Erikson’s theories

Most often when we think of theories of human development relevant to adulthood we think of Erik Erikson, who is probably the most well known psychologist with a theory of development that extends into adulthood. Other theorists, such as Freud and Piaget, only extended their theories to puberty (Freud’s genital stage) and around age 11 (Piaget’s stage of formal operations. See Chapters 1 and 2 for more information). Perhaps the complexities with adulthood and the lack of well-defined, discrete, developmental stages directly related to age have challenged theorising in this area. In this section, we will review Erikson’s theory and will also explore Bronfenbrenner’s ecological theory, Kohlberg’s theory of moral judgement, Baltes’s theory of selective optimisation with compensation and the lifespan model of developmental challenge.

The main stages of Erikson’s theory relevant to adulthood are the stages of intimacy versus isolation, generativity versus stagnation and integrity versus despair (Erikson 1950, 1982, Erikson & Erikson 1997) (see Table 3.1). Table 2.1 in Chapter 2 lists the first five stages of Erikson’s theory.

Table 3.1 Erikson’s final three developmental stages

The stage of intimacy versus isolation is characterised by either the seeking of companionship and intimate love with another person or becoming emotionally isolated and fearing rejection or disappointment. This stage is usually said to occur during early adulthood and is often associated with the chronological ages of 18–24 years. In terms of healthcare practice, recognising that people at this stage may be struggling to come to terms with intimacy issues and that multiple factors can contribute to isolation, health professionals can serve a very useful role in assisting clients to successfully resolve this stage. For example, linking clients with support services, community organisations or self-help programs and groups can go a long way in preventing issues that could become more serious if left unrecognised. This is supported by considering the relationship between social isolation and mental disorders such as schizophrenia (e.g. Cantor-Graae 2007) and that three in four mental disorders occur before age 24 (Kessler et al 2005).

Middle adulthood, according to Erikson, is characterised by a contribution to the next generation, usually through work or employment or having a family (i.e. generativity) or by becoming socially inactive (i.e. stagnation). One of the limitations of the application of Erikson’s theory is that it can be interpreted as an either/or dichotomy; whereas, in reality, adults may find that in some aspects of their lives they have been generative but in other aspects have a sense of stagnation. Take, for example, a woman who is highly successful in her career but who never had children. While she may have a strong sense of generativity in her career, she may have regrets for not having had children (being stagnant in that area). However, it is also not usually that simple. For example, many families also contribute to their siblings’ families rather than have their own families (see section on adoption later in this chapter) and this could be considered either generativity or stagnation, depending upon how the person sees it. It is therefore important to consider diversity in the development and understanding of these concepts.

Finally, in Erikson’s theory, older adults make sense of their lives either as meaningful (i.e. integrity) or they may despair about the things that they did not achieve or accomplish in life. Erikson’s theory is usually considered in the context of an individual and his or her resolution or not of these stages. However, the wider social context has much to contribute to these stages of development. For example, health professionals, again, can serve an important role in assisting clients to develop a sense of integrity rather than despair when working with the chronically ill or those nearing the end of life.

Kohlberg’s theories

Kohlberg’s theory of moral reasoning (1976) includes three levels and six stages roughly from age four to adulthood. Level I, or preconventional morality, includes stages 1 (orientation towards punishment and obedience) and 2 (individualism and exchange). Level II, or conventional morality, generally relates to children aged 10–13 and includes stages 3 (maintaining mutual relations and approval of others) and 4 (social concern and conscience or maintaining the social order). Level III and stages 5 and 6 are most relevant to adulthood and healthcare, although Kohlberg postulated that some people never enter these stages. Level III, or postconventional morality, includes stage 5 (social contract or individual rights and democratically accepted law) and stage 6 (morality of universal ethical principles). In stage 5, people are rational and can be thoughtful and critical of laws and legal issues but inevitably will conform to laws and human rights as morally ideal. In stage 6, however, universal ethical principles will outweigh legal concerns in a moral dilemma. Kohlberg also later included a stage 7 (the cosmic stage) in which people would be able to see the impact of their action on the greater world, rather than only their immediate world (Kohlberg & Ryncarz 1990).

In terms of healthcare, the relevance of Kohlberg’s theory is obvious. There are many moral and ethical dilemmas that health professionals contend with on a regular basis and the resolution of these dilemmas will partly depend on where a person is at in terms of these stages and how the dilemmas are resolved. But it is perhaps too restrictive to just view these as internal stages of moral development. Dealing with moral dilemmas regularly and the social and structural systems in place to facilitate this, such as the quality of debates with coworkers or the policies in place surrounding moral dilemmas, will influence the resolutions of these dilemmas. Take, for example, the issues of euthanasia or, for a less contentious issue, the use of medication that has serious side effects. Kohlberg is saying that how you decide these issues can change with a more or less developed sense of moral

Table 3.2 Kohlberg’s theory of moral reasoning

Health professionals not only will benefit from Kohlberg’s theorising in their own practice but consideration of Kohlberg’s stages in respect of clients will help in treating clients. For example, issues of violence, drug abuse and even parenting can be understood better by considering stages of moral development. They can assume that some clients will be thinking about these issues very differently and health professionals should make an effort to understand all forms of moral reasoning.

