A proposed model of psychodynamic psychotherapy linked to Erik Erikson s eight stages of psychosocial development

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1 Received: 30 May 2016 Revised: 27 September 2016 Accepted: 30 November 2016 DOI: /cpp.2066 RESEARCH ARTICLE A proposed model of psychodynamic psychotherapy linked to Erik Erikson s eight stages of psychosocial development Zelda Gillian Knight Department of Psychology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa Correspondence Zelda Gillian Knight, Department of Psychology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa. zknight@uj.ac.za Just as Freud used stages of psychosexual development to ground his model of psychoanalysis, it is possible to do the same with Erik Erikson s stages of development with regards to a model of psychodynamic psychotherapy. This paper proposes an eight stage model of psychodynamic psychotherapy linked to Erik Erikson s eight stages of psychosocial development. Various suggestions are offered. One such suggestion is that as each of Erikson s developmental stages is triggered by a crisis, in therapy it is triggered by the client s search. The resolution of the search often leads to the development of another search, which implies that the therapy process comprises a series of searches. This idea of a series of searches and resolutions leads to the understanding that identity is developmental and therapy is a space in which a new sense of identity may emerge. The notion of hope is linked to Erikson s stage of Basic Trust and the proposed model of therapy views hope and trust as essential for the therapy process. Two clinical vignettes are offered to illustrate these ideas. Key Practitioner Message Psychotherapy can be approached as an eight stage process and linked to Erikson s eight stages model of development. Psychotherapy may be viewed as a series of searches and thus as a developmental stage resolution process, which leads to the understanding that identity is ongoing throughout the life span. KEYWORDS development, Erikson, identity, model, psychodynamic, stages 1 INTRODUCTION An understanding of Erik Erikson s psychosocial developmental stages has implications for psychotherapy. Seligman and Shanock (1995) integrated Eriksonian theory and relational psychoanalysis, while an article in 2013 by James Marcia and Ruthellen Josselson has attempted to link the empirical research on Erikson s developmental theory with an approach to therapeutic intervention that could be utilized by therapists from an array of therapeutic approaches. The authors, as practising psychologists, illustrate the use of Erikson s theory in psychotherapy by discussing case examples from their own practices. These same two authors noted in their 2013 article that Erikson s theory provides a developmental overview, a descriptive language for where the clients stand currently within a psychosocial developmental context, where they might have become stuck in the past, and where they are heading. They also note that Erikson s theory also provides realistic developmental goals and it can change a therapist s viewpoint from considering only pathology and the past to include also the formation of ego skills and strengths needed for the client to move toward a specific future (Marcia & Josselson, 2013). They also suggest that any therapy technique employed within this Eriksonian framework must be tailored to account for the client s age and psychosocial stage, and while internal conflict remains of concern, early conflicts are understood and framed from within the broader context of the immediate psychosocial world (Marcia & Josselson, 2013). The authors relate the Eriksonian stages to clients appropriate developmental age range and process in therapy. They do not, however, offer a stage model of psychodynamic psychotherapy, based on Erikson s developmental stages, nor view the developmental stages expressed in therapy as not always age related or sequential, as with the current paper. Clin Psychol Psychother. 2017;24: wileyonlinelibrary.com/journal/cpp Copyright 2017 John Wiley & Sons, Ltd. 1047

2 1048 KNIGHT In elaborating this notion of psychodynamic psychotherapy as a stage model, it is important to emphasise that the core focus in psychodynamic psychotherapy is on the relationship between the therapist and the client such that the relationship is the therapy. This implies that the therapeutic relationship becomes a holding environment (Winnicott, 1965a,b) for the reworking of what Freud (1920) noted as the repetition compulsion expressed in the transference and thus the return of unresolved developmental conflicts. With this developmental slant, psychodynamic psychotherapy lends itself to being viewed of as a developmental stage model of therapy and conceptually linked to the developmental life cycle stages of Erik Erikson s psychosocial developmental theory. Just as Freud s psychoanalysis was linked to his theory of psychosexual development, this paper proposes that Erikson s eight stage developmental theory may be used as a conceptual base for an eight stage model of psychodynamic psychotherapy. The value of adopting and using this proposed eight stage model of therapy is that it will contribute to a deeper understanding of clients therapy process, which is important in terms of conceptualising their case and assisting them with unresolved developmental conflicts. In further amplification of this proposal, it is suggested that each of the eight stages of psychodynamic psychotherapy has a core psychological process that relates to a specific kind of existential search or quest for something missing. In this regard, clients come to therapy because they feel uncomfortable about something in their lives and have a vague sense that something is missing or is not right. They want to feel better about themselves and be all right in the world. They are often unaware that this sense of something missing or wanting to feel better is often the same thing. The search for something missing is experienced differently at the different life cycle stages, and thus the nature of the search is stage related and developmental. The resolution of the search at one stage of therapy often leads to the development of another search, which implies that the therapy process comprises a series of searches as clients progress through their therapy. This idea of a series of searches gives rise to the understanding that identity is developmental, and therapy is a space in which a new sense of identity may emerge and reemerge again and again. The notion of hope in therapy is alluded to in terms of the hope for something new. Hope and the searches or searching are linked and imply that there is a series of hopes just as there is a series of searches. 