Questions
7. The Psychodynamic Approach
Arthur Frankel
LEARNING OBJECTIVES
By the end of this chapter, you should be able to:
•understand the basic theoretical foundations of ego psychology,
•understand the intervention strategies in ego psychology,
•see how ego psychology theory and practice have influenced the current practice of clinical social work.
INTRODUCTION
There is no question that Sigmund Freud, the founder of the theory that underlies ego psychology, was a genius. In his era, there was not much in the way of psychological research: no controlled group studies, no research connecting heredity with behavior patterns, and no investigations exploring the connection between brain biochemistry and behavior. Freud used observations to develop his theory in the context of his cultural and religious milieu. Over the years, many have discounted his theory as being sexist, homophobic, and biased toward the more affluent. He did not have what is now available in research and practice experience over the last 100 years to draw upon. Given that his perceptions were coming from the culture and beliefs of his times, we must give him some latitude in understanding that he was a product of his time when he developed his theory.
Given all of these limitations, what he came up with was the first comprehensive theory to explain human behavior. In addition, he developed a concurrent theory of personality development that was integrated into the theory. For the first time in history, when one asked “why” did a person act as they did, there was a coherent answer grounded in a psychological theory. Furthermore, Freud’s personality theory suggested how a person developed dysfunctional behavior patterns. Imagine the power of an assessment process that uncovered where in your childhood problems originated, leading to focusing the therapeutic interventions directly at the source of the behavioral dysfunction. To this day, there has not been another psychological approach integrating a personality theory that directly connects to the practice of psychotherapy.
Regardless of whether you like or hate the constructs of Freudian theory, it has had a profound impact since its inception. The power of the theory can be still be seen, not only in the practice of psychotherapy but also in literature, cinema, the practice of the law, and personal communications. We are aware of our “ego” and how people have “Freudian slips,” and we watch how people use “denial.” We are well aware of and use the terms “libido,” “phallic symbols,” “anal retentiveness,” “sexual repression,” and “defense mechanisms.” The idea that there is an “unconscious” part of our minds, where there are thoughts and feelings not available to awareness, has been utilized in all art forms. You can see his influence in renowned painters such as Salvador Dali and the Surrealists; in literature, Shakespeare, James Joyce, Virginia Woolf, and Dostoevsky; and in cinema, movies made by Alfred Hitchcock and Woody Allen. Freud pioneered a therapeutic process to decipher the meaning of dreams. The concept of “not guilty by reason of insanity” was formulated from Freudian theory, which suggested the concept of “mental illness.” Thus, whether we like Freudian theory or not, after almost 100 years since its introduction in 1923, it still has a pervasive influence in our lives (Kelly, 2014).
HISTORICAL DEVELOPMENT
When Freud officially introduced his theory in 1923, it was groundbreaking (Freud, 1923). It offered a comprehensive explanation of human behavior and a way to intervene to change dysfunctional behavior. The treatment process was called psychoanalysis, and utilized constructs he called the id, ego, and superego. He believed that all human behavior could be explained by unconscious motivations of sexual desires and aggressive impulses. However, these motivations were in an unconscious psychological area, the id, which was not available to our awareness (Freud, 1962). It should be understood that Freud proposed his ideas as “constructs.” There is not a part of the brain that has the id, ego, or superego in it. Rather, these ideas are part of a “map” of how motivational energy is focused and how it is allowed to flow, resulting in behavior.
The model for treating people who had problems emanated from the medical model, which assumed that the patient was “sick” and needed to be “cured.” This approach to dysfunctional behavior morphed into what was called “mental illness,” which is a term that is all too familiar today. The treatment approach was called psychoanalysis, and called for the patient to lie on a couch or sit in a comfortable chair and talk about whatever came to mind. The therapist was supposed to be quiet, making few, if any, comments during the session, which occurred as many times a week as possible, over many months or years. The stereotype of psychoanalysis became one where the patient lay on a couch talking, with the therapist sitting out of sight behind the patient. Because Freud was a medical doctor, it became the norm that the only professionals who could practice psychoanalysis had to have an MD and then be further trained in the specialty that became known as psychiatry.
Before the 1950s, when ego psychology theory and practice started to become more prevalent, the only way a person could get psychotherapy was through a psychiatrist. The idea that one needed a specially trained medical doctor, a psychiatrist, to cure mental illness was established by Freudian proponents. As mental health treatment began to become more available with the inception of the Kennedy Mental Health Act in the 1960s, psychotherapy began being delivered by psychologists and social workers. Many of these professionals were trained in a more psychosocial model using many other therapies along with ego psychology. During these years, psychiatrists were still in charge of most mental health endeavors. However, as time went on, psychiatrists started losing their leadership mantel for psychotherapy and were left with being the medical experts in dispensing psychotropic drugs. Thus, Freudian theory affected not only how therapy was done over time but also who did it and who at the agency level was in charge of clinical services.
It became clear by the 1930s that the practice of psychoanalysis presented serious service gaps. Overall, it took too much time and was too expensive to meet the mental health needs of the population. Proponents of psychoanalysis were fervently espousing its effectiveness, mostly using case study reports. However, there was no way it could be applied to those who did not have the time or money to engage in therapy three or more times a week for months or years. In addition, by the later 1930s, psychology and social work departments were beginning to assess their role in psychotherapy. Schools of social work particularly had begun systematically training professionals to work with immigrant groups and people in poverty (Hollis, 1949).
An academic movement began to emerge particularly in psychology, and to some extent in social work, to re-think how the Freudian approach could become more “user friendly” to the masses. What they came up with was called “ego psychology.” It focused on the parts of Freudian theory that were more available to human awareness, those functions of the ego and superego (Blanck & Blanck, 1974).
Models of interventions were developed that allowed patients and therapists to directly interact with each other, still following basic Freudian theoretical guidelines. Now departments of psychology and social work had a therapy training model outside of psychiatry and psychoanalysis, and were able to start producing a greater number of psychotherapists than was ever possible in medical schools. Psychologists and social workers practicing ego psychology essentially took over the psychotherapeutic marketplace, so that when mental health movement started in the 1960s, ego psychology was in its heyday (Hartmann, 1958).
