Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

When treating children and adolescents who face significant challenges we often focus too narrowly on individual problems—like delinquency or conflict with caregivers—and miss the broader sources of healing and resilience in young people’s lives. In this chapter, we will discuss the theoretical roots of an ecological clinical practice that builds resilience and the microskills clinicians use during therapy. Specifically, this evidence-informed approach to clinical work increases children’s access to factors associated with resilience, such as positive relationships with caregivers and peers, a sense of personal self-control, agency and power, experiences of social justice and fairness, belonging and purpose, spirituality, and cultural rootedness (Ungar, 2010, 2012). Interventions reflect a therapeutic contract to achieve culturally and contextually meaningful goals to ensure that a client’s success during treatment is transferred back into their “real-life” social ecologies. In this way, a resilience promoting practice creates the facilitative social ecologies that nurture and sustain well-being when individuals and families are coping with conditions of significant adversity (Abramson, Park, Stehling-Ariza, & Redlener, 2010; Bottrell, 2007). It is an approach that helps individuals on their own and in groups find ways to navigate to the resources that sustain them and negotiate for mental health resources to be provided in ways that are meaningful (Ungar, 2011).

To illustrate the application of resilience theory to resilience-informed practice, this chapter presents a case study of a 16-year-old male born female who sought help to transition genders to illustrate the approach. While individual work focused on James’ gender dysphoria, interventions were also modeled on a resilience-focused approach to counseling that draws on children’s formal and informal supports as potential sources of resilience and positive development (Ungar, 2005; Walsh, 2006). The approach is, however, not limited to working with gender dysphoria and, as has been illustrated in other case studies (Ungar, 2010), can be used with children, youth and their families across cultures and contexts.

A Case of Gender Dysphoria and the Social Ecologies That Support Resilience

Gender dysphoria refers to the degree of suffering associated with the incongruence experienced by individuals between their body/social identity and their gender identity. The Diagnostic and Statistical Manual V defines gender dysphoria in adolescents and adults as “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration” (American Psychiatric Association, 2013, p. 216) that is manifested in two of six ways and is associated with significant distress or impairment. Getting a diagnosis of gender dysphoria is often a critical step to obtaining a range of services such as hormone replacement therapy. While the standards of care for transsexual, transgender, and gender nonconforming people have moved to an informed consent model (World Professional Association for Transgender Health [WPATH], 2011), the application of these standards is not universal and youth can sometimes be exposed to significant barriers when accessing culturally competent care. We will discuss these barriers and how an approach to counseling that nurtures resilience can address each by reviewing a case involving a 16-year-old natal female, Julie, who identifies as male and has since changed his name to James. James presented with gender dysphoria and sought assistance from the first author to transition. The therapy lasted 9 months. What follows is a brief description of an approach to address broader sources of healing and resilience that a counselor needs to consider when working with children, youth and their families where there are complex psychological and social challenges.

Resilience in Context

One way to understand these interactions between a child and broader systems is to conceptualize them in relationship to the protective factors that predict resilience. We often hear of resilience as an individual’s ability to cope with stress and adversity or the capacity to “bounce-back” to a previous state of normal functioning (Masten, 2009). This view of resilience reflects a cybernetic view of systems (e.g., Bateson, 1973, 1979) that may not account for the experiences of diverse populations of youth, including those that are transgendered. A conservative view of systems suggests that families (or larger systems) return to a state of homeostasis—return to a previous level of functioning—or in some cases experience growth. Both individually and systemically, these processes are seen as predictable and measurable and specific interventions are proposed based on the assumption that people’s social ecologies can be fixed in ways that make people cope better. This interpretation of resilience relies on individuals to exercise personal agency to access opportunities in their environments and focuses most of the attention clinically on efforts to increase psychological well-being. Unfortunately, such an approach is unlikely to account for the experiences of children who are transgendered as even when they are motivated to address the barriers they experience to transitioning, their environments tend to lack opportunities to help them cope. The child’s resilience is, therefore, more a function of the how well the environment facilitates access to supportive resources than the child’s cognitions, personality, or motivation (Abramson et al., 2010; Ungar, 2011; Ungar, Ghazinour, & Richter, 2013).

