Social work has a long history with ego psychology. Ego psychology was very influential in early social work, and Mary Richmond (1867-1928) wrote Social Diagnosis in 1917.
Social work has a long history with ego psychology. Ego psychology was very influential in early social work, and Mary Richmond (1867-1928) wrote Social Diagnosis in 1917. However, backlash emerged in the 1960s and 1970s due to the civil rights movement and the war on poverty. The founding of Clinical Social Work Journal in 1972 and Federation of Societies for Clinical Social Work in 1971 re-emphasized social work’s psychodynamic roots.
Well-known MSW psychodynamic scholars include the following:
Howard Parad, who wrote Crisis Intervention, Ego-Oriented Casework
Eda Goldstein, who wrote Ego Psychology & Social Work Practice; Short-Term Treatment in Social Work: An Integrative Perspective; and Self-Psychology and Object Relations Theory in Social Work Practice
Jerald Brandell, who wrote Psychodynamic Social Work
Joan Berzoff, who wrote Inside Out and Outside In: Psychodynamic Clinical Theory and Psychopathology in Contemporary Multicultural Contexts
Psychodynamic Theory in Current Social Work Practice
Ego psychology is used as the underpinning for supportive counseling. Ego-supportive treatment takes a “strengths-based approach,” and focuses on adaptation, restoring equilibrium, and building social supports. This is especially useful in work with clients who are severely mentally ill, homeless, in crisis, recently traumatized, and/or in nursing homes.
Known as the authority on the application of ego psychology theory to clinical social work practice, Dr. Goldstein’s influence was extensive and her contributions to the profession will be recognized for years to come. (She passed away in 2011.) Once we know the ego functions and ego defenses, how does it inform our assessment, treatment planning, and interventions?
Ego Functions and Defenses
Ego Functions are the essential means by which an individual moderates internal conflicts and adapts to the external world.
The most comprehensive and systemic effort to describe and study ego functions is found in the list produced by Bellak in 1973. The clinical question regarding Bellack’s list of ego functions is how to strengthen adaptive manifestation of these functions in each of our clients. Do we assess a mild, moderate, or severe impairment in any of the client’s ego functions?
Anna Freud elaborated on the mechanisms that the ego uses to maintain homeostasis and mediate the impingements from inside (the id, the unconscious ego, the superego) and outside (unacceptable reality).
Defense mechanisms operate in our unconscious, while coping mechanisms are conscious. Defenses protect individuals from intolerable or unacceptable impulses or emotional experiences. Effective defenses enable optimal functioning without undue anxiety, while maladaptive defenses distort reality and impair overall ego functioning.
In assessment from this approach, the clinician is focused on several critical questions:
To what extent is the client’s stated problem situational or characterological? Or both? If so both, to what extent?
To what what extent is the client’s stated problem a function of impairments in her ego and defensive functioning?
To what extent is the client’s stated problem a result of an ineffective match between clients and their respective external environment?
What inner capacities and environmental resources does the client have that can be strengthened and mobilized to improve functioning?
Key areas of assessment from this approach include intersection between current life stresses, impairments in ego, and defensive functioning and environmental factors.
Ego assessment helps the clinician determine whether interventions should be directed at the following:
Maintaining, enhancing, modifying inner capacities
Mobilizing, improving, or changing environmental conditions
Improving the FIT between inner capacities and external circumstances
Ego-oriented psychotherapy works across a continuum of focus, with one end being ego-supportive and the other end of the continuum at ego-modifying.
Ego-supportive interventions aim to restore, maintain, and enhance a client’s adaptive functioning.
Ego-modifying interventions aim to shift basic personality patterns of thoughts, feelings, and behaviors through insight and emotional resolution of long-standing pre-conscious and unconscious conflict.
The two primary ways of intervening, from ego psychology, are ego-supportive interventions and ego-modifying interventions. Ego-supportive is aimed at maintaining and enhancing ego functions and ego-modifying is aimed at helping clients to make significant shifts in their overall internal and external functioning. Review the following chart to compare the characteristics of each approach.
Characteristics of Ego-Supportive and Ego-Modifying Approaches
Ego Supportive Approach Ego Modifying Approach
Focus Current behavior
Conscious thoughts and feelings
Limit past focus Past and present
Conscious, unconscious, and preconscious
Nature of Change Ego-strengthening
Better person-in-environment fit Insight
Curative Process Strengthen ego
Shore up defenses
Promote adaptation Make unconscious conscious through interpretation
Use of Relationship Real relationship
Corrective relationship Use and understand positive and negative transference
Now that we’ve studied the characteristics of therapeutic interventions, let’s explore case examples of the ego-supportive and ego-modifying approaches.
Ego-Supportive Case: Martin
Martin is a 59-year-old chronically, persistently mentally ill patient who has lived in a residential setting for the past 10 years after a lifetime of psychiatric hospitalizations. He suffers from schizophrenia, and bipolar I. He has been fighting with his roommate and support group mates more than usual. Through numerous sessions with the clinician, the work is aimed at helping him to be less impulsive and less aggressive with others in his social setting. If he does not improve, he may be at risk of losing his bed there.
Ego Modifying Case: Rhonda
Rhonda is a 35-year-old woman who has been maintaining a limited work and social world as an adult. Her childhood was marred by poverty and trauma in uncertain and dangerous environmental experiences—being in harm’s way as each apartment was overrun by rodents or lack of heating, etc. (literal structures letting her down). Her family structure and functioning was equally traumatic, uncertain, and at times threatening. (Mom had drug and alcohol addiction and was in and out of rehab.)
As a result, she has suffered from PTSD and generalized anxiety disorder. In therapy, after building a very positive relationship with the clinician, Rhonda explains that she cannot cope with the COVID-19 virus. She doesn’t believe any of the governors, public health experts, etc. She has withdrawn into her apartment and has been having nightmares about the virus, about the apartment building being dangerous to her, and she will not allow groceries to be delivered. She is dreaming about her building falling down, she has fears that the building itself just cannot be trusted, and that this virus will come and find her and get her regardless of disinfection and social distancing.