As the 1960s rolled on, the practice of ego psychology began to lose its luster, beginning a slide onto the banks of the mainstream of psychotherapy (Goldstein, 2015). A number of phenomena were related to this slippage. First, starting in the 1930s, the principles of behavioral theory began extensively being researched with rats. In early 1940, B. F. Skinner (1953) started publishing books and articles that suggested that behavioral theory, grounded in literally thousands of research articles with lower animals, could be applied with the same empirical rigor on humans. Behavior theory and Freudian theory are diametrically opposed at the most basic levels. What made behavior theory so attractive, especially to academic departments of psychology, was that, unlike ego psychology, behavior theory was eminently testable, resulting in an explosion of applied behavioral research on humans. By the mid 1960s, there was almost a war going on for the hearts and minds of psychologists and social workers, with some departments of psychology and social work completely dropping ego psychology in favor of behavior therapy, whereas others stubbornly hung on to ego psychology for some years. To this day, one would be very hard pressed to find a graduate department of psychology that is not behavioral.
Social work hung on to ego psychology for a little longer. In the 1940s, social work had begun to adopt ego psychology principles into what it called social casework, with Lucille Austin (1948), Florence Hollis (1949), and Helen Perlman (1957) leading the charge. The practice of ego psychology in social work was somewhat different than in psychology. Social work practice was grounded in what became known as systems theory, which assumed that all human problems were not only based on the unique psychology of each individual but were also related to how they were affected by their community, economic status, culture, and social policy. Thus, from a social work perspective, helping a person with a problem, such as depression, required work not only on their personal coping skills but also on such issues relating to community and cultural determinants, such as their being able to support their family, access to sufficient food, work issues, discrimination, and community support systems. Social casework made a valiant attempt to integrate ego psychology into a broader systems theory treatment process (Parad & Miller, 1963).
Behaviorial therapy arriving in the mid 1960s had a similar effect on ego psychology in social work as it did in psychology, but for different reasons. In those years, empirically based practice models were not as prevalent in social work as they are now, so the attraction of using an empirically based model of psychotherapy was not as strong as it was in psychology. In addition, coming along with the advent of behaviorial therapy in the mid 1960s were a number of very attractive alternative psychotherapeutic humanist theories. With such a milieu of possibilities, ego psychology was lost in the sea of new approaches (Goldstein, 2015). It was still being taught in many schools as part of an “eclectic” approach to practice, but not as much as a central focus for clinical social work.
Along the way in the psychodynamic journey of the last 100 years, there have been other offshoots from Freudian theory, owing their roots to Freud. These include self-psychology, attachment theory, relational theory, Gestalt therapy, and transactional analysis. Each of these offshoots either augmented or reacted to basic psychoanalytic theory, attempting to be more practical in implementation, such as self-psychology, person- centered therapy, Gestalt therapy, and transactional analysis, or to focus on particular aspects of psychodynamic theory more clearly, such as attachment theory, and relational theory (Miller, 1976). For example, attachment theory focused on how children became attached to their caregivers and helped explain the etiology of reactive attachment disorder (Ainsworth, 1973). Transactional analysis took the super ego, ego, and id, and redefined them into a more user friendly parent, adult, and child (Berne, 1961). Self-psychology took more of an ego psychology slant, but focused on the importance of interpersonal relationships (Kohut, 1971). Gestalt therapy focused on the here and now in its practice methodology, minimizing the importance of personal history in the behavior change process, yet it kept many of the terms and ideas from Freudian theory (Perls, 1969). Person-centered therapy, founded by Carl Rogers, who is also viewed as the founder of the humanistic therapy movement, took ego psychology principles and reworked them. Therapists were allowed to be empathetically interactive with clients, but not allowed to offer advice. He pioneered the use of active listening, showing positive regard, unconditional acceptance and the importance of the client-therapist relationship in the therapeutic endeavor (Rogers, 1951). Today, there are still pockets of proponents for these theories, but none of them are in the mainstream of the psychotherapeutic milieu in America.
It was reported in a New York Times essay (Cohen, 2007) that in course descriptions in 150 major American universities, where they were looking for courses that mentioned Freudian theory, 86% of these courses were offered outside of psychology departments. This led them to conclude: “Freud is widely taught at universities, except in the psychology department.” Currently, formal training in psychoanalysis or ego psychology is very hard to find except in scattered private institutes. In current agency-based practice, there is an emphasis on empirically based practice methods, such as cognitive behavior therapy, positive parenting training, and contingency management with families. Professionally licensed social workers in private practice can use any psychological theory they choose, but it is not known how many might be using ego psychology or psychoanalysis as their main approach. In any case, it is likely that some of the therapeutic techniques associated with ego psychology are still alive and well.
CENTRAL THEORETICAL CONSTRUCTS
In order to understand ego psychology, we have to start with the major constructs of Freudian theory (Bellak et al., 1973; Frankel, 1984; Goldstein, 1995). There are five basic concepts that need to be discussed: the id, ego, superego, psychic energy, and the pleasure principle. To start, imagine a three-story house with a basement, a first floor, and an attic. The floors between these three levels have many trap doors that can be opened and closed. The basement is the id, the first floor is the ego, and the superego is in the attic.
The Id
The motivation for all human behavior comes from sexual and aggressive impulses residing in the id. We are born with the id, and its sexual and aggressive drives. If you think about what impulses have been historically necessary for the survival of the human race, clearly sex and aggression are important. Sexual impulses are necessary for the procreation of the species; aggressive impulses are necessary to protect the individual, family, and community from aggressors that threaten their existence.
Freud believed that the sexual and aggressive impulses coming from the id were quite primitive. For example, the powerful urge to have sex is always there, every minute of the day. The id makes no discrimination between heterosexual or homosexual urges for sex. Therefore, a man has an equal urge to have sex with women or other men as do women have the urge to have sex with men or other woman. Left to its own devices, the id would drive you to copulate with every attractive man or woman you encountered at work, in the community, or at home. Similarly, the aggressive urge is also very raw. When you become very frustrated or angry with someone, be it a partner, relative, friend, or stranger, the id, left untethered, would urge you to kill that person. Not just to think about killing them but actually doing it.
