Where's my ego gone now that I really need it?

The young man enters the consulting room with the same hesitant shyness and air of apology as at our first meeting, months ago. Physically, as well as emotionally, it's as if he tiptoes through life, scared of leaving any imprint of himself. Often overwhelmed by internal and external stresses, he hopes not to be noticed.

Today, he is agitated about an incident at his work, at an organisation that promotes the arts in education. He is, I imagine, excellent at what he does. But at times he locks horns with one member of staff, an older man and his immediate senior. This man responds to my patient's gentle passivity with irritation and contempt, and my patient responds by avoiding of confrontation and lying low. But this afternoon, after a snide comment, the pressure cooker of his hidden rage erupts.

This has been a recurrent motif through the months of therapy. At one level, it is easy to diagnose. He has, I'd say, a fragile or weak ego that cannot manage eruptions from both internal and external worlds.

The ego is a term often bandied about. We talk of people being egotistical, of having a wounded or boosted ego. But what exactly does it mean? Psychoanalytic theory is rife with differences over this, but there's some agreement that "ego" refers to the conscious image we have of ourselves. Because the ego gazes from inside out, not outside in, it is usually pretty myopic about the effect we have on others. Nor is it very fussed about taking on board unconscious manifestations (such as sudden moods and anxieties) and understanding them. The ego wants, above all else, security and an easy life, and reflections about what the outside might think or what lurks in the depths only upset the order.

So how are our egos formed? None of us, at the start of life, has one. Influenced by both inherited disposition and early life, it comes into existence with the recognition of our essential separateness. If we're lucky to have had a secure early environment, we'll negotiate toddlerhood, teenage years and early adult life with the cut and thrust of a healthy ego. In this first part of life, the pushy side of the ego needs to be given a free enough rein to gain a foothold in the world and feel a solid enough sense of "I am".

Then, in the second part of life, the ego needs to take a nosedive. A new recognition that it isn't the centre of the universe, but an important mediator between the vaster inner and outer life around it, often kicks in at midlife. Ideally, this enables us to tap into a more meaningful experience of life. But managing to give up what we have spent the first half of life developing is rarely easy. Most people struggle at some point.

So what has this to do with the young man? How can he slough off a skin he hasn't sufficiently grown? Is there any remedy for a weak or wounded ego? Well, yes and no. No, in the sense that the clock can't be turned back. I suspect it was a mixture of inherited disposition and early life experience that lay behind his fragility. As a child, he was often bullied because his ego was unable to defend him. He had not been given, or developed, the tools.

But also yes, because now, in his early twenties when he needs a strong ego, he can work to reduce the pain of feeling so defenceless. He needs to become less afraid of the object world and more confidently seated in his own sense of himself. It sounds easy, but in practice is a hard slog.

Elizabeth Meakins is a psychoanalytic psychotherapist in private practice. None of the above clinical material refers to specific individual cases