The Collected Papers of David Rapaport
Rapaport, David (1954).

CLINICAL IMPLICATIONS OF EGO PSYCHOLOGY

Although Rapaport dealt with theory in a far more sophisticated way in his published papers, this hitherto unpublished lecture is presented here because it makes so clear the relevance of theory to specific clinical problems--a relevance that is not always apparent in his more theoretical writings. It also illustrates Rapaport's facility in adapting his presentation to circumstances, his ability to simplify without undue distortion--M.M.G.

I assume that in talking about ego psychology here I can take it for granted that it is familiar to most of you and therefore I will discuss mainly some clinical implications. However, I would like to spend the first third of my presentation on certain concepts of ego psychology, so that I can afterward talk more easily about things clinically important. What is ego psychology? In general, it is a term used in contrast to and complementary to id psychology. The great discovery of psychoanalysis was a thoroughgoing psychic determinism in all behavior. This consideration of motivation had a huge impact upon psychiatry, psychology, and clinical psychology. In the course of the search for the motivation of behavior, we forgot or neglected for a long time our interest in matters not motivational. In the amoeba, whatever motivating state exists is going to create pseudopods. It will reach out, pull in, etc. But it has a nucleus which does not change with motivation. Human behavior has many features comparable to the nucleus of the amoeba: for instance, what we today call inborn ego apparatuses, namely, motility, perception, memory, and the threshold apparatuses. The latter define the point at which the organism is ready to discharge a certain tension. My first point, then, is that ego psychology deals with the apparatuses we use in reaching the goal of a motivation. However, this is not all ego psychology has come to represent.
     Again we have to look back on what we have learned from psychoanalysis and what has become commonplace in psychiatry, psychology, etc.; namely, if a human being behaved in a certain way we have been looking first of all for his motivation and have come to disregard the fact that behavior is determined not only by unconscious motivation but also certain reality conditions. For example, a cigar can be just a cigar and not primarily a penis symbol. We are infected with a kind of thinking: something peculiar a patient does is immediately interpreted in terms of dynamics, to the neglect of environmental conditions. It is a difficult job to create concepts which take account both of intrapsychological motivations and reality adaptation. How difficult this is will be clear to you if you consider for a moment the aims of treatment. What is the aim of psychological treatment? Is it to liberate an individual from his defenses? We all would agree that liberation from crippling defenses is the aim of our work. In the meantime, however, there is also something we keep in the back of our minds, and some of us may even keep it in the foreground: the patient needs to find his place in society and lead a useful, productive life. What is our goal? Is it liberation of the person or is it fitting him into something? This is a kind of choice which probably should not be made by us. Maybe it could be compared with the choice of the young Hungarian nobleman who was waiting for his wife to deliver. As he was waiting the nurse came and brought out triplets. He put his finger to his nose, pondered, and finally said, pointing to the one in the center, "I'll choose this one." Should we lay down the law and say to the patient, "You've got to quit doing rebellious things and be a good boy?" Maybe the patient's only way to survive is to be rebellious and the only way he can serve as a useful person is to be a very sick, reckless person and the way in which to give him help is to help him feel reasonably comfortable as a reckless, rebellious person. Once you start out that way you are all involved in the problem of social adaptation the way Adler, Horney, etc., were and the danger is that you may begin to forget the intrapsychic determination. The balance between understanding unconscious motivation and finding the social niche into which a person fits is not essentially a paradox, but people have chosen to do either one or the other instead of trying, as present psychoanalysis tries, to reach a synthesis. The problem of adaptation versus the problem of freedom from crippling defenses is a problem of ego psychology.
