Case Study

Beyond Clinical Correctness

Unearthing the logic of the client’s solution

Magazine Issue
January/February 2012
Beyond Clinical Correctness

As a clinical social worker and resilience researcher, the children I treat have been my most important coresearchers. They’ve taught me to be careful about what I consider “pathology” and to reconsider the belief that there’s only one clinically “correct” way to help them. By showing me how they see the world, my young clients have made me understand that respecting the underlying reasons for their behavior is usually the best way of helping them find alternative solutions to the challenges they face.

Jake’s story of resilience is a good example. I first met the moody 13-year-old, who had dull, expressionless eyes, 18 months after his parents separated. He came to see me at the community clinic where I worked. His guidance counselor at school had warned his mother that he’d fail 8th grade if he kept skipping school. Jake grudgingly agreed to meet with me, but refused to have his mother or his father in the room. I’d soon learn that he didn’t want to count on anybody but himself to make things right, which was reflected in his choice to see me alone.

Over the course of two meetings, I learned that Jake’s father, Patrick, had made several suicide attempts before he and his wife had separated—the last attempt while his son was home with him alone. With remarkable emotional calm, Jake described the episode that had happened when he was 11. “I found my father hanging from a hot water pipe in the basement,” he said, avoiding my eyes and saying little else. When I asked for more details, he answered with an icy calm, “I went and got my neighbor, who phoned 911.” It was all he’d tell me. Miraculously, his father survived.

After this suicide attempt, Jake’s mother, Cassandra, had had enough and left, taking Jake and his two younger siblings with her. His mother’s decision hadn’t surprised him, but it had upset him. Talking about it was the only time he came close to crying during those first few sessions. He went on to describe a long history of verbal abuse by his father, as well as depression and schizophrenia on both his mom’s and dad’s side of the family. While Jake understood Cassandra had done what she could to protect her children, six months after she separated from his father, Jake left to move back with his dad.

After that, he was truant from school more and more often, attending as little as one day a week. To make matters worse, Jake had Type I diabetes and often ended up in the hospital because he didn’t eat properly. Although his father did buy groceries, they consisted of whatever came in a can or wrapped in plastic. Most days Jake went to school with nothing but a few slices of white bread and a chocolate bar for breakfast.

Mornings were especially lonely, with Jake getting himself up and off to school by himself, if he chose to go at all. “My dad likes to sleep in,” he explained, staring at me defiantly. His meaning was clear. Dad was fine. End of story. The school did what it could to help, providing Jake with a school social worker and a hot lunch. Eventually, though, his principal was forced to refer him to Child Protective Services (CPS). Staff at the school worried that the neglect Jake was experiencing was threatening both his psychological and physical health.

Professionals had given Jake a long list of diagnoses and labels: oppositional defiant disorder, an early-onset mood disorder, post-traumatic stress, a learning disability, argumentative, and parentified. What none of the agencies involved with Jake seemed to appreciate, however, was that he’d chosen to stay home to make sure his dad didn’t commit suicide. Whether I liked his choice or not didn’t matter. In his worldview, he’d solved an unsolvable problem with the limited resources he had available.

What’s Resilience?

The study of resilience began in earnest in the 1970s when developmental psychologists in the United States, Britain, and France began to notice a pattern in data from longitudinal studies of children exposed to significant amounts of stress, whether acute (witnessing a parent’s attempted suicide) or chronic (exposure to family violence, poverty, racism, or the challenges associated with being an immigrant). A remarkably large percentage of children, often as high as 60 to 80 percent, survived these experiences and exhibited normal psychosocial development over time. It was a good news story with a complex explanation.

