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Integrating Ego Psychology and Strengths-Based Social Work

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Abstract: Ego psychology and strengths-based social work are related. Intuitively integrating these theories in clinical practice with
fena, a former gang member and rape survivor, helped her recoverfroma post-rape crisis. The core concepts of ego strength and resil-
ience helped to explain her earlier life experiences, what happened in her therapy, and how therapy helped her heal Limitations and
implications for future practice are discussed.

Key Words: ego psychology, resilience, strengths, sexual abuse, trauma

Integrating Ego Psychology and

Strengths-Based Social Work

A guiding principle of strengths-based social work is start-

ing where the client is. In practice, this means that the
therapist's sense of the client's emotional needs should
guide the therapeutic approach. I found this way of practicing to
be particularly effective with/OTA, who was a client of mine when
I worked at a crisis clinic. In her intake, Jena told me she had
been raped about a year before she came in for treatment. Since
then, she often abused drugs and had sex with men she barely
knew while under the influence. As Jena told me about this, she
seemed angry at herself and confosed.
I remember thinking that it might be complicated for me, a
male therapist, to help Jena work through these issues. To build
a relationship with Jena, I carefully followed my intuitions about
how I should adjust my approach to meet her needs. Sometimes,
this meant I needed to actively guide her therapeutic exploration.
At other times, I needed to listen supportively and just be there.
An Integrative Framework
Psychotherapy integration offers a theoretical framework
for addressing clients' multiple and ever-changing needs. In this
article, I present Jena's case as an example of what integrating ego
psychology and strengths-based social work looks like in practice.
I chose these two theories because, when I was documenting
Jena's case, I discovered my way of working with her was largely
strengths-based. However, ego psychology helped me conceptual-
ize her development, her early life and traumatic experiences, and
what happened in her therapy. An integration of these two theo-
ries explained my psychotherapeutic interventions and confirmed
my professional intuitions about Jena. In particular, I found the
concepts of ego strength (ego psychology) and resilience (strengths- concurred with Freud that the ego was a defensive structure, but
based social work) helped me explain how therapy helped Jena
heal.
I wanted to explain what happened during Jena's therapy be-
cause of the impressive gains she made in just eight sessions. She
was already a resilient person, naturally predisposed to a quick
recovery. At the same time, I was impressed by her coming to
therapy with concerns about regularly abusing drugs and engag-
ing in promiscuous sex, and then ending therapy with 30 days
of abstinence from drugs and being in a monogamous relation-
ship that she felt better about. It has been my experience that,
although resilient clients tend to recover from crisis fairly quickly, the parent-child system. Strengths-based social work goes a step
Jena recovered much more quickly and to a greater degree.
Finding a theoretical explanation for my work with Jena was dif-
ficult because I had no therapeutic model in mind when I worked
with her and wasn't able to pinpoint exactly how therapy may
have helped her until long after the therapy was over. I did not
practice from one particular model because my work with Jena
occurred earlier in my career when my working knowledge of the
models was limited, which led me to feel anxious. Ironically, my
limited knowledge may have helped me to work with Jena more
effectively If I had greater working knowledge of therapeutic
models at that stage in my career, I may have rigidly ascribed to
one model or another rather than following my intuitions about
what Jena needed from me in the moment. These intuitions led
me to focus primarily on Jena's strengths.
Freudian Ego Psychology
Sigmund Freud (1975) theorized that human development
begins with conflict in the tripartite psyche, which includes the
id, ego, and superego. The id propels instinctual drives for sex and
aggression. Because it is not always appropriate to gratify these
impulses, the superego morally represses them. The id demands
discharge of these drives (Freud, 1966), but the ego tempers the
drives and allows them to be discharged in socially appropriate
ways. The ego negotiates compromise between the id and super-
ego through the ego defenses (Freud, 1966).
Freud^'s analysis of the ego led to elaboration of the defense
mechanisms by the ego psychologists, including his daughter
Anna Freud (1966), Heinz Hartmann (1958), and Erik Erikson
(1963; 1964). Whereas Freud (1975) was most interested in
the id, the ego psychologists focused primarily on the ego. They
added that the ego is inherently adaptive and has implications
for human development (Mitchell and Black, 1995). Freud was
interested in how the defenses repressed reality; The ego psycholo-
gists were more interested in how people use their defenses to
adapt to conflict, both in their psyches and immediate-surround-
ing environments. I use the terminology "immediate surrounding
environment" because it wasn't until the theory of strengths-based
social work that theories of the ego encompassed larger systemic
issues. Ego psychology narrowly considered the way in which
development may be influenced by culture and experiences in
ftirther by looking at how development is influenced by larger

The fournal of Theory Construction ó" Testing -9 - Volume 16, Number 1

societal factors such as discrimination, poverty, and oppression.
