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CASE I 6

DEPRESSION IN AN AFRICAN-AMERICAN
TEENAGER: THE CASE OF TAKISHA LANDRY

The case presented here is from "Dealing With Cross-Cultural Is-

sues in Clinical Practice," a book chapter written by Harriet Lefley,
Ph.D., in P.A. Keller, and S. R. Heyman, (eds.), Innovations in Clin-
ical Practice: A Sourcebook (Sarasota, FL: Professional Resource
Exchange, 1991). It is included here with Dr. Lefley's introduction,
comments, and treatment plan to illustrate the role that cultural and
socioeconomic factors can play in the diagnosis and management of
psychological problems. After you read the case, but before you
read the "Comments" section, stop and consider how you might
conceptualize Takisha's problems, and what you might do to re-
solve them. Then, compare your ideas with Dr. Lefley's in the fal-
lowing case:

Two CRIT_ICAL ERRORS EMERGE in therapy with persons who are cultur-
ally different not only in racial/ethnic background, but also in socioeco-
nomic status. One is the misinterpretation of behavioral cues that are
linked to specific cultural values. The other is the tendency to impose
unwarranted psychodynamic meanings on some basic realities of living
at or just above the poverty line. These are exemplified in the following
case example. It is presented in some depth to show patterns of cultural
misinterpretation, reassessment of need, and treatment planning geared
toward empowering both parent and child while restoring psychological
stability to an economically stressed family system.
Takisha Landry (a pseudonym), a female, African-American, 12-year-
 DEPRESSIVE DISORPERS ~ 0
-- 113

old sixth grader, was referred to the school counselor for evaluation. Pre-
viously a fine student, Takisha's grades had slipped in the last year, and
she was now in danger of repeating sixth grade while her peers moved on
to a higher level. During the past 4 months she had seemed tired, preoc-
cupied, and increasingly depressed. The counselor tested her on the WISC
and obtained a Full Scale IQ score of 118. She denied any trouble at
home.
Takisha's mother came to school for a conference and indicated she
was not aware of any trouble at home, did not see particular changes in
Takisha's behavior, but was concerned to learn that her child's school
performance was decreasing. When Takisha and her mother met together
with the counselor, Mrs. Landry spoke sharply to Takisha and ordered
her in no uncertain terms to shape up in school or she would be punished.
Takisha looked down at her hands and said nothing. The counselor ob-
served that there was not eye or body contact between the two, no touch-
ing or overt affection. Takisha, she noted, seemed either afraid of her
mother or distant from her; she addressed her only as "yes ma'am" and
"no ma'am." Later, however, when Takisha returned to class, Mrs. Landry
asked to speak privately with the counselor. She seemed genuinely puz-
zled and concerned. Takisha was a good child, dependable, honest, and a
great help to her. The mother wanted Takisha to finish school and go to
college. She would do anything she could to help.
Takisha was referred to a child guidance clinic for psychotherapy. Be-
cause of her previously fine school performance, which indicated a high
level of intelligence and motivation for learning, she was considered a
good candidate for psychotherapy and was assigned to a young psy-
chology intern from a midwestern white Protestant background. Mrs.
Landry received a letter asking her to come in for a preliminary confer-
ence. She called the clinic and asked to reschedule an 11 :00 A.M. confer-
ence to an earlier hour; her voice seemed harassed and short-tempered.
When she spoke with the interviewer, she again could recall nothing that
would explain Takisha's behavior, was annoyed at the questions, and fi-
nally said sharply it was the clinic's job to "fix Takisha up," because rais-
ing children was just too hard. She was very disturbed that the clinic had
scheduled Takisha's sessions for just after school, saying she didn't know
what she would do with the younger children, but that she would try to
arrange for a neighbor to take care of them as long as it was for only a
few weeks or so.
In the first three sessions Takisha was depressed and spoke in soft, re-
luctant monosyllables, but the following story came out. She was the
main caregiver for her three younger brothers and sisters, aged 5 to 8.
Their father had left long ago. They lived in the projects, and in addition
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114 --.co-- CHAPTER FIVE