A resilience-focused clinical approach builds on research that has shown that resilience among the most marginalized youth is better understood as follows:

In the context of exposure to significant adversity, whether psychological, environmental, or both, resilience is both the capacity of individuals to navigate their way to health-sustaining resources, including opportunities to experience feelings of well-being, and a condition of the individual’s family, community and culture to provide these health resources and experiences in culturally meaningful ways. (Ungar, 2008, p. 225)

This definition, based on work by Ungar and his colleagues with more than 1,500 youth in 11 countries, suggests that resilience is dependent upon the family’s capacity to provide the resources necessary to optimize development for all of its members (Ungar, Liebenberg, Landry, & Ikeda, 2012; Walsh, 2006, 2007). Resilience building with youth and their families not only requires a more contextualized understanding of resilience but also the facilitation of access to a set of protective factors and processes that provide much needed resources to populations exposed to significant adversity.

In the absence of these supports, research has shown that gender non-conformity in childhood is associated with increased risk of abuse and probable Post-Traumatic Stress Disorder (PTSD—Roberts et al., 2012). In one U.S.-based survey of 6,450 transgender participants, those who expressed a transgender identity or gender non-conformity while in grades K-12, reported high rates of harassment (78 %), physical assault (35 %) and sexual violence (12 %). Harassment was so severe that it led almost one-sixth (15 %) to leave a school in a K-12 setting or in higher education (Grant et al., 2011). Another nationwide survey of bias-motivated violence against lesbian, gay, bisexual and transgender (LGBT) people from 1985 to 1998 found that incidents targeting transgender people accounted for 20 % of all murders and about 40 % of all police-initiated violence (National Coalition of Anti-Violence Programs, 1999). In a more recent survey of 433 transgender people age 16 and older in Ontario, Canada, 98 % reported at least one experience of transphobia (Marcellin, Scheim, Bauer, & Redman, 2013). As these statistics show, the social environments for individuals and their families dealing with gender dysphoria are littered with complicated mental health concerns in the midst of violent and abusive social ecologies.

Given this unstable and dangerous context, it is seldom practical (nor ethical) to suggest that individuals and families dealing with gender dysphoria can choose to be resilient in the face of adversity if they simply change their ways of thinking, feeling or behaving. As illustrated in other case studies and well-supported by the research on resilience (Cicchetti, 2013; Panter-Brick & Eggerman, 2012), it is an unrealistic expectation that individuals will eventually bounce back when the environments they bounce back into are more likely to be abusive and violent rather than receptive and supportive. When working with children, youth and their families faced with challenging contexts such as gender variant children and youth, we need a model of practice that can meaningfully incorporate these realities into treatment plans to build children’s resilience in ways that are contextually sensitive. Such a model of practice not only needs to include an informed consent approach to working individually with youth seeking assistance with hormone replacement therapy, puberty-delaying hormone treatment, and making sense of their gender variance, but also one that understands the range of challenges youth and their families may face in their communities, schools, peer groups, workplaces, churches, sport teams, extended family and friends, and other social ecologies that contribute to well-being.

Case Example Background

James is a straight A high school student who had previously “come out” to his parents as lesbian. Initially, his coming out as lesbian to his parents and friends alleviated symptoms of anxiety and depression; however, he continued to struggle with anxiety and depression and began to explore his gender identity. James lives with his mother, step-father, and older sister. He works part-time and reports that he has a group of friends that he feels comfortable talking with about issues of sexuality and gender identity. He is involved with the gay-straight alliance at school, has been dating the same woman for a year, and is very concerned about preparing himself for university and moving away from the small community where he lives.

Children and youth like James who are gender non-conforming are exposed to a variety of stressors including peer rejection, harassment, and physical assault (Alanko et al., 2009; Landolt, Bartholomew, Saffrey, Oram, & Perlman, 2004; Lev, 2004; Plèoderl & Fartacek, 2009; Smith & Leaper, 2006) and poorer relationships with parents (Alanko et al., 2009; Landolt et al., 2004; Lev, 2004). These ecological and social stressors can lead to a variety of mental health problems later in life including depression, anxiety, distress, a lower sense of well-being in adolescence, and suicidality (Alanko et al., 2009; Landolt et al., 2004; Plèoderl & Fartacek, 2009; Rieger & Savin-Williams, 2012; Skidmore, Linsenmeier, & Bailey, 2006; Strong, Singh, & Randall, 2000). Gender non-conformity in children under 11 years of age has been identified as an “indicator for physical, sexual, and psychological abuse in childhood and lifetime probable post-traumatic stress disorder in youth” (Roberts, Rosario, Corliss, Koenen, & Austin, 2012, p. 410).