Freudian defenses include regression, repression, reaction
formation, isolation, undoing, projection, introjection, turning
against the will, reversal, and sublimation, (Blanck and Blanck,
1994; Freud, 1966; Goldstein, 1984). Anna Freud (1966) defined
reaction formation as the unconscious effort to hide one's true
feelings by behaving in the opposite way. She defined sublima-
tion as channeling of primitive emotions into productive activities
(Freud, 1966), a defensive strategy by which id drives become
adaptive (Mitchell and Black, 1995).
Reaction formation and sublimation were Jena's most promi-
nent defensive strategies. In the beginning of our work together,
she more often used reaction formation. At the end of our work
together, she had experiences that were consistent with sublima-
tion. I do not mean to imply that we worked through her defense
system in eight weeks, yet she may have used more mature
defenses toward the end of our work because her ego had grown
stronger. I helped Jena do this by building on her natural store
of resilience. My therapeutic approach was supported by Anna
Freud's (1996) theory that the ego grows stronger when people
work through conflict by using dieir internal resources.
Heinz Hartmann. Jena's emerging ego strength parallels
Hartmann's (1958) theory of adaptation, which is one of the core
principles of developmental ego psychology. Hartmann pioneered
a theoretical shifi: from focusing on intra-psychic structures and
their dysfiinctional effects to focusing on healthy and adaptive
development. In contrast to others before him who saw ego
development as dominated by conflict, Hartmann saw it as a
progression. The ego develops along parallel tracks (personal com-
munication, G. Bellows, 01/07/10).' One is in conflict, the other
in confiict-free capacities within the id and ego. These capacities
include perception, memory, motor coordination, language, gifts,
and talents (Hartmann, 1958). As long as there is a predictable
environment, these conflict-free capacities develop into ego func-
tions, which function independently from id drives.
Erik Erikson. Despite its strong ties to the earlier conflict-
based theories, ego psychology focused on principles that dovetail
with strengths-based social work, including inborn ability,
developmental potential, person-in-environment phenomena,
and internal resources. One of the developmental ego psycholo-
gists who led this movement, Erikson went a step further than
his predecessors by identifying the individual's reliance on the self
and the community (Mitchell and Black, 1994). Like Hartmann,
Erikson formulated progressive theories of the ego. He expanded
traditional psychoanalytic theories of ego development into a
psychosocial model covering the whole lifespan. Erikson theorized
that development happens organically through a series of eight in-
terrelated growth crises or stages that are typified by tension more
than conflict (Mitchell and Black, 1994; Erikson, 1963; 1964).
Erikson and Hartmann were among the first clinical theorists to
consider how human development was influenced by broader
forces in the environment. Agreeing that the individual is pushed
by id drives, Erikson extended Freudian ego psychological theory
by asserting that the individual is pulled by social institutions. He
claimed that society is essentially 'an extension of the ego in its
campaign to regulate the drives" (Mitchell and Black, 1994, p.
143).
Contemporai-y Ego Psychologists
Markstrom is a contemporary ego psychologist who theo-
rized that eight ego strengths corresponded to Erikson's eight psy-
chosocial stages. Markstrom tested her conceptualization of Er-
iksonian theory in many research studies and established validity
and reliability of its core principles. For instance, she confirmed a
relationship between ego strength and psychosocial development,
self-esteem, social support, anci resilience (Markstrom and Hunt-
er, 1999; Markstrom and Kalmanir, 2001; Markstrom, Sabino,
Turner, and Berman, 1997; Markstrom and Marshall, 2007).
Markstrom's ego strengths and their corresponding Eriksonian
The Journal of Theory Construction & Testing -10-
psychosocial stages are hope (which emerges in early infancy from
trust), will (which emerges in earlv childhood from autonomy),
purpose (which emerges in early childhood from initiative), compe-
tence (which emerges in adolescence from industry),fidelity(which
emerges in young adulthood from identity), love (which emerges
in young adulthood from intimacy), care (which emerges dur-
ing adulthood hom generativity), and wisdom (which emerges in
late adulthood from integrity). Resilience is identified as the ninth
ego strength (personal communication, G. Bellows, 01/05/10).