2 A BRIEF NOTE ABOUT ERIK ERIKSON During his lifetime, psychoanalyst Erik Erikson became one of the most respected and prolific authors and thinker of the 20th century, writing 14 books and numerous articles while maintaining a full time and longterm clinical practice (Kivnick & Wells, 2013). He first developed his ground breaking life cycle theory of eight stages of psychosocial development in 1950 with the first edition of the book Childhood and Society with the second edition following in He expanded his psychosocial developmental theory in other key works such as Identity: Youth and Crisis (1968/1994), Insight and Responsibility (1964), Toys and Reasons (1976), The Life Cycle Completed (1982) and, with his wife and a colleague, he explored old age, which is articulated in the book Vital Involvement in Old Age (1986). While theoretically influenced by Freud s psychosexual stages of development (his first four stages correspond to Freud s stages) he also moved away from Freud s classical drive theory in three crucial ways. First, he widened Freud s concept of psychosexual development into the biopsychosocial (later primarily emphasizing the psychosocial) by describing the vital relevance of family system and society and culture in individual development (Kivnick & Wells, 2013). Second, he extended Freud s psychosexual developmental stages by including the temporal understanding of human development from a sequential process that culminates with the completion of adolescence, to one that progresses further into adulthood and beyond to incorporate a theory of individual development that occurs throughout the entire life span (Kivnick & Wells, 2013). Third, he directed the focus of attention to the significance of psychosocial health; thus, healthy development was given attention as opposed to the then contemporary focus on the genesis and remediation of problems (Kivnick & Wells, 2013). The well known eight stages of psychosocial development, synonymous with Erikson s name and which he referred to as his allencompassing psychological theory (Erikson, 1950/1963, p. 424), was remarkably distinctive in its attempts to describe the full spectrum of the human life cycle and the dialectic relationship between the psychological and social dimensions of life. His psychosocial developmental theory was a radical move away from the classical psychoanalytic focus on the intrapsychic dynamics towards a relational and interpersonal focus. With the relational turn (Aron, 1996; Benjamin, 2004; Mitchell & Aron, 1999) in psychoanalytic theory and the concomitant increased attention paid to the psychodynamic therapeutic relationship as a comingling of two subjectivities (Ogden, 1994, 2007) it could be said that Erikson was one of the first psychoanalytic relational theorists. Empirical research aimed at validating Erikson s developmental theory has been ongoing for close to five decades. For example, empirical support for his psychosocial development theory have been linked to personality development, identity formation, culture, and life cycle development (Conway & Holmes, 2004; Hearn et al., 2012; Josselson, 1987; Kenyon, Clark, & de Vries, 2001; McAdams, 1985; McAdams & de St. Aubin, 1992; McAdams, de St.Aubin, & Logan, 1993; McAdams, Diamond, de St.Aubin, & Mansfield, 1997; Marcia, 1966, 1998, 2002; O Brien, 2010; Ochse & Plug, 1986; Peterson, 2002; Sokol, 2009; Van de Water & McAdams, 1989; Van Hiel, Mervielde, & De Fruyt, 2006). 3 ERIKSON S EIGHTSTAGESOF PSYCHOSOCIAL DEVELOPMENT: MALIGNANT AND MALADAPTIVE TENDENCIES Erikson s (1950/1963) eight stages of psychosocial development is a comprehensive theory of not only the processes of how an individual develops throughout the life cycle but a theory of identity formation and the process of establishing a coherent sense of self. Erikson used the term identity to refer to a specific aspect of the self that provides the quality of unity and purpose of the self (McAdams, 1995, p. 385).

3 KNIGHT 1049 Erikson used the word stage to refer to a period of life such as childhood or adulthood and clarifies that in each of the eight developmental stages there is a pair of opposing psychological tendencies, which need to be balanced we must, for each of the major stages of development, propose two seemingly contradictory dispositions, which are here called syntonic and dystonic (Erikson, Erikson, & Kivnick, 1986, p.33). In the first life cycle stage, related to infancy and orality, the two opposing tendencies, Erikson remarks,... are a sense of trust and a sense of mistrust: their balance, we claim, helps create the basis for the most essential overall outlook on life, namely, hope... (Erikson et al., 1986, p. 33). That is,... a favorable ratio of basic trust over basic mistrust is the first step in psychosocial adaptation (Erikson, 1950/ 1963, p. 271). It is therefore not an annihilation or favouring of one tendency over the other (Erikson et al., 1986) but a mixture of both in equal proportions. For example, Erikson suggested that one must learn to trust in the self and the world but also know what and whom to mistrust (for example, that stranger) so that the balance and integration between the two leads to a healthy engagement with the self and the world. Each developmental stage is triggered or initiated by a crisis, which Erikson demarcated as a turning point in the life cycle (Erikson, 1968/1994) that arises because incipient growth and awareness in a new part function go together with an instinctual energy and yet also cause a specific vulnerability in that part (Erikson, 1968/1994, p. 95). It is important to understand that the word crisis does not designate a calamity but rather it is the emergence of a different way of viewing the