It is obvious that these drives have to be managed and/or contained in order for there to be any kind of civilized existence. While most people are aware of their sexual and aggressive drives, the extent of the id’s strength is unconscious, not available to our awareness. Thus, civilized society made rules to rein in sexual and aggressive drives. Laws were made against rape, murder, thievery, and other behaviors societies viewed as dysfunctional. These rules that make civilization possible are going directly against what the id directs us to do. The id uses the “pleasure principle” to guide its motivational energy. It wants to increase our primitive pleasures around sexual desire, and to aggress with vengeance against people who are trying to control or attack us. There is a constant state of tension between what the id directs us to do and what civilized society is requiring of us. This tension is also felt on one hand in our need to have intimacy and on the other hand, the id’s desire for raw sex and aggression in our personal relationships. The ability to therapeutically interpret which drive, sex or aggression, is behind any particular dysfunctional behavior is part of the training in this approach.
The Superego
The superego is where the rules to live by reside. It houses your attitudes, what you consider right and wrong, your judgments, your gender and sexual identity, what feelings are acceptable to you, your religious beliefs, and generally, what behaviors and thoughts you consider to be acceptable for you and others. You are not born with a superego. Everything that is in the superego is initially adopted from a parent or whoever was raising you before the age of 6 years old. In addition, we have many rules, beliefs, and attitudes that are learned from the culture and ethnicity that surrounded us as children. Many of these also end up as part of your superego, having been adopted through our early childhood experiences.
The Ego
The ego has two major functions. First, it encompasses our conscious awareness of ourselves and the world around us. We use five senses to be aware of others and our environment. We are aware of cognitive and feeling processes—what we feel, and what we think and imagine. The ego is our window to life. The ego discriminates what we believe is our current reality, separating our history from the present. This is useful so that energy can be directed in the present moment for problem-solving.
The second function of the ego is to mediate between the powerful sexual and aggressive impulses coming from the id and what our superego says about how we are supposed to live our lives. The ego’s basic function is to keep us from the pain of knowing how the id wants to contradict what is acceptable to our superego rules. For example, in our superego is our gender and sexual identity. If you clearly consider yourself to be heterosexual, this means you would never consider a homosexual experience or relationship. However, the sexual drives from your id say that you are as attracted to the same sex as the opposite sex and would want to actually engage sexually with same sex partners. From a Freudian perspective, this is considered to be a fact. So if by chance you met a person of the same sex, and found yourself unconsciously attracted to them, your ego would check in with your superego to ensure that you are indeed heterosexual. Then, it would counter the energy coming from the id to keep you from consciously knowing that you have sexual feelings for this same-sex person. To actually consciously feel, any same-sex sexual attraction would violate your sense of self and cause you anxiety and pain. It is the ego’s job to keep you from pain as much as possible.
Similarly, in your superego is a rule, hopefully, that you should not kill people who make you very angry, including, for example, your partners and parents. So assume that you are very angry with your mother. The unbridled id sends energy urging you to kill her. The ego, sensing this heightened motivational energy coming from the id, checks in with the superego and indeed finds a rule that you should not kill people with whom you are angry. So the ego clamps down on the id energy before you can even know that unconsciously you want to kill your mother. The ego has again done its job to keep you from knowing what you unconsciously really want to do, thus avoiding this pain of knowing.
The dynamic that the ego uses to clamp down on id energy that would violate the superego rules and attitudes is the concept of psychic energy. Psychic energy is what the ego utilizes to stop or re-channel id impulses that are liable to cause you pain. Consider now the metaphor of the three-story house with lots of trap doors in the floors between the id in the cellar, the ego on the first floor, and the superego in the attic. The id is constantly sending up sexual and aggressive impulse energy into the ego through trap doors in the floor. The ego looks up through the ceiling holes to the superego in the attic to decide what to do. If the energy coming up from the id violates superego rules and would cause pain, then the ego directs psychic energy to close and hold down that basement trap door, cutting off or dampening that unacceptable sexual or aggressive impulse. To use the gender-sexual identity example, the primitive impulse to have a same-sex encounter coming up through id’s trap door would be closed by the ego’s psychic energy, so you wouldn’t even know you felt it.
Since there are many, many trapdoors of unacceptable sexual and aggressive impulses coming up from the id, the ego is one busy construct. It needs to constantly assess whether the id energy would cause a behavior, or even the thought of a behavior, that would violate superego rules. Then it would need to use psychic energy to clamp down on the trap doors, almost like a game of “whack-a-mole.” When there is sufficient psychic energy available, the ego can play this game quite well. However, when psychic energy runs low or something happens that heightens the id’s sexual or aggressive impulses, there may not be enough psychic energy to keep some of the trap doors closed. There might be seepage of id impulses, allowing for a person to have some inkling of their true unconscious desires. When this happens, anxiety, depression, anger, or an uncharacteristic sexual or aggressive behavior can result. However, the ego can replenish its supply of psychic energy. When people get enough sleep, eat well, exercise, calm themselves, meditate, or problem solve, the amount of psychic energy available to the ego can increase.
Defense Mechanisms
The ego has a variety of ways to use psychic energy to protect you from knowing and experiencing unacceptable sexual and aggressive urges from the id. These are called defense mechanisms (Frankel, 1984; Laughlin, 1979). However, they are being used unconsciously. For example, if you knew that the ego was using the defense mechanism called “repression” to deny your true unconscious wish to kill your mother, then the cat would be out of that bag, and you would feel the pain of that knowing. We can on a rational level make interpretations about what defense mechanisms are being used to protect us and others. And in fact, this is what therapists in Freudian practice do. It is also very important to understand that the application of defense mechanisms is protective, helping us avoid pain. There are many times in life that it is essential that we avoid pain to maintain our stability. Therefore, the use of defense mechanisms by the ego should be viewed in the context of their value in maintaining relationships and emotional stability. There are times when it might be helpful to strengthen a defense mechanism.