     I would now like to proceed to some points in ego psychology which have direct clinical relevance. I will first present a concept termed by Hartmann "preparedness for an average expectable environment" and labeled "mutuality" by Erikson. Its significance and clinical relevance is in shedding new light on the mother-child relationship. What is preparedness for an average expectable environment? Erikson and Hartmann attempt to collate evidence that the human infant is born so that it is prepared to be able to survive in an average expectable environment. That is, the mother has a receiving apparatus for the signals of the infant; the infant has a receiving apparatus for certain nonverbal signals of the mother; and from the beginning on there exists a mutual relationship by which the infant steers the mother and the mother steers the infant. Inherent in this concept is the idea that it speaks of an evolutionary product, of one which is guaranteed by evolution for this creature, man, who has the longest dependency period of all creatures. His helplessness has evolutionary advantages only because of certain mutual steering devices of mother and child by which this helplessness can be managed. This might seem to be a very abstract concept. What does it have to do with the clinic? You all, I am sure, have heard about the "schizophrenogenic mother," the mother who makes her child schizophrenic. Such concepts as those of Erikson and Hartmann demonstrate that this is an inadequate concept. This is important because if the concept of the schizophrenogenic mother is canceled out, then our outlook on the illness changes and therapeutic work becomes somewhat more hopeful. I would like to try to show you in what sense the concept of mutuality militates against the concept of the "schizophrenogenic mother." If the relationship is mutual, then the relationship between the mother and child is relative and neither party can be blamed. Once you start with this assumption, you hit on clinical evidence which was not noticed around Washington, where the concept of the schizophrenogenic mother was born. The infant who later becomes schizophrenic often displays very early a certain lack of response to signals. Clinically we see these children later as borderline schizophrenics who do not give you any indication of whether they like what you are doing or not. In that type of case, which is called the autistic or schizophrenic child, there is apparently from the very beginning some kind of lack of mutuality, lack of signal giving and receiving. This deficiency then comes into the hands of a mother who herself may have difficulties of some sort. She reacts to his deficit with rejection and guilt, and thereby perpetuates it. It is easy to forget that it is partly the child who made the mother like that and that it is hard to be a mother to such a child. This is an ego-psychological issue for three different reasons: (1) It deals with the apparatuses, namely, the threshold for signal giving and receiving. (2) It deals with the very first adaptation, and it deals with preadaptation on which all other adaptations are built. (3) As the therapist, you will deal with these patients not by approaching this type of problem in terms of motivation but in terms of the problem of re-establishing a human relationship in which the lack of ability to give signals is going to be re-encountered and re-evaluated, in which the desire to give adequate signals may arise for the first time in such a patient's life. No interpretations are going to bridge the original gap in equipment, yet this gap is not irremediable. It certainly is remediable with schizophrenics who before they became schizophrenic had some achievements, and it is remediable even in some autistic children who never developed the requisite thresholds and signals. All of us as children had, in some respects, weak signals. Our thresholds varied greatly, and our mothers, having met our deficiencies, helped us slowly to develop adequate thresholds and helped us to develop a mutual relationship, out of which later in life trust could develop instead of leaving us in a condition of lack of mutuality, the hotbed of mistrust as a fundamental ego tendency. Even before Hartmann and Erikson, Paul Schilder had pointed out that man does not "become socialized" from being first an "egotistic" little wild animal, as the period of enlightenment and even psychoanalysis thought. Schilder asserted that man is a social being from the word go. This is something important to keep in mind when working with a schizophrenic, because if you had to make him into a social being by your work with him, at some point you would give up, unless your megalomanic ideas about yourself are unlimited. Unless you know that he has it in him and you need only to discover and to liberate it, the courage which is necessary to stick it out with a schizophrenic cannot be had. Even this fundamental, primitive, and really remote ego-psychological concept thus has considerable clinical relevance.