world. The new perspective or outlook on life moulds and forms core relational templates and belief systems on how to engage with self and the world. The successful integration of the two opposing tendencies gives rise to an ego strength or virtue (Erikson, 1950/1963; Erikson et al., 1986; Stevens, 2008) that contributes to the negotiation and resolution of the core developmental crisis at each stage (Kivnick & Wells, 2013). The emergence of the virtue or strength at each stage becomes vitally important for the continuation of the developmental process because it is used to later negotiate the succeeding stages. This means that each of the stages of ego growth furnishes a necessary contribution to the resolution of the succeeding stage. It would be a mistake to view the psychosocial system only as a staircase of achievement and it is important not to underestimate the importance of the negative poles or tendencies of the psychosocial resolutions (Marcia & Josselson, 2013). In old age, for example, it is essential to experience both the thesis of Integrity as well as the antithesis of Despair in order to create and formulate one s own synthesis (Marcia & Josselson, 2013). Erikson (1968/1994) used the term virtue to signify vitality and proposed that without these virtues all other values and goodnesses lack vitality (p. 232). Thus, all eight virtues or ego growth and strengths are critical strengths that are necessary for a mutual involvement in an ever increasing social radius, from infancy through to adulthood and old age (Erikson et al., 1986, p. 33). Although it may appear that the developmental stage model is a map of individual development, each stage of growth occurs within both a social setting and also within an intergenerational setting (Marcia & Josselson, 2013). For example, children s ego development in the first four childhood stages emerges in the context of their parents or other adults development of Intimacy, Generativity, and Integrity. Children confirm or give an endorsement of sorts to their parents in the parents sense of Generativity as much as parents in turn provide necessary supportive conditions for the child s growth (Marcia & Josselson, 2013). Another example, teachers need students for confirmation in their experiences of Identity and Generativity, just as students need teachers for developing their sense of Industry and Identity and in the same way, older people need their adult children to confirm them in their sense of meaningful Integrity while their adult children benefit from grandparents support of their Generative parenting (Marcia & Josselson, 2013). In a sense, each stage occurs at every other stage so that individuals everywhere are going through a stage that has an impact on the development of another individual. In a related sense, all previous stages begin to form the personality structure, and all previous stages have echoes in the current stage and influence on how future stages are negotiated (Erikson, 1968). For example, Basic Trust, the first stage of birth or infancy emerges again at the stage of Adolescence when Identity is the main ego task and focus, this time taking the form of a trust of time (Erikson, 1968). But there is more to it than an echo of previous stages. For example, using this same example of trust in adolescence, Generativity, the primary issue of adulthood, also exists in a prefiguring form during late adolescence, coexisting with the central adolescent concern of Identity. Hence, at Identity in late adolescence, there is a new Trust issue to be resolved as well as a contribution of accrued Trust from preceding stages. Concurrently at late adolescence, a Generativity issue is also present (p. 618). However, the shadows of current on the future stages are less common in terms of what therapists may work with. Rather, therapists experience of clients is more to do with the legacies of incomplete prior stage resolution at a particular life period (p. 619). As a clinician, Erikson (1968/1994; Erikson et al., 1986) noted that if this integration of the two opposing poles does not occur, growth becomes one of maldevelopment. Maldevelopment takes the form of either maladaptive tendencies (a leaning more towards the syntonic or positive side) or malignant tendencies (a leaning more to the dystonic or negative side; Erikson et al., 1986). Maladaptive tendencies are less dysfunctional or pathological than malignant tendencies and gravitate towards the neurotic personality propensities. The malignant tendencies on the other hand, lean towards the psychotic personality propensities and are therefore more severe in terms of psychopathology (Erikson et al., 1986). Both syntonic and dystonic dispositions must, each in appropriate dynamic balance with the other, exist for all eight psychosocial themes, in all eight stages (Kivnick & Wells, 2013, p. 45). For example, a client who has malignant tendencies rooted in the first developmental stage may have an over identification with mistrust in the self and world, and a resultant persistently pessimistic outlook on life with little or no hope (the virtue). Both maladaptive tendencies and malignant tendencies can be treated in later life while the more severe pathologies or malignant tendencies may take longer to correct (Erikson et al., 1986). In line with Erikson et al. (1986) model of the social and the psychological are intertwined, the older man working with issues related to Identity versus Role Confusion is given less support. Psychosocial stage resolution occurs within especially attuned social contexts. When a chronological period has passed, social support is not so available as it was at the appointed time (Marcia & Josselson,