Here are some of the more common defense mechanisms:
Repression: This is one of the most primitive defense mechanisms. Feelings relating to serious aggression, and sexual attraction to parents, siblings, and children are all serious dangers if they came to the level of awareness. The same can be said of feelings violating one’s gender identity. The ego cannot allow even a little seepage into awareness, so it closes that id trapdoor completely with strong and constant doses of psychic energy to completely cut off the knowing of these urges.
Denial: Denial is activated when something happens and the ego is unable to deal with the pain, such as somebody dying or the loss of a job. The ego applies sufficient psychic energy to clamp down on the related id sexual or aggressive energy. When you hear that a friend or relative suddenly died, the first response coming out your mouth is “No,” an immediate use of the denial defense mechanism. In this case, denial is a fleeting response, instinctually used to avoid the pain of knowing. When used for too long, denial might put a person out of contact with reality.
Projection: This is a common and widely used defense mechanism. There are many feelings we have that our superego tells us are not acceptable. Blaming is a perfect example of this phenomenon. When you have an argument with your partner, the rules of your superego may not allow you to own your part of the problem. The way your ego can protect you from the pain of owning your own anger at yourself is to project it onto your partner—it’s their fault. If your friend frustrates you and you have a superego rule that you’re not supposed to show anger, then the ego can arrange to channel that id seepage into a projection. “You appear angry, and I am wondering why you might be angry with me?” It is common that when people use projection as a defense mechanism, they work hard to fulfill their projection. Thus, if you pushed hard enough, your friend would likely get frustrated and blurt out, “I am not angry with you!” And then you can say, “See, I knew you were angry with me!,” thus fulfilling your projection. Another stereotypic use of projection is when a dad gets very angry with any boy who touches his daughter. His superego has strict rules about having sexual feelings about his daughter. Thus, when he views another boy touching her, the id sends up his unconscious sexual attraction for his daughter. This knowing would be very painful and unacceptable for him. Thus, his ego uses psychic energy to redistribute the id urge into a projection, where he is angry with the boyfriend.
Reaction formation: When a parent gets very angry with their child, and the child ends up giving that parent a present, this is reaction formation. The child’s superego won’t allow them to get angry with their parent, so the ego redirects this anger energy into doing the opposite of what the id impulses are demanding. Avoiding a feeling and doing the opposite of that feeling is characteristic of reaction formation. Another example is when something very sad happens, and the person reports being very happy.
Isolation: People use this defense mechanism to separate feelings from the tasks they are doing. For example, there is a reason that surgeons are not allowed to operate on their friends or family. It is essential that they separate, or isolate, their feelings about the patient from the surgery tasks. Similarly, it is normal to associate strong caring feelings with sex acts. People who engage in “recreational sex” have to isolate these intimate caring feelings from having sex, or they would be emotionally overwhelmed as they went from one partner to another.
Displacement: A common defense mechanism. A person gets very angry at their boss, but their superego has rules about not allowing anger at authority figures. Instead, at home, they get angry with their partner, displacing the id aggressive impulse to a safer venue. People will not realize this is what they did, and the fight with the partner will seem to be valid and independent from what happened at the office. When it is deemed by your superego as too risky to show love or hate in one setting, displacement is one way the ego can redirect these id urges to a place where is it more acceptable.
Substitution: The most stereotypic example of substitution is a rebound love affair. When the first love affair ended, there was incredible pain that the person could not adequately cope with. It is the ego’s job to help us avoid pain as much as possible. Therefore, a few weeks after one affair ended, another started, substituting one love attachment for another, ending all the pain from the first. Freud would also view overeating as a substitution defense mechanism, being used to avoid, albeit momentarily, anxiety or depression.
Rationalization: When a feeling becomes too threatening to one’s well-being, the ego can use rationalization to reduce the pain. Rationalization intellectualizes experiences, explaining away failures in nonemotional factual ways. “Yes, I lost my job and am having severe financial difficulties, but it happens to everyone and I’ll be okay.” Indeed, the rationalization might be true, and the rationalization defense mechanism could be an excellent way to cope with the situation. But if it is covering up anxiety or depression, the ego will be using a lot of psychic energy to keep this defense mechanism in place, risking depleting its psychic energy reserves.
Undoing: This defense mechanism uses superstition as a way to avoid pain. For example, the childhood rhyme, “step upon a crack and break your mother’s back,” is a superstitious way for a child (or adult) to avoid the knowing that their id really does want them to break their mother’s back. So avoiding the cracks is a symbolic affirmation of the superego rule not to angrily aggress against one’s mother. Many obsessive compulsive disorder (OCD) behaviors represent an undoing defense mechanism, as these repetitive behaviors act to avoid anxiety.
Introjection or incorporation: Accepting humiliating criticism is an example of introjection. Instead of being angry and aggressive to the person delivering the criticism, one takes it in and considers it as appropriate or being deserved. The superego cannot allow the rage connected with being humiliated, so the ego arranges the energy to be turned inward as an acceptable way to deal with the id’s aggressive impulses and meet the demands of the superego.
Identification: This is one of the core defense mechanisms. We will see, according to Freud, that it is the central defense mechanism used when it becomes time to establish our gender and sexual identity. More commonly, it is the source of empathy. Feeling someone else’s pain is a way of avoiding that their pain is really our pain. For example, when we empathically comfort someone who has experienced a death in their family, we are crying for them, avoiding our own fear and pain of facing our own death. The same can be said when we cry when someone we don’t even know dies. There are many stories from prisons and concentration camps where people have identified with the aggressors, the ego using identification to minimize the pain associated with being a victim.
Somatization: This defense mechanism occurs when people turn unacceptable feelings resulting from the id’s aggressive or sexual impulses into physical symptoms. For example, a person’s superego cannot allow the rage that is coming from the id about being continuously criticized. So the ego directs this energy to the body’s muscular structure, or to other organs, causing aches and pains. These symptoms are very real, and the person has no idea that it is connected to the verbal abuse they are receiving.
