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Nancy McWilliams, PhD, ABPP Rutgers Graduate School of Applied & Professional
Psychology
Oral phase: birth to 18 months. Child is organized around eating/survival; exploration by mouth; development of talking.
Anal phase: 18 months to 3 years. Child faces original socialization into demands of community. Toilet training and attendant issues of cooperation vs. resistance, submission vs. rebellion, cleanliness vs. dirt, promptness vs. lateness.
Oedipal phase: 3 to 6 years. Child perceives others as in relationship, with attendant issues of envy and competition; awareness of dangers of death and body injury, and associated fantasies.
Paranoid-schizoid position: Self-centric. Splits between all-good and all-bad percepts. Effort to preserve the sense of good inside and project the bad outside.
Depressive position: Appreciation of separateness of others leads to realization that caregivers and the self are combinations of good and bad, gratification and frustration.
Basic Trust vs. Distrust: birth to 18 months
Autonomy vs. Shame and Doubt: 18 months to 3 years
Initiative vs. Guilt: 3 to 6 years
Further stages through the lifespan
(Autistic phase: First month)
Symbiotic phase: 2 months to 5 months
Separation-Individuation phase: 5 months to 3 years: ◦ Hatching (differentiation): 5-10 months ◦ Practicing: 10-16 months ◦ Rapprochement: 16-24 months◦ “on the way to object constancy”: 24-36 months
Object Constancy: From 3 years on.
Preconventional level: Childhood Stage one: Actions judged by consequences Stage two: Actions driven by obedience/punishment and
self-interestConventional level: Adolescents and adults
Stage three: Actions judged by good intentionsStage four: Actions driven by authority and social
orderPost-conventional (Principled) level:
Stage five: Actions driven by social contractsStage six: Actions driven by universal ethical principles
(Transcendent level)
Psychic equivalence phase: birth to 18 months: The external world is isomorphic with the internal world.
Pretend phase: 18 months to 3 years: Internal state is decoupled from external reality but thought to have no implications for the outside world.
Mentalization phase: 3 years and upward: Capacity for plausible interpretation of one’s own and others’ behavior in terms of underlying mental states: Reflective function.
Fixation: Temperament and early life experience did not allow full maturation into the subsequent stages.◦ Repressed versus unformulated affect
Regression: Traumatic experience has knocked the person back to previous modes of functioning.◦ Traumatic loss as activating paranoid-schizoid dynamics
even in very psychologically healthy people
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1. Centrality of therapeutic relationship 2. Importance of limits, boundaries, contracts 3. Discouragement of regression 4. Emphasis on the here-and-now 5. Expectation of intensity, strong counter-
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“The classic nosologic divide in psychiatry has been between neurosis and psychosis. The two were originally conceptualized as distinct categories of mental illness, and it was only the odd (irrelevant!) case that “tipped over” from the former to the latter. Extensive research over the past decade and a half has upended this notion, blurring previously sharp diagnostic boundaries, reframing psychosis as a continuum and casting the relationship between neurosis and psychosis in a very different light.”
It allows therapists and patients to relate empathically as one vulnerable human being to another.
It permits therapists to think about and address issues of safety as central to patients in the psychotic range.
Psychotic-level dynamics of terror and humiliation require clinicians to be both realistically authoritative and profoundly egalitarian.
Normalizing is usually important for patients with psychotic tendencies.
Education is usually necessary for patients dealing with psychotic confusions.
Therapists of patients with psychotic tendencies need to be especially appreciative of health-seeking aspects of their symptoms.
Therapy should be conversational and active.
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