While the WPATH guidelines provide a framework for assessment for hormone replacement therapy and surgical re-assignment, ethical practice requires a framework for macro-level considerations when working with transgender individuals and their families (American Counseling Association, 2010). Social ecological factors are central to many approaches to working with youth and their families but are particularly important for transgender people who “have been historically marginalized and pathologized by diagnostic and assessment systems” (p. 138). In this context of broad-based discrimination, individual treatment will necessarily be complicated by the interactions between the child and his or her family, school and community.

Sources of Healing

The ecological practice model described here is an intentional method of intervention that helps children and families with complex needs, change problem behaviors and sustain those changes by increasing their capacity to navigate and negotiate for resources meaningful to them. Changing this capacity to navigate and negotiate means changing the way systems interact with families and with other systems to make it more likely that people find meaningful substitutes for problem behaviors (Bronfenbrenner, 1979; Moffitt, Caspi, Rutter, & Silva, 2001; Rutter, 1987; Sroufe, Egeland, Carlson, & Collins, 2005; Ungar, 2004, 2011; Werner & Smith, 2001).

The techniques that a resilience-focused therapist uses builds on previous research and clinical work that has explored the “family-larger system relationship” (Imber-Black, 1988, p. 3) and the multidimensional relationships between various caregivers, organizations/bureaucracies, and families themselves (e.g., Annunziata, Hogue, Faw, & Liddle, 2006; Imber-Black, 1988; Madsen, 1999, 2009; Minuchin, Colapinto, & Minuchin, 2007; Ungar, in press). The need to attend to the individual child’s interactions with his or her family and other larger systems is especially important in contexts where the child’s caregivers and informal supports are ambivalent or antagonistic toward the child. Even when caregivers themselves are supportive, families dealing with gender dysphoria of a child may be exposed to a range of services, stigma, and a multitude of questions that can leave them feeling coerced, patronized, or simply ignored (Imber-Black, 1988; Lev, 2004). While the focus of treatment may remain the child, a child’s dependence on his or her caregivers makes family involvement particularly important to good treatment outcomes.

Istar-Lev, a leader in the field of families dealing with family members who are gay, lesbian, bisexual, or transgendered, writes of transgendered people being treated as people without families or being given a choice to either transition or remain part of their families (Lev, 2004). There is little research or clinical writing about how to work with families (or other larger systems such as schools or child welfare services) dealing with gender dysphoria or gender reassignment though there is a growing understanding of how to assess and work with people to independently explore their gender identity. As with most problems that are perceived as psychologically, exploring the impact of the problem (e.g., gender dysphoria) in the context of family and, just as importantly, people’s broader social ecologies of peer and community networks, is a critical aspect of the clinical work (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010).

Protective Factors

Protective processes make the factors associated with resilience available and accessible (Rutter, 1987; Ungar et al., 2013). Because the factors associated with resilience are cumulative (access to one potentiates access to others), the more protective factors an individual child and his or her family have, the greater their capacity to engage in actions to withstand stress (Benson, 2003). Depending on a family’s exposure to challenges and adversity, different processes may be more or less helpful (exert a differential impact on outcomes), thus allowing for complexity in a counselor’s response to the needs of vulnerable clients.

Any counselor using a resilience-informed model of practice can integrate other (often more individually focused) clinical strategies he or she has developed over the years as long as the clinical work is done in ways that are congruent with the goals of a contextualized practice. For example, clinicians trained to assess for hormone replacement therapy and diagnose gender dysphoria may continue to integrate these vital skills when working with youth exploring their gender identity, relationships, and the not-so-subtle messages about their gender that are culturally embedded. A resilience-informed practice reminds counselors, however, to pay attention to intervention goals that are decentered from the client (meaning the focus is just as much on changing risk exposure and the threats posed by the client’s environment as changing clients themselves), complex in their understanding of problems and solutions, reflect atypical solutions (like social withdrawal) to problems experienced in challenging contexts, and are culturally and contextually sensitive, avoiding the counselor’s bias for specific solutions.