At first, the explanation was a naïve assumption of “invulnerability” in some children, which attributed success to inborn traits of temperament or personality. These hypotheses were quickly rejected as new research by Michael Rutter in Britain and Norman Garmezy, Ruth Smith, and Emmy Werner in the United States began to show that it wasn’t personality traits or what these children presumably had inside them that counted most—it was their dynamic interactions with their environments. Those who exhibited the most resilience were the kids who behaved in ways that allowed them to experience self-esteem, maintain attachments to others, and enjoy opportunities to exercise personal control in meaningful ways.

While I was worried that Jake appeared to be depressed and showed the effects of trauma, I knew from my work with other youth like him that he could still experience his “maladaptive” way of coping as satisfying. What seemed like problem behaviors to others actually allowed him to feel a sense of control over his life rather than feeling like someone subject to the decisions of others. I’ve come to call such patterns of coping “hidden resilience”—contextually specific ways children survive and thrive—which clinicians tend to overlook.

Jake impressed me with the satisfaction he’d found in being his father’s caregiver. “Nobody gets it,” he told me. “I’m the one who keeps my father alive.” If I challenged Jake and asked him to consider the consequences to himself, he just pushed back in his chair, and then went cold and silent. He simply refused to give up the one role he’d found that kept order in his world.

My problem was that Jake’s solution, while better than crumbling into despair, came with serious consequences to his psychological and physical health. My job, whether he liked it or not, was to help him find a substitute pattern of coping—one that would still fit with his worldview. I set about trying to do that by inviting Jake to work with me, using a three-stage process I’ve developed—reflect, challenge, and perform—to discover more effective ways of coping with his challenges.

Stage 1: Reflecting on Current Solutions

As Jake became a little more talkative, we spent time reflecting together on all the past and present coping strategies that he’d used to organize his life when the adults in his life didn’t do what he’d expected them to do. In these discussions, we looked for coping strategies that others in Jake’s family and community had found helpful for solving similar problems, like protecting someone who was drinking too much by helping them get into treatment. We also talked about how the world was perceiving him—that his mother worried that he was just as depressed as his father, and that his teachers and school administrators viewed him as a traumatized boy in need of therapy.

During one such discussion, he said: “Nobody in my family is good at looking after anyone else. Everybody does things for themselves. But I’m not like that.”

“So who are you more like?” I asked.

“I dunno. Maybe like some superhero?” he smiled, embarrassed. “Not like I’m great or anything, but if I didn’t stay home, Dad wouldn’t be doing too good.”

“I get the superhero thing,” I said. “But that means you have to have superhuman powers. Is there anyone you know who helps others without being quite so different from you and me?” Jake shrugged and went quiet for a minute.

When I reflect with clients on these patterns of coping, I often use a large piece of flipchart paper on which I list possible problem-solving strategies, returning to the same sheet of paper during each session as we add more and more ideas. There are other techniques I use as well, like genograms that plot solutions across generations and detailed family history, and eco-maps that help plot the reactions clients have received from the solutions they’ve tried. The point is to focus the conversation on a range of different, more socially acceptable, patterns of coping. I try to draw new solutions from coping patterns that clients have seen in movies and TV shows or learned from teachers, mentors, parents, grandparents, or other relatives.

With Jake, the first glimmer of hope that he’d be able to develop less troubling patterns of coping than being a “superhero” came when he told me about his support worker from the Diabetes Association. “I like her because she stood up for me. She’s told the school that I’m different from other kids and that my diabetes makes it difficult to go to school every day.” Jake appreciated her taking up his cause and, in general, he admired people advocating for the needs of others. When I asked him whether his support worker sacrificed herself when she advocated for him, he laughed, “Of course not. My problems are mine. Not hers.”

I was both surprised and pleased to hear that he understood the difference between advocacy and self-sacrifice. Could he learn to become his father’s advocate rather than remain the parentified child who risked his own future to keep his father alive? Could being an advocate become a pattern of interaction between Jake, his father, and his father’s professional caregivers that would help Jake retain a sense of control over his world, while demanding less self-sacrifice?