4 1050 KNIGHT 2013, p. 619). This has implications for psychotherapy. It means that therapists should be aware that clients may have issues related to other developmental stages, and that, as indicated, the stages are not strictly age related. Table 1 illustrates Erikson s eight stages of development with the adaptive strength or virtue and maldevelopment tendencies. Erikson s developmental system furnishes a road map of development with reasonably expectable attainments in ego growth and equally expectable hindrances, challenges, and alternatives (Marcia & Josselson, 2013). Ego growth within this theory, as in classical psychoanalytic theory, emerges from conflict that is both inner and outer and that is either facilitated or blocked by social contexts in which the person must necessarily live and function (Marcia & Josselson, 2013). Psychosocial development therefore occurs as the person negotiates the life cycle journey, sometimes aided, sometimes hindered by his relational or interpersonal world (Marcia & Josselson, 2013). 4 THE PROPOSED EIGHT STAGE MODEL OF PSYCHODYNAMIC PSYCHOTHERAPY LINKED TO ERIK ERIKSON S EIGHTSTAGES OF PSYCHOSOCIAL DEVELOPMENT Psychodynamic psychotherapy is concerned with the treatment of maladaptive and malignant tendencies that have their roots in core developmental conflicts. Erikson understood that these tendencies give rise to current relational and relationship difficulties. However, while he did write about the therapy process and development of pathology, he did not explicitly link therapy process to his eight stages of psychosocial development and generate a stage model of therapy. It is therefore suggested that Erikson s comprehensive eight life cycle stages of psychosocial development may correspond to an eight stage model of psychodynamic therapy so that the therapy process may be understood as moving through, not necessarily sequentially, similar developmental stages with similar needs for the integration of opposing tendencies and the emergence of crises and ego growth and strengths or virtues. In other words, the stages of his theory can be viewed as stages of psychodynamic psychotherapy. The proposed eight stage model of psychodynamic psychotherapy linked to Erik Erikson s (1950/1963) eight stage model of development is shown in Table 2. In Table 2, one can observe that the two opposing poles or tendencies at each of Erikson s developmental stages are linked to each of the stages of therapy. For example, Erikson s stage 2 Autonomy versus Shame and Doubt is linked to Stage 2 of therapy Balancing the poles of Letting Go versus Holding On. Both follow the infantile developmental process of anal control and its psychological shift to becoming a centre of initiative and the experimenting with free will within the context of societal authority and limitations. Whereas Erikson noted that the shift from one stage to the next is triggered by a crisis, the shift from one therapy stage to the next is triggered by a search. This search is experienced as a psychological existential search for something missing in life, and therefore it is experienced as wanting something wanting things to be different, to feel better, to be different, and to have better relationships. The search is related to the stages of development. The implication is that there is a series of searches during the life cycle and thus a series of searches during therapy depending on what stage or stages clients are working within. The resolution of one search leads to the development of another search, which implies that the searches are linked to the evolving sense of self. Therapy becomes a safe space in which the sense of self is developmental and linked to developmental searches and their resolutions as clients move through the stages of therapy. This idea implies that not only can therapy be redefined as a developmental stage resolution process (Marcia & Josselson, 2013) but as a developmental stage resolution of searches. Within the therapeutic relationship and the psycho social dynamics of the past and the present, clients find what they are missing. As they do this, they are simultaneously changed and a new form of self emerges. This suggested eight stage model of psychodynamic psychotherapy is inclusive of other related relational theories that describe a process of psychological development such as Attachment Theory, first described by Bowlby (1969, 1973, 1980, and 1988) and later developed by others (Ainsworth, Blehar, Waters, & Wall, 1978; Eagle, 2013). For example, the notion of an insecure attachment pattern as a mode of being and relating is linked to the over identification with the dystonic tendency and thus the lack of integration of the two opposing tendencies. For example, an insecure attachment pattern could be linked to the over identification with the dystonic tendency of mistrust, giving rise to malignant tendencies expressed as withdrawal. More recent research has identified disorganized attachment strategies, or contradictory and unintegrated behaviours toward the TABLE 1 Erikson s eight stages of psychosocial development Stages Stage Description (Syntonic Tendency Dystonic Tendency) Adaptive Strength / Virtue Maldevelopment (Maladaptive tendency Malignant tendency) Infancy Basic Trust vs Mistrust Hope Sensory maladjustment Withdrawal Early childhood Autonomy vs Shame and doubt Will Shameless willfulness Compulsion Play age Initiative vs Guilt Purpose Ruthlessness Inhibition School age Industriousness vs Inferiority Competence Narrow virtuosity Inertia Adolescence Identity cohesion vs Role confusion Fidelity Fanaticism Repudiation Young adulthood Intimacy vs Isolation Love Promiscuity Exclusivity Adulthood Generativity vs Stagnation / self absorption Care Over extension Rejectivity Old age WISDOM Integrity vs Despair Wisdom Presumption Disdain

5 KNIGHT 1051 TABLE 2 The proposed eight stage model of psychodynamic psychotherapy linked to Erik Erikson s (1950/1963) eight stages of psychosocial development Stages Stage 1 Infancy Stage 2 Early childhood Stage 3 Play age Stage 4 School age Stage 5 Adolescence Stage 6 Young adulthood Stage 7 Adulthood Stage 8 Old age Erikson s eight stages of psychosocial development Basic Trust vs Mistrust The virtue of Hope Autonomy vs Shame and Doubt The virtue of Will Initiative vs Guilt The virtue of Purpose Industry vs Inferiority The virtue of Competence Identity cohesion vs Role confusion The virtue of Fidelity Intimacy vs Isolation The virtue of love Generativity vs Stagnation / self absorption The virtue of care Integrity vs DespairThe virtue of wisdom The eight stage model of psychodynamic psychotherapy The Search for Courage: Balancing the poles of Basic Trust vs Mistrust The Search for Knowing When: Balancing the poles of Letting Go vs Holding On The Search for Tenacity: Balancing the poles of Moving Onwards vs Guilt The Search for Efficacy: Balancing the poles of Productivity vs Inadequacy The Search for Belonging: Balancing the poles of Duplicity vs Faithfulness The Search for Mutual Loving: Balancing the poles of Connectivity vs Segregation The Search for Needed ness: Balancing the poles of Being Relevant vs Inertia The Search for Inner Peace: Balancing the poles between Contentment and Regret caregiver when security or comfort is required, which can first be identified at 12 months of age (Hennighausen & Lyons Ruth, 2010). The work of Lyons Ruth and colleagues (Hennighausen & Lyons Ruth, 2010; Lyons Ruth, Bronfman, & Atwood, 1999; Lyons Ruth & Jacobvitz, 2008; Lyons Ruth, Bureau, Riley, & Atlas Corbett, 2009) has shown that freezing, huddling on the floor, and other depressed behaviours when under stress and in the presence of the caregiver form are parts of the coding criteria for disorganized behaviours. These researchers claim that contradictory approach avoidance behaviours when under stress and toward the caregiver are also indicators of a disorganized strategy. These various contradictory and unintegrated behaviours are understood to be the infant s inability to organize a coherent strategy for eliciting comfort and security from the caregiver (Hennighausen & Lyons Ruth, 2010). Moreover, disorganized attachment behaviours may arise as a result of a blending with other insecure behaviours that are part of an avoidant or ambivalent attachment strategy (Hennighausen & Lyons Ruth, 2010; Lyons Ruth & Jacobvitz, 2008). Furthermore, many disorganized behaviours have been observed in a combination with behaviours that are normally a part of a secure strategy, such as protesting separation, seeking comfort with mother at reunion, and becoming less anxious after being cuddled and picked up (Hennighausen & Lyons Ruth, 2010). It has been suggested that as the child mature and reaches the ages of six years of age, the child has the cognitive capability to think about the caregiver s emotional states, and as such the disorganized attachment behaviours of early infancy are gradually replaced by controlling forms of attachment strategies (Early Child Care Research Network, 2001; Hennighausen & Lyons Ruth, 2010; Lyons Ruth & Jacobvitz, 2008). Controlling attachment behaviours may be expressed in two ways controlling punitive and controlling caregiving. Controlling punitive behaviour is defined as the child s attempts to keep the parent s attention and care through hostile, intimidating, or more subtly humiliating behaviours when attachment concerns are awakened (Hennighausen & Lyons Ruth, 2010). Controlling caregiving behaviour is characterized by the child s attempts to keep the parent s attention by amusing or giving approval to the parent (Hennighausen & Lyons Ruth, 2010). It appears that both disorganized attachment strategies in early infancy and controlling attachment strategies in the preschool years are seen to be closely related to preschool and school aged aggression and psychopathology (Lyons Ruth & Jacobvitz, 2008). In addition, disorganized attachment in infancy remains a possible source of late adolescence psychopathology (Hennighausen & Lyons Ruth, 2010). The disorganized attachment strategies in early infancy and controlling attachment strategies in the preschool years could also be linked to the over identification with the dystonic tendency in each of the early Eriksonian stages of development. For example, it is suggested that at the first stage of development there would be a lack of integration of trust and mistrust, and thus, due to the disorganised attachment pattern, a disorganised behavioural swing between the two poles, giving rise to later controlling strategies in the child (punitive or care giving, or perhaps even a combination of both strategies). At adolescent and adult stages of development these controlling strategies towards others, including a therapist, may continue to be expressed. It is possible that these controlling strategies may take shape in other ways in adulthood and be regulated by, for example, the sexual system (Stoller, 1975). The case study below of Olive and her promiscuous sexual activities could be viewed of as a controlling mechanism to get what she wants. In this case, her sexuality could give rise to sexual perversions (Stoller, 1975) in which the persons she sexually engages with are no longer related to as a human beings but as objects, to be used and later discarded (Stoller, 1975). In this light, it is further suggested that insecure and disorganised attachment patterns may have a direct impact on the quality of other self relationship and the possible inability to integrate the two opposing poles within each of the eight stages of development, leading to the development of psychopathology. On the other hand, a secure attachment pattern, as described by Bowlby and others (such as Ainsworth et al., 1978; Eagle, 2013) could be linked to the balancing of the two opposing tendencies. For example, the integration of trust and mistrust and the emergence of the virtue of hope is an expression of a secure attachment. The same principle can be applied to successive developmental stages, which will

6 1052 KNIGHT result in various forms of functional attachment patterns. The point made here is that all kinds of attachment patterns (secure, disorganised, and insecure) may be linked to the successful or unsuccessful integration of the two opposing poles within each of the eight stage of development, as documented by Erikson. Regardless of which other developmental theories may or may not be linked to therapy, it is important to note that the development of trust in the therapeutic relationship is crucial for the therapy process at the start, during the process, and until the last session. Many theorists (Castonguay, Constantine, McAleavey, & Goldfried, 2010; Crits Christoph & Connolly Gibbons, 2003; Hatcher, 2010; Horvath, 2001; Wolfe & Goldfried, 1988) have written about the notion of the therapeutic alliance as one of establishing trust, and empirically, it has become the most widely studied aspect of the treatment process across different psychotherapies and psychological conditions (Castonguay, Constantino, & Holtforth, 