These ego strengths consolidate into ego integrity, which is a sense
of positivity about one's life. Markstrom's eight ego strengths are
related to the kind of resilience that is emphasized in ego psychol-
ogy and strengths-based social work.
Goldstein's (1984) discussion of defenses and coping skills
is another example of how ego psychology and strengths-based
social work complement one another. Defenses and coping skills
co-exist. Goping skills are preferable, but both coping skills and
defenses are necessary for survival. They are similar because
both are employed by the individual to provide protection and
facilitate survival in times of stress; however, they diverge mark-
edly in their function. Goldstein (1984) noted that defenses
are rigid and automatic. Gonversely, coping skills are flexible
because the individual has power to choose how and when to
apply them. Defenses distort reality, whereas coping skills orient
one's experience to reality. Goping involves a complex, expanded
consciousness, while defenses repress consciousness. Goldstein's
(1984) principles of positive coping within a multi-dimensional
reality and her view that people who are suffering should focus on
the present and future rather than the past are consistent with a
strengths-based theory of social work.
Strengths-Based Social Work
When I first started^ my Masters of Social Work program, I
was repelled by clinical theories which emphasized how people
were defective. Instead, I was attracted to strengths-based theories,
which focused on clients' impressive stories of survival against all
odds.
Social work clients oft:en present for therapy with multi-lay-
ered problems, which make their suffering and impairments in
ftinctioning understandable. What is amazing is that they come to
therapy in as good shape as they do, despite the harshness of their
surrounding environments. Strengths-based social work acknowl-
edges clients' suffering and overwhelming life circumstances and
conceptualizes client impairments as systemic rather than psychic
deficiencies (Saleeby, 2009). Whereas die earlier Freudian mod-
els conceptualized human suffering as the result of unresolved
inter-psychic conflicts, the strengths-model conceptualizes human
suffering as a result of such systemic deficiencies as poverty, dis-
crimination, and racism.
In strengths-based social work practice, the goal is to help
clients of color explore and re-claim their natural talents and
abilities, cultural, creative, and spiritual practices. These internal
resources helped clients of color survive a lifetime of stress and
oppression and can be mobilized to facilitate positive coping in
the present (Saleeby, 2009). If clients of color use their internal
resources to cope and work through external challenges, they gain
confidence and skills to survive and adapt. This experience can in-
spire clients of color to be hopeful di^isn, which strengthens them
internally and prepares them for an uncertain future (Saleeby,
2009). //o/>i strongly predicts a positive therapeutic outcome.
Among clients ofcolors, resilience is a primary strength.
Saleeby (2009) noted that resilience explains why most at-risk
youth grow up to be emotionally well-rounded adults. Markstrom
et al. (1997) found that resilience was a key determinant of ego
strength relative to the individual's corresponding psychosocial
stage.
Empowerment is the power to make choices that influence
one's life (Wachtel & Messer, 1997). Glients become empowered
through strength-based therapeutic conversation, which affirms and
Volume 16, Number 1
builds on their strengths through confrontations or interpreta- progressing through stages of development by using their internal
tions which are less threatening. For example, a therapist may tell resources in order to adapt to both internal and external challeng-
a client who struggles with being open and expressive that he or es. When efforts to adapt are successful, people grow internally
she is more open at some times than others. This observation gently stronger. Similarly, strengths-based social work conceptualizes
pushes the client to move toward deeper self-analysis. clients of color as having to survive threats from broader, stronger
Another advantage of a strengths-based social work model is that forces. If they are able to use their strengths to work through these
severely suffering clients oft:en present for therapy with consid- challenges, they will build resilience. Each theory promotes a be-
erable damage as a result of trauma and oppression, and they lief in maturing people's abilities to use their internal resources or
may lack the ego strength necessary to tolerate deep exploration. strengths to work through larger, often external challenges, which
When clients present in ways that suggest weak ego functioning, can change potential crises into growth experiences.
the therapist should be more active, supportive, and focused on
current, observable circumstances (Goldstein, 1984). A strengths- The Case of Jena
based approach to treatment can help clients build ego strength. This case presentation will demonstrate an integration of ego
psychology and strengths-based social work. I will describe what
Integrative Psychotherapy happened during Jena's therapy in enough detail so the reader
The core principle of integrative psychotherapeutic practice can get a sense of what Jena was really like and what it was like
is that no one clinical theory is comprehensive enough to meet for me to be in the room with her. This intimate perspective will
all of a client's needs (Wachtel and Messer, 1997). Because each establish a clinical basis my untraditional interventions. I will
model has strengths and weaknesses, it is likely that a particular introduce some practice-focused concepts in ego psychology at
model may be helpful at some times and not so helpful at others. relevant points in the case. Clinically insignificant details will be
It is impractical for clinicians to rigidly subscribe to one model disguised to protect Jena's confidentiality.