     Now I would like to pick up another concept, Freud's definition of the ego in The Ego and the Id (1923). The first definition that Freud gave of the ego, and the most general one, was that the ego is "a cohesive' organization of mental processes" (1923, p. 15). [Both here and elsewhere Rapaport quotes Freud as defining the ego as a "cohesive" organization, whereas both the Riviere and Standard Edition translations say "coherent" organization. Apparently Rapaport felt that "cohesive" better expressed the idea of a unity, and we will let his usage stand where it appears, for Freud did speak of the "tendency to unity, which is ... characteristic of the ego" (1923, p. 64) -Ed.] This definition distinguishes the ego from the id, which is not a cohesive organization; drives coexist in it side by side. The superego is not a cohesive organization either. It collaborates with the id in what it is intending and punishes the ego for its intentions. Maybe you know the story about the little boy going toward the candy jar. Before he got there, there was a great clap of thunder and the boy looked up and said, "Good God, isn't one even permitted to think of it?" I suggest that the superego does that in an even more extreme way. The boy would not even have to be sure he was going after the candy; just some slight yearnings and punishment would already be there. On the other hand, there is a fluid transition between the ego and the superego in what we call the ego ideal. So the superego is not cohesive either. This definition thus counter-distinguishes the ego from the other structures in the psychic apparatus. Is this all it is supposed to do for us? No, this definition implies quite a bit more. If it is a cohesive organization, then it should be capable of keeping various of its aspects coordinated. It indeed does so, through what we call the synthetic function of the ego. What is this synthetic function and what is its clinical relevance? I will try to give an example. Suppose that among the few ideas I have introduced so far, one is relatively new to some of you here. Let us assume that I tried to present that relatively new idea so that it should not come out of the clear blue sky. But even then the connections in which I presented it were only in my mind and did not yet have a place in your own thought organization. After a while, however, if you are struck by one such idea, it will lodge safely and securely among other ideas you have in your mind. It is not my job to put it in place in your mind. If you had to place it by an effort, listening would be a most difficult job. Actually, neither my nor your special effort places a new idea in its place in your thought organization. It is done quasi-automatically by the synthetic function. The new idea is put together with old ideas rather automatically. True, we can do a deliberate and effortful job of thinking at times, but most of us, most of the time, rely on the synthetic function of the ego in general, and in particular on that aspect of this function which works in thought organization to put things together for us. We say it "fell into place" and we understood. This may not happen while we listen, but maybe not until later; the beginnings, however, are there. The speaker tries to bring the material in and move it into position for that function to grab it and put it into place. What is the clinical relevance of this? First of all, it is relevant in relation to the long-standing discussion of the dynamics of the effect of our most important therapeutic tool, namely interpretation. How does it help? An interpretation brings into a new relationship the existing conflicts and defenses and then leaves it to the synthetic function of the ego to do its job on it. If the interpretation did not take, you work it through, over and over again, applying it with the patient to ever new areas. It is like a big stone which is lodged heavily in a stream. You are trying to get the dirt from around it and start rolling it, leaving it to the stream to lodge it in a place where it will not be an obstacle but an advantage. With schizophrenics we know that unless we bring about a situation where synthetic forces can work again, the job cannot be done, because it cannot be done by the therapist alone. To achieve this is often not a job of interpretation but a job of a different sort, that of creating a relationship that can free sufficient energies with which synthetic forces can begin to work. A knowledge that you can rely on the synthetic forces to come into play sooner or later is actually what can keep you working at psychotherapy with the schizophrenic or even with the neurotic.
     I would like to turn now to a third problem, that of autonomy. What is autonomy? First of all, it means that the sensory apparatuses, the motor apparatuses, the memory apparatuses, and the threshold apparatuses are not born out of conflict. These are ego apparatuses, the most important use of which is in searching for the drive object in reality. If one assumes that ego apparatuses are, from the beginning, part of the psychic organization, then the old psychoanalytic conception that ego is born out of id does not hold up. It becomes necessary to assume, as Hartmann indeed does, that the ego and the id both emerge by differentiation from a common undifferentiated matrix. These primary ego apparatuses pre-exist conflict and enter the conflict as independent factors. Although they may be drawn into conflict, they are autonomous from the beginning. But there is also another type of autonomy: if, in the course of an instinctual conflict, new structures, for example defenses, are created, these defenses may persist after the conflict that gave rise to them has long since subsided. They become independent from the original conflict and become secondarily autonomous apparatuses. They become ready-made tools to cope with all kinds of tasks of executive, conflictual, or adaptive nature. Language is a good example. There may be a question about any autonomous apparatus or ready-made tool of behavior, about whether it is a primary, ready-made tool pre-existing the differentiation of ego and id, or is only acquired in the course of the battle of life and then becomes detached from its instinctual, conflictual source of origin.
