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Beyond Clinical Correctness: Unearthing the logic of the client’s solution

By Michael Ungar

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.

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1 Comment

  • Comment Link Wednesday, 11 January 2012 09:56 posted by Manny Munoz

    It was refreshing to read Ungar and Sasson Edgette’s discussion in "Beyond Clinical Correctness" (Jan/Feb 2012) about a holistic treatment approach that emphasized beginning where the client is, respecting the client’s strengths, establishing a collaborative relationship to problem solving and utilizing the resources of the larger system in contrast to the curriculum, manual driven, evidence based treatment approaches that many clinicians in community based programs are being "strongly encouraged" and in some cases forced to use. The approach described a disciplined, economical, sophisticated and effective therapeutic intervention. Sounds like evidence based practice to me. How do we get it funded?
    Manny Munoz, LCSW-R