Donna Little is a 39-year-old Indian woman who has a history of substance misuse and has struggled with reunification with her adolescent children over the last 6 years. She was in residential school from the age of 6 to 16 years old. She has a history of domestic violence in her previous relationships. Donna was the youngest of four children in her family. Her parents, siblings, and herself were raised in the same small northern reservation. Both her parents had gone to residential school in the early 1950s, as did her grandfathers and grandmothers on both sides of her family system in the late 1910s. Donna was raised in an environment of violence and mayhem in her early childhood, which she has talked about quite extensively in counseling. Although her parents abused alcohol, she emphasizes repeatedly that her family was quite ceremonial and participated in the big drum feast and singing within the community. When Donna was 6, an Indian agent wearing a red, white, and black checkered jacket gave her candy and took her to the residential school. She never had the opportunity to say good-bye to her mom and dad, who died of tuberculosis while she was in the residential school. Donna reflects on her residential school experience with a despondent look. While in the residential school, she had only one friend she could count on. Her siblings, who were also at the school, were older and thus not allowed to play with her or sleep near her at the residence dorms. This created an incredible loneliness that Donna did not know how to fill, and often she would use alcohol to help numb that pain. She did not like to drink, but it helped her to stop her thinking badly about the past. Donna was a victim of sexual abuse in the residential school, primarily by the Roman Catholic priest who was in charge. The first time she was assaulted she was 7; the last assault occurred right before she ran away at age 16. When Donna had attempted to tell the head nun in charge of her dorm what was happening to her, she was beaten severely, to the point of unconsciousness. Donna recalls it was her friend, Sue, who nursed her back to health. Donna describes her life as difficult. She went home to her community, only to find a partner who turned out to be as violent toward her as her father was to her mother. She loves her children and cares for them deeply. She breast-fed her three children and still today can feel that connection to them. When her children were taken from her home after the last time her husband beat her, she spiraled out of control. Donna has had long periods of abstinence, has a home in her community that is well cared for, and now has a partner who loves her deeply. Donna is on welfare but hunts and fishes to help with sustenance. Donna and her partner have been together for 10 years, however, they both misuse alcohol on occasion. Donna’s present partner is nonviolent and a former residential school survivor as well.
Counseling Across Cultures (Kindle Locations 3850-3871). SAGE Publications. Kindle Edition.
Case Study of Simon Ho – Chapter 6
Simon Ho is a 19-year-old Chinese American sophomore attending a midwestern university. He has a good academic record, with a 3.25 grade point average, but he is having difficulty understanding various concepts in his advanced chemistry class. With a big exam approaching, Simon is not only increasingly worried but also experiencing headaches and stomach troubles. Fearing the possibility of failing the exam and disappointing his family, Simon decides to seek assistance from his chemistry professor. Upon approaching the professor, he is greeted happily and courteously. His professor spends more than an hour with him, reviewing some of the material for the exam. After this review, Simon feels a bit more confident about his understanding of the concepts. Unfortunately, Simon receives a D on the exam. Disappointed by his poor performance, he begins to skip class to avoid his professor and never seeks his professor’s assistance again.
Counseling Across Cultures (Kindle Locations 4609-4615). SAGE Publications. Kindle Edition.