Others’ theories

Limitations to these classic theories have pushed the need for theories that are more contextual and not so limited to Western notions of individuality and chronological age (Qin & Comstock 2005). These more recent theories include the ecological approach of Urie Bronfenbrenner (1979, 2004), Paul Baltes’s lifespan perspective (Baltes 2000, Baltes & Baltes 1990, Baltes et al 2006) and the lifespan model of developmental challenge (Hendry & Kloep 2002).

Bronfenbrenner’s (1979, 2004) theory takes individual development into a wider social context, considering micro (e.g. family and work), meso (the interactions between the individual’s social connections, e.g. your mother interacting with your partner), exo (which are the social connections that the individual’s social connections have, e.g. your partner’s work colleagues) and macro systems (e.g. religion and politics). Bronfenbrenner’s system, also called a ‘bioecological’ system, is multidirectional in that it is not only the social systems that impact on the individual but that the individual also impacts on those systems. ‘Development is not something that just “happens” to the individual person but an interactive, dynamic process that involves all the system levels of a society’ (Hendry & Kloep 2002 p 12).

Lifespan perspectives, or lifespan theories, of human development consider development across the full lifespan and suggest that to fully understand someone’s development, one needs to consider how life events influence development. The lifespan perspective also considers the important social and political factors that impact on development such as policies impacting on Aboriginal Australians (such as the ‘stolen generations’) or economic conditions (such as post–Second World War depression). In Baltes’s lifespan theory, a further dimension relates to how gains and losses in life contribute to change and development (Baltes 2000). Overall, greater gains and fewer losses result in positive development (Baltes at al 2006).

Carol Gilligan is a human development theorist who argued that human development theories (especially Kohlberg’s) do not adequately account for development as it relates to girls and women. In her research with pregnant women contemplating abortion, she found that conflicts with responsibility to self and to others related to moral development for women that is not adequately addressed in Kohlberg’s theory. Overall, Gilligan found that morality for women relates to an ethic of care and suggested that differences between men and women should not be minimised (Gilligan & Farnsworth 1995). Although some research has shown that Gilligan’s critiques of Kohlberg’s theory were unjustified, her theorising drew attention to the often male-dominated theorising in human development.

Another female theorist in human development is Marion Kloep who, with Leo Hendry, has recently proposed the lifespan model of developmental challenge (Hendry & Kloep 2002). In Hendry and Kloep’s lifespan model of developmental challenge, the concepts of challenges, resources, stagnation and decay feature prominently (2002). Basically, in this model, people have ‘potential resources’, and these resources influence how an individual will respond to various challenges (‘potential tasks’) that will occur throughout life. Resources include an individual’s biology, social resources, skills, self-efficacy and structural resources. An interesting feature of the developmental challenge model is the relationship between task demands (whether there are many or few) and the availability of resources and how they relate to feelings of anxiety or security and whether the task is then a risk, a challenge or routine. If tasks are often routine and the resources exceed the task, then stagnation can result. Also, if there are not enough resources and the tasks are risky, then decay can result.

Take, for example, the person who is overworked with high family demands but on a low income. Over time, the resource pool will deplete and the person risks ‘decay’. Success, in this model, is ‘development’ and development can contribute more resources to the pool. However, people can be in a state of ‘dynamic security’ in which their resource pool is full and there are not many challenges. This is not necessarily an ideal situation because boredom can ensue. It is in this way that the model is also interesting in that individuals are active players through their seeking or not seeking challenges to continue their development. If people do not seek out a challenge they may then be in a state of ‘contented stagnation’. On the contrary, ‘unhappy stagnation’ occurs when there are no challenges but the individual does not have the resources to seek them out.

The lifespan model of developmental challenge is useful for health professionals because it reflects more of the complex realities of people’s lives that we observe in real situations. Health professionals are in a position where they may often see people experiencing a challenge (e.g. a health condition or an accident) and can also determine whether people and their families have the resources to successfully develop through the challenge. From the client’s perspective, the heath professional who assists in identifying these factors will contribute to improved outcomes, both from the healthcare situation and more holistically for the client.

Marriage and family

With the religious and cultural diversity of Australia, mate selection, marriage and family are correspondingly diverse (Hartley 1995). We might generally think that differences in marriage fall into distinct categories of ‘love marriages’ or ‘arranged marriages’ or we may have ideas about what it is that makes up a family. A family, according to the Australian Bureau of Statistics (ABS), is two or more persons, one of whom is at least 15 years of age, who are related by blood, marriage (registered or de facto), adoption, step or fostering and who are usually resident in the same household (ABS n.d.) This definition is a very Western conception and revolves around the concept of the ‘nuclear’ family. The ABS also identifies couple families with and without children, one-parent families, step families and blended families but these, too, are basically ‘nuclear’ family conceptions. However, how families are conceptualised can differ quite drastically in different ethnic groups. For example, for some, the ‘family’ would not exclude those who ‘are not usually resident in the same household’ and the relevance of the ‘household’ may have different meanings for different people and groups.