2006). Few theorists have linked the therapeutic alliance to Erikson s stages of development. It is suggested that within this proposed model of therapy, the development of the therapeutic alliance is linked to the development of trust in the first stage in Erikson s theory that of Basic Trust versus Mistrust, while difficulties in forming a good therapeutic alliance is linked to the underdevelopment of trust in this first stage in Erikson s theory. The therapeutic alliance is present at the other levels of Erikson s stages but the quality of the alliance is always dependent on the development of trust. Trust is not automatic but a developmental achievement. The first stage in Erikson s theory that of Basic Trust versus Mistrust is therefore critical to progression or advancement in therapy regardless of what therapy stage clients may be working in. It is at this early developmental stage that Erikson (1950/1963) asserted that a rudimentary sense of identity is formed, and together with the successful integration of Basic Trust versus Mistrust, hope emerges as the core virtue of Hope. Within therapy, with trust and hope, clients can endure the challenges and promises of the therapy process. As Erikson (1950/1963) noted, trust and hope reverberate throughout the life cycle and flavour so much of how the world is encountered and the self is treated. Erikson (1950/ 1963) observed that there are few frustrations at this or any other stage that cannot be endured once the individual has established a basic sense of trust in him or herself and in the world. Hope becomes vital for the work of all resolutions of successive stages and thus hope is a core ego strength to be used in all life experiences and challenges. Erikson (1968/1994) defined hope as the enduring belief in the attainability of fervent wishes, in spite of the dark urges and rages which mark the beginning of existence (p. 106). Hope is a core strength to be used not only in life but at each therapy stage within the proposed eightstage model of therapy. Hope in therapy manifests as a hope for something new, a new beginning, and without it there is no sense of a future and no grasping of what can be and of moving onwards (Knight, 2016). Hope in therapy is the concretising of what Winnicott (1951) referred to as potential space. It is noted that in recent years hope has become a central theme within psychodynamic and psychoanalytic psychotherapy (Cooper, 2004; Knight, 2016; Summers, 2005, 2012) and is connected to the idea of becoming a new person, of the creation of a new self (Summers, 2005, 2012) and with it, new ways of being and relating to self and others (Knight, 2016). As Erikson s theory is a theory of identity formation, the proposal is that each stage of therapy is an ever evolving process of identity formation. In terms of the developmental perspective in the proposed therapy stages, therapy is a series of developmental hopes corresponding to the idea of therapy as a series of developmental searches: There is hope in each search as clients come to therapy, a hope for something new to happen, a hope to find a different way of being, a hope for a better relationship with others, and a hope to heal. Without hope and trust in the process, the therapy will often stagnate or stall and be misinterpreted as resistance to change. Stagnation in therapy however, can also be understood as a loss of hope. The work to be done in therapy is about installing hope where it has failed, and developing trust where it has been betrayed or aborted. The first stage of therapy The Search for Courage: Balancing the poles of Basic Trust versus Mistrust will always shadow all therapy stages because trust is the basis of a good therapeutic alliance, while hope is the basis of courage. Some therapy stages may emerge concurrently during the therapy process while some stages may or may not be experienced sequentially. In addition, age related stage development is not always as specific and clear. Some authors have ascribed age ranges to the stages (McAdams et al., 1997; Marcia & Josselson, 2013). However, Erikson did not provide specific age ranges for the stages and thus no ages are given in Table 1. This lack of specificity points towards Erikson s integrative tendencies as he sought to place the stages as simultaneously chronological and mutable (Saccaggi, 2015). Therefore, Erikson s stages need to be viewed as interrelated or interconnected and overlapping and not as stagnant and distinct entities with clearcut boundaries (Saccaggi, 2015). In terms of the proposed stages of therapy, they are not always age related stages. For example, a young female client of 16 years will not normally start therapy with issues related to Erikson s stage of Old age Integrity versus Despair and work towards an integration of Wisdom. It is possible however, that this same client could begin therapeutic work at this stage if she is working with existential issues of death and dying, perhaps because she is dying, for example, of a terminal illness. At this level, the client may be concerned with the therapy stage termed The Search for Inner Peace, and the need to Balance the poles between Contentment and Regret despite being young in age. It is also possible to understand that the therapy process of some clients may be age related. For example, teenagers in therapy may be dealing with issues of identity formation and belonging as they form gangs and social groupings, or older clients may be dealing with issues of being needed and relevant as they face old age and retirement. It is important to be flexible with the therapy stages and the links to the age of the client. Most clients will not progress through all eight stages of therapy. Most will work with one or two, possibly three therapy stages for the duration of their therapy process. Furthermore, it is not difficult to identify which therapy stage or stages clients are working from. Work with the transference countertransference matrix indicates which concerns and unresolved developmental conflicts clients have. The therapy process, no matter at which stage, must necessarily become a safe place for, what Freud (1915a,b) noted as the return of the repressed and the development of a new sense of self.

