A modification of this article was originally published on the Brainblogger website. Note, also, that Dr. Ann Olson has published a book entitled “Illuminating Schizophrenia: Insights into the Uncommon Mind.” This book is available for purchase on the Amazon.com website.
Erik Erikson developed a psychosocial stage theory that illuminates how people progress through certain stages during their life spans. The stages in this theory of development may be negotiated poorly by people with chronic illness and schizophrenia. For this reason, Erikson’s theory may have bearing on treatment for schizophrenia in adulthood.
Erikson’s life stages
1. Trust versus mistrust -> Hope
2. Autonomy versus shame and doubt -> Will
3. Initiative versus guilt -> Purpose
4. Industry versus inferiority -> Competence
5. Identity versus role confusion -> Fidelity
6. Intimacy versus isolation -> Love
7. Generativity versus stagnation -> Care
8. Ego integrity versus despair -> Wisdom
Although it is acknowledged that schizophrenia is – at least in part – a biochemical disorder, it is hypothesized that failure to achieve a positive result for two stages in particular may contribute to the condition of schizophrenia in adulthood.
The first of these stages – trust versus mistrust – is usually more or less mastered during the first year of life. If the baby has a warm and secure symbiotic relationship with his or her primary caregiver, it will provide the individual with positive feelings toward the world and a vital sense of hope and trust of other people. Hope provides a basis for the individual’s relationships in terms of all of his or her future relationships.
The next stage is called ‘autonomy versus shame and doubt’. At this stage of life, the child is toilet trained – a significant event in a child’s life, especially if you look at it symbolically. Being trained to use a toilet corresponds with self-control, independence and confidence. The helplessness of not achieving this is congruent with shame, both in childhood and in adulthood. This stage, if negotiated successfully, will culminate in confidence and self-control, or as Erikson terms it, the ability to utilize ‘will’.
‘Initiative versus guilt’ is the next stage of psychosocial development during which the child develops a basic understanding of morality, gains self-esteem and learns to cooperate with peers. This is affected by means of a sense of power and control of the child’s environment, resulting in the positive outcome of ‘purpose’.
‘Industry versus inferiority’ represents the next stage of development. The goal of this stage reflects the individual’s ability to rely on himself, during which the child will learn about friendship, self-evaluation and teamwork, providing a sense of ‘competence’ in terms of educational achievement.
The next stage is signified by ‘identity versus role confusion’, which occurs in adolescence. If the individual successfully negotiates this stage, he or she will form an identity linked to beliefs, political views, religion, career choice, sexual identity and many other qualities of the self. The goal of this stage is ‘fidelity’ or faithfulness with respect to one’s self-definition.
It is significant that this stage aligns itself with the time of life that individuals may become schizophrenic. This stage may be poorly negotiated due to the emergence of mental illness, compromising the successful accomplishment of tasks of this stage of development. The goal of fidelity associated with this stage may be compromised as a result. The individual with a mental illness may be alienated and therefore not exposed to various choices and ways of viewing the self. As a result, he or she may define himself as mentally ill, and this self-definition may represent the greatest component of his identity, contributing to his or her own sense of stigmatization.
This stage of ‘identity versus role confusion’ represents a recapitulation of the ‘autonomy versus shame and doubt’ stage of development. This means that the person who is diagnosed as a schizophrenic may have had difficulties in early childhood that re-emerge in late adolescence. Of course, the concept that the root of mental illness is biochemical does not support this view regarding the etiology of mental illness, and biochemistry is clearly implicated in the emergence of psychotic mental illness.
The next stage of development that may be impacted by mental illness is the ‘intimacy versus isolation’ stage. The successful culmination of this stage results in the choice of a mate with the goal of ‘love’. It is obvious that schizophrenics have difficulties at this stage, perhaps due to alienation caused by other symptoms of mental illness. This stage involves a recapitulation of the early ‘trust versus mistrust stage’. In terms of the etiology or causes of schizophrenia, poor negotiation of the first stage of Eriksonian development may impact the success or failure of the ‘intimacy versus isolation’ stage. Again, this hypothesis is not consistent with the medical model of schizophrenia, but it may be complimentary.
Given that these two latter stages may occur when the schizophrenic is first experiencing mental illness, it is clear that he or she may need support at this time of life. This holds true regardless of to what extent he or she succeeds with the tasks of these latter two stages. He or she may require help with the final stages of ‘generativity versus stagnation’ and ‘ego integrity versus despair’. In fact, all of the stages that the individual is required to negotiate may be compromised by psychosis.
Indeed, the Eriksonian paradigm may inadequately replicate the development of the mentally ill. Note that the schizophrenic may regress in terms of development as a result of his or her psychosis, rather than simply having difficulties within the earlier stages of development. However, it is clear that these stages may allow for an understanding of the psychopathology of the mentally ill, in terms of exploring a contrasting view of development in the light of the impact of psychopathology on these developmental stages.
Treatment for mental illness by means of psychotherapy could potentially involve a psychotherapeutic paradigm based on the Eriksonian stages as a model for therapeutic treatment. The ‘trust versus mistrust’ stage would be the initial focus of the therapy, and the ‘autonomy versus shame and doubt’ would be the next focal point. The stages of therapy would continue, replicating the Eriksonian stages in terms of achieving positive outcomes for each subsequent goal.
This model for treatment of serious mental illness involving trauma has been offered by others in the fields of psychiatry and psychology. Nevertheless, it is clear that a replication of the first two stages should be renegotiated in terms of psychotherapeutic treatment of schizophrenia, as these first two stages of Erikson’s developmental model represent a basis for success in the key ‘identity versus role confusion’ and the ‘intimacy versus isolation’ stages.
As indicated, however, the effect of schizophrenia on the psychosocial self may cause the schizophrenic individual to regress to a more primitive state of psychosocial functioning. This may preclude the contention that poor negotiation of the “trust versus mistrust” stage and the “autonomy versus shame and doubt” stage by the small child may lead to poor negotiation of the “identity versus role confusion” stage and the “intimacy versus isolation” stage in later life, although this theory is valid. Regression of an individual as a result of mental illness also represents a valid theory of psychosocial functioning in the adult schizophrenic. .
Given that social involvement is helpful if not curative of serious mental illness such as schizophrenia, an emphasis on psychosocial development may ameliorate some of the psychopathological aspects of schizophrenia. Ultimately, using the Eriksonian stages as a paradigm for psychotherapy may provide a substantial basis for work with schizophrenics that overshadows simple social skills training.