Case Study of Liliana – Chapter 8
Liliana, who is 24 years old, is voluntarily seeking counseling for “relationship issues.” She has lived in California’s San Francisco Bay Area for most of the time since her family emigrated with undocumented status from Mexico. Recently married, Liliana currently lives within a few miles of her mother and sisters. Liliana’s family of origin is economically poor. She has met but does not have ongoing contact with her biological father, who is “somewhere in Mexico.” Her mother and two older sisters are deeply committed to the Apostolic Christian Church, but Liliana does not attend services regularly. Liliana speaks reverently of her grandmother, although relations between the two were tense for a time. Liliana and her grandmother were not speaking to each other because of her grandmother’s rejection of Liliana’s younger sister. According to Liliana, her grandmother could not accept that her sister’s biological father was African American. Despite a very difficult time in public school, Liliana was able to succeed at a small private high school, and she was accepted by an Ivy League university. She left the university after her sophomore year to raise her own family. She is currently working for a successful technology firm as she completes her degree. Liliana’s sense of humor engages young people and adults, her penetrating insights guide conversations, and she is well liked by those who know her well. She continues to defy authority when she feels that it is unjustifiably imposed, is occasionally impatient with what she perceives to be the irrelevance of other people’s emotions or reasoning, and sometimes balks at what she sees as unnecessary or unimportant work. How might the framework described in this chapter be useful to a counselor’s efforts to improve Liliana’s mental health? The framework does not provide a script that Liliana’s counselor might follow. In fact, the framework is designed to discourage a search for solutions, pointing instead to better questions to guide a counselor’s practice. Some of these guiding questions might become actual questions that the counselor could ask Liliana. Others could guide the counselor’s attention during their meetings, helping the counselor discern those important ecological factors, identify the particulars of Liliana’s orientation to the counseling situation, and design and cocreate a safe physical and social space. The discussion questions that follow provide a limited example of guiding questions, organized according to the broad categories of variables described in our framework.
Counseling Across Cultures (Kindle Locations 6068-6086). SAGE Publications. Kindle Edition.
Case Study of Sawsan – Chapter 9
Sawsan, a 17-year-old girl, was brought by her father to counseling because she had withdrawn herself from family meetings and activities during the past 2 months, instead spending most of her time listening to music in her bedroom. Lately, she had complained about headaches that lasted all day with no relief, despite the use of painkillers. The family’s medical doctor had told Sawsan’s parents that she may be passing through a stressful period and referred them to counseling. At the initial intake meeting with Sawsan and her father, the father dominated the conversation, and Sawsan displayed approval of his views. The father described her as a perfect girl who always met her parents’ expectations in school and in social behavior. The change in her behavior made her seem to him as “not her.” He tried to attribute this change to “bad friends” or “bad readings.” He also denied that Sawsan was experiencing any stress and emphasized how much the family loves Sawsan and cares for her needs. He said, “Nothing is missing in her life. We’ve bought her everything she wants. She couldn’t be passing through any stress.” Knowing that most Arab girls find it very difficult to express their feelings in front of their fathers (or both parents), after listening to the father the counselor asked to be allowed to have a private conversation with Sawsan, and the father agreed. At the beginning of this conversation, Sawsan continued to go along with her father’s views, describing how much her parents love and support her and denying any stress. Only after the counselor validated to her that she indeed has good parents was she ready to reveal a conflict that had been raised recently concerning her desire to study at a university located far from her village, which would necessitate her living in the student dorms. Her father rejected the idea of his daughter living away from the house, far away from his immediate control. In an attempt to compensate for this, he bought her a new computer and suggested that she study at a nearby college. She insisted that she wanted to study at the university and tried to push until her father became angry, claiming that she was imitating “bad girls” who sleep away from their homes. As she described this conflict, she continued to remove any accusation from her father, saying, “He did this because he is worried about my future,” and “He is right and I should understand this.” The counseling process lasted for five sessions, during which the counselor met with only the father three times in order to establish a positive “joining” with his position and worries. The counselor then revealed to the father some contradictions within his belief system regarding the importance of education, as described in culturanalysis. After that, the counselor met with both father and daughter and encouraged Sawsan to explain to her father why she felt she needed to study at the university and to express her commitment to her family values. The counselor also encouraged the father to express his care and worry to Sawsan and then to discuss a compromise that may be accepted by both of them. He agreed to allow his daughter to study at another university, in a city where she could live with her uncle’s family. In a follow-up meeting, Sawsan and her father expressed satisfaction. Sawsan had returned to normal interaction with the family and no longer complained of headaches.
Counseling Across Cultures (Kindle Locations 6760-6784). SAGE Publications. Kindle Edition.
