York: Lippincott Williams & Wilkins; 2000. Slater C. Generativity versus stagnation: An elaboration of Erikson’s adult stage of human development. J Adult Dev. 2003;10:53. Van Hiel A, Mervielde I, De Fruyt F. Stagnation and generativity: Structure, validity, and differential relationships with adaptive and maladaptive personality. J Pers. 2006;74(2):543. Westermeyer JF. Predictors and characteristics of Erikson’s life cycle model among men: A 32-year longitudinal study. Int J