or another. The best interventions from compatible models may
be unified to produce a more comprehensive psychotherapy. The Beginning our Therapeutic Work
decision about which model to use in which situation should be Jena came to my drop-in University-based mental health
based on the clinician's professional experience, training, educa- clinic one day because she was experiencing stomach aches and
tion, consultation with colleagues, relevant personal experience, wanted pills. I was randomly assigned to do her intake and
and other use-of-self factors (Corey, 2009). preliminary assessment. As the triage nurse handed me her chart,
Though I often felt like I didn't know what I was doing, I I looked out in the lobby and callea her name. Jena got up from
intuitively used an integrative method when I worked with Jena. her seat and followed me into an intake room without looking
I adjusted my approach based on my intuitions about when Jena up at me. She was strikingly attractive, though she wore baggy
needed me to sit and listen, when she needed me to challenge her, clothes and a black beanie hat, which she pulled low over her face.
and when she needed me to interpret her behavior. It has been As we sat down in the intake room, Jena looked uninterested.
my professional experience that this complex array of presenting I asked her how we cotild help her, to which she responded that
needs is typical of most highly traumatized social work clients. I she had been having stomach aches and was struggling to con-
will present my work with Jena as an example of the integrative centrate on her school work. I listened supportively and inquired
method of technical eclecticism. (See Subtypes ofIntegrative Psycho-about her symptoms, including when they started and when they
therapeutic Practice.) increased in severity. She responded somewhat irritably, "It started
a year ago when I got raped. I can't focus on my work. I can't pay
attention in class. My stomach hurts like shit, and now..." Sud-
denly, I felt a rush of emotion that I still can't name as any one
Subtypes of Integrative Psychotherapeutic Practice
particular feeling. I remember only that it was intense and that I
felt it right when Jena said she was raped. "Oh my god, I'm sorry
The four subtypes of integrative psychotherapeutic practice
that happened to you!" I blurted, raw and genuine. Jena looked
are Common Factors, Theoretical Integration, Assimilative
up slighdy from the floor to a meaningless spot on the wall, as
Integration, and Technical Eclecticism (Gurman & Messer,
if she had just become aware that I was in the room with her.
2005). Common factors assert that, if therapy is to help the
She began to cry and went into a long, emotionally charged, and
client, certain common factors must be present, regardless
complex narrative that chaotically jumped around from one time
of which model the therapist prefers. These factors include
in her life to another.
that a therapeutic alliance must be established, the thera-
pist needs to be warm and have a positive regard for the First, she told me about the young man at her school who
client, and both the therapist and the client must believe that got high with her at a party, and then invited himself to accom-
treatment can provide the client with a corrective emotional pany fier back to her dorm room. After he violently raped her,
experience. In assimilative integration, the clinician starts the police showed up and interviewed her in a way that made her
with one particular model, but is willing to integrate other feel like what happened was her fault. "You invited him to your
models in treatment as needed. In technical eclecticism, room? You didn't yell out? Mmm-hmm," the responding male
the clinician does not start with any one particular model. officers inquired of her. As she told me this story, Jena tended to
Instead, two or more models may be used depending on go back and forth from crying quietly, to staring hard at me while
what the client needs at the moment. Theoretical integration she angrily condemned her assailant and the interviewing police
is the most complex and challenging of the four subtypes of officers, to crying quietly again.
Integrative practice. This method is about trying to integrate After a half an hour of this, Jena looked up at me and seemed
the approaches of many different models in order to build a suddenly aware that I was listening closely to her story with a
grand unified theory. concerned look on my face. She sat straight up in her chair and
stared hard at me as if she might throw a punch. I felt frightened
and small and wondered what I had done to make her so angry.
Perhaps Jena became aware that she was presenting as vulnerable
and responded by asserting her ability to protect herself (e.g.,
reaction formation).