Case Study of Nikki – Chapter 10
Nikki is a 17-year-old male-to-female transgender client. She was sent to counseling by her parents because of their concern that she has become more withdrawn in the past few months. They noticed that she spends much of her time alone in her room and sometimes does not go to school. They are fearful that she will not be able to graduate and go on to college. Nikki disclosed to the counselor that she began to be bullied by her classmates after she asked a friend to the Sadie Hawkins dance. Since then, her classmates have shunned her and she has not felt safe going to school. She mentioned that she would prefer to be homeschooled or to drop out of school. During the course of therapy, the counselor spent time validating Nikki’s experiences, providing psychoeducation to her parents about the effects of bullying, and advocating with school administrators to provide a safe learning environment for her. Nikki eventually was allowed to pursue independent studies while taking select classes with supportive educators who were able to provide her a safe space on campus so that she could work steadily toward graduating with honors.
Counseling Across Cultures (Kindle Locations 7421-7429). SAGE Publications. Kindle Edition.
Case Study of Sean – Chapter 11
Sean, a 15-year-old multiracial (Native American, White, and Black) male, initiated services of his own accord to manage symptoms of depression, including suicidal ideation. Sean was academically advanced for his age and excelled as an artist and skateboarder. He prided himself most on his academic success, and he aimed to graduate from high school early and attend college. Sean had poor self-esteem and lacked a strong cultural identity. In the state where Sean resided, he could consent to treatment. He did so, stating that his father, who was his legal guardian, would not consent. The counselor developed a strong rapport with Sean. Sean was raised in a single-parent household. Sean’s father had a severe and chronic mental illness for which he received sporadic treatment, and he was currently stable. According to Sean, during his childhood he was placed in state custody for a year due to his father’s alcoholism and physical abuse toward him. Sean also spent a year living in a homeless shelter with his father. During this time, he was required to attend therapy, which he found unhelpful to his family. Sean’s father believed it was yet another example of the “White man trying to destroy the Indian.” Sean’s siblings were all incarcerated. His grandparents experienced relocation, boarding school abuse, and slavery. Sean’s immediate family was relatively isolated because of his father’s outrageous behavior. Sean reported that his father would often denigrate him. One day, Sean was limping when he arrived for a therapy session. When asked what had happened, he stated that his father had been angry with him for not doing well in his Native language class and had taken a belt to his legs and then shoved him through the screen door, breaking it. Sean further reported that his father’s fits of rage were a rare occurrence (every few months) and Sean had learned to manage them by accepting the abuse. The counselor reminded Sean of his duty to report child abuse or neglect. Sean then attempted to downplay the story, reporting that he had fallen through the door himself. Sean asked that the counselor not report the incident because he feared being taken away from his father again; Sean felt that his father depended on his care. He was also concerned that any type of investigation would disrupt his schooling and cause his grades to suffer. The counselor was conflicted about whether to report. He considered the following points: (a) client safety, including assessment of the severity, frequency, and impact of the abuse and the vulnerability of the client; (b) obligation to report given the state laws around child abuse and neglect; (c) psychological benefit versus harm to the client as a consequence of reporting, including betraying the client’s trust, potential family fragmentation, and loss of stability, predictability, and family social supports in the client’s environment; (d) client level of independence and maturity; and (e) concern regarding the client, family, and community perceptions of social services as a systemic enactment of violence on families. Sean’s family had experienced generations of marginalization and victimization enacted through systems meant to uphold social policies. The counselor consulted with several colleagues. In addition to emphasizing the legal and ethical obligations of the profession, one colleague asked, “What if something more violent or lethal were to happen to this child and you did not report? Would you be able to live with that?” The counselor decided that he could not. He talked with Sean about the need to report, encouraging Sean to report with him, but ultimately the counselor made the call. The counselor had plans to work closely with the family if the case was investigated, to ensure that the caseworker considered the family’s context and culture. He also hoped to help the adolescent develop a safety plan and build broader networks of social and cultural support while also continuing to support him in his academic strengths. However, after the counselor reported the abuse, Sean did not return to counseling.
Counseling Across Cultures (Kindle Locations 7999-8029). SAGE Publications. Kindle Edition.