Stages 2 and 3: Challenge and Perform

When I find a pattern of coping that’s perceived by a young person as just as powerful as the one others label “dysfunctional,” I know we’re ready for part two of the treatment process: challenge. However, to be a viable challenge, the new solution must be just as effective as the previous maladaptive behavior. In Jake’s case, we needed to find a way to prove to him that he could still protect his father and exercise some say over his father’s care. Any solution that would infantilize Jake and leave his father adrift—like simply making him go to school—wasn’t going to work. In addition, the new pattern must be capable of being defended discursively. By this, I mean Jake and I needed to be able to get others to appreciate his new solution and accept it, even if it sounded unconventional.

At this point, we began to move from the challenge part of the intervention to the third part: the performance. Any good solution needs eventually to be performed for others to see. In Jake’s case, rather than remaining the self-sacrificing child, we explored how he could become his father’s advocate.

It was January when we finally met to discuss this strategy. After we settled in and swapped holiday stories, I asked him, “What would be the one place where you think you could be the most helpful to your dad?”

“At home,” Jake answered quickly, reverting back to his old, comfortable solution.

“Sorry, I meant, as your father’s advocate,” I said, emphasizing the new solution we’d begun to explore.

Jake paused for a moment, and then sat up straight in his chair. “I should be able to meet with my dad’s treatment team at the hospital. They don’t get what he’s all about. I should be there when dad goes for his appointments.”

It seemed like a reasonable request and, within an hour, we had a contract. Jake agreed to attend school more regularly and to accept support from his teachers and guidance counselor, if he could have a role in advocating for his father’s care. My job—and it wasn’t easy—was to position a 13-year-old boy on his father’s care team. At first, my proposal brought small chuckles from my colleagues at the hospital, but when I fully explained to them the background of Jake’s proposal, they agreed to let him attend his father’s case conferences.

Two weeks later, I asked Jake how the first conference had gone. “I talked more than my dad,” he said proudly. He’d told the team about how his dad slept in late every day and didn’t seem to have any friends. Jake wondered whether his dad was lonely because his mother had left him. “They all thought I was right,” Jake told me, clearly basking in the recognition he was receiving in his new role.

As he became a regular participant in these case conferences, Jake found a new way to take care of his father without sacrificing himself. His school attendance was never perfect, but it improved enough to get his CPS file closed. Our work continued, though, and finally, in early February, we began talking about Jake’s experience of his father’s attempted suicide and his frustration with his mother. It was at this point that we managed to get his mother, and later his father, to individually join us in therapy, encouraging each parent to acknowledge Jake for the role he played in the family. Like the psychiatric team, Jake’s parents, too, became an audience for his performance as the responsible, and resilient, young advocate he’d become.

Jake continued to live with his father, but as a better case plan was put in place, the two of them were provided with a home-support worker once a week to make sure their basic needs were met. While not ideal, it was a cheaper solution than institutionalizing Jake’s father and avoided the rebellion everyone anticipated if Jake was forced to live with his mother. Of course, Jake remained at some risk, but he’d returned to school and begun to see his mother more often. Though no one was quite sure what would happen next for him and his father, I ended my work with Jake at his insistence. “I’m going to school. I don’t need a therapist,” was how he’d phrased it. I had to agree. He’d found a way to both play his role as his father’s advocate and look after himself. To my mind, that was resilience.

A New Therapeutic Model

Research has shown that neither temperament nor personality accounts for differences in resilience as much as power does—the power to access what others make available and accessible, and the power to influence how others perceive us. While Jake could easily be seen as a traumatized child in need of protection, he preferred to see himself as a capable boy with a contribution to make to those he cared about.

To my knowledge, Jake was never again sufficiently at risk to require CPS involvement or another mental health intervention. In fact, I recently heard from Jake’s school social worker that he’d advanced to the next grade and was making academic progress. In my experience with clients like Jake, I’ve learned that if limited, short-term involvement can get them past developmental hurdles without pathologizing them, they often don’t need further mental health intervention. Collaborating with clients in the way I’ve described without seeking some perfect solution or total transformation is helpful to them and means that my work with them is easier, quicker, and less burdensome for everyone concerned.