     There is one specific issue of autonomy on which I would like to dwell further. Suppose a person developed a certain defense; for example he can not show, or even experience, his aggressions. He leans over backward and is oversweet, with a great inclination to be very helpful to all comers. "No, I am not aggressive at all, I am most accommodating." He aims to please. Suppose you analyze that person. Does it mean this person then must quit being a helpful and serviceable human being and become an aggressive bastard? Is this an inescapable implication of therapy? Luckily, human nature is not that way. An autonomy once achieved survives. That is why Koestler is wrong when, in his Arrival and Departure, he has his hero arrive on an island as an honest radical and depart from it after being analyzed as a smug Philistine. Man does not happen to be made that way. What is the clinical relevance of this? It is that in a schizophrenic the structures that have been built up in the course of the development of his personality have not been obliterated by his illness. They go into disuse, they become unreachable--just as your sense of humor may be lost for a time when you are in a disagreeable position but returns to you later--but they are not destroyed. Sometimes when we are with a bore, we find ourselves to be just as big a bore as our counterpart. You know the situation, don't you? Does it mean that we have lost all the structure we have achieved, all the knowledge, all the interest? We do not lose them, they have just become unusable. The same for the schizophrenic patient: his structures just become unavailable to him and your job as the therapist is to help rediscover them. This is what we help them to get at and not something. strange that belongs to somebody else. Dynamically as well as therapeutically, this autonomy is of the greatest significance. It is easy to see what is wrong in our patients but a lot more difficult to see what is right, what is preserved. To learn to look for what is preserved is of great importance and is the point driven home to us by the conception of autonomy: whatever was once achieved is never lost. Any achievement noted anywhere in the case history, any valid perception, any single bit of knowledge, any differentiated feeling, any success, indicate to us that somewhere there was once something that can serve again as a nucleus of a new departure, providing we can reach it, free the synthetic forces, and progress from there to further self-discoveries of the best in the patient's essential social nature. This is the point no patient fully expects and that many of us do not fully appreciate in ourselves: there are persevering secondary autonomous structures and there is a basic sociability, and there are primary autonomous ego apparatuses even in our . sickest patients.
     The last point I would like to dwell on is the issue of identity. I have indicated already that the social adaptation that man makes is outside of our ken while we are hunting only for motivations. The explanation of social adaptation has not been part of our psychoanalytic teachings for a long while. While Adler, Kardiner, Fromm, Horney, and Sullivan were very interested in this adaptation problem, they forgot to deal with the problem of unconscious motivation. The problem arises: What kind of concept can one develop by which both adaptation and unconscious motivation can be dealt with simultaneously? In order to be able to talk about concepts I will dwell on Erikson's concept of identity. Let us assume that to begin with there is a loose ego organization holding together the various thresholds and the apparatuses of motility, perception, memory, etc. As instinctual development progresses, we reach the point where this ego organization has to cope with thoughts, approvals, disapprovals, etc. All of these will impinge on this ego organization and alter it. There will remain a continuity between the original, loose ego organization and the later, more differentiated ones. For this continuity we do not have an agreed term. Sullivan talked about "self." But he used this term for the ego also, while it does not replace the "ego." In the eight stages of man, Erikson attempts to represent both the alterations in ego organization coming about in the course of libido development and the constant features of ego organization and their developmental phases. Hartmann and Loewenstein too speak of autonomous ego development, but Erikson's eight phases are the only consistent attempt to characterize the autonomous course of ego development. To come closer to the clarification of this point, let us turn to another definition Freud gives of the ego in The Ego and the Id (1923). According to this definition, the ego is the precipitate of identifications with abandoned objects (p. 36). The point is that is order to sever a relationship to a drive object, we reinstate it in our internal world by identification. Indeed, you know people tell you, "You are just like papa"; you put your coat on the way he does, you spit the way he does, etc. But what of the continuity of ego development? Do a person's identifications simply remain a congeries of all these identifications? According to Erikson, in the course of development the synthetic functions of the ego jell all these identifications into one unity. They do not remain disparate parts within us, such as father, grandfather, Uncle Sam, etc.; they are turned into one unity. It is similar to what happens in the course of studies; when you have studied books by various authors your knowledge of psychology is that of the authors, but you are not going to keep each of their thoughts and principles separate very long. Sooner or later they will yield to a unity: your own view of psychology will jell out of them. Similarly the identity jells together all identifications. Erikson was able to demonstrate that in puberty and adolescence there is not only a recrudescence of the various impulses of earlier libido-developmental phases, but also of identifications which were made in the periods in which they were prevalent. They are revived and pass review. Indeed, these and many new identifications which are made are then jelled into one unity: the identity. But these identifications, their socialrole, vocational-role, etc., components, acquired skills and expectations, are so jelled into an identity as to guarantee the person a niche in society compatible with his expectations and self-respect. In other words, you find here in Erikson's concept a flowing together of three different conceptual strains. (1) From id psychology the dynamics of identification. (2) From ego psychology the dynamics of synthesis. (3) From social psychology the dynamics of fitting into a social niche, social role. You can see that here we are dealing with concepts integrating these three strains. This I believe is the core and the most lasting merit of Erikson's contribution.