Case Study of Ling and Mohammed – Chapter 12
Case Study of Eduardo – Chapter 13
Laura is a counselor at a small, private, progressive, and predominantly White university in the northeastern United States. Laura is a White, straight, U.S.-born cisgender woman of Dutch descent who graduated from an Ivy League university. She has been a mental health practitioner for the past 8 years and considers herself to be an effective and competent clinician. For the past 2 months, Laura has been working with Eduardo, a 19-year-old cisgender man, a freshman at the university, who initially presented with a depressed mood, inability to concentrate, and general anhedonia. Eduardo is an immigrant from the Dominican Republic; he was 5 years old when he arrived in the United States with his family. He grew up in the Southeast, which he considers home and where his family still lives. He is the eldest of four siblings (María, Carmen, and Lissette are 14, 12, and 6, respectively) and the first one in his family to go to college. Eduardo’s parents, who are extremely proud of their “college boy,” worked multiple jobs while he was growing up and now own a small neighborhood restaurant. Eduardo works there during school breaks and is studying business so that he can take over the management of the restaurant and allow his parents to retire. In the course of treatment, Eduardo discloses that for the past 6 months he has been having erotic encounters with men. He discounts these encounters as “just playing” and, after a recollection of every encounter, he tells Laura about his plans to get married to a woman and to have a large family. He tells Laura that he is not gay, because he is “very masculine” (un tigre) and always the “top” during sex, which he considers comparable to having sex with a woman. Lately, Eduardo has been talking a lot about one particular young man, Clive, with a lot of tenderness and affection. Eduardo talks about Clive wanting to go on “real dates” and finds these requests “ridiculous,” as he does not date men. At the same time, Laura notes Eduardo’s worsening mood and apathy turning into passive suicidal ideation. She is familiar with research linking closeted homosexuality with negative psychological consequences. Since coming out is empirically correlated with improved mental and general health functioning, Laura is convinced that Eduardo’s worsening mental health is related to his inability to come out and decides that she will assist Eduardo with this process. Laura’s therapeutic goals are not easy to implement, however. No matter how gently she brings it up, Eduardo becomes angry and, at times, leaves sessions prematurely. At one point, Laura shares her experience of being the only nonlegacy student among her friends at her Ivy League university in order to show Eduardo that she knows what it means to feel different and not always accepted. She also shares the story of her gay cousin, who came out about 10 years ago. She states that she knows how hard it is to come out, but she imagines that things must be so much easier for gay people now than they were for her cousin. Laura’s disclosure is met with a blank stare from Eduardo. One day, Laura looks around her office and notices that none of the books or pamphlets she has available relate to “gay issues.” She makes an effort and brings in pamphlets advertising the university’s Gay, Lesbian, Bisexual, and Queer Student Union. At Eduardo’s next session, she asks him if he would be willing to go with her to the organization’s open house the next week. Eduardo’s eyes well up with tears. He says, “I cannot believe you. You have no idea who I really am.” He storms out of the room and does not come back for his next three scheduled appointments.
Case Study of “The Team”– Chapter 16
As a member of a team of Native American mental health professionals and traditional spiritual leaders (hereafter called “the Team”), I have had the opportunity to respond to community crises in Native communities. Often these responses have come after communities have experienced clusters of youth suicides. The following is a description of one of those responses. The health director of a remote tribal community of approximately 2,500 contacted and met with the Team leaders (one of the community’s traditional spiritual/cultural leaders and me, a clinical psychologist). She described the occurrence of 17 youth suicides in the community, all by hanging, over a 2-month period. Most members of the community had been affected directly in some way, and some families had lost more than one child. Service providers and first responders in the community were overwhelmed and exhausted as suicide attempts were continuing almost every day. Community leaders had sent the health director to request that the Team respond as soon as possible to help stop the suicide attempts and help the community begin a healing process. Team Activities The Team prepared itself through spiritual ceremony and then traveled to the community within 3 days. The following are some of the activities of the Team over the next several weeks. Meeting with first-line service providers (FLSPs). The Team spent the first day meeting with a group of service providers and first responders from the community, providing training on the effects of traumatic stress and using talking circles to give the FLSPs a chance to talk about the ways they had been affected by the suicides. The FLSPs became the lead group for all the following work and worked closely with the Team for the remainder of the visit. Community meeting. The Team conducted an open community meeting to hear the perceptions and ideas of community members about what had been happening. Meeting with tribal government. The Team met with the tribal government to ensure that community members recognized that the Team had been authorized to be in the community, and to present a report and recommendations to tribal leaders at the end of the visit. The Team maintained contact with tribal leaders as recommendations were implemented over the next several years. Meeting with spiritual leaders. Traditional Native