to picking up each of the children from their various schools and walking
them home, Takisha was required to prepare their meals, monitor them,
and keep them from playing outside because it was too dangerous. She
also had to do laundry and housework. The children wanted to play out-
side and were getting increasingly harder to handle. Their mother was
always away from home working, because she refused to be on welfare.
About 6 months ago, a man had moved in with them, but he stayed only
briefly, maybe a few months.
The therapist thought Takisha's depression was tied into that particu-
lar time frame-to the man's coming and leaving. He questioned gently
about abuse, particularly sexual abuse, but Takisha denied any. Ulti-
mately it came out that, following the man's departure, Takisha's mother
had taken a second job; she worked from 3:00 P.M. to 11 :00 P.M. as a
hospital aide, then went on a midnight to 8:00 A.M. shift at an all-night
restaurant. It was only after four sessions that the therapist began to un-
derstand why the mother had seemed so short-tempered about the clinic's
scheduling of appointments for herself and her daughter-schedules that
were for the convenience of the clinic rather than responsive to Mrs.
Landry's needs for sleep and her job responsibilities as a breadwinner.
The enormity of Takisha's role as a parental child, whose tasks extended
from early morning to night, from getting the children up to putting them
to bed, also began to take on significance. The therapist thought that the
only time the mother seemed to assume her proper parental role was on
Sundays, when the family spent the entire day and evening in church.
The therapist still thought that strained relations between mother and
daughter were at the root ofTakisha's depression. The mother was viewed
as harsh and demanding, insensitive to Takisha's needs as a child, and
emotionally distant. All of this went into the case record. Takisha was
approaching puberty and had had no life as a child. The treatment goal
was to remove the yoke of parental child, to allow her time to study, and
to give her some play experience with children her own age. To accom-
plish this, the therapist hoped to validate Takisha's separation from her
parenting role by counteracting her need for maternal approval. He
would substitute unconditional positive regard within the therapeutic al-
liance. He gently normalized: "Sometimes we all get mad at our parents,
at the things they expect of us." Takisha looked startled. He continued: "I
used to get angry at my mother all the time. I was just about your age
when I realized that parents don't know everything!" But instead of re-
sponding, Takisha looked terrified. The therapist decided there was really
something profoundly disturbing going on between Takisha and her
mother. However, the more he tried to explore this, the more withdrawn
and depressed Takisha became, and after six sessions they seemed to be
getting nowhere.
 DEPRESSIVE DISORDERS - - c10- ~ - 115

Comments

Given the therapist's perceptions, a psychodynamically oriented ~rea~-

ment approach is doomed to failure because the "insight" he is seeking ts
based on incorrect premises. First, let us consider some realities of cul-
tural life in the lower income African-American community. The sharp-
ness heard in Mrs. Landry's admonitions to her daughter, and the child's
seeming passivity, are culturally normative in ghetto life. For centuries,
beginning with the harsh realities of slavery, children have learned to ac-
cept the withholding of praise and the strictures to behave obediently-
often reinforcing submissiveness and passivity with elders-that were
essential for survival in earlier times. Children learned to accept these
parental behaviors without missing the underlying love and approval
that are typically invisible to cultural outsiders. The passive response
does not mask anger, but indicates acceptance of culturally normative
parent-child interactions and perhaps a tacit understanding of the mean-
ing of the behavior. A child's avoidance of eye contact with an adult still
connotes respect, in American Indian as well as in African-American cul-
tures. Lack of tactile contact between a mother and 12-year-old daughter
does not in any way indicate that affection is missing; as a baby, Takisha
was undoubtedly cuddled and held on the laps of numerous adults. But
hugging in front of strangers is not commonly done.
Finally, criticism of one's mother is unacceptable in its overt form, in
both black and Hispanic lower income life. This is such a powerful tool
for insult and metaphor that it has become transmuted into an art form
in ghetto life: games such as "playing the dozens" are based on insults to
another's mother. The most penetrating attack on another person's integ-
rity comes through insulting his or her mother. In the black community,
for a child to acquiesce in criticism of his or her mother is called "flying
in the face of God." It defies the most powerful of cultural taboos, and
can be harmful to subject and object. It is inappropriate for an adult au-
thority figure to give a child permission to express anger toward the
mother. In some belief systems, anger can harm the mother and in some
cases even cause her death. Nor is depression always the obverse side of
object-related anger; in this particular case, a child is trapped in an im-
possible situation, and this is reason enough for her dysphoria.