     The clinical significance of this is great. In our society, young adulthood is prolonged and reaches well into the 30s, which is later than--to my knowledge--has ever been the case before in history. Because of this, finding an identity and a definite choice of occupation becomes necessary and is made possible by a social moratorium, that is, by society's acceptance of experimentation. This does not explain the dynamics and I am not endeavoring to go into that now. We do know, however, that what the adolescent and young adult are struggling for is to unify identifications and a lot of roles so as to find the niche that fits them, and thus to gain recognition which will guarantee self-respect. Our first rule in therapy is to interpret what is readily available. This struggle for identity and role definition is usually the most obvious and readily available material in young adulthood.

The Ego in the Session
Pine, Fred (1998)

For some analysts ego psychology has a bad name, whether because of psychoanalytic politics (a wish to disavow the so-called classical position) or because it appears to leave the "depths" of the mind behind or because--as a nonexperiential concept--"ego" does not have the appeal of, say, sexual or aggressive urges, affects, repetitive object relationships, or subjective states. "Ego" is an indispensable concept, however, and central to all clinical work. At the very least, the concept helps us in any assessment of a person's capacity to enter and participate in the analytic task. But much more is addressed by the concept "ego:' In this chapter I use clinical vignettes to illustrate three of the ways in which the ego makes its appearance in sessions: first, in terms of the achievements and failures in its developmental history; second, in terms of its participation in the work of the analytic process; and third, in its more frequently described role in defense in relation to some intrapsychic disturbance. Each discussion will center on clinical judgments within the session.
     I use the concept "ego" to consider the person from the standpoint of defense, adaptation, and reality testing: defense in relation to experienced dangers in the internal world, adaptation to the expectations and perceived realities of the external world, and reality testing in relation to both internal and external and to the capacity to know them in themselves and to tell them apart. The term ego is shorthand; it need not be reified; it always refers to the person's modes of managing psychic life and the world.
     If we did not have an ego psychology, it would be necessary to invent one, and Freud (1923, 1926) did just that, followed by Anna Freud (1936) and Heinz Hartmann (1939). Hartmann expanded the ego concept greatly, and some of these expansions enter into my clinical discussion. But Hartmann's conceptual and aclinical style also contributed to a turn away from ego psychology in the current era of primary focus on technique. Ego concepts need not be aclinical, however, and in Anna Freud's writings they were part of a living clinical process. I try to write here within that tradition.
     A psychology of ego function was indispensible for Freud and was present in his writings before it was formally conceptualized as such. it was clearly present in nascent form in his concepts of defense and repression (Freud, 1894), concepts that were necessary for him to use in order to explain what he was seeing clinically. Years later (1926) another clinical observation, that anxiety seemed to precede defense rather than follow it as a conversion of blocked libido, led to his signal theory of anxiety and thence to a concept of a stronger ego--an ego that could call the pleasure principle, in this case pain avoidance, into play on the side of defense and against the instinctual drives. Also, as I noted in Chapter 2, the requirements of Freud's theory in itself led to an ego psychology: since the system Unconscious and, later, the Id are timeless and do not learn, some means was needed to explain learning and change, in the analytic process as well as in life. But the ultimate requirement for an ego psychology stems from our position in evolution. We are not outside of evolution, and evolution would not have produced a creature with no adaptive capacities; that would not serve survival of species.
     As I have tried to make clear throughout this book, my own recent clinical work has been heavily influenced by current psychoanalytic theories of technique and of mind. But I wish also to demonstrate that an ego psychology, while certainly not the new wave, is as relevant as it ever was and central to a full understanding of issues of technique. I have chosen to use as my main clinical examples instances readily subsumed under the structural theory. I believe, however, that the ego concept is relevant to every extant theory of mind; each involves issues of defense, adaptation, and reality testing though they vary in their conception of what it is that is defended against--that is, the nature of the intrapsychically experienced danger or pain.

