On the face of it, it would appear that the less compensated individual would require more ego-building therapy while the more compensated character would require more of those techniques which bring to his attention the great cost of his compromises and adaptations. While there is some truth to this, particularly in the initial stages of treatment, the underlying theory is helpful in alerting us to the fact that an individual who appears to be very adaptive may really be covering some very severe deficiencies in ego development. Similarly, the client whose ego abilities are overwhelmed by panic, for example, may possess some fairly highly evolved functions which have been temporarily overwhelmed. In the first case the treatment may be far more protracted and reparative than would initially be suggested, while in the latter case the prognosis for treatment may be more favorable than is indicated by the initial evaluation. A deep appreciation of the client’s level of ego functioning requires time and experience with the client’s coping mechanisms over the course of treatment. Usually, inexperienced therapists tend to overestimate rather than underestimate the client’s level of emotional development.
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What follows is a still-incomplete list of questions which a therapist may ask concerning any client to establish some general understanding regarding his level of ego functioning. In reviewing this list, it may be well to consider the fact that while there is a general tendency for the level of ego development to be consistent at a certain level across categories, this is not always the case. It is still quite common, particularly in reasonably well-functioning adults, to find a person who has “missed a stitch” in some pocket of ego functioning, such that his level of development is very primitive in that area while much more developed in others. It is possible, for example, for a schizoid client to respond with a great deal of anxiety to situations of personal threat, almost as if reactivating an early schizoid fear of annihilation, while at the same time possessing a very intact level of ego functioning. Where there is a full-blown and clear-cut borderline or narcissistic adjustment, however, there is frequently a surprisingly consistent profile in terms of the analogue developmental level of the ego functioning in question. In formulating the questions that follow, I wish to acknowledge my considerable debt to Gertrude and Reuben Blanck who have so well synthesized a good deal of this material in Ego Psychology: Theory and Practice (1974), chapter 7, and Ego Psychology II: Developmental Psychology (1979), chapters 5 and 12. Most of the questions outlined below are attributable to the work of Blanck and Blanck though this specific elaboration is my own.

1) Self-representation: Is there a firm representation of the self? Does this self-representation include a clear self-image, a kinesthetic sense of self identified with the body, and a cognitive understanding of “who I am”? Is the self-representation clearly differentiated from the representation of others, such that one knows what is coming from inside and what is coming from outside? Is this differentiation stable or fluctuating? If it fluctuates, what triggers that fluctuation? Is there splitting in the self-representation such that the client experiences himself as all good at certain points in time and all bad at others? Does the client expect you or others to read his mind and fulfill his wishes on the basis of only his having that wish? Does the person continuously seek union with another and feel incomplete outside that merger? Does the self-representation include a solid sense of gender identity? Does the individual desire in a significant other someone who is “just like me”?

2) Object-representations and relations: Does the client perceive others as they really are or as he wishes or fears them to be? Are others valued beyond their need-gratifying abilities and is there a relative “constant” value placed on others which does not fluctuate with the person’s need level or mood state? Can the person maintain a relatively stable visual, kinesthetic, and auditory representation of the other? Are others self objects or real objects? What is the nature of transference in therapy—distrust, merger, dependency, twinship, idealization, placating, manipulative, challenging? Is the desire for merger, if present, conscious, denied, or defended against in some other fashion? What is the quality of the person’s outside relationships in love, work, and friendship?

3) Anxiety: What is the primary anxiety —fear of annihilation, fear of loss of the object, fear of loss of the love of the object, “castration anxiety” (fear of retaliation), or fear of the superego? How does the client handle anxiety? Can an anxiety-provoking situation serve to enhance performance, indicating that it serves a signal function, or does it consistently overwhelm the individual’s ability to function, indicating that signal anxiety has not been achieved? With respect to anxiety or distress, what is the extent of self-soothing capacities and to what extent can the individual be externally soothed? To what extent does the level of anxiety fluctuate and to what extent is anxiety situation-specific? What situations elicit anxiety and what situations elicit relaxation?

When anxiety is overwhelming in one or a few areas, this does not necessarily indicate that signal anxiety is not operative. It may simply mean that, in that area of functioning, there is some internal conflict which seriously debilitates performance in that area. Blanck and Blanck (1979, p. 223) write:

The patient whose anxiety does not abate, who cannot employ competent defenses nor tolerate the small doses of anxiety that we all live with, who is in terror most of the time, who does not have self-soothing mechanisms but needs to be soothed, or the one who cannot even accept soothing, is living with levels of anxiety that have not diminished to a signal.

4) Defensive functions: How well can the individual defend? What is the developmental level of the defensive function? Are the defenses primarily so primitive in nature as to be characteristic of the earliest kind of developmental arrest, which we have labeled schizoid—denial, introjection, projection? Or are defenses more characteristic of the oral period, including turning against the self, reversal, displacement, and identification? Or do the defenses more characterize those later phases of separation-individuation so as to include undoing, reaction formation, isolation or splitting, intellectualization, and even regression? Or is the defensive structure primarily oriented around repression and suppression of id impulses, characterizing the more highly developed ego structures? Which mechanisms of defense are ego-syntonic and which ego-dystonic?

5) Regulation or containment: Is the person capable of regulating or containing anger or grief in response to frustration, loss, or disappointment? How is the containment accomplished both cognitively and energetically? Does the containment require withdrawal or elicit paranoid ideation?

6) Adaptive functioning: What is the quality of the individual’s overall external perception (reality-testing)? What is his ability to delay gratification? To what extent can the client formulate intentions and follow through on them? What is the quality of abstract thought, the ability to synthesize and integrate? What is the level of functioning of memory? Are deficits in memory content-specific? Where adaptive functions are adequate, what are the properties of the adaptive strategies involved? Where the adaptive functions are impaired, where is the deficiency in the adaptive strategy?

7) Internalization: To what extent has the individual internalized parental and societal values to formulate a “superego” or cohesive value structure? What is the developmental level of the person’s moral sense and is there consistency between belief and behavior? Is the value or moral structure cohesive and unified or does it exist in unintegrated components? Does the primary anxiety involve fear of the superego and experience of true guilt or does it involve developmentally lower levels of anxiety? Who were the primary figures for identification? Were there difficulties in development which would have precluded or interfered with identification or prompted a refusal to identify? To what extent were the identificatory figures adequate from the point of view of developing a mature moral sense?

8) Affect; range and differentiation: How much can the person feel and how subtle are the differentiations among feelings? Are particular or all affects muted or out of proportion to the eliciting situation? How does the client stand in relation to the ability to experience and express the primary colors in the affective range: anger, grief, fear or anxiety, love, joy, personal power, etc. What is the extent of mood swings? What is the preponderant affective state?

9) Regression: Can the individual regress and maintain ego control of that regression? In what areas does such regression occur—in regulation or containment, object relations, adaptive functions, anxiety level, defensive functions? Is such regression engaged in for pleasure or creativity? This ability to regress while maintaining ego control is essential for the successful completion of much of the Gestalt, affect release, bioenergetic, and certain forms of hypnotic processes outlined here. When these abilities are not intact, the client may be seriously retraumatized in the process, further stiffening the resistance to change.

10) Oedipal complex: Is there evidence from the client’s material that the oedipal situation was confronted in the family of origin? To what extent did preoedipal issues and the failure of their resolution affect the nature and eventual resolution of the oedipal complex? What were the attitudes of the parents to the love and sexual reaching out of the child? What were the patterns, if any, of parental seduction, rejection, threat, etc.?