Integrating Ego Psychology and Strengths-Based Social Work Jena went on to tell me that she used to be in a gang and
The theory of strengths-based social work is essentially the often engaged in violent behavior, including robbing a casino
ego psychological theory of development applied to therapeutic and being shot at several times. She proudly informed me that
practice. Ego psychology conceptualizes people as growing and

The fournal of Theory Construction & Testing -11- Volume 16, Number 1
being in a gang provided her and other poor young Latinas in her
neighborhood with an opportunity to "be a somebody in a place
of nobodies." My sense is that Jena probably had to fight twice
as hard to prove herself as a girl in a gang, and had internalized a
socio-culturally appropriate value for aggression and disdain for
anything reminiscent of weakness. I sensed that this mentality
probably helped her survive and made it doubly hard for her to
face the reality that she had been raped. I could tell she was trying
to move on with her life as if the rape never happened, which may
have been why she had such intense stomach aches. By trying to
repress the experience of being raped, she expressed her emotional
pain in somatic symptoms.
Throughout Jena's first session, I listened supportively to her
and non-verbally communicated my understanding of her point
of view by maintaining eye contact with her and nodding my
head at appropriate times. When I would listen supportively, Jena
would elaborate on her experiences and more deeply express her
feelings. After a few minutes, however, she would grow angry at
herself for "letting it happen" and would begin to speak loudly
and angrily in a way suggesting that she might be overwhelm-
ing or re-traumatizing herself. Jena's ego was weakened, possibly
damaged by her trauma. With a stronger and more functional
ego, she would be better able to process her experiences in doses
that she could handle. If she started to feel emotional discomfort,
she might change the subject to something less threatening or
otherwise manage herself in a way that helped her to self-regulate.
Jena's tendency to become angry and overwhelmed when she ex-
plored her feelings suggested that her ego was not strong enough,
at least in the face of feelings associated with her trauma, to initi-
ate coping. She needed me to actively guide her psychic explora-
tion in a manner consistent with the analyst's role in classical ego
psychology (Freud, 1966).
For example, when Jena became overwhelmed and angry
in-session, I would interrupt her to ask questions that encour-
aged her to consider a less punishing view of herself Building
Jena's ego through cognitive therapeutic work (Goldstein, 1984)
required an active, assertive approach, which helped Jena calm
down rather than decompensating further. Jena's positive response
indicated that I was helping her modulate difficult feelings and
providing her with boundaries so she could explore her experienc-
es safely. Serving as Jena's atixiliary ego (Freud, 1966), I provided
nurturing and positive reinforcement until her ego reach a more
functional level of independence. Because more hardened clients
like Jena are often less receptive to professional helping efforts, I
sensed she might be receptive to my efforts to help her if I related
to her in a directive and assertive manner that resonated with her
gang experiences.
In che first half of her first session with me, Jena went
through a cycle of experiencing intense anger and then intermit-
tent periods of regulation. After this cycle repeated a few times,
Jena went on to resentfully tell me about how her mother used to
beat her until she was old enough to carry weapons and defend
herself She told me that her mother's abuse reinforced her devo-
tion to the gang because the gang accepted her and gave her a
sense of purpose which she did not experience at home.
Joining the gang was adaptive and suggested the ego strength
of adaptive regression-in-service of the ego (Bellak, Hurvich, &
Gediman, 1973). Jena described her gang involvement as a socio-
culturally appropriate way for her and others like her to obtain
validation and protection from would-be-predatory criminals in
their impoverished, dangerous neighborhoods of origin. Jena's
experience was that she had to participate in violence in order to
maintain an auxiliary source of^validation and boundaries. How-
ever, Jena had to participate in violence in order to remain a gang
member, which could be considered a poor decision concerning
her personal welfare and might indicate weak ego functioning.
It was debatable whether Jena's gang membership was adap-
tive. Nonetheless, it was important for our relationship that I
understand and not judge her reality as she experienced it, while
The Journal of Theory Construction & Testing -12-
incorporating her strengths into an overall assessment of her ego
functioning (Goldstein, 1984).
Jena's Auxiliary Ego
After telling me about being abused by her mother, Jena
changed the subject to her declining grades. She said she used to
be a straight-A student and was dissatisfied with the B's and C's
she had received over the past year. She told me that, once she
was accepted to college, she promptly left: the gang because school
was always her planned "way out." Jena was resilient. Maintaining
good grades demonstrated .that she was able to plan for the long
term and delay gratification. These abilities are consistent with
ego strength (Bellak, Hurvich, & Gediman, 1973), positive cop-
ing (Goldistein, 1984), and psychosocial maturity (Markstrom et
al., 1997).