Developmental Achievements and Failures
Billy, age seven and the only child in a cleanliness-oriented household, was still soiling fairly regularly when he began treatment with me. The symptom was maddening to his parents. Three years later, by age ten, he had given up the soiling, at least in part through work he and I did together. I describe three incidents (widely spaced over the three years), each of which confronted me with questions: Was this an alternative (displaced) expression of the symptom or was it more socialized or even a sublimation? How much "ego work" had been done by him? And, depending on my answers, should I intervene or not, and if so, how?
     One day toward the end of the first year of treatment, Billy came in sadly complaining that his parents had taken away his new gun--a gun, he explained, that shot little paper pellets. They said he was making a mess all over the house with the pellets. He said he was having fun; the gun was supposed to shoot pellets. Of course I noted the messing in this story (to myself). And I also knew that, though he was at times ashamed and depressed about his soiling, at other times he took a provocative delight in "messing;" specifically by turning his back on me, bending over, and sending a loud fart in my direction. The gun play could have been another instance of this delight in provocation, but it also could have been a step up--boyish, displaced, better paper pellets than soiling his pants. How should I intervene with him or with his parents? I was uncertain.
     Billy resolved my uncertainty in the next session. His parents had given back the gun; he brought it to the session to show it to me. In no time my office was littered with paper pellets. But, more instructively, each shot of the gun was accompanied, as the pellet fell to the floor, by a loud "plop" sound from Billy's lips--and the same impish smile and glint in his eye I had seen after the farts directed toward me. So perhaps some "ego work" in the form of displacement had been accomplished by him, but not much, and certainly not enough; I now had no doubt that he was crapping on my floor and that he knew it. At this point my interpretive stance was clear to me, and I easily showed him (and he readily recognized) that this was another form of soiling. This event did, however, provide entry into discussing his pleasure in tormenting his parents, and he came to see how he was torn between that pleasure and his inner shame and depression.
     About a year later, when he had pretty much given up the soiling--though there was still frequent staining of his undershorts and he still inwardly defined himself as a soiler and carried the associated shame and depression--Billy came in with something new to report. He had had an afterschool date with a friend twice that week. He confided to me a "great game" they had developed. They would gather up a large clump of toilet paper, soak it and bunch it up into a wet wad, and try to drop it out the window on a passerby. It was great fun, he let me know. Again I was torn. The parallels to soiling seemed clear enough, but again some displacement to boyish activity had taken place, some ego work, and I thought it likely that he was not aware at the moment of the link to soiling. I saw no real danger to passersby; death by toilet paper wads is uncommon. Additionally the play had a socialized component; Billy, ordinarily a social isolate, was doing this with a friend. I chose to inquire a bit, to listen, and to say nothing.
     Again things changed by the next session. Billy came in anxiously, painfully telling me that he had not been able to fall asleep at night. He would lie awake worrying that he had not played his toilet paper "game" that day, and he felt a compulsion to get up and "play" it. Clearly this was no longer play. So it now seemed to me that, even if this were a boyishly socialized displacement into play, a developmental step up of sorts, it was not working. After I listened a bit more, and in light of his particular report of anxiety and compulsion if he had not thrown toilet paper, I chose to say the following: `Billy, I think throwing toilet paper is like making b.m.'s, and you felt you had found a regular-boy way to have fun attacking people with messes instead of a b.m.-in-your-pants way. That's why you worried if you had not thrown the paper. It was supposed to prove you were a regular boy. I think you're still worrying about yourself even though you don't make in your pants like you used to:' He looked at me with recognition and relief; following this exchange the symptom that was in the process of being created (the compulsion that kept him awake) disappeared, and our work went on.
     Then again, about one year later, another incident in this series occurred. Billy told me he had started a penny collection; he had hundreds of them. I thought I recognized the old symptom again in the little copper pellets, but this time they were collected and seemingly a big step beyond the "plop" of paper pellets or the tossed toilet paper wads. Here, I thought, real transformative work had been done intrapsychically; a sublimation had evolved.