Conversion: Of all of the defense mechanisms, this is one of the most interesting. One behavioral manifestation of this defense mechanism is called hysterical paralysis or hysterical blindness, both of which are extremely rare. After experiencing a traumatic experience, a person will literally become paralyzed in some part of their body or go blind. For example after seeing a horrific act, a person goes blind, or after accidently hitting someone, their arm becomes paralyzed. The superego was so violated that the ego used conversion to help the person avoid the pain associated with the situation in which they were involved.
Provocative behavior: This defense mechanism is a favorite for adolescents, but all ages can imbibe. When a teenager agrees with their father to take out the garbage every day and then forgets to do it, dad usually get frustrated or provoked. We are not talking about the normal “goat-getting” behavior that is common between adolescents and their parents; the teenager knows what they are doing. When the teen forgets to take out the garbage, they are sincerely sorry and promises to do better. The provocative behavior defense mechanism is covering up the anger they feel toward their parents. As the pattern of forgetting emerges, the teen cannot explain how this is happening. Their superego has rules about respecting their parents and taking their responsibilities at home seriously. So the ego arranges for them to “forget” as a way to channel their rage at their parents by frustrating them.
The construct of how the id, ego, and superego work using psychic energy and defense mechanisms is really quite elegant. It explains how and why we behave as we do. Seepage of sexual or aggressive impulses from the id, when complete repression fails, can be directed in many different ways using a wide variety of defense mechanisms. We can easily identify with wanting to avoid pain. There is a clear place for where our rules and attitudes reside. We know that we are aware of our world and have problem-solving skills. Sex and aggression issues are central in everyone’s life, so it does seem reasonable that they play an important role in motivation of behavior. There is so much in Freudian theory that just makes sense.
Yet, the entire model is grounded on a motivational system of unconscious sexual and aggressive impulses. This construct shows both the power of the model and its limitations. If one believes there is an unconscious part of our minds, and in it are sexual and aggressive impulses, then the theory flows from there. But since the unconscious can’t be accessed, except by inference, it does not allow for much empirical validation. It’s almost as if one has to believe it to be so. This is not a great foundation for any psychological or scientific theory and is more akin to what people do when they are involved in a religion. However, the fact that the Freudian ideas have persisted for almost 100 years is a testament to the power of this theoretical construct.
Personality Development
Freud had created a model of psychology that was groundbreaking. But he didn’t stop there. He created a theory of personality development that paralleled the psychology model, and explained how patterns of behavior were learned in the context of the id, ego, and superego construct. He understood that children were influenced by family dynamics from the time they were born to when they were emancipated. The personality development model he came up with predicted adult patterns of behavior based on how children were treated by their parents. He observed nuances of child and parent behavior that were deemed important in childhood development, a remarkable achievement (Erikson, 1950, 1959; Frankel, 1984; Goldstein, 2005).
Freud hypothesized that there were five major stages of child development: oral, anal, Oedipal, latency, and adolescent stages. Each stage confronted the child with a major problem to be resolved before moving on to the next stage. When the resolutions to each stage were incompletely resolved, that left unfinished business, called residuals. These residuals predicted specific dysfunctional behavior patterns as an adult.
However, no one ever leaves childhood without unfinished residuals from each stage. Residuals at each stage are also called “fixations,” as the child is stuck or fixated on the issues left unresolved. The terms “oral” and “anal fixations” are familiar to most people. No parent or caregiver is perfect. At best, adults raising children love them and do the best they can. At worst, children are neglected and/or abused. Clearly, the worst-case scenario will have the most destructive residuals and these children as adults will be seriously psychologically damaged. The age ranges for each stage are approximate, as children develop psychologically as differently as they do physically.
Oral Stage (0–2 Years)
1.The problem to be resolved: Instant gratification and trust. Anyone who has been around babies knows that they initially explore their world through their mouths. From the time they are born, they are instinctively sucking on a nipple for food. As they learn to crawl, anything they find immediately goes into their mouths. It is no surprise that Freud called this first developmental stage the oral stage. The psychological problem facing children in these early years is indeed acted out through the mouth, but it is more profound than just eating. Babies follow the pleasure principle. When they are hungry, they cry and expect to be fed. When they are lonely, they expect to be held and cuddled. These are instinctual needs. For this reason, in the first few months of life, mothers or fathers usually pick up their babies whenever they cry to feed them. This is called demand feeding and meets the needs of the child. Similarly, the child is usually also picked up when they cry before and after feedings, meeting the baby’s need for cuddling and contact. The psychological position of the baby is one of expecting instant gratification: “I want what I want when I want it, and you are expected to give it to me.” However, at some point, the baby will be put on a feeding schedule. It then becomes clear to the baby on some instinctual level that they are not getting instant gratification of their eating and contact needs as they did before. They are not happy campers.
2.Resolution: Delayed gratification and substitution. Babies instinctively begin learning techniques that calm them between feedings—they suck on things, starting with fingers. Parents/caregivers support this process by offering pacifiers. When babies realize that adults won’t be picking them up as often as they feel they deserve, they latch onto objects during these lean times, stereotypically a doll, stuffed animal, or blanket. To the extent that parents/caregivers support these substitutions, it helps the child learn there are other comforting options when they are not getting fed or held. Along with learning substitution skills, the child also needs to learn that while they are not getting fed or held on demand, it eventually will happen on a regular schedule, one that they can count on. They need to learn that they can trust their caregivers to come through for them every day—feedings happen on a reasonable schedule; contact happens frequently between feedings.
3.Residuals: Unfinished business from this stage will come in two ways: (a) Children who have not been able to find ways to delay gratification and substitute for the loss of instant gratification; and/or (b) children who have had experiences with caregivers where their feeding and/or contact with adults was inconsistent. In both cases they will come out of the oral stage with “oral fixations” that will follow them into adulthood. Adults with oral fixations will likely be more dependent, demanding, and have serious trust issues in relationships.