Seven Resilience Factors

With regard to clinical and community interventions, a focus on process and context is critical as it is easier to change the environment around an individual in ways that open opportunities than it is to fortify an individual to make him or her strong enough to cope in an environment that fails to provide adequately for the individual’s needs. In ecological studies of resilience, there are at least seven factors that are reported as contextually important (Ungar et al., 2007). What follows is a description of these seven factors and how they were explored in the clinical work with James. The illustration of these factors with a case that included gender dysphoria does not limit the model to children, youth, and their families dealing with gender dysphoria. These seven resilience factors can be seen in context specific ways with other youth as well.

The first factor is access to material resources that includes availability of financial and educational resources, medical services, employment opportunities, as well as food, clothing, and shelter. Returning to the case example, we see that James’ resilience was in part attributable to his living in a safe home with access to his basic needs like food and clothing (though he did find it difficult to access male clothing). His workplace and school, however, were not as safe once he began to dress and appear more male. Working with a resilience focus, James’ therapist connected with his client’s school and workplace to address issues as they arose. For example, James had planned to spend his last year in high school as a male and this decision raised a number of concerns about safety such as bullying and ensuring access to a male or gender neutral washroom. Specific strategies included working with James and his guidance counselor to ensure there was a support person on site. Fortunately, James had been on the gay-straight alliance with the guidance counselor he chose and the counselor, when approached, was keen to offer his support though he made a point of mentioning that he had little experience with gender variance. He did, however, understand how to navigate the education system. In return for his help navigating the school board’s bureaucracy and providing emotional support to James at school, James’ therapist provided the guidance counselor and his colleagues with opportunities to explore a range of transgender issues in their workplace.

The second resilience factor is relationships with significant others such as peers, mentors, and family members in both one’s home and community. A study of 84 youth who had come out to their parents and begun to socially transition gender shows that transgender youth who indicated their parents were strongly supportive of their gender identity and expression were significantly more likely (72 %) to report being satisfied with their lives than those with parents who were not strongly supportive (Travers et al., 2012). Furthermore, 70 % of those adolescents with parents strongly supportive of their gender identity and expression reported positive mental health compared to 15 % of those whose parents were not strongly supportive.

While most often the focus of intervention is a young person’s significant attachments with immediate family members, the meaningful relationships that support resilience can also come from outside a child’s immediate family. In James’ case, clinical work began by engaging James’ mother and step-father, both of whom James wanted to have accept him as a male. While beginning to understand gender dysphoria, his mother continued to harbor some concerns. For example, she was reluctant to support his going out in public appearing male, believing it would be safer for him to minimize the visibility of his transition. James experienced his mother’s worry as a lack of support and a misunderstanding of his gender dysphoria. As Lev (2004) points out, transitioning is easier when families are supportive. When they are not, a child’s peers and community supports will be much more important to the child’s successful coping.

A third factor that contributes to building resilience is identity, the personal and collective sense of one that fuels feelings of satisfaction and/or pride, a sense of purpose to one’s life, self-appraisal of strengths and weaknesses, and spiritual and religious identification (Bottrell, 2007; Lalonde, 2005). Resolving gender dysphoria is critical to identity development, though it remains only one dimension of an individual’s sense of who he or she is. As Bruessow (2011) notes, the WPATH guidelines now recommend psychotherapy as an appropriate referral for support in helping patients through the negative effects of stigma, identifying a gender expression that is comfortable, and facilitating gender role changes while “coming out,” all aspects of identity formation while transitioning. In James’ case, his therapist was given consent to speak with both James’ guidance counselor and a therapist he had been seeing for anxiety. Both were briefed on the range of possible work ahead with developing a gender identity that fit for James and about how he might feel (e.g., satisfied, proud, stigmatized). The transition process is evidently complicated, requiring careful exploration of a range of possibilities including the opportunity to identify one’s self outside of a gender binary of male/female.