Treatment Plan

This particular case calls for involving the mother in a collaborative role
in treatment planning. From a structural viewpoint, the mother's author-
ity should be reinforced and redirected, not undermined. There is no rea-
 116 -----c0 - CHAPTER FIVE

son to think the underpinnings of this case are psychodynamic conflict

between mother and daughter; it is rather a matter of reality needs, cul-
tural expectations, and the daughter's approaching the age of puberty
when the burdens are becoming overwhelming .
. . . The therapist cannot and should not remove the parental role in a
family where this is necessary for survival. Rather, the therapist helps re-
distribute the burden by alerting the family to alternative resources. In
Takisha's case, the best therapeutic option is to work with the mother in
solving the problem. Mrs. Landry realizes her daughter has no life; she
just cannot see her way out of the situation. The therapist works with the
mother and children to draw on the social network of available helpers.
A relative, neighbor, or friend, perhaps available before but unsolicited, is
now asked to help out. If necessary, the family's pastor and church are
enlisted. The therapist works with the school to assign special help, per-
haps a tutor. A specified amount of time is set aside for Takisha to do her
homework, and a specified number of hours to spend on her own or with
friends. The younger children are assigned tasks. The therapist praises
Mrs. Landry for her hard work in keeping the family together-it is legit-
imate praise-joins with Takisha in admiring her mother, and joins with
the mother in admiring Takisha's contribution to the family. Finally, since
Takisha is nearing puberty, the therapist may give the mother instruction
and reading materials so she can share with Takisha the functional as-
pects of menstruation and prepare her for her approaching role as a
woman. In this process the mother's directive role is reinforced, mother-
daughter bonding is reinforced, and Takisha is endowed with a more
adult female identity that will legitimate and ease her needed role as a
caregiver to the young.

Thinking About the Case

Depression is, by far, the most common psychological problem of adoles-

cence. Takisha exhibited its most prominent symptoms, dejected mood
and lack of pleasure in previously enjoyed activities (called "anhedonia"),
as well as decreased concentration, lethargy, and declining school perfor-
mance.
This case illustrates the importance of considering the context in which
a disorder is manifested, both in terms of understanding the ca uses of the
disorder and in planning treatment. Models of mental illness are not
culture-free. Freud's view of neurosis developed out of his experiences
with middle-class women in late nineteenth-century Vienna. Skinner's
view that reinforcement is the primary (if not only) factor in the develop-
ment and maintenance of behavior comes out of the radical environmen-
 DEPRESSIVE DISORDERS ____,. 0
~ 117

talism of mid-twentieth-century America. The current emphasis on bio-

logical bases of behavioral disorders is, no doubt, related to technological
developments in brain-imaging equipment as well as to ongoing turf bat-
tles between the medical establishment and non-medical mental health
practitioners. In attempting to understand any individual case, it is useful
to be aware of one's own biases and to keep an open mind with respect
to alternative perspectives. The perspective of the patient (in medical ter-
minology) or client (in non-medical language) is particularly important.
Studies indicate that feeling understood may be the primary feature of a
successful therapeutic relationship. Interventions which are based on
models that are substantially different from that of the person being
treated are unlikely to be successful.