The assessment of the patient's ego strength is essential. It involves identifying whether the patient's difficulties restrict his self-observational capacity and other executive ego functions that would contribute to diffuse boundaries and encourage acting out. A patient's ego strength is inferred from presentation at assessment. It reflects those personality assets that will enable the patient to overcome anxieties and acquire more adaptive defences. At its most basic, ego strength refers to the patient's capacity to be in touch with reality whereby perception, thinking and judgement are unimpaired. A psychotic patient, for example, when in the grips of psychosis would be deemed to have very limited, if non-existent, ego strength. Ego strength reflects the patient's capacity to hold on to his identity in the face of psychic pain, without resorting to excessive distortion or denial.
Ego weakness manifests itself in poor frustration tolerance and impulse control, a lack of tolerance of anxiety and an absence of sublimatory activity. For example, a patient who is angry and has weak ego strength is more likely to be unable to reflect on the source and meaning of his anger and may instead act on it and hit another person. The patient with more ego strength will either be able to think about his anger or might manage to sublimate it and channel it into some other more constructive activity, for example, exercise.
The capacity to symbolise is an important indicator of ego strength. A key developmental task from infancy onwards is the acquisition of the capacity to interpose thought between impulse and action. If this capacity breaks down or fails to develop the consequences are serious; when mental experiences cannot be conceived of in a symbolic way, thoughts and feelings have a direct and sometimes devastating impact (e.g. thinking is felt as words that have been spoken and cannot be retracted). Hobson summarises the advantages of symbolisation eloquently:
... symbolising enables us to think of absent realities but also to conjure up imagined worlds; symbolising allows us to fix objects and events as experienced, and then to think about them; symbolising gives us mental space in which we can move to take up one and then another attitude to things (2002: 99).
To assess ego strength, we look for evidence that the patient is oriented in time and place, that thinking is rational and the capacity for judgement is unimpaired either by organic or by psychological problems. The patient's capacity to persist with relationships and occupational or vocational endeavours in the face of challenges provides us with another opportunity to indirectly assess ego strength. This is why it is important to take an educational and occupational history: patients who present with histories of dropping out of education, being fired from jobs or flitting from job to job, would raise the question of whether they have a sufficiently well-developed capacity to persevere with stressful situations. Difficulties in this area would not bode well for a course of psychoanalytic therapy, especially of a brief nature.
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