Case Commentary

By Janet Sasson Edgette

Michael Ungar’s case study of 13-year-old Jake was a terrific lesson in clinical economy and the impact of a clinician’s bearing on the therapy process. Ungar, a leading researcher in the area of resilience in children, delivered a lean yet unhurried therapy in a case that practically begged for intervention overkill. Imagine how easy it would have been for a therapist to go to town on this one. The boy came gift-wrapped with a cluster of diagnoses, and then, of course, there was the climactic event of finding his father hanging from a hot-water pipe.

However, instead of rushing in with a corresponding index of treatment objectives, Ungar settled into a comfortable back and forth relationship with a boy who, for the time being at least, wanted most of all to keep his father from killing himself. Ungar’s easy-going manner and understated compassion lent the therapy a composed and reassuring feel, and struck me as a fitting match for Jake—much better than the sometimes gushing (and often claustrophobic) empathy expressed to children whose case histories tug at our heartstrings.

Ungar saw Jake as a resilient kid—resilience being defined, in part, as a child’s ability to navigate his way to the psychological, social, cultural, and physical resources that will help him withstand adversity. A second part of resilience has to do with a child’s ability to negotiate for these resources to then be provided and experienced in ways that are most meaningful, which Jake did, most obviously in his successful insistence that he remain involved in his father’s treatment. I loved Ungar’s willingness to take up Jake’s cause, and was taken aback by his ability to broker the deal. I don’t know how often other therapists could make that sort of thing happen, but there’s still a great takeaway here: the importance to children of having a voice in the processes affecting them that’s genuinely taken into consideration.

Ungar’s conceptualization of resilience seems hopeful, emphasizing as it does children’s capitalizing on community resources, rather than having to rely only on their own particular personality or temperament. Nonetheless, I can’t shake off the idea that another 13-year-old boy with a history similar to Jake’s could have reacted quite differently to the same services that Jake was offered. The power to access resources constructively, which Ungar notes is partly what determines resilience, seems to me to be very much a function of personality. For example, Jake’s request to be placed on his father’s treatment team seemed powered by a sense of entitlement—not the entitlement of someone who’s demanding and self-absorbed, but the healthier kind that comes from self-respect and a belief in the authority of one’s voice (a premature, but not unreasonable, adaptation on his part, given his parentification). Figuring out how much of this Jake brought to the table on his own and how much was fostered by his interactions with Ungar, his guidance counselor, and teachers could, I imagine, be tricky stuff.

I appreciated Ungar’s concluding point about letting kids leave therapy easily when enough has been done. It’s a refreshing break from the possessiveness some clinicians show in relation to their clients. There’s always more to do, and in a case like Jake’s, the to-do list could go on indefinitely. I could only hope that I’d have had the chance to position Jake to see around the next corner before his exit from therapy. For instance, how will he know when his dad is safe enough for him to drop his vigil? What does it say about him and his family that he thought he was the only one to do the job? But that’s just me.

Sometimes you can’t do it all at once, and you may not even need to. Besides, the easier we make it for kids like Jake to leave, the easier I think we make it for them to come back when they’re ready to do more.


Illustration © Sally Wern Comport

Michael Ungar

Michael Ungar, PhD, is principal investigator of the Resilience Research Centre and Killam Professor of Social Work at Dalhousie University in Halifax, Canada. His books include Researching Resilience, edited with Linda Liebenberg, and Nurturing Hidden Resilience in Troubled Youth.

Janet Sasson Edgette

Janet Sasson Edgette, PsyD, is the author of Adolescent Therapy That Really Works, Stop Negotiating with Your Teen, and The Last Boys Picked: Helping Boys Who Dont Play Sports Survive Bullies and Boyhood.