     Another incident took place a few sessions later. I opened the door to my waiting room for his session and there he was. Also in the waiting room was an adolescent boy waiting to see my office partner. Billy had a beaten-up brown paper bag on his lap and was hunched over it, holding it together; I soon learned that all of his pennies were in it. He looked distraught. As soon as he entered, still hunched over and struggling to hold the bag together, he explained in a pained voice: "Dr. Pine, I brought my pennies to show you, but the bag started to tear and the pennies almost spilled. It would have made a big mess. That big boy would have thought I was such a baby!" So here we were again. But this time I made a different choice based on my assessment of Billy's ego functioning within the total situation. I judged that this time he had absolutely no awareness of any link to his soiling; I considered that the penny collection was an age-appropriate sublimation; and I felt that any link I made between the penny collecting and the soiling, however well intentioned to help him with the momentary eruption of shame in the waiting room, would or at least could lead to an invasion of the sublimated activity by the soiling ideation, thus spoiling it. I therefore said only: "I'm sure the big boy wouldn't have thought badly of you. Anyway, I'm glad you brought your penny collection. Let me see it." And later I gave him something more secure to carry the pennies home in. I assumed that, were there subsequent breakthroughs of soiling-related ideas, urges, or affects into the penny-collecting, I would have later chances to deal with it either similarly or differently, depending on my assessment of his ego functioning at the moment. But it did not come up again.
     With some patients, at some times, depending on how the clinical material seems to fall at the moment--but not as a general rule of technique or as something always in the forefront of my consciousness-I am working with a concept of the ego and its development that helps me to conceptualize what is going on and whether and how to intervene. I have just illustrated that closely with Billy, where in three incidents I found myself questioning whether the soiling and associated affects or some more socialized, displaced, or even sublimated activity was at the center, reflecting transformative ego work. Related matters, suggested by a concept of the achievements or failures of ego function and ego development at various ages, come up in numerous ways. I illustrate a few, but more briefly.
     Issues parallel to those with Billy arise with adults in analysis with respect to sublimated activities. Writers, painters, but also graduate students writing dissertations, or persons involved in the more mundane activities of daily work or living--each scenario, when going smoothly, may teach us something about the person but is more likely to attract attention and require interpretive work when interrupted, when anxiety or shame or doubt invades the activity or when the activity becomes otherwise blocked. For some individuals, interpretive work with smoothly functioning activities is experienced as intrusive or reductive; it can sometimes actively corrupt certain otherwise egosyntonic activities when their establishment is tenuous or the person involved is fragile. This is not always the case, and we learn in the doing which patients can work interpretively with well-functioning, egosyntonic activities as a source from which to learn, without its interfering with the activity.
     This view has much in common with the interpretation of play in child treatment. Since the child is ordinarily not knowingly intending to communicate through the play, interpretations can be intrusive and lead to termination of the playing. One can almost always safely interpret a child's play when it has been disrupted by some negative affect or by the associations it has stimulated; in this situation, the interpreter can come in on the side of the ego to make play possible once again, or to relieve the anxiety. So too with the timing of intervention with respect to sublimations and their disruption, as with Billy and his paper "plops," his toilet paper game, and finally--but in reverse (noninterpretation)--his penny collection. The assessment of level and intactness of ego function guides the timing and form of interpretation.
     The examples I have given from Billy's treatment can be thought of in terms of the construction of a sublimation. Related issues can be described from another standpoint as the achievement of secondary autonomy in relation to activities born out of early conflict but now having a life of their own in the present. To view them only genetically can lead to losing touch with the patient. Let me give a nonclinical example from a recent New Yorker article (Seabrook, 1996).
     Steve Redgrave is a gold-medalist Olympic rower, part of the English team. For specific physiological reasons, rowing at Olympiccompetition speed levels is an excruciatingly painful activity. When asked about it, however, Redgrave denies the pain. The question has come up whether Redgrave, now thirty-five years of age and old by Olympic standards, will retire after the 1996 Olympics. His wife, who is also the physician of the English rowing team, doubts it. What drives him on?

"Oh, I don't know," she said. "I suppose it comes from his dyslexia, his learning disability. That made it very difficult for him in school-until he found rowing, which was something he could do well. The others he went to school with who had that problem had to face it earlier, but because of Steve's rowing he never had to, and now it's a bigger problem, because he put it off that long. Rowing's given him an avenue away from facing it:'
      Steve disagreed with this. "If I don't stop rowing, it's because I love to row. My dyslexia is not a factor." (Seabrook, 1996, P. 35)