Marriage is generally considered to be a permanent and legally recognised arrangement between two people that includes both a sexual and an economic relationship with mutual rights and obligations. An endogamous marriage is one where the bride and groom are from the same group (like Italians marrying other Italians or Jewish marrying other Jewish) and an exogamous marriage is one in which the partners are from differing groups (like a Catholic marrying a Muslim or someone from Iraq marrying someone from France). For example, for Australian Aboriginal groups it is important to marry outside of one’s ‘skin group’. While only monogamous marriages are legal in Australia (that is, only have one husband or wife), it is perhaps useful to know that this is not the case in all countries around the world and with the increasing migration to Australia from non-Western countries, health professionals should be aware of other types of marriage arrangements. For example, polygamy, or marriage to multiple spouses, is desirable in most Islamic countries, where it is acceptable and even expected for men to have up to four wives (also called polygyny). Less common are polyandrous marriages where a woman has more than one husband at the same time. Perhaps more common in Australia is serial monogamy, or successive marriages that may be short or long term, although these, too, are generally uncommon.

There are also differing notions of relatives that are important for health professionals to recognise. For example, consanguineal kin are people who are related by blood, ancestry or descent and affinal kin are people who are related by marriage. In-laws and their relatives are therefore affinal kin. Adopted kin are family created through adoption and fictive kin are those who you might consider to be related to you, like calling your best friend your sister. Figures 3.2 and 3.3 illustrate two alternative ways that relationships in a family can be construed. Figure 1 shows the Euro kinship pattern while Figure 2 illustrates the Dravidian kinship pattern. The Euro kinship pattern is common in Western groups, while the Dravidian system is found in South India and in some Aboriginal and Oceanic groups. These are only two kinship patterns and there are a number of other ways in which relationships between blood and marriage can be understood. However, in Australia, perhaps the Dravidian and the Euro patterns are most common.

Figure 3.2 Euro kinship

Adapted from Dousset 2002

Figure 3.3 Dravidian or Australian Aboriginal kinship

Adapted from Dousset 2002

In Euro kinship, siblings are called brothers and sisters and offspring from the brothers and sisters of one’s mother and father are called cousins. The brothers and sisters of one’s mother and father are not distinguished and are referred to as aunts or uncles, based on gender. Similarly, the parents of one’s parents are referred to as grandmother or grandfather, again, depending on gender.

In Dravidian kinship, a person can have multiple mothers and fathers and sisters and brothers who are outside the immediate family unit. For example, the sister of one’s mother is also called mother and the daughter or son of that mother is called a brother or sister. In terms of parenting (discussed next), this kinship pattern can be very useful, for example, if a teenage boy is getting into trouble, then another father may be called on to offer guidance. In terms of healthcare, a mother’s sister may take children to healthcare appointments in her role as another mother. Another characteristic in Aboriginal kinship systems is ‘avoidance relationships’, which is the avoidance of, or not interacting with, certain relatives out of respect. For example, a man and his mother-in-law constitutes an avoidance relationship.

Marriage in Australia is a hugely important and common event, reflected by the fact that in 2006 alone, 114,222 marriages were registered (ABS 2007). Although, historically, the number of marriages in Australia has decreased, they have slightly increased in the past few years. Age at marriage, on the other hand, has been steadily increasing, with the current median age at marriage 29 years for women and 31 years for men. Living together before getting married (i.e. cohabitating) is now a very common practice with 76% of couples reporting cohabitating prior to marriage. One drastic change in marriages over time is that marriages are much more likely now to have been performed by civil celebrants rather than religious ministers. While the majority (61%) of marriages in Australia are between men and women who were both born in Australia, 30% were between men and women born in different overseas countries and 9% were between couples born in the same overseas country (ABS 2007).

Marriage is an important consideration of health professionals because of the research showing various relationships between marriage (or being single) and health (Jaffe et al 2007). For example, people who are married have a longer life expectancy, ‘Marriage reduces the risk of an earlier death as a person is less likely to participate in risky behaviour and more likely to nurture or “guardian” each other’s health through promoting good diet and physical care’ (Elliot 2008 p 1). A large study in the United States by the Centers for Disease Control and Prevention (CDC) (2004) found that married people were overall (except in bodyweight) healthier than people who are not married. This better health includes being less likely to suffer various conditions such as headaches or back pain, as well as lifestyle factors such as not smoking, drinking alcohol or being physically inactive. Married men, however, were more likely to be overweight. Interestingly, the patterns did not hold for people who were living together but not married whose health was similar to the poorer health reported by divorced or separated adults (CDC 2004).