A fourth factor contributing to resilience is experiences of power and control. This includes experiences of being able to care for oneself and others, personal and political efficacy, the ability to effect change in one’s social and physical environment in order to access resources, and political power. Aspects of power and control were evident in the assessment process with James, with the emphasis being on informed consent. An informed consent process recognizes people’s ability to effect change in their lives, elaborates a sense of personal efficacy, and positions the client in a central role when making decisions about which resources to access and when. Despite the shift to an informed consent assessment process, medical and mental health systems are not bound by the WPATH guidelines and may retain systems in place that pose barriers to youth seeking appropriate services. With James, the process was assisted by a referral to a psychiatrist who could confirm the diagnosis and an endocrinologist who was able to treat him when he was ready to begin hormone replacement therapy. Recognizing the significance of power and control as a factor that contributed to James’ health and well-being, and ensuring he had access to trans-informed services that would facilitate his continued exploration, were both important steps in a sequence of interventions that helped James develop a sense of personal efficacy.

A fifth factor that contributes to building resilience is cultural adherence. This may be adherence to one’s local and/or global cultural practices, and assertion of one’s values and beliefs that have been transmitted across generations or between family and community contexts. In the case of James, cultural considerations included his family and community’s values, religious and cultural assumptions concerning gender, and even the values and beliefs of his care providers. Conflicting values influence access to care and the support young people receive when they transition. One might also consider culture an attribute of the psychological and social space where James connects online and in person with other transgendered youth and adults. Association with others can create a set of norms for shared values and behaviors (like James’ desire to dress as male for his final year of high school).

A sixth factor related to an ecological understanding of resilience is social justice which results from experiences of being perceived as part of one’s community, fair and equitable treatment by others (including service providers), the right of participation and opportunities to make a contribution. Much of James’ success can be attributed to a school and home environment that promoted social justice values even if putting them into practice-created stress. James was the co-chair of his school’s gay-straight alliance and made a point of involving himself in other school committees where he could effect change for children and youth struggling with gender dysphoria. Counselors can support social justice for transgendered youth by helping them to learn to advocate for themselves (find their voice), or advocate on their behalf by building bridges to services and supports. This aspect of resilience is particularly important for youth dealing with gender dysphoria who might be refused timely medical and mental health services which could cause further gender dysphoria and expose young people like James to further abuse and stigmatization (WPATH, 2011). We know that the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010). As a counselor working with gender variant youth, integrating an understanding that withholding puberty suppressing and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents but a necessity if they are to explore all aspects of their identity.

A seventh and final factor that contributes to building resilience is a sense of social cohesion. This includes balancing one’s personal interests with a sense of responsibility to the greater good or feeling as if one’s life has meaning. It is often associated with spirituality or participation in organized religious activity and results typically in a sense of connection to community. For gender variant youth, threats to cohesion may result as they transition and social and institutional support for their decisions becomes complicated. To illustrate, well along in the clinical work, James announced that he had told his entire school about his transition at a school assembly. The counselor became anxious, scared for what kind of abuse or violence this might expose him to. Follow-up conversations were held with James’ supports at his school to ensure James remained safe and connected in positive ways to his peers. James and his counselor also discussed what this disclosure meant to him. James said he wanted to take control of the information as well as make the path that he was going down easier for other students. He wanted to provide people wondering about their own gender an opportunity to see that someone else in their school was openly exploring. The significance of his disclosure, then, was that it made James’ individual experience an overtly political act. Not only did it help him feel in control of the transition and how others see him, it was also his way of making his personal experience meaningful for others and changing perceptions of transgendered youth in his school and community.

A successful intervention does not have to address all seven factors at once. Engaging in a process that makes even one factor more accessible tends to influence access to the other six. In James’ case, it would have put him at greater risk of harm to ignore or delay exploration of his gender dysphoria. At the same time, to focus exclusively on an assessment for hormone replacement or puberty suppressing therapy with James while ignoring contextual factors, would have missed not only the tremendous risks in his environment but also important opportunities for resilience. Fortunately, in this example, James is provided access to most of the seven factors that predict resilience through processes that are facilitated by different service providers, educators and his family. He is given the means to form positive relationships with caring adults, to exercise some control over his life by engaging in the decision about his gender, to gain a sense of safety with his family, create for himself a sense of belonging in his school and community, and find meaning as a leader among his peers who is standing up for the rights of transgendered youth.

Each of these experiences is part of a process that makes it possible for James to cope well in a very challenging context. As counselors, these resilience-promoting processes (interactions with the environment) are as important to focus on as individual interventions like assessment for hormone replacement therapy. Arguably, without facilitating engagement in protective processes that changed James’ interactions with his environment, James’ transition would have been fraught with even more psychological and social barriers.