After Jena told me about her declining grades, I communi-
cated an understanding of why getting good grades was so impor-
tant to her by nodding slightly, while internally modulating my
own anxiety, fear, and anger, which may have been clues to what
Jena was feeling. Meanwhile, she began to talk about herself in
a harshly judgmental manner. She looked away from me and sat
back in her chair as she told me that she was frustrated with her-
self because her increasingly severe stomach aches made it difficult
for her to study for several hours in a row without taking breaks. I
gendy questioned her harsh views of herself, but she responded by
angrily asserting that she was stupid and lazy. Jena's harsh self-as-
sessment is consistent with Schiller's (2009) theory that a trauma
survivor's superego may be punishing, and the survivor may look
upon her victim-self with revulsion. When Jena's self-deprecation
became sufficiently intense, however, I felt the need to step in and
more assertively protect he:fiom herself.
"Jena, stop beating up on yourself!" I fairly demanded. For
the first time in this initial session, Jena stopped abruptly and
looked up as if she might be deeply reflecting on what she had
just been saying. After a couple seconds of what felt like a produc-
tive silence, she laughed and endearingly called me her "thug
doctor."
I smiled shyly and looked up to see that two hours had
elapsed. I felt tired, but a little relieved. Jena's eyes looked heavier
and she sat with a slumped posture suggesting that she might feel
the same way I did. It was as if we were both relieved and amazed
that we had survived the session. I asked Jena if she might be
interested in coming back to see me ^ain and she readily agreed.
Though I doubted my therapeutic abilities, I was excited to think
our work might help her. I had very little experience working
with sexual trauma survivors and was overwhelmed by Jena's
complex history and emotional volatility.
I looked up at Jena in wonder and asked: "How can I help
you from here? What should I do?" She looked hard at me, as if
both daring me to give her what she would ask for and doubting
I would: "Tell me straight up what's going on! I can take it!" Jena's
forthright demand reflects the control-mastery theory that clients
may test their therapists in order to build mastery-competence
capacities (personal communication, M. Coombs, 06/10/09).
When I asked Jena if she was sure about wanting me to work
with her in this way, she laughed from her belly, probably at my
assumption that she, a hardened gang member, might not be able
to withstand a challenging therapy. Jena seemed certain that this
therapeutic approach would help her, and I felt obliged to respect
her wishes. I remember thinking that my agency permitted a
maximum of eight crisis-focused sessions, which gave me the
sense that getting right to the point might be a good way for us to
clinically make the most of our limited time together.
Jena's Ego Grows Stronger
In the next few sessions of our work together, Jena told me
more about her present day issues than her past traumas, which
gave evidence that she was beginning to stabilize. This sign of
progress encouraged me. Despite a trauma that damages the ego.
Volume 16, Number 1
survivors with a good showing of ego strength in the past may
recover quickly (Goldstein, 1984).
In the latter half of her therapy, Jena still tended to depre-
cate herself for not being able to study for long periods of time
without taking breaks, but her self-deprecation surfaced with less
intense anger. She would pause periodically, which gave me more
opportunities to intervene and help her modulate her feelings. At
the deepest level, perhaps, she wanted me to step in and protect
or reassure her. Jena still lacked the ego strength to self-regulate,
but our relationship was deepening; she was beginning to trust
me and feel safe in therapy. Progressively, she used my support to
regulate. Her ego was stronger than when she began the therapy
because she was developing an object relationship with me. Our
relationship was strengthening to the point of providing a safe
container for her positive relational growth. A strong object
relationship often becomes the ego strength which all other ego
strengths tie into (Goldstein, 1984).
During the last half of her therapy, Jena judged herself less
harshly for struggling to complete her schoolworlc. I would usual-
ly let her talk freely until she began to speak loudly or with more
pressure. When she reached a level of relendess self-punishment,
I would interrupt her and inquire whether she could take a break
when studying. I would suggest that, maybe, she could get back
to her work after eating or taking a walk, which she mentioned
were two of her primary coping skills. At this point in our work,
Jena was less defensive and more amenable to coping. She never
openly agreed to my suggestions, but would usually calm down
in response. I provided a psychotherapeutic container for Jena's
exploration, which I gradually widened as she seemed capable of
safely going further. This helped Jena build remedial ego strength
and independence (Freud, 1966), fostered her psychosocial
maturation (Markstrom et al., 1997), and enabled me to use my
inevitable position of power to empower her (Wachtel, 1993).