spiritual leaders and church leaders had never met together before but were able to come together to provide united spiritual support to community members. Working with schools. All of the schools serving the reservation children (public, church-based, tribal) were visited. This was facilitated by school counselors who were part of the FLSP group. Team members working with members of the FLSP group held talking circles with children in every grade, all teachers, and all administrators to educate (in grade-appropriate formats) about the effects of traumatic stress and to identify high-risk children. Meeting with affected families and relatives. Team members traveled to families’ homes or met them in places they felt comfortable. In some cases, families had not yet reentered the homes where their children had died. Spiritual leader members of the Team conducted the appropriate ceremonies that would allow them to go into their homes or enter their children’s rooms. Mental health members of the Team worked with the children, adults, and families to help them express their grief, honor their loved ones, and support one another. Meeting with representatives of the judicial system. Some children whose siblings had died were afraid to return to school because they were afraid someone else in their families would die. The schools had started to press charges against the parents for truancy. Team members met with representatives of the judicial system and were able to work out solutions that included in-home schooling for affected children. Building a context. Meetings with the tribal health director over a 2-week period revealed a broader context that included 4 years of massive flooding on the reservation, basements that held 3–4 feet of standing water, increases in respiratory illnesses, deaths of elders, occurrence of hantavirus, and washed-out roads requiring school buses to detour 70 miles (resulting in children going to school in the dark and not returning until dark). Many families had moved to the central district of the reservation, where services and schools were centered, but a severe housing shortage required them to live with friends or relatives. Families were separated, with members scattered among multiple households and their possessions somewhere else. Federal funding cuts meant that service providers were overwhelmed. Overcrowded living conditions led to increases in substance abuse, domestic violence, and gambling. Preexisting racial tensions between the reservation residents and people living in the nearby town were exacerbated. There was a single half-time mental health professional for the reservation, and when the suicide attempts started, young people who attempted to harm themselves were sent off the reservation to hospitals more than 100 miles away for evaluation. Often, their families did not have access to transportation and could not go with them. When the young people returned, their families were not informed about diagnoses, medications, or warning signs, and there was no aftercare in the community. This was the case for many of the young people who had died. People started to believe that when their children were “sent away,” they were put on medicine that contributed to them killing themselves, so now there were many more suicide attempts that went unreported. The young people who had died were actually seen as the youth leaders in the community. Sharing the context. The Team worked with the health director and tribal governance to build the context for the current crisis situation. The tribal chairperson called a mandatory meeting of all community members so that the Team could share the context with community members. People in the community had not connected the long-term stress brought on by the flooding to the suicides. The tribe did not think of the flooding as a “disaster” because it was a part of the natural world (there actually is no word for disaster in the tribal language). Team members had also been working with the young people, developing a new set of youth leaders. These youth shared their grief, feelings of loss, and need for adult guidance at the community meeting. Sharing this context allowed community members to get a “big-picture” view of what had been happening and allowed them to come together and mobilize community resources to support each other and begin a healing process. Developing a community crisis team. The Team worked with the FLSP group to develop a community crisis team with an emergency plan and connection to needed resources. The Team had discovered a pattern of suicide attempts, and planning was done for the community crisis team to use time periods when no suicide attempts were happening to do community education and outreach. Engaging in advocacy. The Team was able to advocate with FEMA to get needed resources to the community. Acknowledging the relationship. The Team maintained contact with the community and its leaders. Follow-up visits focused on further development of the crisis team, the youth leadership, community education, and advocacy for resources. It was important for the Team to acknowledge that its relationship with the community did not end at the end of the crisis. Engaging in self-care. The Team met at the end of every day so that members could debrief and check in with each other. Even when the Team worked late into the night, this meeting was important to make sure that everyone remained healthy. In a situation where children have died and everyone in the community has been affected, it is difficult for helpers not to be overwhelmed as well. Throughout this intervention and the several years that followed, the Team maintained a supportive presence, stayed in the background, and empowered community leaders and service providers to shape and implement their plans. Community members who had felt helpless in the beginning became active leaders for change in their own community. The suicide attempts stopped, the youth leadership asked for representation in tribal governance, and needed resources (including mental health professionals) were received in the community.