Navigation and Negotiation Micro-Skills

Accessing the factors that build resilience requires counselors to play two roles: they must help clients both navigate to the resources they need while helping them negotiate for resources that are meaningful to them. Effective counselors use a broad set of skills to accomplish both tasks, ensuring they are positioned in ways that avoid the imposition of the counselor’s worldview on youth who experience marginalization. A number of microskills are evident in the work of counselors who are working with the goal to build resilience. What follows is a brief description of several of these skills and how they were employed during work with James.

Navigation

A counselor explores which internal and external resources are realistically available and how youth can access these resources. Exploring the resources available includes discussing the barriers to change youth experience and how those barriers can be changed. Integral to understanding resources that are meaningful and relevant is developing an understanding of possible allies who can help a client access resources and put new ways of coping into practice. Establishing the client’s level of motivation to implement new solutions is also critical to successful navigations.

The skills required to help young people navigate in challenging social ecologies are multidimensional. Below is a short list of some of the ways that James’ therapist supported James with an intentionally resilience-focused practice. Individually oriented treatment goals were also achieved, such as exploring James’ gender identity, but it was these more ecological interventions that ensured James had the confidence and supports he needed to continue to explore his gender.

The navigation microskills used during sessions with James included:

  • Make resources available (The counselor helps the client identify the internal and external resources that are available). James and his counselor discussed the services and supports that the counselor was familiar with and how his role as a bridge builder could help make new resources available. While services related to James’ transition were discussed at length, a resilience-focused understanding of James’ decision in a larger context meant that together he and his therapist also worked to identify the supports James required at home and at school to avoid stigma, feel emotionally stable, and develop a positive identity as a male.

  • Explore barriers to change (The counselor discusses the barriers to change the client experiences, and which resources are most likely needed to address which barriers). While WPATH guidelines have moved to an informed consent model, the context that James was living in required further confirmation of a diagnosis of gender dysphoria and access to the one endocrinologist in his area who was trained and willing to prescribe hormone replacement therapy. James was very frustrated that he had to see yet another professional to discuss his gender identity and get access to the treatment he had a right to. He and his therapist discussed what the barriers were in the local mental and health service context, what James’ options were if he wished to begin hormone replacement therapy in the near future, and how he wanted to proceed.

  • Build bridges to new services and supports (The counselor discusses with the client the services and supports that the counselor is familiar with and her or his role as a bridge builder to help make new resources available and accessible). James agreed to a referral to a psychiatrist with the local youth mental health services that the counselor knew was informed about trans-related issues. This particular psychiatrist was also receptive to the documentation and diagnosis that the therapist and James had developed together, thus accelerating the work the psychiatrist would do with James. In this case, it was the counselor’s efforts to build bridges to service that expedited James’ access to medical resources.

  • Ask what is meaningful (The counselor explores with the client which resources are the most meaningful given the client’s context and culture). While participation in the gay-straight alliance at school was a meaningful activity for James, he was already connected there and did not identify the need for further peer supports. Instead, James was concerned about managing his anxiety and depression and asked his therapist to help him find ways to stay connected with his parents as he transitioned. Those were the resources that were meaningful for him and became the focus for most sessions.

  • Find allies (The counselor explores possible allies who can help the client access resources and put new ways of coping into practice). It was quite simple to locate James’ allies. Both his guidance counselor at his school and a community-based therapist who he had previously worked with were willing to engage with his new therapist and do whatever they could to provide complementary care. The therapist also discussed with James what role he could play in helping James’ parents understand James’ gender identity better. When the therapist met with them together as a family, James’ parents had a number of questions and were generally afraid about what impact the transition would have on James’ health and well-being physically, the stigma he would experience in the community, and the quality of his life after transitioning. Meeting with them provided a safe place for them to explore and ask questions without being judged.

  • Explore the client’s level of motivation (The counselor discusses with the client her/his/their level of motivation to implement new preferred solutions): WPATH guidelines recommend that therapists assess readiness and prepare clients for hormone replacement therapy or surgery as needed. James’ motivation was very high, unlike other youth who seem more frustrated at how slow the assessment process is when they are ready to transition.