In our last few sessions, when I would interrupt Jena's self-re-
crimination, she would often stop, calmly look away, and tell me
more about the rape. When she talked about the rape in the be-
ginning of our work, she expressed rage and presented herself as a
victim. When she talked about the rape in the last few sessions of
our work, she shared her feelings of remorse that it happened. She
would also wonder about whether she cotild have done something
to prevent the rape, but in a way that gave us much more room
to explore the possibility that, maybe, there wasn't anything she
could have done. The earlier stages of Jena's therapy helpecTher
establish that she could be safe in the therapy, eventually making
it possible for her to explore her deepest, most painful feelings of
loss and sadness (Mui, 2005).
In these periods, I would listen supportively and gendy
encourage her to consider that women who have been raped often
feel similar to how she felt. Helping Jena connect her experience
of being raped to the broader issue of gender-based oppression
(Smith, 2003) was a powerfiil intervention. I repeatedly used this
intervention when she experienced sadness and vulnerability hop-
ing she might link her most deeply loathed feelings to a female-
centric identity that was more ego-syntonic than her previous
ego-dystonic identity of a helpless victim — the ultimate insult in
her gang subculture. When clients develop more ego syntonic-
identities, their egos grow stronger and more capable of initiating
Rjnctional adaptive processes (Markstrom et al., 1997). I intui-
tively sensed that Jena could not tolerate anything too feminine,
but that survivorship might be strong enough for her to tolerate
and feminine enough for her to have some empathy for herself
When Jena felt painful feelings, she usually dealt with them
defensively. I did not have enough time with Jena to change her
primary defensive patterns, but it was possible that therapy helped
her think in more adaptive ways. I consistently linked Jena's deep-
est, most intolerable feelings to her being an oppressed woman,
which gave her an empathie frame of reference for her painful
feelings outside of therapy.
Jena often seemed dubious about my view of her as an op-
The fournal of Theory Construction & Testing -13-
pressed woman. Nevertheless, in our last session, she came in and
proudly informed me that she was presenting a piece of artwork
in an art show which showcased the work of female rape survi-
vors. She told me that she was determined to try to "help other
women relate to each other", illustrating a strengths-based theory
of empowerment, and the mature ego defense ot sublimation
(Mitchell & Black, 1995).
Results of Jena's Therapy
Jena informed me that she had been sober for 30 days and
had stopped having sex under the influence of drugs with men
she randomly met at parties. She went on to say that she had met
a young man at school three weeks ago, and had been seeing him
and only him ever since. She told me that she felt good about
having let him know that they "would not be having sex for a
long time". Through Jena's supportive relationship with me (her
therapist), she learned how to selectively trust men again and how
to be in boundaried relationships with them. My active assertion
of boundaries in our relationship (i.e. when I told Jena to stop
beating up on herself) modeled for Jena how to set and maintain
ego boundaries in her new relationship.
Jena was a resilient individual, which helped her recover
quickly. Psychiatric medications prescribed in my clinic may have
helped her feel some relief. Jena's growth through therapy was par-
ticularly noteworthy because she only came to my clinic because
she wanted to get pills for her stomach aches. My role in helping
Jena stabilize was to modulate her emotions while her medications
and natural store of resilience helped her grow internally stronger.
Modulating Jena's emotions was a complex process because she
was not the kind of client who would normally be receptive to
a traditional therapeutic strategy. As an example, when I would
listen supportively to Jena or reflect the emotional content of her
experiences back to her, she would elaborate on her experiences
and quickly become angry and overwhelmed. While my empathy
helped Jena feel safe enough to explore herself, she could not use
it to self-regulate.
Jena needed to explore herself to release some of the painful
emotions that would otherwise continue to be expressed somati-
cally. Jena also needed to explore herself safely, which required
that I actively and assertively contain her therapeutic explora-
tion. By providing the more challenging therapy she requested, I
validated Jena's intent and may have helped her be more receptive
to my interventions and use them to regulate her emotions. This
is an example of how the client-centered principles of strengths-
based social work may help to get a traumatized client talking.
But integrating the directive aspects of ego psychology may be
necessary to validate and contain the client's surfacing emotions.
Discussion and Critique
The client-centered principles of strengths-based social work
helped me work effectively witli Jena. However, I found that the
strengths-based perspective failed to account for the extent of Je-
na's psychological distress and overemphasized the resilient aspect
of her functioning. Ego psychology partially helped me close this
gap by providing a more developmentally-focused explanation of
what happened in her therapy.