What are some of the reactions to traumatic stress seen in the community described above? Would you describe the community above as resilient? Why or why not?
How did culture play a role in the crisis that occurred in this community?
How do the IASC guidelines apply in this setting? How do they serve to protect a community during a crisis response?
Case Study of Jeanette – Chapter 17
Jeanette, a 54-year-old married African American woman, presented at a community mental health center in rural Georgia with symptoms of depression (weight gain, irritability, social isolation, crying spells). Jeanette’s husband is an independent contractor, but construction jobs have been few and far between with the economic downturn, and Jeanette herself is currently unemployed. Jeanette has one adult daughter with whom she describes a “distant” relationship because her daughter identifies as a lesbian and lives in Atlanta with her girlfriend. Jeanette states that she garners the majority of her social support through her women’s group at church, though she notes feeling “guarded” around friends who “don’t know too much” about her past. As a child, Jeanette experienced severe physical and psychological abuse from her mother and sexual abuse from her older brother. Despite having been raised in the 1960s, Jeanette grew up in a childhood home that had no indoor plumbing or heat, and she states that she was too embarrassed to make friends for fear they would find out about her poverty. She dropped out of high school in the 10th grade in order to get a full-time job as a line cook that enabled her to move away from her abusers and support herself. Jeanette entered therapy at the prompting of her husband, who claims that she “overeats away her pain” rather than facing her past trauma. Jeanette has a history of severe drug abuse, but she indicates that due to Narcotics Anonymous, raising her daughter, and her Baptist faith, she has been able to remain substance-free for 17 years and has instead shifted her coping method to food. Since her daughter moved away and came out as lesbian, Jeanette reports feeling that she has lost her identity as a mother and homemaker. Jeanette completed her GED after her daughter was born and has since enrolled in a few classes at the community college, but she has little desire to earn her associate degree. To pass the time, she is currently seeking employment, but because of her past involvement with narcotics, she has a criminal record and has been unsuccessful in securing even a minimum-wage position. Jeanette indicates that she would like to work on her anger toward her family of origin, her feelings of helplessness, and her lack of a sense of purpose. In sessions, she explores the context of her traumatic experiences. Growing up in the rural and racially segregated South, she felt as though she could not report her abuse or rely on law enforcement for support or intervention. Moreover, as a Black woman, she describes feeling pressure not to bring negative attention to her family and community by reporting these assaults. Through therapy she begins to process how these early traumatic experiences may have contributed to her feelings of hopelessness and disempowerment, which eventually led to substance abuse and overeating. Jeanette feels “trapped” and discouraged by her inability to find employment and notes that her present disempowerment is triggering her to relive past trauma. At the end of her fourth session, Jeanette expresses the desire to set concrete goals for reestablishing her sense of personal mastery while allowing for a more healthy release of anger toward her mother and brother. Jeanette also notes that she would like to work on her relationship with her daughter but feels “stuck” because of her spiritual beliefs that same-gender romantic relationships are immoral. She fears that if her friends in the Baptist women’s group find out that her daughter is a lesbian, she and her husband will be marginalized by their community, and they might also lose the sporadic economic support they receive from religious leaders and food banks run by faith-based organizations.
Jeanette’s presenting concerns emerge at the nexus of several poverty- and racism-related factors. How would you describe the influence of these systemic forms of oppression in her life and in her presenting concerns?
A primary element within Jeanette’s history is the childhood abuse that appears to have triggered a pattern of withdrawal, depression, and avoidance of emotions via substance abuse. How has the impact of the trauma been exacerbated by the poverty that Jeanette’s family faces?
