ABSTRACT
A fifth psychological function relevant to building an alliance and planning psychotherapy is the quality and sturdiness of the patient's conscience. Termed superego by Freud moral development by Kohlberg and Gilligan and judgment in the mental status exam, conscience refers to the internalized moral guidelines that direct our behavioral choices. The quality of concern for others is a useful, pragmatic way to measure the developmental maturity of conscience. Persons suffering from one of the broad spectrum of pervasive developmental disorders, characterized by impairments in interpersonal awareness, are thought to have neurobiological underpinnings. The next orienting point on the continuum of conscience development is consistent concern, motivated by remorse and guilt rather than by shame, but with misuse of the function of guilt. Shame implies that the person feels concern about behavior because she fears being humiliated if her behavior warrants censure. Guilt is also operating dysfunctionally when it is offered as payment for an implicit sanction to repeat the behavior.