  • Advocate (The counselor advocates with, or on behalf of, the client, or shows the client how to advocate independently to make resources more available and accessible): Interactions between James and his therapist provided James time to discuss the resources he needed and to strategize ways to acquire these. This often put the therapist in the position of James’ advocate, negotiating with other service providers and natural supports for what James needed to sustain himself through the transition.

Negotiation

The process of negotiation occurs concurrently with navigation, facilitating discussion of clients’ thoughts and feelings about their problems, the contextual factors that support these problems and eliciting from clients’ preferred solutions. Counselors then explore who has responsibility to change patterns of coping that are causing problems for the client, and/or for others in the client’s life. Ensuring the client’s voice is heard is central to the counselor–client process of negotiation (Brown, 1998; Ungar, 2004). A counselor may also, however, offer different descriptions of problems, and invite clients to comment on how well these new descriptions fit with the client’s worldview (White, 2007). When negotiations are effective, the counselor and the client are able to explore ways of performing new patterns of coping that meet the client’s needs and prevent resistance to intervention.

The following are some of the microskills evident in the work with James that are necessary to help clients negotiate effectively:

  • Explore who has responsibility for making change happen (The counselor and client discuss who has responsibility to change patterns of coping that are causing problems for the client, and/or for others in the client’s life). In James’ case, his responsibility was to consider whether the process of transition would address his experience of gender dysphoria, but responsibility to create an environment where he could be gender variant and access services to make the transition rested with others such as his educators, parents, therapists, and medical doctors.

  • Make the client’s voice heard (The counselor helps the client’s voice be heard when she/he/they name the people and resources necessary to make life better). The process of identifying resources and supports that are meaningful and culturally and contextually relevant necessarily requires that the volume of the client’s voice be increased during counseling so that his or her understanding of the world is more privileged than it was before.

  • Consider new names for old problems (When appropriate, the counselor may offer different names for a problem, and explore what these new descriptions mean for how the counselor and the client will work together). The new name is intended to re-frame the problem as being less centered on the client. The problem is situated in the client’s context incorporating an understanding of how different elements of the client’s social ecology contribute to the problem. For example, with James, he became very comfortable with seeing himself as male. The “problem” was how would he and his counselor ensure he had access to the medical services he had a right to, keep his school safe, maintain his part-time job, and sustain the support of his family. The “problem” was not just gender dysphoria, even though that was the initial reason for the referral. Thinking ecologically, the problem was how would James live in a world that imposes simplistic binary notions of gender.

  • Make the client feel valued (The client is given help to influence the way others see her/him/them. The client feels valued for her/his/their input). Knowing we have family and community supports is very important to the development of our overall sense of health and well-being (Abramson et al., 2010; Walsh, 2006). Knowing we have support for our gender identity and expression is also important. For James, this meant feeling valued by his mother in particular, and his family in general as he transitioned to male.

  • Identify opportunities to perform new coping strategies (The counselor and the client identify times when the client will perform new way of coping and discuss who will notice the changes). As James was able to identify the issues and resources that had the most meaning for him in counseling, he began to disclose his male identity to more and more people. In instances like this, discussing disclosure plans with clients helps them to anticipate the supports they will need and plan for how they will disclose. Having told people close to him about his intent to transition, James had decided he had enough supports to risk telling larger numbers of people. James also performed his new identity as a male through the clothes he chose to wear and other artifacts of identity. There can be a number of complicating factors when gender variant youth make these very public performances. How will their school, peers, and workplace deal with the youth’s changed identity? Will they be harassed or physically assaulted in their community, on public transportation, or in their own homes? Finding safe places for James to perform as male while transitioning was critical to his resilience.

Conclusion

When performed well, a resilience-informed practice broadens the scope of clinical work for therapists who are assisting youth with psychological and social challenges like gender dysphoria. Interventions focus attention on the social determinants of health that are contextually and culturally relevant. When this approach reflects an understanding of the protective factors that build resilience, treatment is likely to provide the kind of support clients like James report is helpful to their psychological and social development. Multiple skills, however, are required to make this kind of practice intentional. By working with clients to explore and develop resources to navigate and negotiate, counselors decenter the focus from individual level factors and client responsibility for change, focusing instead on how to facilitate access to the factors that are associated with resilience among child, youth and family populations experiencing stress.