To supplement her husband’s sporadic wages, Jeanette and her husband receive support from their church—though this faith-based support feels tenuous, as Jeanette worries that it may be revoked if word of her daughter’s sexual orientation reaches members of the conservative church leadership. How do oppression-related issues intersect in this element of Jeannette’s story? How do they contribute to Jeanette’s lack of connection to others?
Case Study of 17-year old student – Chapter 18
Imagine that you are a school counselor in an urban center. A concerned teacher at your school has referred a 17-year-old female student to you because her behavior has become withdrawn and her grades have been consistently dropping over the past few months. The referring teacher, who leads the school orchestra, had noticed that the student, a second-generation immigrant from a Middle Eastern background, did not attend orchestra practice for 3 consecutive weeks and asked the other students if anyone knew the reason for her absence. In private, one of her friends disclosed that the young woman has been having family problems because her parents found out that some of her classmates were dating boys from another school and that as a group they had all been spending time together. Although the girl herself is not in a relationship, after finding out that she was unsupervised in the company of young men, her parents have stopped allowing her to go to extracurricular activities and outings with her friends. They also now drop her off at school and pick her up every day, and they will not let her answer phone calls from her friends. This situation is obviously negatively affecting the student’s well-being as well as her school performance.
In the contextual domain, what elements of the broader social setting and the specific school setting do you think are influencing the situation?
In the relational domain, how would you identify who should be part of the counseling process? Should friends, family members, or others be involved? Who should make the decisions regarding whom to include or exclude, and how will these choices affect the sessions?
In the individual domain, what identities, personality attributes, and personal characteristics are pertinent to the situation?
Case Study of Martinez Family – Chapter 21
A family therapy research program focusing on drug abuse in a large metropolitan city on the West Coast included 41 families, 16 of which were Latino. The clients were affected by a variety of psychological disorders, and all had histories of drug abuse. The Latino families in the program came from a wide range of Latin American countries. The research program entailed 10 sessions of family intergenerational therapy that was manual based and conducted in a bilingual format. The Latino participants were all second-generation immigrants (i.e., the children of immigrants to the United States). During the course of the therapy, a number of issues came up, as illustrated by the material presented here. Most of the Latino families were struggling with challenges related to immigration, family roles, and separation from the nuclear and extended family, in addition to the challenges of drug abuse. Nearly all of the Latino families were facing issues that often emerge in family counseling and therapy with linguistically and culturally different clients. As an example, we present the case of the Martinez family. Identifying details of this family have been altered to protect anonymity. The Martinez family consisted of Victor, the 33-year-old “identified patient,” and the family members with whom Victor lived: his 57-year-old mother and his 36-year-old sister, both divorced; a 10-year-old nephew; and a great aunt, 84 years old. Victor’s extended family included an older brother (age 40) and the brother’s wife and children. Victor had a history of heroin abuse since adolescence. At the moment of entering the family therapy treatment, he was in a methadone maintenance program, yet he admitted to continued casual use of heroin. He was disconnected or cut off from his father. Victor’s older sister, Patricia, was the breadwinner of the family; Victor did not finish high school and could not hold a job for more than a few weeks. Victor’s mother received Social Security benefits and helped support Victor, which included giving him money for his drug use. She was worried about the shame that would come to her family if Victor were arrested for a crime and convicted, so she preferred to give him money to prevent his committing a crime. Later it became clear that the vergüenza, or shame, would be particularly bad for the older brother, who was a law enforcement officer. When Victor was 5 years old, he and his mother lived with his grandmother and Patricia in Nicaragua; his mother then migrated to California alone before gradually bringing her children to join her, beginning with her daughter. It took 9 years for Victor to be reunited with the rest of his family. An examination of the family genogram showed a three-generation pattern of losses and separations, with women in charge of the family but without much help from their male partners, who were involved in alcohol abuse. Victor’s mother left Nicaragua to improve the family’s economic situation and left the children behind under the care of the grandmother. The women were seemingly overinvolved and enmeshed with their children. Gradually, the mother began to bring the children to the United States, first her daughter and later the grandmother and Victor. One of the key elements in family counseling is engaging the family. The research context in this case