The main benefit of integrating strengths-based social work
and ego psychology in Jena's case was that integration of these
theories helped me explain the linkage between Jena's earlier life
experiences and her therapy in a way that was consistent with
what actually happened. Clinical theories often use concepts that
are overly abstract and remote from the client's deep, emotional
experiences. Fully understanding these experiences from the
client's perspective is necessary for the clinical work to deepen.
Integration of strengths-based social work and ego psychology
helped to explain wriy Jena needed psychotherapeutic interven-
tions she would accept in order to regulate her feelings, work
through her psychosomatic symptoms, face the reality that she
was raped, and grapple with the emotions related to the rape in
Volume 16, Number 1
ways that facilitated growth. Jena was receptive to my interven-
tions because our work coincided with her cultural reality, a point
that is virtually ignored in early ego psychology and is one of the
core principles of the strengths-based model of social work prac-
tice.
Limitations
One of the most glaring limitations of my work with Jena
is that she was paired with a male therapist. It may have been ben-
eficial for Jena to be paired with a female therapist who could be a
positive female role model for her. At the conclusion of our work
together, she did in fact link to a female nurse practitioner at an
outpatient women's clinic. Jena described this woman as being
warm and gentle, which seemed hard for her to tolerate, though
was probably what she most needed. Jena said that, in their first
meeting, the nurse practitioner listened supportively and was very
kind. Jena resentfully told me that this was the type of woman
who she might have beaten up in high school.
Ego psychology and strengths-based social work offer different
conceptualizations of Jena's reaction to the nurse practitioner.
Analytically-focused ego psychology would view Jena as reacting
strongly to the most loathed victim part of herself, which this
kind, gentle woman reminded her of An analyst might see this as
an opportunity for Jena to work through a particularly meaning-
ful transference. My concern is that this pathological view of
Jena would guide therapy in a direction that she probably would
reject. A strengths-based perspective would consider that Jena was
strong and assertive because these attributes helped her survive
in overwhelmingly harsh circumstances throughout her life. Fur-
thermore, Jena didn't stay in therapy with me because she wanted
to become soft: and gentle in the way that early ego psychologists
might assume was good for her. Jena wanted to get back to her
old, tough and resilient self My role in helping Jena do this was
to modulate her emotions while her natural store of resilience
helped her to recover.
A concern about the aforementioned strengths-based concep-
tualization of Jena is that it may minimize the harsh reality of her
presenting circumstances and inhibit a deep consideration of how
her personality may have influenced therapy. Similarly, I tend
to be more therapeutically active and encouraging with clients,
which may have sent Jena the message that I expected her to get
better. It is possible that she presented as more stable because this
is what I expected and wanted. Lower-income Latino people of-
ten view the therapist as a doctor to whom they must defer out of
respect for his ascribed position as an authority figure (Organista
Sí Muñoz, 1995).
Another limitation is that Jena and I had only eight sessions
to work together. Although I believe this time limitation helped
us get right to work and was conducive to my own therapeutic
style, there are obvious concerns about a male clinician being so
therapeutically active with a woman who had been raped. Work-
ing with her in this way risked re-traumatizing her, which is why
I closely monitored how she responded to my interventions. My
sense was that, when I intervened more actively, she was able to
calm down and refocus. Nevertheless, my being a white male in-
herently limited my ability to understand Jena's reality as a Puerto
Rican woman.
Conclusion
Integration of ego psychology and strengths-based social
work offers a framework for therapists to more deeply connect
with highly traumatized clients, intervene in ways that support
healthy development, and explain what happens in therapy in
ways that account for inter-psychic conflict and environmental
phenomena. Orienting my integrated treatment approach to
Jena's culturally-rooted survival strategies helped her build resil-
ience and a sense of empowerment.
Though the results from my work with Jena were promis-
ing, further study is needed to ascertain validity and reliability
The Journal ofTheory Construction & Testing
of technical eclecticism, an integrative psychotherapeutic method.
My contribution to Jena's recovery was to validate her, guide her
psychic exploration, contain her in a way that respected of her
cultural values, and help her grow internally stronger.
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Acknowledgments:
This research was overseen by faculty at The Sanville Institute. I
particularly acknowledge Dr. Mary Coombs for her invaluable men-
torship, and my research assistant Yajaira Kennison for all her hard
work.

Bellows is a PhD and practicing Freudian analyst in Northern

California.

Coombs is a PhD and professor of social work at University

California at Berkeley.

The Journal of Theory Construction & Testing -15- Volume 16, Number 1
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