7 KNIGHT 1053 While it is possible to describe eight clinical cases each case corresponding to one of the eight stages of therapy, it has been decided to present two clinical case vignettes to illustrate that one or two, maybe three therapy stages may frame the process and give meaning to what is happening. 5 THECASEOF OLIVE 1 :THESEARCH FOR MUTUAL LOVING When 32 year old Olive came to see me for therapy she reported a pervasive sense of feeling depressed and empty as well as self loathing. On further investigation it became evident that she could not sustain romantic relationships and reported having many one night stands. Within the therapeutic relationship we explored her depression and self loathing in the context of her relational pattern of quick and meaningless sexual liaisons. It emerged that during the past five years she had had many unsatisfying relationships in which she would manipulate and pull men into her life, have a one night stand with them, and then quickly push them away. Despite this push pull tendency, which may indicate her unconscious conflict about, on the one hand, wishing for commitment, while on the other hand, not wanting to commit, she did have an overwhelming desire to have a close and sustained relationship. In the transference countertransference matrix, this push pull tendency was reenacted and I felt myself being pulled and pushed in the relationship as the men had been and I wondered how long therapy would last. It was a challenging process. Her sense of emptiness made sense in the context of these unstable sexual relationships. While many of the one night stands ended in sexual intercourse, it was also revealed that it was where she felt alive. But afterwards, lying in bed with the various partners, she felt lonely and the feeling of emptiness would return. She described the sex as a way for her to feel something and she would pull in men in a desperate and addictive manner so as to feel something and to fend off a sense of emptiness and isolation. The sexual activity was usually one of sadomasochism where she allowed herself to be humiliated and abused. It was in the pain and degradation that she could feel somehow wanted by the other and thus that she existed. Olive s promiscuity (linked to Erikson s maladaptive tendency of promiscuity) could be interpreted in several ways but overtly it was a symptom of deep feeling of unworthiness. It was also a conflicted longing to find someone, to make a connection to them and to herself. After several sessions in the first month of therapy the relationship between us opened up more and she began to explore her promiscuity and her way of relating to self and others the push pull action. Informed by Erikson s maladaptive tendency of promiscuity and the developmental stage of Intimacy versus Isolation, I tentatively placed her process at the therapy stage of The Search for Mutual Loving. This is the developmental stage of early adulthood where the adult must use the achievements of the previous stage (Identity vs. Role Confusion and the virtue of Fidelity) to focus on 1 All identifying data of the female client called Olive have been disguised. In some instances, case material has been made up from various similar cases so as to make it impossible to further identify the person referred to as Olive finding intimacy or the sharing of self with another (Erikson, 1950/ 1963) and as such intimacy is really a counterpointing as well as a fusing of identities (Erikson, 1968/1994, p. 135). It is at this early adulthood stage that the individual must also leave the nest of the family and those familiar relationships to begin to look outwards to peer related relationships while still maintaining a connection to the original familial ties. It is an extension of adolescence and the need to find a sense of self amongst friends and outside of the family. Intimacy is therefore not only related to sexual and romantic intimacy (Erikson, 1950/1963) but to the forging of a close and special tie to others and a deep commitment and care to their well being (Erikson, 1950/1963). Olive s therapy process progressed from her promiscuity to her lack of connection to others and also to her own sense of self, which had become devalued. As her trust in the therapy process developed, Olive indicated a hope that maybe one day she would find someone to love. Her process centred more on her search for a reciprocal loving relationship. But this is not an easy process. According to Erikson (1950/1963) this developmental stage requires a sense of self that is fairly cohesive and stable although developing and changing because intimacy is risky in that it is the merging with another not to find the self in another but to contribute to the relationship with an already developed sense of self. The search for mutual loving and intimacy is, however, ongoing throughout the life cycle, but at this stage, if the previous stage (Identity vs. Role Confusion) has not been resolved, it can lead to a sense of not knowing who one is and thus of a persistent unhappiness, loss, and emptiness. As this developmental stage involves a willingness to reach out it includes a significant risk of rejection (Erikson, 1950/1963). Without a sense of self, an individual like Olive will struggle to forge new and intimate ties with another. The unending one night stands are the anchor for a sense of self and this explains the perpetuation of the behaviour. This stage of therapy raises issues of connection versus withdrawal, of the pullpush tendency of relating, and thus the opposing tendency of isolation, all the while encompassing a search for mutual loving. In this regard, Erikson notes that intimacy is the capacity to commit oneself to concrete affiliations which may call for significant sacrifices and compromises (Erikson, 1982, p. 70). Thus, intimacy is a developmental achievement of note in that it calls for the deepest commitment to the relationship and also, paradoxically, to let go of the self to lose [the self] so as to find one another in the meeting of bodies and minds (Erikson, 1982, p. 67). Olive was not able to commit to another because she loathed herself. Her underlying sense of unworthiness and self hate was rooted in early experiences of not being seen or recognised in the eyes of the other (Winnicott, 1965a,b). It emerged in therapy that much of her childhood and early adolescence was a mixture of showing off and wishing to be liked in an attempt to gain the approval of others, which was an unconscious longing to gain the approval of her original caretakers. In addition, as a little girl, Olive would subjugate herself to the will of others. This compelling compliance meant that she lost her sense of self in service of pleasing or placating others. Her sense of unworthiness was coupled with a need to feel pain in sexual activity, and to feel, at least for a moment, that someone in the form of the sadist lover did recognise

