Introduction
Families that come from a different cultural background always pose a challenge to the family therapy practitioner if s/he is not well versed with the intricacies of the culture of the concerned family.
Every family has a ‘reality that they have created over time as in the way they view themselves and their environment; each of the family members is given a unique identity and role in the day to day interaction; they bring this to the therapy environment for remedy when they feel that there is a problem. In essence, what they are really asking for is help to better handle the reality that they have created; regardless of whether this reality is dysfunctional or not.
The main concern of the therapist after encountering would be to define the therapeutic reality; this is done by collecting data during the therapeutic transactions. Therefore, therapy begins with a collision between the two frames of reality. The therapeutic process aims at driving the family towards a better understanding of their dysfunctional reality.
Case Study
A local Puerto Rican community referred Mr. and Mrs. Acre to me for family therapy; the family was seeking help to deal with their children especially their year old son.
Respect for Authority
Setting of clear limits and Reward system
From the beginning, the attending therapist focused on aiding the parents to set clear limits and provide a reward system for their children. The effectiveness of this intervention can only work if the value patterns of the family support the rewards that the parents are offering to their children for keeping inside the boundaries set.
Influence of culture
The fact of the matter is that such value patterns are determined by the respective cultural orientation of the clients in question; and that the rewards used in one group of clients are not guaranteed to work in another. For example, the Puerto Rican society may not view the issues of social interactions (of the children), religion economic empowerment and free time the same way as other families that can identify themselves as having a mainstream American culture. The families that retain their original cultural beliefs as opposed to getting completely acculturated have been shown to have fewer problems than those who do (Fraenkel, 2000). It would have been more prudent if the therapist had sought to tailor-make such intervention with regard to the Puerto Rican culture in mind.
Control of aggression and the pattern of handling stress
Getting the children to respect the authority of the parents by setting the boundaries regarding the acceptable and unacceptable behaviors is a very crucial step in solving some of the issues afflicting the family. This will help in controlling any aggressive behaviors coming from the children.
However, aggressive behavior emanating from the couples is harder to deal with since each member regards him/herself as an equal partner in the relationship and cannot be controlled by the other. The main task of the therapist would be to bring this couple to appoint that they realize that they are part of the same team; and that they need to show a united front to the children to get more respect.
Additionally, the way couple manages stressful situations may not be helping in their problem; for example, the husband refuses to attend therapy sessions and blaming his wife for most of the issues afflicting their marriage. The therapist should aim at modifying the way this couple responds to situations that arise every day without putting their relationship in jeopardy. Some of the problems the children have may very well be arising from the inability of the couple to handle everyday stresses.
Identifying the problem
When handling the family, the attending therapist had recorded that the parents appeared distant and even had difficulties working together; and that there was clear tension between them. However, on further inquisition, they had denied having any difficulty and went ahead to make decisions quickly and efficiently. However, the husband refused to attend the subsequent session as the wife reported that he did not believe in therapy.
From the description, it is clear that the couple is having some problems in their relationship; however, the relationship of the couple cannot occur in isolation of the general welfare of the family. This was confirmed by the further complaints from the wife that the husband was no longer interested in her and that he blamed her for the disrespect and the disobedience from the children; and his frequent outbursts of anger.
Despite Mrs. Acers complaints, it would not be prudent to assume that all the problems in the family have stemmed from the behavior of the husband; in fact such behavior would very well be a result rather than a cause of the problems. In this case, the appropriate steps to take in regards to intervening in the family would involve the application of a Bowenian model; this involves drawing of genograms, relationship experiments, detrianglelising coaching, process questions, displacement stories and taking off the ‘I-position’ (Nichols and Schwartz, 2005, pg 128).
Family structure
The Nuclear family
Therapy sessions should involve all members of the family; this does not mean that all members have to be present at the same time, each member can come at his or her own time; and some sessions should involve more than one member of the family.
The therapist should initiate a process of active inquiry so as to obtain maximum information that would allow proper diagnosis of the problems affecting the family. However, this process should be distinct and separate from the sessions aimed at inducing self-reflection; in sessions involving several members of the family, the therapist should strive to address questions as individuals so as to get personal answers; and to avoid development of a discussion.
The extended family
The extended family should not be involved in a wholesale manner; only those who are intimately related to the family, for example living in the same house or close vicinity with close contact should be brought into the sessions. Some members of the extended family may not offer any useful insight into the situation of the couple for example due to separation of time and/or space.