provided a great deal of flexibility with regard to making reminder calls to the family about appointments or even holding sessions in the home if necessary. The sessions with the Martinez family were conducted in both English and Spanish. The older members of the family were addressed in Spanish, and the younger ones spoke English. Language can be a powerful tool for engaging the less acculturated members of a family. Deciding which family members to invite is also important. From an intergenerational perspective, the ideal approach is to invite anyone who is available and can help. These invitations are not left up to the identified patient or any other family member. In the case of the Martinez family, the counselor obtained the necessary contact information and called the potential participants, inviting them to one session. With Latino families, the value of familismo often means that family members will show interest in being part of at least a first session. Soon thereafter, the use of the genogram helped to broaden the family members’ views of their situation. An early task assigned in therapy was for all family members to engage in the joint project of diagramming their family tree as far back as possible. The diagram was later discussed in a session with all members present. Discussion This case illustrates many of the complexities involved in counseling families. A first concern was how to handle the integration of a serious substance abuse condition within the psychological, family, and social contexts. Our approach was based on a family therapy strategy that incorporates culture and context. We used the contextual family therapy (CFT) model, which aims to include all available individuals in its preventive strategies (Boszormenyi-Nagy & Ulrich, 1981) for the benefit of current and future generations. We culturally adapted the approach as suggested by Bernal and Domenech Rodríguez (2012). CFT views drug abuse as predominantly rooted in social and community processes that affect the entire family. Second, we needed to culturally adapt and contextualize notions about high levels of interpersonal involvement among family members, often viewed as “enmeshment” and considered pathological and indicative of overly flexible boundaries. When mothers become single parents, left to take care of their families on their own, how is it possible for them not to be “overly” involved with their children? Here we see that Victor’s mother assumed both instrumental and affective roles. And given the cultural context of familismo (valuing the unity of the family), we needed to culturally adapt and contextualize the pathological concepts of enmeshment, fusion, and undifferentiated ego mass. A third consideration is the immigrant experience, which includes the intergenerational conflicts that evolve from the pressures on the younger generation to assimilate, adapt, and/or acculturate. With migration comes the loss of social capital and disconnection from the family of origin and the network of relationships at home. In this case, a number of relational issues arose. Victor’s mother migrated alone to the United States from Nicaragua with hopes of improving the economic situation and quality of life of the family; that by itself is a courageous endeavor for anyone and in particular for a woman from a context of limited resources and education. She left her children to be raised by her mother when Victor was 5 years old. The therapy supported Victor and his mother in talking about the losses they had experienced and ways for the mother to give to her son directly that did not entail paying for his drug use, perhaps as a way to make up for having left him. At the same time, Victor’s contribution was recognized as a sacrifice—that is, through his addiction he seemingly remained dependent on the family as a way to give to his mother. The effort here was to build trust in family relationships. Could the contributions of each member of the family be recognized, and could a plan be devised based on an understanding of the legacy of abandonment, limited resources, and loss? Once mother and son exonerated each other, the focus of the therapy turned to identifying resources and problem solving for all family members. Finally, the genogram was a resource for exploring the family’s history and changing contexts. From the genogram it was clear that the family had a three-generation pattern of women leaving children with their mothers, serious challenges with men suffering from alcoholism and subsequently abandoning the family, and overinvolvement of women with their children. A broader contextual view emerged in which all were understood to be victims of a legacy of poverty, war, and exploitation. The question became what they could do about it now, and the promise of therapy was that they could learn how to transcend the generational legacy to prevent the younger generation from further victimization.
What definition of “family” would you use in this case? How would you describe the structure of the Martinez family and the impact of social, historical, and cultural processes on the family’s basic functions (e.g., instrumental, expressive, child rearing)?
What conceptual resources or tools could help you approach a family that is different from your own racial, ethnic, and cultural background, given the changing social, historical, and multicultural contexts?
What is your assessment of the Martinez family intervention? What other culturally sensitive approach might have been suitable for this family, and what would you have done differently?
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