8 1054 KNIGHT and see her in her cries of pain. While she would never describe herself as isolated, her lack of commitment to relationships could be seen as a fear of intimacy and perhaps, a fear of being dominated again. Such a fear of intimacy is also a fear that the self will be harmed (Erikson, 1950/1963). This retreat from intimacy is the opposing tendency of Isolation. Isolation is the need to protect oneself from the pain of exposure to the tenderness of being loved and intimate with another, and thus of being seen for who one truly is. It is the desire to keep out that which is seen as hostile and dangerous (Erikson, 1950/1963). Olive was making sure that she kept out the dangerous other and so her promiscuity was a false intimacy and connection where she could engage and disengage with another. They would never know how inadequate she felt, nor that her longing for connection was always self sabotaged. As therapy moved into the third month, Olive realised that she did not have the capacity to take a chance and risk opening up to another as Erikson (1968/1994) wrote, this level of functioning is the incapacity to take chances with one s own identity by sharing true intimacy (p. 136). In the ensuing months in the transference she began to work with the integration of the opposing tendencies of Isolation and Intimacy, and to balance the two ways of being and relating. This spontaneously shifted towards work on her self esteem and the realization that she has always been compliant to the detriment of her own growth. It was a process of the return of the repressed as she worked within the transference to experience a different kind of relationship with me that would allow her to experiment with taking a risk with someone and being known. As she continued to experience a series of corrective emotional experiences (Alexander & French, 1946) in the therapeutic relationship she also began to show a balance between moving towards another and allowing herself to be alone and separate. At this time, six months into therapy, and with an increased sense of self worth, Olive met a man. This relationship was not marked by abuse, compliance, nor sadomasochism. As therapy progressed and the therapeutic relationship continued to provide a holding environment, she became more trusting and supportive of the new romantic relationship, just as she became more trusting of our therapeutic alliance. After a year of therapy, of working with finding a balance between the two opposing poles, she began to feel less depressed and empty. In the transference she tested her newly developed sense of self as capable of loving and being loved. Her search of Mutual Loving was achieved in the romantic relationship that was sustained and nourished. The virtue love for self and other began to emerge. Over the following months, while the balance between the two opposing poles of Intimacy and Isolation continued to give rise to a sense of love for self and other, this strength of love also allowed Olive to explore her childhood more. It is noted that the claiming or reclaiming of a virtue or strength at one therapy stage becomes a source of strength to confront unresolved issues at other stages. As the sharing of childhood events occurred, and with the strength of her newly found sense of love for herself, Olive shifted away from issues of promiscuity and isolation to the therapy stage of The Search for Knowing When and the Balancing the poles of Letting go and Holding on. 6 THE CASE OF DUGGIE 2 :THESEARCH FOR EFFICACY Douglas was a mature man in his early 50s and liked to be referred to as Duggie, as he said it was a softer name. He came to therapy because he felt angry and mistreated after being asked by colleagues and his line manager to step down from a position of leadership in the workplace. For several years he had held this coveted position and to be asked to step down was like being fired : It was devastating to his sense of identity. Afterwards, for almost three years he felt degraded, angry, displaced, cheated, and hungry for revenge. Most of his anger was directed at his coworkers who it seemed to him had ganged up against him to complain to his line manager. In an attempt to have some revenge he often undermined their work, spread rumours about them as incompetent and the workplace as being in constant chaos because there was no leadership. For years he wished that they would be also fired, especially the new leader who was seen to have been the instigator of his demise. As therapy progressed into the first month, it became apparent that Duggie displayed postures of grandiosity. In the transference he wanted me to be impressed. I realised that the displays of grandiosity were symptoms of a sense of inadequacy and inferiority, reminiscent of pathological narcissism (Kernberg, 1975; Kohut, 1977, 1984). At times in the transference he made me feel inferior and degraded as he has been. The therapy process was challenging but I made meaning of it by viewing his process as located at the therapy stage of The Search for Efficacy with the two opposing tendencies of Productivity versus Inadequacy. This is the developmental stage that Erikson noted as the last of the childhood stages and he termed this stage Industry versus Inferiority. Here the growing child is ready to leave home to attend school and mix with other children and learn to become a socialised and a responsible member of society (Erikson, 1950/1963, Erikson, 1968/1994). Industry refers to productivity and the child s task is to learn to adequately use the tools of society in terms of technology. The successful resolution of this stage results in the virtue of competence, (Erikson, 1968/ 1994) which is defined as the free exercise of dexterity and intelligence in the completion of serious tasks unimpaired by an infantile sense of inferiority (p. 126). The integration of the two opposing poles of inferiority and industry and the emergence of competence sets the scene of future ambitions, (Erikson, 1982) and thus, it is an important stage for it is also the lasting basis for cooperative participation in productive adult life (Erikson, 1968/1994, p. 126). Depending on the resolution of the earlier three development stages and the gaining of the previous three virtues (hope, will, and purpose) the child may be inadequately prepared for school and learning to use the tools of society to be productive (Erikson, 1968/1994). Inferiority is thus rooted in a sense of not being able to do. This sense of not being able to do (being fired) and its expression in a deep feeling of anger and yearning for revenge hides the deeper layer of feelings of inferiority. Duggie s experience of being asked to step down from a leadership role was the ultimate injury to his already 2 All identifying data of the male client called Duggie have been disguised. In some instances, case material has been made up from various similar cases so as to make it impossible to further identify the person referred to as Olive