EGO PSYCHOTHERAPY

A therapeutic approach developed by Paul Federn and his disciple Edoardo Weiss, based upon the theory that mental disturbance involves a blurring of the boundaries between the ego and outer reality or between the ego and the id. The approach is applicable primarily to psychotic and schizoid disorders.Though Fedem was an associate of Freud, he created a theory of the ego and a treatment technique which differed sharply from those of classical psychoanalysis. In contrast to Freud, who conceived the ego in terms of consciousness and “executive functions,” Fedem defined it as “the feeling of unity in continuity, contiguity and causality in the experience of an individual” (1952). The ego is therefore equated with ego feeling, which can remain unified even though the contents of experience are constantly changing. The experience of “I” is generated by what he called the “ego-cathecting” of mental contents, a process in which energy arising from body metabolism is used as an integrating force. The stronger the “binding capacity,” or integrating ability, of the ego, the better it can endure frustration, give acceptable expression to id impulses (sex, aggression etc.), and maintain a clear boundary between the ego and the outside world.In Federn’s view, the healthy ego not only has boundaries which separate it from external reality, but boundaries which separate it from the id. There are, then, basically two kinds of “ego states.” “Reality” is sensed when energy from the id or from the outside world crosses these boundaries. But if the boundaries are disturbed, profound mental disorder sets in. Where the boundary between the ego and the id has been weakened, primitive id material may break through and be experienced as hallucinations; where the boundary between the ego and external reality is blurred, the patient often experiences feelings of estrangement and depersonalization. These feelings—the sense of being in an alien world and the sense of unreality—are steps on the way to loss of contact with the outside world. They are due to “loss of the ego’s inner firmness” (Weiss, 1952), or loss of the ability of the “ego nucleus” to integrate new experiences with old ones and to relate them to already acquired knowledge in terms of time, place, and causality—a process to which Fedem applies the old term “apperception.”Therapy is largely a question of redirecting the “ego cathexis,” or integrating force, so that the patient can exert control over his id and distinguish himself and his mental contents from external reality. It attempts (a) to bring about a better balance in the expenditure of the ego energy, so that it will be utilized more effectively in dealing with impulses and relationships with the outside world; (b) to increase the “reality testing” ability of the patient by helping him understand the process by which he “misperceives” reality and by encouraging him to check his subjective thoughts, feelings, and impulses (“inner mentality”) against objective fact or “external reality”; and (c) to bring about repression of the id, in contradistinction from Freud, who sought to release its contents.Federn introduced a number of therapeutic approaches in the treatment of psychoses which were at variance with the psychoanalytic school. He eliminated the anamnesis or autobiographical history of the patient on the ground that the memories of former psychotic episodes would release the id and lead to a relapse. He felt that the patient needs the continual support of the therapist outside as well as inside the analytic sessions, and recommended that treatment be interrupted if a negative transference takes place. He did not, however, encourage the development of a transference neurosis, which is an integral part of the Freudian technique, since this would become a transference psychosis. (A transference neurosis is an intense attachment or antagonism toward the therapist stemming from childhood attitudes toward the parents). He advocated reinforcing rather than removing resistance to disclosure of unconscious material, since he believed the psychotic process was already producing too much of this material. He dispensed with the couch and the recumbent position of the patient, since this not only encouraged the production of unconscious material but also because he thought the patient would make more normal associations while sitting up. He felt that a moderate amount of sexual gratification would promote recovery. (Freud insisted on celibacy during analysis because he felt that the energy of the libido would help to release unconscious impulses.) He believed in working with the family and environment of the patient in order to help him solve current problems of adjustment. And finally he insisted that treatment could not be successful without the help of a skilled woman, on the premise that the mother is the original source of support of the patient’s ego.In carrying out his procedures, Fed- em held that a successful transference could be established with schizophrenic patients even when they were severely deteriorated and were considered “unreachable.” He insisted that the boundaries between the mental world and the real world could be re-established if the therapist confines himself to simple explanations, reality testing, and emotional support while the patient is in the psychotic state, using only very small doses of typical analysis.