Anal Stage (2–4 Years)
1.The problem to be resolved: Control, right versus wrong, and love and hate. While this stage has been associated with toilet training, it is much more pervasive an issue for a child, occurring in many aspects of a toddler’s life. Toilet training, however, is a good symbolic metaphor for this stage and certainly brings to the foreground the issues faced by the child. For the first time in the child’s life, they are being asked to do something that is not natural for them. Up to this point, they naturally pooped and peed whenever they felt the need. Now, caregivers are demanding that they poop and pee in a toilet. Someone is trying to control them, control their natural functions. In addition, it is being made clear to them by their caregivers, whom they love, that there is a right and wrong way to do this. This is the first time they have been exposed so directly to a moral dilemma, clearly being told what is right and what is wrong by people who are supposed to love them. They don’t want to give up their poop, and often will hold it in, becoming anal-retentive. Or, they will purposely not use the toilet but go in their pants or even on the floor to frustrate the caregiver. Subsequently, as this process unfolds, they may be faced with shame and guilt, depending on how parents/caregivers are dealing with the toilet training. And it’s just not for toilet training. There are other natural functions that are being asked to control, like demands they not be aggressive to siblings and peers, to control their eating habits and their sleep times. Again, issues of shame and guilt can come up, depending on how caregivers respond to their resistance to change. Often, they are very angry at attempts by caregivers to control their lives. It’s not called the “terrible two’s” for nothing. They feel confused how they can feel both love and hate at the same time for people on whom they are dependent. All of this is a lot for a little tyke to handle.
2.Resolution: Reciprocity, conformity, integration of love–hate for the same person, and acceptance of right–wrong polarity. Again, we can use how parents respond to toilet training as an example of how they can help children get through the anal stage. If parents try to coerce or punish children in the toilet training process, or show frustration or anger, the child will eventually learn to conform, but will also learn that conformity is associated with shame and guilt. Behind shame and guilt is the rage from the id, which may manifest itself as serious residuals in adulthood. A more supportive way to help a child accept the reality of control issues is to maintain calm, and let the child learn at their own pace. Better yet is to teach the concept of reciprocity. When someone asks you to do something you really don’t want to do, it is more acceptable if there is some reciprocal transaction, that is, what’s in it for me to do this for you. This type of transaction is common in life, and not only saves face but also acts to develop closer relationships. One of the major techniques that are used for toilet training is to advise caregivers to offer praise and appreciation when the child has a successful attempt. The child gives up their poop for you, and you give them praise in return. Another kind of reciprocity is to allow the child to get rewards for each successful attempt. Again, they give you their poop, and you give them something in return. In this way, they learn that there can be some benefit for conformity. Similarly, if the caregiver relationship during this time is more calm, they can integrate the fact that they both love and hate the person who is trying to control them. The more contentious the caregiver relationship during the anal stage, the more difficult it will be for the child to make this love–hate integration. Similarly, the same dynamics hold for dealing with the right–wrong dilemma. In a more calm, loving parental approach during the anal stage, children will learn that when they do something wrong it can be dealt with in a more acceptable and loving way. Doing something that is considered wrong in a contentious parent–child relationship is much more dangerous to the child’s well-being.
3.Residuals: An adult having fixations at the anal stage would be more stubborn and self-centered. They could have some ambivalence about intimate relationships, be very sensitive to being criticized, and be more rigid in their moral and personal beliefs. They might collect things and not want to throw anything away. Some OCD may also come from residuals from the oral stage, needing to control one’s environment by keeping things in order.
Oedipal Stage (5–7 Years)
1.The problem to be resolved: Gender and sexual identity. The Oedipal stage is the most controversial of all of Freud’s developmental stages. As America and the Western world went through the eras of the Women’s Liberation Movement and Gay Rights Movement, the Oedipal stage as a viable construct was left in their dust. According to Freudian theory for the Oedipal stage, girls, have “penis envy,” and really want to be boys. Homosexuality was viewed as a dysfunctional residual from emanating from the Oedipal stage. Up until the early 1970s, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by psychiatrists, reported that homosexuality was a mental illness. Neither of these ideas sat well with the more progressive psychologists and social workers after the turbulent 1960s and 1970s.
Given the limitations of the Oedipal stage of development theory, Freud did raise important developmental issues. Regardless of whether you like Freud’s view or not, there must be a time in a child’s life where they begin to grapple with gender issues. It would seem reasonable that this process starts when the child is in the 5- to- 7-year-old range, but certainly children are affected much earlier as caregivers impose gender roles for behavior, clothes, and play. It is clear that when there is interference with gender identity development, it has serious lifelong consequences for children.
The Oedipal stage was where children adopted their superego, and was, as the Freudian model suggested, a crucial part of how personality and behavior were controlled. With a successful superego adoption, the child’s ego would have some clear guidelines to decide where to supply psychic energy and defense mechanisms. Freud believed that between the ages of 5 and 7, children were faced with a gender identity crisis connected to their parental love attachments. With the awakening of id impulses relating to sexual and gender identity, children begin to feel some unease with their parents. Boys begin to feel that the father is threatening his relationship with his mother; that he is competing with his dad for his mother’s love—his father was coming between him and his mom. Similarly, a girl feels threatened that her mother was competing with her for her dad’s love—her mother was coming between her and her father.
2.Resolution: Identification with the same-sex parent. Freud postulated that the way out of this dilemma was for the child to identify with the superego of the same-sex parent. In that adopted superego were all of the rules and attitudes about how to live your life, including what it means to be a man or a woman. So the child was not only getting the rules for their gender identity, they were also getting the whole package of life rules and attitudes carried by their same-sex parent. This identification worked to resolve the gender identity crisis by melding the child with the same-sex parent through a shared superego. Since boys were now integrated with dad through a shared superego, they both could love the mom together, and neither would need to feel any competition for mom’s love. Girl’s identification with their mom’s superego helped them know their gender identity as well. In the same way, melding with mom’s superego meant that both of them did not need to compete for dad’s love.
3.Residuals: From Freud’s perspective, residuals from this stage were caused by inadequate identification with the same-sex parent. Boys fixated at this stage are said to have an Oedipal complex and girls an Electra complex. Obviously, if parental superegos are confused or weak, then what is adopted by their children will reflect this into adulthood. The residuals in adulthood from this stage would include gender identity confusion, with possible sexual issues resulting as well. With only partial identification with the same-sex parent, boys might enter adulthood still feeling the unconscious rage of not having successfully won the competition for the mother; girls with rage of not having successfully won the competition for the dad. This could result in difficult adult parent-child relationships, and conflictual marital and parent-child dynamics. And yes, from the original Freudian theory, homosexuality could be a residual, as well.