On the other hand, some members of the extended family can give a therapist invaluable insight into the family history and cultural background of the client’s family; and may reveal issues that the immediate clients may be reluctant to; therefore giving the therapist more tools help this family. As such, a delicate balance has to be struck between the nuclear and extended family.
This way, the therapist will be able to identify any underlying triggers such as economic difficulties or physical dysfunctions of any party in the marriage that might be leading to the tension
Cultural beliefs and Spirituality
As mentioned before, the husband in this family had stated categorically that he did not believe in therapy. Authors have argued that most (lower-class) Puerto Ricans hold a conviction that psychotherapy can not solve their problems. Additionally most do not believe that they need to discuss their psychological problems with a medical professional (Gavira & Wintrob, 1979). A more prevalent practice is the use of Espiritisimo or Spiritism as a remedy of both physical and psychological issues (Núñez Molina, 2001). In a study done in Puerto Rico, 18% of all respondents admitted to having visited a spiritist healer to get solutions for emotional problems (Hohmann, Richeport, Marriot, Canino, Rubio-Stipec & Bird, 1990). However, this is not entirely in the disadvantage of mental health in this population; in fact other studies have shown that some severe mental dysfunctions can be effectively treated using spiritism (Garrison, 1977a, 1977b; Koss, 1992, 1980; Núñez Molina, 1990; Pérez y Mena, 1991).
In our case however, this may stand in the way of effective therapy; if the husband cannot see the benefits of sitting in the sessions with his wife or any other member of the family. And applying the measures prescribed by the attending therapist, the maximum benefit of attending such a program cannot be attained.
The Dignity of the individual
However, the real problem may not have been a cultural barrier to western therapy; rather, the most likely issue would have been a perception of infringement of his personal boundaries and a perceived diminished role as the husband in the family thus lowering his personal dignity. In this case the steps that the therapist took in reinforcing the boundaries to the intimate matters of the husband; and offering him more support in his role were in the right direction.
Discussion
In the endeavor to help such a family handle their reality better, the therapist has the task of balancing sensitivity and rigor rather than letting them develop into opposing forces (Hasanoviæ, 2005). The therapist has to be able to identify and solve the (albeit) complex needs of the family and within a time frame that is sustainable for the practice. Topmost on the list is the control of any aggression that may especially be coming from the twelve-year-old son not only for his safety but that of the other siblings and their own; the couple should be led to a point where they can handle such a scenario with maximum benefit both to their children and to themselves (Pynoos, et al, 1999).
References
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Garrison, V. (1977b): The “Puerto Rican Syndrome” in psychiatry and Espiritismo. In V. Crapanzano & V. Garrison (Eds.), Case studies in spirit possession. New York: Wiley.
Gavira, M. & Wintrob, R. (1979): Spiritist or psychiatrist: Treatment of mental illness among Puerto Ricans in two Connecticut towns. Journal of Operational Psychiatry, 10, 40-46.
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Hohmann, A., Richeport, M., Marriott, B., Canino, G., Rubio-Stipec, M. & Bird, H. (1990): Spiritism in Puerto Rico: Results of an island-wide community study. British Journal of Psychiatry, 156, 328-335.
Koss, J. (1992). Women as healers, women as patients: Mental health care and traditional healing in Puerto Rico. Boulder: Westview.
Nichols, Michael P. Richard C. Schwartz. (2005): Family Therapy: Concepts and Methods: 7th Edition, illustrated, revised. Pearson/Allyn and Bacon, 2005: Pages; 115 – 144.
Núñez Molina A. Mario (2001): Community healing among Puerto Ricans: Espiritismo as a therapy for the Soul: Published in Healing Cultures (2001) Margarite Fernández Olmo (Ed.) University of Puerto Rico at Mayagüez.
Núñez-Molina, M. (1990): Preventive and therapeutic aspects of Puerto Rican Espiritismo: Homines, 13, 267-276.
Pérez y Mena, A. (1991). Speaking with the dead: Development of Afro-Latin religion among Puerto Ricans in the United States: New York: AMS Press.
Pynoos RS, Steinberg AM, Piacentini JC. : (1999) A develop- mental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biol Psy-chiatry. 1999; 46:1542-54.