Latency Stage (7–12 Years)
1.The problem to be resolved: Integration. This time is supposed to be a latent or quiet period after a very exciting and sometimes stormy journey through the oral, anal, and Oedipal stages. Now that their gender identity has been established (hopefully), and they have faced the challenges from the oral and anal stages, whatever they have learned needs to be practiced and integrated. Their new adopted superego needs a chance to be exercised in the context of family and peer relationships; there are defense mechanisms from their new superego that need some rehearsal and old ones that need to be evaluated before being put on the road in adolescence and adulthood. The ego needs to learn how to use the available defense mechanisms to deal with all of the accumulating residuals from the oral, anal, and Oedipal stages.
2.Resolution: Time and space. Children need this time to develop their character, allow the more varied use of their defense mechanisms, and practice the rules and attitudes of their adopted superego. In order to accomplish this, caregivers need to allow children the time and space to be with their peers and other adults to achieve these tasks. It should be noted that during the latency stage boys tend to play with their male peers and girls with their female peers. This allows them to cement their gender identity and all of the related superego rules. Should children not be allowed this opportunity, then this would be the cause of residuals from the latency stage.
3.Residuals: Adults with unfinished business from this stage might be viewed as lacking character or having an undifferentiated personality and might have asexual tendencies as well. In addition, residuals from this stage predict what we now call personality disorders.
Adolescent Stage (12–18 Years)
1.The problem to be resolved: Dealing with sexual and aggressive impulses and developing independence. This stage has also been called the “genital phase,” as many of its issues revolve around sex. Suddenly, with no real preparation, hormones begin producing greatly heightening primal sexual and aggressive impulses. The id is in high drive, and the ego is very busy, using what psychic energy is available to deal with id impulses it had never seen before. The superego rules adopted in childhood don’t seem to cover this new reality. The teen is experiencing real motivation to experiment with new sexual and aggressive drives in ways quite different than were in the superego adopted from their parents. Peer influences often become more important than parents as the teen is watching how their peers are behaving and rewriting superego rules for sex and aggression. This, of course, does not make parents happy.
2.Resolution: Modifying the superego to reflect the new adolescent reality; managing sexual and aggressive impulses. As the years go by in adolescence, the teen is changing many of the rules in their superego to reflect their new reality. These new rules, hopefully, will allow them to act out sexually and more assertively in a manner that adapts to community norms in a safe and legal way. Unfortunately, with the advent and availability of addictive drugs, new superego rules relating to drug and alcohol experimentation can have tragic consequences. Independence from parental influences requires the adolescent to establish new more adaptive rules based on the realities of their experience, thus preparing them for eventual emancipation from their family.
3.Residuals: Adults who have not successfully learned to manage sexual impulses will be more likely be promiscuous and have trouble with intimacy. In addition, the stormy aggressive feelings associated with adolescence might be maintained in adulthood, making for unstable relationships. There are those, of course, whose adolescence is relatively calm. They are able to continue using the superegos adopted from their parents with little modification. If that works for them, it will not likely be problematic.
CONCEPTION OF THERAPEUTIC INTERVENTION
The Ego Psychology Treatment Process
There are five basic components in the ego psychology treatment process: assessment, ego strengthening, insight, the transference, and the corrective emotional experience (CEE; Frankel, 1984).
Assessment
During the initial client sessions, clients are encouraged to tell their story about why they are seeking treatment. Therapists are carefully listening, observing clients’ interactive behavior, looking for signs where clients have been fixated, and interpreting what defense mechanisms are likely being utilized.
Ego Strengthening
Having a strong ego is of course desirable as it increases awareness and improves problem-solving. There are four ways therapists work to strengthen client egos:
Partialization. When confronted with a task or problem so big that it is seemingly unsolvable, an ego can become paralyzed. The therapist offers to help break up the problem into small more solvable tasks, thus allowing the client’s ego to put energy on a more doable problem-solving process.
Offering support. Active listening is one major support for clients as it shows them that someone who cares is hearing them. Offering praise and appreciation also is important.
Improving client self-esteem and self-image. Therapists attend to positive behavior and make sure that clients do the same. Asking clients to give themselves positive self-statements is also helpful.
Providing a safe place. Clients need to know that the therapy session is a safe place (where they can share without concern of being judged or criticized, where confidentiality will be ensured, and where session schedules will be predictable) and that the structure of each session will be generally predictable.
Insight
In ego psychology treatment, it is thought that having insight into your problems supports their resolution. Insight is a connecting phenomenon. It is helping clients make the connection between what happened to them growing up and their current problematic relationships and behaviors. It often comes as an “aha” moment. Therefore, therapists support clients in remembering their history and telling their stories.
The Transference
The transference is a projective phenomenon where clients symbolically put a parent’s face onto their therapist. They act out in the session to the therapist who becomes a “stand in” for their mother or father. Developing this dynamic is an important part of what will become the curative elements in the ego psychological approach. It is assumed that client problems are related to unfinished business with parents—parents were, after all, responsible for the fixations at each developmental stage. It is also assumed that there is repressed rage, fear, hurt, and/or sadness associated with these fixations. By fostering transference in the session, the therapist and client can recreate in the moment these unfinished parental dynamics. The client can then revisit the unfinished business using the therapist as a stand in for the parent, in the safety of the therapy session. Therapists can more readily foster the development of a transference by being nondirective, which is exactly what the theory tells them to do.
The Corrective Emotional Experience
All the previous four components lead to the CEE, which is a dramatic culmination of a client’s work and leads to resolving client problems. When the client, through the transference reaction, finally confronts a parent on how they contributed to their present dysfunctional behavior, it can be quite dramatic and emotional. The CEE can lead to new behavior patterns.
A case study will be instructive here.
CASE STUDY
Mike, age 34, entered therapy because he was having trouble maintaining relationships. In the past 4 years, he had five girlfriends, but none lasted more than a few months. About 9 months ago, he met a woman he really liked, and with her encouragement, he entered therapy. His work had settled around his inability to keep intimate relationships with women. He was a successful businessman, lived alone, and reported that he often felt lonely and sometimes depressed. He had been in therapy for 6 months and had been spending more and more time getting in touch with feelings about his upbringing. He had recently had the insight that his inability to be vulnerable with women was one way he kept them distant. We will pick up on his session as he is talking about this new insight:
Mike:
I’m not completely sure why people want you to be vulnerable before they will love you.
Therapist:
Has that been your experience?
Mike:
Well, my former girl friend kept saying she would do anything if she could make me cry.
Therapist:
Why don’t you cry?
Mike:
I want to sometimes, and I know that if I did I would probably feel better, but I just can’t.
Therapist:
Why not?
Mike:
Oh, I know the traditional reasons. My mother wanted me to be strong and kept telling me that if I let myself be weak, I’d end up like my father, who was an emotional cripple. I’m sure that’s the way it happened, but it doesn’t do me any good to know that.
Therapist:
If that’s the reason, how do you feel about it?
Mike:
Look, God damn it! I don’t know how I feel. Why do you keep asking me how I feel when I don’t know? (pause) Oh, god, I’m sorry for blowing up.
Therapist:
(softly) You can be angry with me, Mike.
Mike:
(tears in eyes) No, I can’t. I just can’t.
Therapist:
Who are you talking to, Mike?
Mike:
(pause) To you! (another pause) No, my mother. (another pause with tears now streaming down Mike’s face) Oh, Mom, why wouldn’t you let me feel the way I wanted to? You spent so much time worrying that I’d turn out like Daddy that you never let me feel; you never wanted to listen to how I felt. Didn’t you ever want to know me? At least I could get close to Daddy, but never to you. (Mike is really sobbing now)
Therapist:
(gives Mike some tissues—there is a 5 minute pause while Mike sobs)
Mike:
(somewhat composed now) Well, mother must be so proud of me. I turned out to be just like her.
Therapist:
Not just like her, Mike. You’re letting yourself be vulnerable now in front of me. (pause) I hesitate to ask you again, but how do you feel?
Mike:
(laughing) Better now. I think I needed to get that out.
The dynamic here that supported Mike’s corrective emotional experience was his transference with the therapist. Mike was able to release years of grief, tears, and sadness about how he felt about growing up with his mother. By reenacting an early scene with his mother, he was able to do something he had never done—tell her how he felt. His work began a superego rewrite allowing sadness and tears, thus freeing up psychic energy that for years repressed his feelings. The freed up psychic energy could now be used for other conflict resolution (Frankel, 1984).
COMPATIBILITY WITH THE GENERALIST APPROACH
There is one overarching theory that binds together those practitioners who follow the generalist approach, particularly as it is defined in social work—systems theory. From this perspective, it is difficult to integrate the psychodynamic approach in the context of a micro, mezzo, and macro generalist practice. Almost by definition, psychodynamic theories are focused on interpsychic variables, with some offshoots moving into intrapsychic variables. This is likely the reason that in schools of social work, the psychodynamic theories, when they are taught at all, are put into the historical perspective of clinical social work. In psychology departments, the lack of an empirical foundation for ego psychology, and its humanistic offshoots, has been a serious barrier, especially when compared to the research-grounded behavioral approach.
However, there are many skills that emanated from the psychodynamic theories that are integrated into a generalist practice. These include active listening, the importance of eliciting feelings, unconditional regard, unconditional acceptance, ego-strengthening skills (support, praise, acknowledgments, having a safe place in which to work), partialization, and the idea that our history affects our present. If you look at the work of social work and psychology professional practitioners, you will see the these Freudian “skill marks” in every session.
CRITIQUE
One of the major critiques of the Freudian constructs was how difficult it has been to develop a research model that would validate their use. Unfortunately for ego psychology, and those humanistic relatives that were spawned from Freudian concepts, both independent and dependent variables are very difficult, and often impossible to define. Interventions and outcomes, in general, lack behavioral specificity, which of course, means that the effectiveness of these theories is subject to serious question about whether they work. For example, one essential basis of psychoanalysis is the id, which cannot be identified in any observable way. Even in ego psychology, where the id is downplayed as part of its theory, it still exists as a construct that explains defense mechanisms and motivational drives. Therapist behavior is another extremely difficult independent variable to define. There may be general treatment process behaviors that ego psychology therapists use, but certainly not uniformly across practitioners. Even dependent variables are hard to define. The outcomes for clients in ego psychology practice include very general concepts, such as changes in personality, CEEs, and ego strengthening. Insight, which might be behaviorally defined, has not been shown to be necessary for behavior change. In addition, even when behavioral outcomes are clarified for clients, it is impossible to attribute these changes to therapist behavior, except in a very general sense. In ego psychology, therapist intervention techniques are too variable and not easily quantified from session to session, thus making any cause-and-effect relationships between therapist interventions and client outcomes extremely difficult, if not impossible.
CONCLUSION
From a social work perspective, ego psychology theories lack the scope to be easily integrated into the systems approach, the foundation of social work practice. Social workers tend to gravitate to those theories that can be used in the context of our broad assessment and intervention approaches. This includes looking at not only the personal psychology of a person but also the whole person and the issues that affect them from family, community, organizations, social policy, and social justice. It is not a simple task to integrate ego psychology and the other humanist approaches into micro, mezzo, and macro assessments and interventions.
It is true that vestiges of Freudian theory have lasted for 100 years. Many of Freud’s ideas resonate with our experiences and make sense to us; some ego psychology techniques are still being used. However, there are many professionals practicing clinical social work or psychotherapy who believe that this is not enough to justify the continued use of either psychoanalysis or ego psychology in the mainstream of practice. Yet on the mantle place of social work and psychology history, there is an important place that cannot be ignored by anyone who values our history and how it affects our present.
SUMMARY POINTS
In summary, this chapter has:
•explored the basic theoretical foundations of ego psychology,
•described the intervention strategies associated with ego psychology, and
•described how ego psychology has influenced current practice in clinical social work.